Digital Debut

Accreditation Agencies Release ASC Top Deficiencies List

AAAHC, ACHC, QUAD A and The Joint Commission identify their most frequent citations

BY SAHELY MUKERJI | JUNE 2023

The Accreditation Association for Ambulatory Health Care (AAAHC), the Accreditation Commission for Health Care (ACHC), QUAD A and The Joint Commission have announced their lists of top deficiency areas that ASCs got citations for in 2022.

AAAHC: Ambulatory Surveys (non-Medicare Deemed Status)
CHAPTER/STANDARD	STANDARD DESCRIPTION
8: Facilities and Environment 8.I	Scenario-based drills of the internal and external emergency and disaster preparedness plan are conducted.
6: Clinical Records 6.G	The presence or absence of allergies, sensitivities and other reactions to drugs, materials, food and environmental factors is recorded in a prominent and consistently defined location in all clinical records.
2: Governance 2.II.L	Privileges to carry out specified procedures are granted to legally and professionally qualified applicants.
4: Quality of Care 4.E	High-quality health care is provided.
7: Infection Prevention and Control and Safety 7.I.B	The written infection prevention and control program describes how infections and communicable diseases are prevented, identified, and managed.

AAAHC: Medicare Deemed Ambulatory Surgery Centers
CHAPTER/STANDARD	STANDARD DESCRIPTION
2: Governance 2.I.I	The governing body is responsible for approving and ensuring compliance of all major contracts or arrangements affecting the medical and/or dental care provided under its auspices.
8: Facilities and Environment 8.I.G, 8.I.H, 8.I.F, 8.I.N These standards refer to items in the Life Safety Code^® guidance requirements, which is part of the MDS survey.	Except as otherwise provided in this section, the ASC must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served, and must proceed in accordance with the Life Safety Code. Except as otherwise provided in this section, the ASC must meet the applicable provisions and must proceed in accordance with the 2012 edition of the Health Care Facilities Code. The ASC must have a safe and sanitary environment, properly constructed, equipped, and maintained to protect the health and safety of patients. Scenario-based drills of the internal and external emergency and disaster preparedness plan are conducted.
2: Governance 2.II.L	Privileges to carry out specified procedures are granted to legally and professionally qualified applicants. 1. Privileges are granted based on: The applicant’s written request for privileges. Qualifications for the services provided by the organization. Recommendations from qualified medical or dental personnel. Privileges are granted to the health care professional to practice for a specified period of time.
7: Infection Prevention and Control and Safety 7.I.B	The ASC maintains an ongoing, written program designed to prevent, control, identify, investigate, and manage infections and communicable diseases.
6: Clinical Records and Health Information 6.H	Clinical record entries are consistent across records.

