By Apryl McElheny

Progressive Surgical Solutions annually conducts a comprehensive review of industry reports to unveil critical insights into the state of Ambulatory Surgical Centers (ASCs). This includes the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage and deemed status survey reports from leading accrediting organizations — The Joint Commission (TJC), the Accreditation Association for Ambulatory Health Care (AAAHC), Accreditation Commission for Health Care (ACHC), and the American Association for Accreditation of Ambulatory Surgery Facilities (QUAD A). These reports identify industry deficiencies as well as the most commonly issued citations, providing valuable insights for improving ASC practices. In this blog post, we’ll explore the findings of these reports, highlighting the key ASC deficiencies identified in 2023.

Year after year, ASCs struggle with similar challenges as they strive to meet the Conditions for Coverage set forth by CMS. Commonly, ASCs tend to fall short of compliance with the following regulations.

ASCs must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice including:

• Addressing ventilation and water quality control during construction/renovation
• Emphasizing safe air handling systems in critical areas like operating rooms
• Implementing robust practices for food sanitation, cleaning, disinfecting, and waste disposal
• Establishing effective pest control measures

ASCs must prepare and administer medications in accordance with established policies and acceptable standards of practice including:

• Ensuring physician orders are on file
• Adhering to manufacturer’s labels and avoiding preparation too far in advance
• Implementing infection control practices for drug administration
• Maintaining meticulous records of controlled substances, with a designated professional overseeing pharmaceutical services.

ASCs must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevention program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines and standards including:

• Having a qualified professional lead the program
• Integrating infection control into the Quality Assessment and Performance Improvement (QAPI) program.
• Providing a proactive plan of action for preventing, identifying, and managing infection

ASCs are required to keep a medical record for each patient. Each record must be accurate, legible, promptly completed, and include:

• Patient identification, medical history, pre-operative diagnostic studies, operation findings, anesthesia administration details, informed patient consent documentation, and discharge diagnosis.

ASCs must adhere to the regulations applicable to Ambulatory Health Care Occupancies, irrespective of the number of patients served, and must follow the guidelines outlined in the Life Safety Code (NFPA 101 and Tentative Interim Amendments 12-1 through 12-4) including:

• Addressing issues such as smoke detectors, fire drills, fire doors, sprinkler systems, medical gases, fire walls, and fire extinguishers
• Ensuring proper documentation and compliance with fire safety regulations

In addition to CMS deficiencies, the following outlines the high deficiency standards established by various accreditation organizations.

AAAHC: Governing body is responsible for approving and ensuring compliance of all major contracts or arrangements affecting the medical care provided (2: Governance, 2.I.I).

TJC: Implements infection prevention and control activities when performing intermediate, high-level disinfection, sterilization of equipment, devices, supplies (IC.02.02.01, EP 2).

ACHC: Governing Body is responsible for the safety, effectiveness of services provided by contracted employees, entities 91: Governing Body and Management, 01.01.02 Contract services).

QUAD A: Pre-op record includes a written screening protocol for venous thromboembolism risk (8.B.23).

Addressing these top deficiencies is cruicial for maintaining compliance, ensuring patient safety, and delivering exceptional care. Through our consulting services, we gain a comprehensive understanding of the range of issues our clients’ encountered, allowing us to provide valuable insights and support to our clients; thereby, helping them steer clear of common industry pitfalls.