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Administrator Archives - Pinnacle III

Oct 03
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Header image for AAAHC deemed status survey blog

Preparing for Your AAAHC Deemed Status Survey  

By ASC Development, ASC Management, Leadership

Why Accreditation?

Undergoing a AAAHC “deemed” status survey, where compliance to both Accreditation Standards and CMS Conditions for Coverage (CfCs) are assessed, is demanding for an ASC. However, there are many reasons why this is beneficial. In general, accreditation may help with consumer confidence, providing a competitive edge for your center in your market. Some states require accreditation in order to maintain licensure, and many insurers and third parties require accreditation as a prerequisite to eligibility for insurance reimbursement and for participation in managed care plans or contract bidding. In addition, being accredited may reduce liability costs.

Deemed status provides these benefits plus it qualifies as a state agency review for Medicare certification for new and existing centers. In most cases, the state will not review an ASC that has been accredited through the Medicare or AAAHC deemed status survey, but it does not preclude the state from conducting validation or complaint inspections.  State licensure inspections are separate from Medicare surveys and are conducted according to state requirements.

Public Notice of AAAHC Deemed Status Survey

Prior to the start of the on-site survey, a packet of information about the upcoming, unannounced site visit is sent to the applicant ASC’s primary contact person.  The packet includes a general outline of the survey event, a listing of documents surveyors may request for review, a copy of the Notice of Accreditation Survey for posting, and other survey information.

It is important that the center post the Notice of Accreditation Survey for at least 30 days prior to AAAHC’s arrival for survey.  If not, the survey will still be conducted, but an accreditation decision cannot be rendered until the Notice has been posted for a period of 30 calendar days.

The Accreditation Process: The AAAHC Deemed Status Survey Team

Although an accreditation survey is, of necessity, evaluative, AAAHC emphasizes the educational and consultative benefits of accreditation. Thus, AAAHC uses health care professionals and administrators who are actively involved in ambulatory health care settings to conduct surveys. 

The Accreditation Process: Surveyor Conduct

Surveyors are representatives of AAAHC. Their priority when conducting surveys is to serve as ambassadors of AAAHC, by being objective fact finders, and educators when appropriate. It is AAAHC policy and practice that surveyors do not participate in surveys of organizations that may be in direct competition with the surveyor’s business interests, or that bear any significant beneficial interest to the surveyor or the surveyor’s immediate family. AAAHC policy also states that, while serving as representatives of AAAHC, surveyors may not solicit personal business or take part in any activities that appear to be in furtherance of their personal, entrepreneurial endeavors.

The Accreditation Process: The On-Site Survey

Each survey is tailored to the type, size, and range of services offered by the ASC seeking accreditation. The length of the on-site visit and the number of surveyors sent by AAAHC are based on a careful review of the information provided in the Application for Survey and supporting documents submitted by the ASC. Questions regarding the scope of a survey should be directed to the AAAHC office prior to the survey.

At the start of the survey, the survey team conducts an orientation conference for the organization. The members of the survey team will introduce themselves, review the survey format, confirm written documentation for which they anticipate a need, and ask the organization to identify the key personnel who will provide the information and access necessary to complete the survey. This is also a time for the organization to ask questions.

The Survey Process: Preparing for Surveyors

ASCs are notified in advance to have specific documents and other information available for surveyors during the on-site visit. This allows surveyors to gather and review information with minimal disruption to the daily activities of the ASC being surveyed. Surveyors may, however, ask to see additional documents or request additional information during the on-site survey.

ASCs are asked to make a work-space available for surveyor use. This private or semi-private area is used to review polices, conduct interviews, and hold survey team meetings to discuss findings.

The Survey Process: The Tour

Survey teams conduct their tours differently; however, most will conduct the tour within one to two hours of being on site. Generally, the tour will closely follow the patient flow throughout the building.

During the tour, the surveyors will be escorted to the areas of observation, including patient check-in. During this time, surveyors will observe posted signs and evidence of quality of care.

