Case Study: CMS Halts Procedures at an Ambulatory Surgery Center


An ambulatory surgery center (ASC) located in the Southeast, specializing in genitourinary procedures, underwent an unannounced Centers for Medicare & Medicaid Services (CMS) survey by the state. Despite a well-run program overall, with staff members who were very dedicated to the safety of patients, the state surveyors, collaborating with The Joint Commission (the ASC's accrediting organization), made the decision to halt further procedures until their high-level disinfection (HLD) procedures were assessed by an independent consultant/consulting firm. This seemingly well-run facility was missing one critical step that was severe enough for the surveyors to suspend business.

Temporarily halting procedures had a significant impact on the center’s economic state, a loss of services to the patients and a temporary layoff of staff.


Infection Control Consulting Services (ICCS) was engaged by the administrator and director of nursing to conduct an onsite visit for the purpose of reviewing practices, including, but not limited to, HLD. A team expert for ICCS visited the ASC the day after the facility contacted ICCS, and she spent two days with the staff.


  • Assessed overall best practices as they pertain to infection prevention.
  • Assessed detailed steps for HLD.
  • Assessed written program, including policies and procedures.
  • Walked through HLD processes, including missing step that created the CMS compliance issue.
  • Identified areas of weakness and practice breakdown.
  • Provided a written report of findings and suggestions for improvement.
  • Educated the staff, including reprocessing technician, on the correct techniques for conducting HLD for semi-critical items.
  • Provided written competencies for management to conduct on staff.
  • Conducted a return visit prior to CMS return visit window.
  • Liaised with director of nursing for a one-year period following the ASC's reopening.


A return visit by the state was favorable, and the ASC was allowed to begin procedures after the entire practice of HLD was revised and competencies were in place. A favorable response was received by the surveyors who felt that the facility had been immediately responsive to their issues, enlisted independent assistance of a consultant and instituted recommended procedures and policies.