Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
Compliance tips for:
CHAPTER 05: INFECTION PREVENTION AND CONTROL 05.00.02 Infection Prevention and Control Program Development Frequency of the citation: 29% Overview of the requirement: The program to prevent and control the spread of infection in the ASC is based on recognized guidelines. Comment on deficiencies: Surveyors evaluate compliance by reviewing documentation, interviewing staff, and observing infection prevention in action. Deficiencies identified incomplete policies and a failure to implement policies and procedures. Hand hygiene and glove technique was consistently identified in deficiency descriptions. Examples of ACHC Surveyor findings: ■ The organization lacks a policy that addresses compliance with state-level notifiable disease reporting requirements. ■ The facility’s hand hygiene policy requires use of a handwashing agent or alcohol-based hand rub before gloving and after removing gloves. Two staff members were observed exchanging dirty gloves for clean gloves without performing hand hygiene between the exchange. This process was noted to occur two times by each of the two staff members. ■ The ASC lacks an ongoing Infection Control Program. The facility was unable to produce policies and procedure for development and implementation of infection control activities related to personnel. The facility was lacking policies articulating the authority and circumstances under which the ASC screens personnel for infections likely to cause significant infectious disease or other risks to the exposed individual, and for reportable diseases, as required under local, state, or federal public health authority. ■ There was no nail policy for the facility. The RN circulator was wearing ½ inch artificial nails. ■ The facility policy titled “Education,” states that employees will receive infection control training within 30 days of hire and annually that includes: ٝ Hand washing and use of alcohol-based hand sanitizers. ٝ Safe injection practices. ٝ Cleaning and disinfecting the environment. ٝ Infection prevention and follow-up. ٝ Standard precautions. ٝ Bloodborne pathogens. Four staff members did not receive any of this training based on document review.
The ASC is expected to select and adopt nationally-recognized infection control practices, train its staff on infection control, and maintain active surveillance. The standard requires a program that requires at least: a sanitary environment, mitigation of healthcare-associated infections, screening for infection/immunization status, monitoring for compliance, and periodic program evaluation and revision. ■ Audit your infection control policy(ies) against the standard to ensure inclusion of all required elements. ٝ .Identify the source of your guidelines (for example, WHO, CHC, SHEA, AORN, APSF). ■ Audit personnel files to ensure they include initial and periodic training. ■ Review monitoring data so that you can develop and deliver targeted infection prevention training modules to support improvement in infection control practices.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
05.00.06 Sanitary Environment Frequency of the citation: 43%
Overview of the requirement: All areas and equipment in the ASC must be maintained to avoid sources and transmission of infection. Policies define expectations for specific aspects of environmental cleanliness, including water quality, ventilation systems, and storage. Comment on deficiencies: Compliance is evaluated through direct observation, interviews, and reference to policies. Deficiencies noted were all based on Surveyor observation and therefore avoidable by an alert, and action-oriented staff.
Examples of ACHC Surveyor findings:
■ All air vents throughout the facility were dirty. ■ Floors throughout the facility were visibly dirty and unable to be cleaned with a Sani-wipes. The dirt was noted to be “waxed” over. ■ The sink faucet in pre-op room 2 was detached from the sink and the toilet does not flush. ■ Suction tubing was open to air on uncovered shelves in the hallway. ■ In OR2, post room turnover, and just prior to a case starting, dust and waste including used alcohol wipes, needle caps, and papers left from a previous procedure in this room were observed under the table.
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