Information intake will be next. Limited questions are asked.  Surveyors may ask staff to clarify a process or a policy (i.e., ”How often do you check the refrigerator?” or “What kinds of snacks do you give to patients?”).

Watch for breaches in infection control during the times surveyors are observing staff.  Stethoscopes around the neck, missed opportunities for hand hygiene, multiple bags of IV fluid pre-spiked are some examples of infection control breaches.

Generally, surveyors will look into an operating room through the windows or doors. Remember to be firm on protocol at this point. The clinical surveyor will determine when to observe a procedure. The surveyor may ask for a daily schedule to review to facilitate selection of a case or the surveyor may want to spend time with staff for casual observation.

The surveyors will then be shown recovery, post-op/PACU, and discharge.  At this point, the surveyors will return to the designated survey work-space.

The Survey Process: After the Tour

After the tour is completed, the surveyors will most likely conduct a confidential discussion between themselves before they proceed with the remainder of the survey.  If conducting a Medicare survey, the clinical/administrative surveyor will break off from the life safety surveyor. If you have a maintenance employee or employ a building maintenance company, it is best to have them present to assist in providing information to the surveyors, who may have questions related to facility management and maintenance. The life-safety surveyor is generally at the facility for one day; therefore, all information gathering is performed in a brief period of time.

At the conclusion of the on-site survey, the surveyors hold a formal summation conference where they present their findings to representatives of the organization for discussion and clarification. Surveyors are fact finders for AAAHC; they do not render the final accreditation decision. No information regarding the organization’s compliance with the standards or the accreditation decision is provided during the summation conference. Members of the organization’s governing body, medical staff, and administration are encouraged to take this opportunity to comment on, or rebut, the findings, as well as to express their perceptions of the survey.

After the AAAHC Deemed Status Survey

Accreditation decisions are made by the AAAHC Accreditation Committee following a thorough review of the information gathered during the survey and documented in the surveyor’s report, any other applicable supporting documents, and recommendations of surveyors and staff. All documents reflecting the opinions or deliberations of any AAAHC surveyor, staff member, committee member, or its officers or directors constitute peer review materials and are not disclosed to the organization seeking accreditation and Medicare deemed status, or to any third party.

AAAHC expects substantial compliance with the applicable AAAHC Standards requirements. Accreditation is awarded to ASCs that demonstrate compliance with the AAAHC Standards and adherence to AAAHC accreditation policies.  

Compliance with each requirement is assessed through at least one of the following means:

  • Documented evidence.
  • Answers to detailed questions concerning implementation.
  • On-site observations and interviews by surveyors.

The ASC will receive a written, comprehensive copy of the findings after the on-site survey.

AAAHC works with a third-party calling center (customer satisfaction Survey Company) to conduct an evaluation of our survey process and our surveyors.  A representative from the calling center will phone the organization’s designated primary contact approximately one week after the survey to discuss the recent survey experience.  Obtaining this input by telephone provides the surveyed organization and AAAHC with a streamlined, efficient means of providing and receiving feedback about the survey process.  An organization’s feedback has no bearing on the accreditation decision. 

Approximately ten business days after the last day of survey, the ASC will receive a formal request and instructions for completing the required Plan of Correction if deficiencies have been cited. AAAHC will provide the ASC with directions and a timeline for submission for the required Plan of Correction.

The letter of accreditation is typically received approximately 30 days after the completion of the survey.

source: Accreditation Association for Ambulatory Health Care, 2019, www.aaahc.org.

additional resource: Preparing for an ASC Accreditation Survey, 2018, www.pinnacleiii.com/preparing-for-an-asc-accreditation-survey.

Jovanna Grissom, Regional Vice President of Operations

Nov 14
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Understanding the Administrator's Role in ASC Quality Improvement

Understanding the Administrator’s Role in ASC Quality Improvement

By ASC Management, Leadership No Comments

A quality assurance performance improvement (QAPI) program has long been the foundation for the delivery of quality care in an ASC. That’s because an effective QAPI program helps improve all aspects of an ASC’s operations. Despite its longstanding importance, ASC quality improvement has taken on greater significance in recent years.

