The ASC Infection Control Surveyor Worksheet could serve as a good tool for ASC administrators to use when assessing their own infection control and prevention policies and procedures. The survey is 17 pages of multiple questions with “yes” and “no” options, including the very basic question, number 15: “Does the ASC have an explicit infection control program?” (The CMS checklist can be found at: http://go.cms.gov/2iYWS7o.)
For every answer provided, CMS will want to see supporting documentation, according to Tammeria Tyler, RN, CIC.
“They like to see a policy based on national guidelines and documentation supporting what you’re saying you’re doing,” she says. “In 2009, CMS said they’d start surveying us on infection control. Then they said you had to have a person in charge of this, a qualified person who is trained in infection control.”
Certification wasn’t required, but Tyler became certified because surveyors like to see the certification, she notes.
Question 17 on the CMS checklist asks, “Does the ASC have a licensed healthcare professional qualified through training in infection control and designated to direct the ASC’s infection control program?” The question’s highlighted note states that designating a professional is necessary to avoid a citation, but the person does not need certification, although CMS asks in question 17b: “Is this person certified in infection control (i.e., CIC)?”
“I’m a CIC, which is very hospital-driven, because that was the only thing out there when I became certified in 2013,” Tyler explains. “Our patients, typically, are much different than hospital patients, who are ill with multiple comorbidities.”
Another important question in the checklist relates to the IC guidelines. Question 16a on the checklist asks: “Is there documentation that the ASC considered and selected nationally recognized infection control guidelines for its program?” The answer must be “yes,” or CMS will consider it a deficiency, related to 42 CFR 416.51(b).
“We use the CDC as our chief guidelines, but we also pull from other sources,” Tyler says.
For instance, both the Association of periOperative Registered Nurses (AORN) and the Society for Healthcare Epidemiology of America (SHEA) offer national infection control guidelines.
“A best practices policy is to document what you base your policy off of,” Tyler adds.
In another example, question 19 asks: “Do staff members receive infection control training?” A CMS surveyor will want to see documentation of infection control training sessions, how often these have been held, and in what type of settings. There might be infection control training in staff meetings, during inservices, and/or on posters. All these types of education and training should be documented.
“We keep documentation of staff training in a separate binder,” Tyler notes.
The CMS surveyor checklist also asks about hand hygiene, including whether patient care areas can readily access soap and water and alcohol-based hand rubs and whether staff perform hand hygiene after removing gloves, before direct patient contact, after direct patient contact, before performing invasive procedures, and after contact with blood, body fluids, or contaminated surfaces.
In addition to following the CMS checklist, Tyler recommends ASCs’ designated infection control professionals attend national infectious disease conferences. These both can help them stay on top of the latest information, but also provide valuable networking resources. Once, an ASC patient presented with a strange infection. It made no sense in the context of the patient’s procedure, so Tyler contacted an infectious disease expert she met at a conference and told him about the infection, describing the case in detail. The expert offered a plausible explanation: The patient’s infectious agent had started in the patient’s gut and migrated.
“He pulled two small studies for me,” Tyler recalls. “We need to have the ability to pull on these resources when we run into something odd.”