Volume 2024 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
n Evaluate competencies as part of the initial orientation and training process and note annual competency assessment on a master calendar. n Conduct periodic audits of personnel files for accuracy and completion.
02.01.05 Personnel Records 02.01.06 Orientation Plan 02.01.07 Staff Training 02.01.08 Identification of Patients at Risk for Harm
To keep adverse events rare, training is critical. Staff must know how to manage situations with a potential impact on patient care or safety.
Overview of the requirement:
These closely-related standards require that the ASC maintain individual personnel records for each member of the ASC staff (including contracted staff) that include evidence of qualification, current licensure/certification/ registration, initial orientation, ongoing training, and competency assessment. Compliance is evaluated through review of personnel files. Standard 02.01.05 identifies six types of items that constitute a complete file. No deficiencies cited a failure to maintain personnel records, but many noted missing elements within a category, e.g., orientation (02.01.06) or annual training (02.01.07). The requirement to assess patients for risk of harm to self or others (02.01.08) was introduced in 2022. It is grouped with these standards because many ASCs were did not include this assessment in staff orientation and/or training.
Consider adopting the Columbia Suicide Severity Rating Scale (C-SSRS) short form as part of your registration process.
Comment on deficiencies:
CHAPTER 03: MEDICAL STAFF
03.01.01 Applications for Medical Staff Privileges 03.01.02 Credentialing Files 03.01.05 Reappraisal and Renewal of Privileges
Frequency of citation:
02.01.05: 23%; 02.01.06: 25%; 02.01.07: 26%; 02.01.08: 38%
Examples of surveyor findings:
n Two of 17 files lacked evidence of a current nursing license. n Among files reviewed, individual files lacked evidence of orientation to or annual training on: » Patients’ rights. » Managing adverse events. » Ethics and corporate compliance. » Management of an incapacitated or impaired provider. » Handling hazardous waste. n Based on Interview and document review, the ASC has not provided training on the identification of patients at risk for har m. n All files reviewed lacked evidence of an annual employee evaluation. n One employee file for a radiology technologist included a competency assessment signed by an individual not trained in radiology. n Standardize an orientation agenda that includes all required elements. Do the same for items that require an annual training update. n Orient and train contract and temporary staff. n Note license/registration/certification expiration dates on a master calendar with renewal reminders well ahead of those dates.
Overview of the requirement:
Privileges are granted by the governing body based on complete applications with documentation to support assertions of credentials related to education, training, competence, and mental/moral fitness. Renewal of privileges follows a similar, defined process at least every 36 months, or whenever additional privi - leges are requested. Compliance is assessed through review of credentialing files. Deficiencies were noted for missing applications, missing follow-up actions by the ASC, or a failure to complete the reappraisal process. The large number of required elements in these standards creates many opportunities for error, but the credentialing and privileging process is critical to the ASC’s ability to ensure that patient care is delivered by qualified providers whose performance meets established quality indicators.
Comment on deficiencies:
Frequency of citation:
03.01.01: 23%; 03.01.02: 64%; 03.01.05: 23%
Examples of surveyor findings:
n Files for contracted anesthesia providers did not contain an application for privileges. n Over 70 % of provider files did not include an application for privileges. n Files did not include evidence of a criminal background check. n Letters granting privileges were signed by the credentialing staff rather than a member of the governing body acting in that capacity. n Credentialing files were missing procedural logs demonstrating skills and experience for the procedures requested and approved.
Tips for compliance:
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