Infection Control Surveyor Worksheet

Form Template

The Infection Control Surveyor Worksheet mobile app is a list of items that must be assessed during the on-site survey, in order to determine compliance with the infection control Condition for Coverage.

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Items are to be assessed primarily by surveyor observation, with interviews used to provide additional confirming evidence of observations. In some cases, information gained from interviews may provide sufficient evidence to support a deficiency citation. The interviews and observations should be performed with the most appropriate staff person(s) for the items of interest (e.g., the staff person responsible for sterilization should answer the sterilization questions). A minimum of one surgical procedure must be observed during the site visit. The surveyor(s) must identify at least one patient and follow that case from registration to discharge to observe pertinent practices. For facilities that perform brief procedures, e.g., colonoscopies, it is preferable to follow at least two cases. When performing interviews and observations, any single instance of a breach in infection control would constitute a breach for that practice.

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