Ambulatory Surgery Center Infection Prevention & Control Consulting
Reviewed by Phenelle Segal, RN, CIC, FAPIC — Founder, Infection Control Consulting Services (40+ years in infection prevention and control)
ICCS introduction video for ambulatory surgery center infection prevention services
As more complex procedures move from hospitals to outpatient settings, ambulatory surgery centers (ASCs) face growing pressure to prevent healthcare-associated infections while meeting an expanding set of federal, state, and accreditation requirements. ICCS has spent more than 40 years helping ASCs build infection prevention programs that satisfy CMS and accreditation standards and pass survey with confidence.
Why It Matters
The ambulatory surgery sector is experiencing major growth throughout the United States. With increasing numbers of patients receiving treatment at ASCs, and with treatment becoming more complex, the risk of acquiring infections as a result of admission also increases.
Federal, state and accreditation regulations and standards are continuing to challenge ASC infection prevention and control programs as ASCs lead hospitals in the number of procedures performed annually. Facilities are expected to implement and report several infection prevention core measures developed by the Centers for Medicare & Medicaid Services (CMS), and meet standards from their accreditation organization (e.g., AAAHC and The Joint Commission).
Reprocessing of endoscopes, instruments, and other reusable items remains one of the most heavily scrutinized areas during survey, requiring meticulous documentation and consistent staff training to stay in compliance.
How ICCS Supports ASC Compliance
Infection Control Consulting Services (ICCS) specializes in infection prevention practices for ASCs nationwide. The team of ICCS consultants has successfully help facilities prepare for and pass Medicare and accreditation surveys through mock CMS surveys utilizing the surveyor worksheet to satisfy the requirements of CMS Conditions for coverage (i.e., 42 CFR 416.51). Mock surveys are performed by conducting on-site visits with observation and assessment of perioperative best practices in the following areas:
Holding and pre-op
Within the operating room (OR) suite during a procedure
Central reprocessing
Sterile supply room
PACU
Environmental cleaning between cases
Surgical attire
Hand hygiene/scrub technique
Skin prep
Additional ASC Services
Other services provided to ASCs include the following:
Assistance with meeting CMS and accreditation standards (AAAHC, The Joint Commission, QUAD A, ACHC)
Development of infection prevention and control written programs
Assistance with surveillance for post-operative surgical site infections (SSIs)
Assistance with regulatory and accreditation deficiencies, including corrective action plan development
Educational programs for staff during visits or via webinar/audio conferences
Follow-up visits
Frequently Asked Questions
How often are ambulatory surgery centers surveyed for infection control compliance?
Survey frequency depends on accreditation status and state licensure. Accredited ASCs typically undergo a full survey every three years, with unannounced or focused surveys possible at any time, and CMS-certified ASCs are also subject to periodic state agency surveys tied to their Conditions for Coverage. Many facilities run internal mock surveys between accreditation cycles to catch gaps before a real surveyor does.
Is a written infection prevention and control program required for ASC licensure?
Yes. CMS's Conditions for Coverage (42 CFR 416.51) require ASCs to maintain an active infection prevention and control program, and most states require a written program as part of licensure or relicensure. The specific content requirements vary by state and accreditor, which is why many ASCs bring in outside expertise to make sure their documentation satisfies every applicable standard at once.
What happens during a mock CMS survey for an ASC?
A mock survey follows the same surveyor worksheet used in an actual CMS or accreditation visit. A consultant observes practices on-site — in pre-op, the OR, central reprocessing, the sterile supply room, PACU, and during environmental cleaning between cases — then delivers a detailed report identifying gaps along with a corrective action plan before a real surveyor arrives.
Do ASCs need a dedicated infection preventionist on staff?
Most surgery centers don't have the patient volume or budget to support a full-time, dedicated infection preventionist, so the role is usually assigned to a nurse or manager on top of other duties. That's one of the most common gaps ICCS consultants find: the designated person hasn't had formal infection control training. Bringing in outside expertise, even periodically, keeps the program grounded in current evidence-based practice rather than guesswork.