CMS Infection Control Breach Reporting

CMS issues new reporting requirements for Deemed Status ASCs - 6/30/2014

Effective Immediately, CMS has mandated reporting of infection control breaches to public health authorities by acrediting organizations.

When any of the following infection control breaches is identified during any Medicare Deemed Status Survey, the State Agency (SA) or accrediting organization (AO) should make the appropriate state public health authority aware of the deficient practice:

  • Using the same needle for more than one individual.
  • Using the same (pre-filled/manufactured/insulin or any other) syringe, pen, or injection device for more than one individual.
  • Re-using a needle or syringe that has already been used to administer medication to an individual to subsequently enter a medication container (e.g. vial, bag), and then using contents from that medication container for another individual.
  • Using the same lancing/fingerstick device for more than one individual, even if the lancet is changed.

AAAHC surveyors will inform the AAAHC office of any identified breach to verify that it is a reportable event. The AAAHC office will notify the relevant public health authority of any such reportable event.      

As a reminder, AAAHC-accredited organizations are required to identify reporting requirements for the state in which they are located (see Standard 7.2.A.2), know to whom reports should be made, and develop a process for carrying this out. Surveyors, in their regular review of adverse event logs, will look for documentation of infection control breaches and how they were addressed.

State public health contact information may be found in the state-based HAI Prevention Activities map at

Media Contact

Mary Wei

Michon Villanueva

Midyear updates to 2014 Accreditation Handbook for Medicare Deemed Status Surveys can be reviewed here.