There are a few reasons why. Physicians, staff, regulatory bodies, payors and even patients are demanding increased transparency concerning quality and quality improvement data. Accreditation organizations are requiring a high-level QAPI process to meet standards. Reimbursement is increasingly tied to quality measures and outcomes. Reports of poor quality tend to make the news and spread like wildfire.

This makes it vital that a QAPI program be an organizational commitment for ASCs. It is the administrator’s responsibility to secure such a commitment from employees, management, physicians and the governing board. To do so, an administrator must be an active participant in ASC quality improvement and embrace the steps necessary for success.

10 Steps for Administrator Involvement in ASC Quality Improvement

Here are 10 steps administrators can follow to help ensure effective involvement in their ASC’s QAPI program.

  1. Understand your program. Allocate the time necessary to learn about your QAPI program, plan, and processes. Without a strong understanding, administrators cannot provide effective oversight and participation.
  2. Learn requirements. If your ASC delivers care to Medicare and/or Medicaid patients, you are required to meet the Centers for Medicare & Medicaid Services’ (CMS) QAPI requirements. As noted earlier, if your ASC is accredited, your QAPI program must comply with accreditation standards. While there is likely overlap between the requirements, there may be some differences. Understand what surveyors expect to see when they visit your ASC.
  3. Focus on what matters. ASC quality improvement can feel overwhelming when you’re unsure what areas of operation to focus on for improvement. Study performance data and identify those measures and benchmarks critical to your success. This will help ensure you measure, track, trend, report on, and improve what is most important to your ASC.
  4. Carefully select a program manager. While administrators should be active participants in ASC quality improvement, they do not normally serve as the QAPI program manager. Rather, they select and appoint a responsible individual. This person, who is often a nurse, must have interest, knowledge, and experience in quality improvement. Passion for improving care is vital to your QAPI program manager’s success. Also critical: administrative and organizational skills, including using spreadsheets and databases, and developing meaningful presentations for QAPI committee meetings. Note: Maintain a current, clear QAPI program manager job description for guidance and accountability.
  5. Establish oversight. Develop a process to ensure effective oversight of the QAPI program. Follow your organizational chart to maintain accountability of the employee responsible for the QAPI program. Include yourself on that chart as you will likely work directly with the QAPI program manager on specific projects.
  6. Support the program. A surefire way for a QAPI program to fall short of its potential is lack of support. Provide resources critical to a successful program. These can include time for the manager to work on ASC quality improvement, training, education (e.g., industry conferences, webinars, publications) and software. It also includes authority for the QAPI program manager to hold stakeholders accountable.
  7. Be active on committees. Take an active role on your QAPI committee. This will help you provide a comprehensive summary about QAPI activities to your medical advisory committee (MAC) and governing board.
  8. Serve as interface. As administrator, you are the interface between staff, physicians, MAC, and the governing board. You are responsible for maintaining an efficient flow of information regarding QAPI activities that help achieve objectives. Work closely with the MAC and governing board to ensure implementation of their directives.
  9. Stay involved. QAPI programs are most successful when administrators are continually involved, even when the program is delivering strong results. Such involvement demonstrates commitment and support. It also provides the opportunity to share input on benchmarking and studies appropriate and important to QAPI priorities.
  10. Keep current. Healthcare is a dynamic sector, undergoing frequent changes. This extends to ASCs. Administrators must keep abreast of industry changes that impact ASC quality improvement efforts. When changes arise, incorporate revisions to your QAPI process to meet new needs and requirements.

