An ASC Administrator’s Guide to Responding to a CMS Survey & Plan of Correction

By January 17, 2017 June 11th, 2019 ASC Management
CMS Survey

At some point, most facilities undergo a Centers for Medicare and Medicaid (CMS) Survey. These unannounced surveys can occur on any given day; hopefully your ASC is ready!

Prepare for Your Survey – Know the Conditions of Coverage

CMS establishes minimum health and safety standards, called Conditions for Coverage (CfCs), that ASCs must meet to obtain and maintain certification.  The standards cover all aspects of an ASC from operational organization – including patient care and safety – to facility design.  CfCs must be met for all patients seen in your facility,  not just those covered by Medicare and Medicaid.   You can find these standards in Appendix I:  Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys[1] and Appendix L:  Interpretive Guidelines for ASCs[2] of the CMS State Operations Manual.

It is imperative for all members of your facility to be familiar with and understand these standards prior to a survey.  To ensure sufficient preparation for an unannounced survey, put together binders of all the documentation the surveyors will want to review – policies, contracts, and other agreements – that address each CfC.  Include an index that references back to each standard.  These binders can then serve as survey preparation for your staff.   As staff review each standard and locate the documentation supporting the standard, they are also educating themselves.  Remember, the more educated and prepared your facility is, the higher the likelihood that you will achieve a satisfactory survey outcome. 

What to Expect When Your Surveyor Arrives

Surveyors usually arrive early in the morning for unannounced surveys. You can plan on them conducting their on-site review for one and a half days to two full days depending on the size of your facility. They will review all aspects of your clinical and business operations. The surveyors will ask to review a multitude of items and one of them will follow a patient through the entire treatment process. The Life Safety surveyor will focus on the building and Life Safety Codes. 

Although aiming for a perfect score, even the most highly functioning ASCs are typically cited for something.  That’s the nature of the beast.   Surveyors, intent on ensuring safety and quality of care for patients and staff alike, seek strict adherence to their certification standards.  Deficiencies cited, no matter how “minor,” prompt a Plan of Correction.  

Upon completion of your survey, you will receive a report via certified mail.  The report, which usually arrives within a few weeks of your survey, will include a request for a Plan of Correction (POC).  The POC outlines any deficiencies cited during the survey.  The deficiencies are reported on CMS-2567.[3]  You must respond to each deficiency with specific details pertaining to the corrective actions you plan to take to fully resolve the citation.  Your responses are recorded on the right side of the form. 

Components of Your Plan of Correction (POC)

Five main components need to be included in your POC:

  1. The first component is the deficiency standard number and a detailed statement of what needs to be corrected. This should be a concise sentence related to the shortcoming. 

If you are cited for expired medications in your inventory, for example, your response could be:  Q181. The entire medication supply will be monitored monthly for expiration dates.

  1. Next, specify how the deficiency will be corrected. Note detailed information about the corrective action taken and who was involved.  List all the items you completed to correct the inadequacy and maintain documentation regarding how you addressed the issue. 

For example:  Performed staff training on 12/12/2016.  All clinical personnel were in attendance.  Reviewed policy on expiration of medications and solutions.  Revised policy to clarify preference for single dose vials and ampules.  Responded to questions from staff regarding who retains responsibility for monitoring medication expiration dates.

  1. The third component notes how you will ensure ongoing compliance with the corrected deficiency – via random audits, for example. If you do audit, retain documentation of audit results.  Be specific about how you will monitor the corrections made.  Ensure monitoring is consistent and timely.  Clearly state how you will maintain compliance.

For example:  Updated emergency cart medication lists.  Began actively monitoring the expiration dates of all medications throughout the facility. Implemented random audits of the medication supply to ensure compliance. Initial audit was conducted on 12/16/2016 in various locations around the facility.  No expired medications were found. Compliance expectation is 100% removal of expired medications from floor stock as evidenced by monthly inspections.

  1. Name the responsible party for completion of each task and ensure ongoing compliance. You are permitted to use a person’s name but noting someone’s title (e.g., Clinical Director or Business Office Manager) ensures responsibility is linked to a defined role rather than a specific individual. 
  1. The final component is provision of a completion date for the deficiency. Ensure the deficiency is corrected by the date you set.

Next Steps

Upon completion of the plan, sign and date the form.  Return the document to the person and address noted on the Plan of Correction.  You typically have 10 days after receipt of the POC letter to return your response.

Make sure you retain a copy of the POC on file at the center with all your corrective action documentation.  As you work through the POC and collect supporting documentation, keep everything together in one binder.  This is very helpful in the event of a re-survey.

The CMS regional office will review your POC.  You can then expect a response letter from them regarding acceptance or denial of your plan of correction.  If your POC was accepted, the letter will also inform you whether a re-survey will occur.  A rejected POC will contain information regarding any changes that need to be made and a new deadline for completion.  Update the POC and return per the letter’s instructions by the specified due date.

Conclusion

Although preparing, undergoing, and responding to a survey is a daunting task, surveys provide us with opportunities to view our ASC operations from the outside in.  They allow us to implement best practices that ultimately lead to a center of excellence, a goal we are all trying to achieve.  Don’t let the prospect of an unannounced survey worry you.  Preparation and organization is key to successfully completing your survey, even if you are required to submit a plan of correction.


Kelli McMahan – Vice President of Operations

[1] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_i_lsc.pdf

[2] https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf

[3] https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2567.pdf

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