Fillable Printable Infection Control Risk Assessment Template

Infection Control Risk Assessment Template

Centers for Medicare & Medicaid Services

Hospital Infection Control Worksheet

Name of State Agency: _________________________________________________________________________________________________

Instructions: The following is a list of items that must be assessed during the on-site survey, in order to determine compliance with the Infection Control

Condition of Participation. Items are to be assessed by a combination of observation, interviews with hospital staff, patients and their family/support persons,

review of medical records, and a review of any necessary infection control program documentation. During the survey, observations or concerns may prompt

the surveyor to request and review specific hospital policies and procedures. Surveyors are expected to use their judgment and review only those

documents necessary to investigate their concern(s) or to validate their observations.

The interviews should be performed with the most appropriate staff person(s) for the items of interest, as well as with patients, family members, and

support persons.

Hospital Characteristics

1. Hospital name: ____________________________________________________________________________________________

2. CMS Certification Number (CCN):

3. Date of site visit:

/ / to / /

Module 1: Infection Prevention Program

Section 1.A. Infection Prevention Program and Resources

Elements to be assessed Surveyor Notes

1.A.1 The hospital has designated one or more individual(s) as its

Infection Control Officer(s).

Yes

1.A.2 The hospital has evidence that demonstrates the Infection

Control Officer(s) is qualified and maintain(s) qualifications

through education, training, experience or certification related

to infection control consistent with hospital policy.

Yes

1.A.3 The Infection Control Officer(s) can provide evidence that the

hospital has developed general infection control policies and

procedures that are based on nationally recognized guidelines

and applicable state and federal law.

Yes

If no to any of 1.A.1 through 1.A.3, cite at 42 CFR 482.42(a) (Tag A-748)

1.A.4 The Infection Control Officer can provide an updated list of

diseases reportable to the local and/or state public health

authorities.

Yes

1.A.5 The Infection Control Officer can provide evidence that

hospital complies with the reportable diseases requirements of

the local health authority.

Yes

No citation risk for questions 1.A.4 and 1.A.5

1.A.6 The hospital has infection control policies and procedures

relevant to construction, renovation, maintenance, demolition,

and repair, including the requirement for an infection control

risk assessment (ICRA) to define the scope of the project and

need for barrier measures before a project gets underway.

Yes

If no to 1.A.6,

cite at

42 CFR 482.42(a) (Tag A-748)

Section 1.B. Hospital QAPI Systems Related to Infection Prevention

Elements to be assessed Surveyor Notes

The hospital infection prevention program is coordinated into the hospital QAPI program as evidenced by:

1.B.1 The Infection Control Officer(s) can provide evidence that

problems identified in the infection control program are

addressed in the hospital QAPI program (i.e., development and

implementation of corrective interventions, and ongoing

evaluation of interventions implemented for both success and

sustainability).

Yes

If no to 1.B.1, cite at 42 CFR 482.21(e)(3) (Tag A-0286)

1.B.2 Hospital leadership, including the CEO, Medical Staff, and the

Director of Nursing Services ensures the hospital implements

successful corrective action plans in affected problem area(s).

Yes

If no to 1.B.2, cite at 42 CFR 482.42(b)(2) (Tag A-0756)

1.B.3 The hospital utilizes a risk assessment process to prioritize

selection of quality indicators for infection prevention and

control.

Yes

If no to 1.B.3,

cite at

42 CFR 482.21(a)(2) (Tag A-0267)

Section 1.C. Systems to Prevent Transmission of MDROs and Promote Antimicrobial

Stewardship

Elements to be assessed Surveyor Notes

1.C.1 The hospital has policies and procedures to minimize the risk of

development and transmission of multidrug-resistant organisms

(MDROs) within the hospital (applicable to all persons in the

hospital).

Yes

1.C.2

Systems are in place to designate patients known to be colonized

or infected with a targeted MDRO and to notify receiving units and

personnel prior to movement of such patients within the hospital.

Yes

1.C.3 Systems are in place to designate patients known to be colonized

or infected with a targeted MDRO and to notify receiving

healthcare facilities and personnel prior to transfer of such patient

between facilities.

Yes

If no to any part of 1.C.1 through 1.C.3, cite at 42 CFR 482.42(a) (Tag A-0749)

1.C.4 The hospital can provide a list of target MDROs.

