CMS infection control worksheet

By Sandra Jones, Ambulatory Strategies Inc.


I heard there was a revised CMS infection control worksheet. What is new and where do I get the worksheet?


You can obtain the Centers for Medicare and Medicaid Services (CMS) worksheet by going to and typing “ASC ICSW” or “S&C: 15-43-ASC” into the search cell. The document is “Exhibit 351, Ambulatory Surgery Center (ASC) Infection Control Surveyor Worksheet” which was revised in June 2015 and effective July 17, 2015. The document provides the changes in red font so it is easy to spot what has changed on the worksheet from the previous edition.

Even if your surgery center is inspected by SC DHEC or by an accrediting body, you can expect the surveyor to review your compliance to the infection control areas in this worksheet.

Here are some of the most frequently cited deficient practices, according to a study of CMS survey reports:

  • Providers are not wearing masks appropriately. CDC issued a clinical reminder that providers should wear a face mask when performing spine injection procedures. You can obtain the CDC information at Other instances of inappropriate wear include not covering the nose, wearing the mask for multiple cases and extended period of time, untying the mask and having it dangle from the neck so the provider and the patient are exposed to contaminated material.
  • CMS added to the updated worksheet a requirement that staff providing direct patient care are not to wear artificial fingernails and/or extenders. This has been a CDC recommendation since the CDC published Guideline for Prevention of Surgical Site Infection, 1999. Gel nails are also considered artificial nails.
  • Observations of practices often discover a failure of staff to disinfect the rubber septum on medication, whether unopened or previously accessed, prior to piercing.
  • When multi-dose medication vials are used, the multi-dose vial is not to be accessed in the immediate patient care area unless it is treated as a single dose vial and discarded after use on one patient. The immediate patient care area is the operating room, anesthesia carts, pre-operative areas and PACU bays. Surgery centers that have medication or anesthesia work rooms conveniently located near their operating rooms have adjusted by having staff access multi-dose vials in these medication preparation areas, labeling the syringe, and then taking the syringe to the patient for use. For those surgery centers without medication preparation areas, surgery centers have increasingly moved to stocking only single dose vials.
  • Staff access to manufacturer’s instructions for use, knowledge of instructions for cleaning and sterilizing instruments, using chemical indicators in sterilizers and instrument packs, and following required practices are all areas of focus of surveyors. The staff may be asked to produce manufacturer’s instructions for the cleaning and sterilization of an instrument tray or a particular instrument. In addition, the surveyor will ask to see logs of biological indicator use at least weekly for each sterilizer and with every load containing implantable items.
  • Hand hygiene and the wearing of gloves along with the handling and cleaning of finger stick devices for laboratory results will be observed. It is important to have the manufacturer’s instructions handy. Copy and highlight specific information and have it available for staff education as well as showing the information to a surveyor. Information to highlight includes the manufacturer’s statement that the machine is for multi-patient use, instructions on machine calibration, and information on how the machine is to be cleaned after each patient use. A surveyor may ask a nurse to explain how the machine is to be cleaned between patient use. Too often, the answer is not what the manufacturer recommends.


With the CMS Infection Control Worksheet as your guide, conduct your own audit of your practices. Ask your staff questions about how they perform activities and check their answers against the policies you have, the manufacturer’s instructions, and nationally recognized guidelines. This audit could indicate there are opportunities for improvement and give you excellent material for a quality assessment and performance improvement activity. Your own audit will also prepare you and your staff for a survey as well as the delivery of safe patient care.