Top 5 Infection Prevention-Related CMS Survey Citations

Since the beginning of 2016, Infection Control Consulting Services (ICCS) consultants have visited numerous hospitals and ASCs throughout the country that are working to address CMS infection prevention-related citations and deficiencies.

Phenelle Segal, RN CIC, President of ICCS, reports that remediation efforts have been challenging, but successful. ICCS has worked with organizations to address a wide range of issues, from first-time citations to potential and actual loss of Medicare license. Citations have been common in both the hospital and ASC setting.

Here are five of the top infection prevention- and control-related CMS survey citations.

1. Failing to ensure that the designated "Infection Control Officer" was qualified through experience, ongoing education, and/or training to develop and implement an effective Infection Control Program.

2. Infection Control Program failed to identify, prevent, and control infection control issues and/or breaches by failing to implement an effective infection control risk assessment. This assessment must be consistent with acceptable professional standards governing surgical services and acceptable infection control standards of practice in order to identify potential infection control issues/breaches and/or to mitigate risks associated with potential infection control risks.

3. Hospital or ASC that chose* to follow the Association of periOperative Registered Nurses (AORN) "Guidelines for Perioperative Practice, 2015 edition - Guideline for Surgical Attire"  violated one or more of the following:

  • Tying of masks tightly to mitigate the risk of transfer of organisms from the mouth or nose
  • When in the semi-restricted or restricted surgical areas, all personal clothing should be completely covered by the surgical attire.
  • Undergarments such as T-shirts with a V-neck, and shirts with sleeves which can be contained underneath the scrub top, may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn
  • Failing to launder scrubs by an approved company or home laundering
  • Failing to identify semi-restricted and restricted areas 
  • All personnel should cover head and facial hair, including side­burns and the nape of the neck, when in the semi-restricted and restricted areas
  • A clean, low-lint surgical head cover or hood that confines all hair and covers scalp skin should be worn

*Note: The CMS ASC Infection Control Surveyor Worksheet states that an ASC’s infection control program is required to follow nationally recognized infection control guidelines (see question #16). This can include AORN's Perioperative Standards and Recommended Practices, CDC/HICPAC Guidelines or appropriate guidelines issued by a specialty surgical society/organization.

4. Central processing failures are numerous. They include, but are not limited to, the following:

  • Inappropriate packaging of instruments, particularly peel pouches (more than one instrument when the instrument should be sterilized alone)
  • Hinged instruments not opened wide enough
  • Clean supplies stored in same room as sterile supplies
  • Inadequate monitoring of the environment in the central processing department

5. Failure to adhere to standards for reprocessing of endoscopes. They include, but are not limited to, the following:

  • Transport of endoscopes from the procedure room to the reprocessing area
  • Monitoring of temperature and humidity in decontamination room
  • Manual high-level disinfection practices via soaking (Note: ICCS has witnessed several citations in this area, including those related to the temperature of the soak solution)
  • Use of personal protective equipment by employees in the decontamination room

If your hospital or ASC requires assistance with preparing corrective plans of action related to survey deficiencies or assistance with accreditation survey preparation and regulatory requirements including, but not limited, to CMS, The Joint Commission, AAAHC, HFAP, DNV and AAAASF, contact ICCS today!