Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
Compliance tips for: Nerd Newbies
■ Develop checklists of required items for personnel files. ■ Audit files for inclusion of all required items.
Nerd Apprentices (audit for excellence)
Admission to any health care setting is an opportunity to assess individuals at risk of harm to self or others. The ASC’s goal is to provide a safe environment for all patients, staff, and visitors, to mitigate identifiable risk factors, and to provide appropriate professional referrals. The intent of the standard is to identify at-risk patients, identify environmental safety risks, and identify mitigation strategies. Direct employees, contractors, per diem staff, and others providing clinical care under arrangement are included in the requirement for training. ■ Audit personnel files for inclusion of this element in orientation and training. ■ Document the expectations of your ASC for individual and environmental risk assessments through a policy. ■ Consider adopting the Columbia Suicide Severity Rating Scale (C-SSRS) short form as part of your registration process.
(understand the requirement)
■ Standardize a basic orientation agenda to include all required elements. ■ Standardize a basic annual training agenda to include all required elements. ■ Review relevant policies for items to be included in personnel files (job descriptions, certifications, timing of evaluations, etc.). ٝ Ensure agreement across policies and other materials, e.g., employee handbook.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
02.01.08 Identification of Patients at Risk for Harm Frequency of the citation: 27%
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: Initial employee orientation and annual training must include identification of patients at risk of harm to self or others. Comment on deficiencies: Surveyors review files for initial orientation and annual training that covers individual and environmental risks and mitigation strategies. Deficiencies were noted when there was no documentation of this training. Examples of ACHC Surveyor findings: ■ Based on interview, after review of documentation, the ASC does not currently provide this training. ■ There was no evidence of adoption of a screening process to identify patients at risk of harm to self or others. According to the Clinical Director, the facility was not aware of this requirement. ■ Two of six files lacked evidence of this training at orientation. Six of six files lacked evidence that this training was provided annually.
CHAPTER 03: MEDICAL STAFF 03.01.02 Credentialing Files Frequency of the citation: 57%
Overview of the requirement: A credentialing file is maintained for every applicant for medical staff privileges and all submitted information is retained regardless of whether the applicant is awarded or denied privileges. Comment on deficiencies: Compliance is assessed through document review. Surveyors noted missing required elements. Letters awarding privileges must be signed by the governing body, and must specifically identify the privileges granted and the duration of the appointment (no longer than 36 months). Examples of ACHC Surveyor findings: ■ Documents from seven CRNA applicants were together in one file and lacked evidence that they were granted privileges. ■ 13 of 16 files lacked primary source verification (PSV) of education. ■ One file was granted privileges on 8/7 but PSV of education was not received until 8/12. ■ Files reflected expired malpractice insurance or no evidence of malpractice insurance.
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