Note: Hospitals should provide a list of MDROs that are targeted for

infection control because they are epidemiologically important

(e.g., MRSA, VRE). Please refer to CDC’s Guideline for Isolation

Precautions for criteria that may be used to define epidemiology

important organisms:

http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

Yes

1.C.5 The hospital can demonstrate the criteria used to determine

epidemiologically important MDROs on their list.

Yes

1.C.6 The hospital can provide justification for any epidemiologically

important organisms not on their list and otherwise not targeted

in their hospital.

Yes

N/A

No citation risk for questions 1.C.4 through 1.C.6; for information only.

1.C.7 The hospital has an established system(s)

to ensure prompt

notification to the Infection Control Officer when a novel resistance

pattern based on microbiology results is detected.

Yes

If no to 1.C.7, cite at 42 CFR 482.42(a) (Tag A-0749)

1.C.8 Patients identified

as colonized or infected with target MDROs

are placed on Contact Precautions.

Note: This does not imply that hospitals are required to perform

active surveillance testing to detect MDRO colonization among a

specific subset or all patients.

Yes

If no to 1.C.8,

cite at

42 CFR 482.42(a) (Tag A-0749)

1.C.9 The hospital has written policies and procedures whose purpose

is to improve antibiotic use (antibiotic stewardship).

Yes

1.C.10 The hospital has designated a leader (e.g., physician,

pharmacist, etc.) responsible for program outcomes of antibiotic

stewardship activities at the hospital.

Yes

1.C.11 The hospital’s antibiotic stewardship policy and procedures

requires practitioners to document in the medical record or during

order entry an indication for all antibiotics, in addition to other

required elements such as does and duration.

Yes

1.C.12 The hospital has a formal procedure for all practitioners to

review the appropriateness of any antibiotics prescribed after 48

hours from the initial orders (e.g., antibiotic time out).

Yes

1.C.13 The hospital monitors antibiotic use (consumption) at the unit

and/or hospital level.

Yes

No citation risk for 1.C.9 through 1.C.13; for information only.

Section 1.D. Infection Prevention Systems, and Training Related to Personnel

Elements to be assessed Surveyor Notes

1.D.1 Personnel receive job-specific training on hospital infection

control practices, policies, and procedures upon hire and at

regular intervals.

Yes

1.D.2 The hospital infection control system trains personnel

expected to have contact with blood or other potentially

infectious material is anticipated on the blood borne pathogen

standards upon hire, at regular intervals, and as needed.

Yes

1.D.3 The hospital infection control system puts in place and

monitors efforts to prevent needle sticks, sharps injuries, and

other employee exposure events.

Yes

1.D.4 Following an exposure incident, post-exposure evaluation and

follow-up including prophylaxis as appropriate, is available to

the individual and performed by or under the supervision of a

practitioner.

Note: An exposure incident refers to a specific eye, mouth, other

mucous membrane, non-intact skin, or parenteral contact with

blood or other potentially infectious materials that result from

the performance of an individual’s duties.

Yes

1.D.5 The hospital tracks healthcare personnel exposure events,

evaluates event data, and develops corrective action plans to

reduce the incidence of such events.

Yes

1.D.6 The hospital infection control system ensures all

personnel are

screenedfor tuberculosis (TB) upon hire and, for those with

negative results, determine ongoing TB screening criteria based

upon facility/unit risk classification.

Note: Risk classification based on aggregated rates of TB test

conversions are periodically reviewed by the Infection Control

Officer to determine the need for modification to the screening

and TB control measures due to increases or decreases in

transmission.

Yes

1.D.7 The hospital infection control system ensures personnel with

TB test conversions are provided with appropriate follow-up

(e.g. evaluation and treatment, as needed).

Yes

1.D.8 The hospital infection control system ensures the hospital has

a respiratory protection program that details required worksite-

specific procedures and elements for required respirator use.

Yes

1.D.9 The hospital infection control system ensures that respiratory

fit testing is provided at regular intervals to personnel at risk.

Yes

1.D.10 Hospital has well-defined policies concerning contact of

personnel with patients when personnel have potentially

transmissible conditions.

•

The hospital provides education to personnel on need for

prompt reporting of illness to supervisor and/or

occupational health.

Yes

If no to any of 1.D.1 through 1.D.10, cite at 42 CFR 482.42(a) (Tag A-0749)

1.D.11 Personnel competency and compliance with job-specific

infection prevention policies and procedures are ensured

through routine training and when the Infection Control Officer

has identified problems requiring additional training.

