Written by: Leanne Gallegos, BSN, RN
Every year, the Progressive Surgical Solutions team has the opportunity to review several reports that uncover industry deficiencies. This includes the 2567 report — which is published by the Centers for Medicare and Medicare Services (CMS) — as well as deemed status survey reports published by accrediting organizations such as the Joint Commission, the Accreditation Association for Ambulatory Health Care (AAAHC), and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
In addition to uncovering deficiencies, these reports allow us to track the most commonly issued industry citations. Generally, the most frequently seen citations are related to:
- Incomplete credentialing files;
- Incomplete personnel files;
- Incomplete medical records;
- Missing or incomplete Life Safety Code (LSC) documentation;
- Quality Assurance Performance Improvement (QAPI) programs lacking required documentation, including the use of performance measures to improve outcomes;
- Failing to follow the Association of periOperative Registered Nurses (AORN) standards, the Centers for Disease Control and Prevention (CDC) guidelines, or facility policies and procedures for infection control practices; and
- Lack of required annual in-services staff training or documentation thereof.
A closer look
As most facilities struggle with the same issues, it is helpful to know what CMS and accrediting agencies focus on from year to year. Listed below are the most common regulations ambulatory surgery centers (ASCs) fail to meet, all of which fall under the CMS Conditions for Coverage.
416.54 Condition: Emergency Preparedness
The ASC must comply with all applicable federal, state, and local emergency preparedness requirements.
On Sept. 8, 2016, the Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The regulation went into effect on Nov. 16, 2016. Health care providers and suppliers affected by this rule must comply and have implemented all regulations one year after the effective date (Nov. 16, 2017).
416.51 Standard: Infection Control
The ASC must maintain an infection control program that seeks to minimize infections and communicable diseases.
The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.
The ASC 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 guidelines. The program is:
- Under the direction of a designated and qualified professional who has training in infection control;
- An integral part of the ASC’s Quality Assurance Performance Improvement (QAPI) program; and
- Responsible for providing a plan of action for preventing, identifying, and managing infections and communicable diseases and for immediately implementing corrective measures that result in improvement.
416.43 Condition: QAPI
The ASC must develop, implement, and maintain an ongoing, data-driven QAPI program.
416.45 Condition: Medical Staff
The medical staff of the ASC must be accountable to the governing body.
416.45(a) Standard: Membership and Clinical Privileges
Members of the medical staff must be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges granted. The ASC grants privileges in accordance with recommendations from qualified medical personnel.
416.45(b) Standard: Reappraisals
Medical staff privileges must be periodically reappraised by the ASC. The scope of procedures performed in the ASC must be periodically reviewed and amended as appropriate.
Life Safety Code (LSC) Overview
Medicare-certified ASCs should expect a more intensive and comprehensive LSC survey due to the presence of specialized life safety code surveyors. In the past, the LSC survey focused almost exclusively on the built environment. Today, the LSC survey includes long-standing, but seldom checked, requirements for the ongoing inspection, testing, and maintenance of components in accordance with National Fire Protection Association (NFPA) standards.
Tap into Our Knowledge
Working with many diverse facilities gives Progressive consultants access to a variety of real deficiency notices. Our ability to review different types of surveys — including state licensing, accreditation, and Medicare certification — allows us to stay in tune with the types of issues surveyors are looking for and help centers avoid common industry pitfalls.
WANT TO LEARN MORE? Leanne Gallegos will lead a Progressive Surgical Solutions webinar touching on the ASC deficiencies cited this past year on Monday, Sept. 30 @ 11 a.m. PST / 2 p.m. EST. The 20-minute webinar is free and open to the public. Register for the webinar here.
