Volume 2024 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
CHAPTER 02: ADMINISTRATION 02.01.03 Position Descriptions Overview of the requirement:
There are written position descriptions for all employee roles not covered by the credentialing and privileging process, including leadership and contract staff. Compliance is evaluated through interviews and review of personnel files. This standard was also cited at a similar frequency in last year’s report but was not an issue in 2021. Citations occurred when an individual’s description of their responsibilities did not correspond to the position description in their personnel file. Often, important tasks get “added on” to an individual’s role on an ad hoc basis and appropriate documentation is overlooked.
Comment on deficiencies:
Frequency of citation:
28%
Examples of surveyor findings:
n Job descriptions were not found for the roles of quality, laser safety officer, and risk management. n Based on the interview with the director of nursing, the DON has been given responsibility for infection control and quality management. His personnel file contains job descriptions for the roles of director and IC, the file lacks a job description for the quality management role. n During discussion with the radiology tech about her duties, she confirmed that she fills in for sterile processing tasks when needed. She verbalized the correct procedures for those tasks, but they are not referenced in her personnel file. n Tie position descriptions to the role, not the individual. Establish a written description for each role/function. If a credentialed and privileged member of the medical staff also serves as administrator, risk manager, quality manager, etc., a description of each additional role for which this individual is responsible is present in the HR files.
Tips for complianc e:
Inventory all roles in your ASC and create job description sheets that can be added to individual personnel files as responsibilities are assigned.
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