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 / /
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