ASC Quality Improvement Quick Tips

The steps outlined above should help define your role in your QAPI program. Here are a few tips that can further boost your ASC quality improvement efforts:

  • Rely on your data. Using data helps administration make evidence-based decisions, allocate resources more effectively, and engage in targeted corrective actions.
  • Involve many staff in your QAPI program. This will help create a learning organization where ASC quality improvement processes are understood and improvements are sustained and built on.
  • Promote your program. Keep QAPI as a top-line item for MAC and governing board meetings. Share program results and explain how they improve your ASC. Provide this information to payors to further demonstrate your ASC’s commitment to quality.
  • Leverage partner support. If your ASC has a management company and/or hospital partner, its QAPI expertise can be an asset to the manager and program.

The importance of QAPI and ASC quality improvement efforts are likely to magnify as the demand for quality information and data grows. Quality improvement must be an ongoing effort if ASCs want to achieve meaningful results and maintain compliance. By carefully balancing their participation with QAPI program oversight, administrators can play a crucial role in achieving these objectives.

Ross Alexander, Director of Operations

Aug 29
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Launching an ASC Staff Certification Program

Launching an ASC Staff Certification Program

By ASC Management, Leadership No Comments

When members of your staff indicate they want to get better at their jobs, your response is probably enthusiastic support. After all, a more competent, skilled staff is better prepared to achieve improved clinical and financial results and higher patient and surgeon satisfaction. These are some of the reasons ASCs allocate time and resources to staff training and in-service education. They are also compelling reasons for developing a program that supports ASC staff certification.

ASC Staff Certification Program Components

Here are some of the essential components to address when developing your ASC staff certification program guidelines.

Eligibility

Determine certification program eligibility. Is the program limited to full-time employees or are part-time employees also eligible to participate? Are staff required to work at your ASC for a specific amount of time (e.g., one year) before they are eligible for the program? Will you restrict participation to employees in good-standing?

Acceptable Certifications

Specify which certifications your program will cover – preferably, those that are essential to your facility’s success. Examples of certifications you may want to include:

  • Certified Perioperative Nurse (CNOR)
  • Certified Post Anesthesia Nurse (CPAN)
  • Certified Ambulatory PeriAnesthesia Nurse (CAPA)
  • Certified Surgical Tech (CST)
  • Certified Gastroenterology Registered Nurse (CGRN)

It’s important to permit staff to propose certifications not included in your program. You can weigh the merits and applicability of each proposal. While you may add to your original program list, consider including only those certifications awarded by nationally recognized professional organizations.

Covered Expenses

Identify which expenses are eligible for reimbursement upon successful completion of the ASC staff certification. You will likely want to cover the certification exam fee. You may want to reimburse certification renewal fees. Other expenses to consider:

  • Educational resources to support exam preparation (e.g., books, webinars, conferences)
  • Practice exams
  • Transportation to and from an exam center
  • Continuing education required to maintain the certification

Include a qualifier noting that reimbursement only applies to the portion of eligible expenses not already covered by other payment sources, such as scholarships. Put a cap on the amount of reimbursement available for a single certification and/or timeframe (e.g., annually).

Documentation

Require documentation at the beginning and end of the program. Employees seeking certification assistance should submit their application/request in writing. Following certification program completion, ensure employees provide documentation demonstrating they earned the certification. If you are covering other expenses, request itemized receipts.

Secure a Return on Your Investment

An ASC staff certification program is one way for your ASC to invest in staff. Help protect your investment by including a reimbursement qualifier in your guidelines. State how long employees are expected to remain with your surgery center following completion of, and reimbursement for, the certification program. Clearly outline the financial penalty for failing to reach this mark.

For example, you might require employees to repay 70% of their assistance if they do not stay with your ASC for one year after achieving certification. While you cannot require employees to remain at your center, financial penalties encourage them to thoughtfully consider the impact leaving prior to completion of the qualifying term will have on them and your ASC. Financial qualifiers also deter individuals not fully committed to staying with your ASC from applying to the program.

ASC Staff Certification Program Expansion

If you launch a program that is successful, consider additional ways to encourage staff members to participate. One way is to add certifications to your list. Ask staff for their recommendations. Monitor the development of new certifications, such as the recently launched Certified Ambulatory Infection Preventionist (CAIP).

