Infection Control Compliance Made Simple

A federal worksheet helps ASCs avoid accreditation deficiencies.

I love my job. I have always enjoyed educating new ASC leaders and watching them grow professionally. Although I no longer mentor leaders one-on-one, I’m happy that I can contribute to their growth through other avenues.

I was recently contacted by an ASC leader who was seeking resources after an accreditation survey citation. The leader understood they were only partially compliant with the infection preventionist’s (IP) training because the IP was not certified through a nationally recognized entity like the Association of periOperative Registered Nurses (AORN) or the CDC and its Healthcare Infection Control Practices Advisory Committee (HICPAC). The leader was looking for a certification course for their IP that would meet compliance. As I considered the situation, I felt there was some confusion and welcomed the opportunity to provide clarification, while also saving the leader time and money. I realized other ASC leaders may also be confused by this accreditation requirement.

Although organizations that provide accreditation to ASCs have their own requirements, they are all very similar and align with the requirements of the Centers for Medicare & Medicaid Services (CMS). The federal agency’s ASC Infection Control Worksheet provides a list of items that must be assessed during the on-site survey to determine compliance with the CMS infection control Condition for Coverage. The worksheet covers hand hygiene, injection practices, high-level disinfection, sterilization, environmental infection control, point-of-care devices and other topics.

The infection control component of the worksheet asks a series of questions, including whether the ASC has a detailed infection control program. If it does, does the program follow nationally recognized infection control guidelines? Can the ASC document process it followed to select which guidelines it chose from CDC/HICPAC, AORN or a specialty surgical society?

The worksheet then asks if the ASC has a licensed healthcare professional with training -- not necessarily certification -- in infection control to direct its infection control program. (The worksheet does ask if the person is certified in infection control but notes that certification is not required.)

Getting back to the ASC leader’s dilemma, there are two ways to solve it:

First, the ASC’s infection control program must consider, select and follow nationally recognized guidelines for infection control and have documentation of such to avoid a cited deficiency. Next, the ASC must designate a healthcare professional who is qualified through training to direct the ASCs infection control program. Although the infection preventionist does not need to be certified, they do need to have received some type of infection control training.

For ASCs that are not following nationally recognized infection control guidelines, the worksheet gives the examples of recommended practices from the CDC/HICPAC and AORN guidelines. ASC leaders should choose one of these guidelines and use it to create their own center’s infection control program. Although I encourage certification for professionals seeking to demonstrate advanced competency in a specialty, I understand that ASCs have conflicting priorities, and the immediate need is often compliance with the infection control requirements.

If I were in this ASCs leader’s place, I would assign the AORN ASC Academy: Infection Prevention Online course to the person responsible for the infection control program. The course follows the CMS Infection Control Worksheet and includes the AORN guidelines and recommended practices for each part of the worksheet. I would ask the infection preventionist to review the AORN recommendations and present the information to the infection control or quality committee for adoption of the guidelines. The course itself serves as documented proof of the required infection control training and will assist your infection preventionist in creating a program that provides a clean and safe environment for your patients and staff, while meeting accreditation requirements. OSM