ACHC: Ambulatory Surgery Centers
CHAPTER/STANDARD	STANDARD DESCRIPTION
1: Governing Body and Management 01.01.02 Contract services	The ASC’s governing body is responsible for the safety and effectiveness of services provided by contracted employees and entities.
2: Administration 02.01.04 Personnel records	Basic information is obtained for employees and contracted staff at the time of hire including documentation of time-limited license, certification, or registration.
3: Medical Staff 03.01.03 Surgical privileges roster	A current roster identifying each surgical practitioner’s specific surgical privileges is available in the surgical suite and where scheduling takes place. The roster includes physicians and non-physician surgical assistants.
4: Quality Assessment/ Performance Improvement 04.00.04 Quality Program data	Quality metrics are identified for all patient care and contracted services provided.
6: Medical Staff 06.00.02 Medical staff: Granting privileges	The ASC’s medical staff makes recommendations to the governing body regarding initial, renewal, and revised privileges. Based on the information provided, the governing body may award, amend, withdraw or deny privileges to the applicant.
6: Medical Staff 06.00.03 Medical staff: Credential files	A credentialing file is maintained for each provider seeking privileges in the ASC. It includes evidence of professional qualifications and current competence that is updated as needed as well as evidence of review and action by the governing body following the request for privileges and recommendation of the medical staff.
6: Medical Staff 06.00.04 Medical staff: Reappraisals	The governing body has a formal, written process for periodic reappraisal and renewal of privileges. Reappraisal occurs at least every 36 months. The standard details specific requirements for those requesting new/additional privileges and for an ASC with a single physician owner.
8: Medical Records 08.00.03 Form and content of the medical record	Each patient of the ASC has a complete, accurate, and legible medical record that includes defined information, at minimum.
14: Life Safety 14.05.04 Generator inspection	Emergency power generators located within the building that houses the ASC are in a room with no other equipment and protected by a minimum 2-hour fire-rated barriers. Externally located generators are protected from rain and snow. Documented inspection occurs weekly.
14: Life Safety 14.05.05 Generator monthly load test	Emergency power generators must be tested 12 times annually for at least 30 minutes with tests occurring between 20 and 40 days apart. The standard provides specific parameters and expectations for testing.
14: Life Safety 14.05.07 Automatic transfer switch test	Automatic transfer switches (those that activate the emergency generator) must be tested monthly, operating the transfer switch from the standard position to the alternate position and then returning to the standard position.
15: Emergency Management 15.01.07 Invoking the 1135 Waiver	The ASC must develop and implement policies and procedures that describe its role in providing care during emergencies. This requirement encourages providers to collaborate with their local emergency officials in proactive planning to allow an organized and systematic response to assure continuity of care for their community.

QUAD A: Ambulatory Surgery Centers
CHAPTER/STANDARD	STANDARD DESCRIPTION
13.A.10	Except as otherwise provided in section 42 CFR 416.44, the ASC must meet the applicable provisions and must proceed in accordance with the 2012 edition of the Health Care Facilities Code (NFPA 99, and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 1).
2.B.2	The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.
8.B.23	The pre-operative clinical record includes a written screening protocol for venous thromboembolism (VTE) risk. This protocol and assessment tool is to be placed in the facility manual for reference.
6.D.2	There is a dated controlled substance inventory and a control record which includes the use of controlled substances on individual patients. Such records must be kept in the form of a sequentially numbered, bound journal from which pages may not be removed.
6.A.2	Drugs must be prepared and administered according to established policies and acceptable standards of practice.
3.G.2	Personnel are properly trained in the control procedures and work practices that have been demonstrated to reduce occupational exposures to anesthetic gases.
5.D.30	The training program must consist of initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
6.A.5	Outdated medications are removed and destroyed in accordance with federal/national, state, provincial, and local pharmacy regulation.
11.I.1	Each personnel record has evidence of annual hazard safety training.
6.G.5	All staff must be trained: annual drills are conducted for MH crisis and management including actual dilution of at least one vial of actual Dantrolene (expired OK). Staff should be assigned roles prior to drills and a written protocol outlining those personnel and their roles is on file. Documentation of drills is required.
8.L.2	An operative log must include sequential numerical listing of patients either consecutive numbering from the first case carried out in the facility or consecutive numbers starting each year.
11.I.3	Each personnel record has evidence of annual universal precaution training.
11.I.5	Each personnel record has evidence of at least Basic Cardiopulmonary Life Support (BLS) certification, but preferably Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) for each operating room and PACU team member, depending on patient population.

The Joint Commission: Ambulatory Care
CHAPTER/STANDARD	STANDARD DESCRIPTION
IC.02.02.01, EP 2	The organization implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
IC.02.01.01, EP 2	The organization uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.
MM.01.01.03, EP 2	The organization follows a process for managing high-alert and hazardous medications.
MM.01.02.01, EP 2	The organization takes action to avoid errors involving the interchange of medications on its list of look-alike/sound-alike medication.
EC.02.05.01, EP 7	In areas assigned to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation systems provide appropriate pressure relationships, air-exchange rates, filtration efficiencies, relative humidity, and temperature.

Write your respective accrediting agencies with any questions.