Another way to expand the program is to go beyond certifications. Include courses provided through an accredited educational institution of higher learning (e.g. college, university, trade or vocational school). These offerings may attract individuals already holding certification(s) or those not interested in certification.

Here are some additional considerations if you are going to offer reimbursement for course tuition:

  • Require the primary business of the institution attended is education. Academic or college credit hours should be earned upon successful completion of the class.
  • Ensure course work is applicable to the employee’s current position or tied to a degree related to an employee’s career path with your ASC.
  • Require proof of completion, such as a transcript or grade report.
  • Determine whether to reimburse for books and other supplies mandated for course participation.

Offering reimbursement for certifications and courses is a potentially low-cost, high-reward method to improve staff performance and productivity. This investment can encourage greater staff loyalty and appreciation of leadership support. An ASC staff certification and educational course program promotes an ASC’s mission of providing compassionate, high-quality care. That’s a proposition easy to endorse!

Michaela Halcomb, Director of Operations

May 03
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ASC Administrator

Successfully Transitioning into an ASC Administrator Role

By ASC Management No Comments

In the spring of 2016, I was approached by my management company supervisor about accepting an interim administrator position at our ambulatory surgical center.  Interested, yet hesitant, I agreed, as his confidence in me to take on the role was genuine and complimentary.  

With a new boss and role ahead of me, the necessity to decipher what was needed to succeed occupied my thoughts.  As clinical director of the surgery center for three years, I understood the importance of leadership and management.  However, I did not possess a complete understanding of the administrator role.  To gain this understanding and to succeed in my new role, I needed a plan.

Success Requires Knowing the Answers

Initially, I needed to understand the expectations.  Specifically, I wanted to gain knowledge about the following:

  • What was the vision of the ASC’s board of directors?
  • How will the management company assist with executing this vision?
  • What was required of me to meet this vision?

Success Requires Knowing Who Has the Answers

To determine who had the answers I was seeking, I needed to build relationships and identify what resources were available to me.  I found myself asking:

  • Who are the members of the management team and what are their roles?
  • How does each role impact the facility?
  • How is each role impacted by the facility?
  • Which members of the team have experience or expertise in which areas?
  • How can I tap into this experience or expertise to create success in my new role?
  • Who are the points of contact for the daily tasks of conducting business (accounting, banking, business insurance, credentialing, etc.)?

Success Requires Knowing the Deficiencies

As I began gathering responses to my questions and utilizing the educational resources available to me, I recognized the importance of assessing my needs.  I asked:

  • Where can knowledge and information assist me in successfully accomplishing the expectations of my new role?
  • Where can I obtain that knowledge and information?
  • What areas within the facility need immediate attention?
  • Are there resources available to address the areas requiring immediate attention?

In my twenty plus years in healthcare, I discovered relationships are an integral and necessary part of success.  This was true in my new position as well.  It was incumbent upon me to reach out for assistance, build relationships, and successfully integrate into the existing management team.  Within the healthcare industry, or any business for that matter, an open mind, patience, and willingness to visualize the big picture all propel an individual’s efforts forward.  An African Proverb states, “If you want to go fast, go alone.  If you want to go far, go with others.”

My integration into an ASC’s existing management team consisted of the following–

  • Knowing the vision of the stakeholders
  • Aligning the facility with that vision
  • Building relationships within the existing management group
  • Researching and obtaining useful resources
  • Identifying areas of improvement
  • Proactively addressing the identified needs

Later that year, having successfully navigated the interim role, I was offered the administrator position. 

In summary, I found Henry Ford’s statement to be true: “Coming together is a beginning.  Keeping together is progress. Working together is success.”

Tara Demuth Fenton – Facility Administrator, Children’s North Surgery Center

Jan 17
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CMS Survey

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

By ASC Management No Comments

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

Jan 17
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CMS Survey

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

By ASC Management No Comments

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/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf

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