Yes

If no to 1.D.11,

cite at

42 CFR 482.42(b) (Tag A-0756)

1.D.12 The hospital infection control system provides Hepatitis B

vaccination series to all employees who have potential

occupational exposure and offers post-vaccination testing for

immunity after the third vaccine dose is administered.

Yes

1.D.13 The hospital infection control system ensures and documents

that all personnel have presumptive evidence of immunity to

measles, mumps, and rubella.

Yes

1.D.14 The hospital infection control system provides Tdap (tetanus

toxoid, reduced diphtheria toxoid, and acellular pertussis)

vaccination for all personnel who have not previously received

Tdap.

Note:

Tdap is not licensed for multiple administrations; therefore,

after receipt of Tdap, HCP should receive Td (Tetanus diphtheria)

for future booster vaccination against tetanus and diphtheria.

Yes

1.D.15 The hospital infection control system ensures and documents

that all personnel have evidence of immunity to varicella.

Yes

1.D.16 The hospital infection control system ensures that all

personnel are offered annual influenza vaccination.

Yes

No citation risk for 1.D.12 through 1.D.16, for information only.

Module 2: General Infection Prevention Elements - to be applied to all locations providing patient care

Section 2.A. Hand Hygiene

Elements to be assessed Surveyor Notes

Hand hygiene is performed in a manner consistent with hospital infection control practices, policies, and procedures to maximize the prevention of infection and

communicable disease including the following:

Note: Observations for compliance with hand hygiene elements should be assessed throughout the hospital.

2.A.1 Soap, water, and a sink are readily accessible in appropriate

locations including, but not limited to, patient care areas and

food and medication preparation areas.

Note: Medications should not be prepared near areas of splashing

water (e.g. within 3 feet of a sink). Alternately when space is

limited, a splash guard can be mounted beside the sink.

Yes

2.A.2 Alcohol-based hand rub is readily accessible and placed in

appropriate locations. The locations may include:

•

Entrances to patient rooms,

•

At the bedside,

•

In individual pocket-sized containers carried by healthcare

personnel,

•

Staff workstations, and/or

•

Other convenient locations.

Yes

2.A.3 Personnel perform hand hygiene:

•

Before contact with the patient

•

Before performing an aseptic task (e.g., insertion of IV or

urinary catheter)

Yes

2.A.4 Personnel perform hand hygiene:

•

After contact with the patient

•

After contact with blood, body fluids, or visibly contaminated

surfaces

•

After removing gloves

Yes

2.A.5 Personnel perform hand hygiene using soap and water when

hands are visibly soiled (e.g., blood, body fluids) or after caring

for a patient with known or suspected C. difficile or norovirus

during an outbreak.

Note: In all other situations, alcohol-based hand rub is preferred.

Yes

2.A.6 Personnel do not wear artificial fingernails and/or extenders

when having direct contact with patients at high risk of

infection (e.g., those in intensive care units or ORs) per hospital

policy.

Yes

If no to any of 2.A.1 through 2.A.6, cite at 42 CFR 482.42(a) (Tag A-0749)

Section 2.B. Injection Practices and Sharps Safety (Medications and Infusates)

Elements to be assessed Surveyor Notes Surveyor Notes

Injections are given and sharps safety is managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and

communicable disease including the following:

Note: If possible, questions in this section should be assessed through observation in two separate patient care areas or

settings of the hospital.

Second observation not available (If selected,

questions 2.B.1 – 2.B.15 RIGHT column will be

blocked)

2.B.1 Injections are prepared using aseptic technique in an area

that has been cleaned and is free of contamination (e.g., visible

blood, or body fluids).

Yes

Unable to

observe

Yes

Unable to

observe

2.B.2 Needles are used for only one patient.

Yes

Unable to

observe

Yes

Unable to

observe

2.B.3 Syringes are used for only one patient (this includes

manufactured prefilled syringes).

Yes

Unable to

observe

Yes

Unable to

observe

2.B.4 Insulin pens are used for only one patient.

Yes

Unable to

observe

Yes

Unable to

observe

2.B.5 The rubber septum on all medication vials, whether

unopened or previously accessed, is disinfected with alcohol

prior to piercing.

Yes

Unable to

observe

Yes

Unable to

observe