Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
Examples of ACHC Surveyor findings: ■ The ASC’s policy regarding patient rights states, “the ASC shall, prior to the start of the surgical procedure, provide the patient with verbal and written notice of the patient’s rights and responsibilities in a language and manner that ensures the patient understands.” At the time of registration, patients are asked to initial a statement that they have received a copy of their rights. In the 20 charts reviewed, all patients had initialed this statement. Based on observation, they are asked if they want a copy, but no explanation of the rights is given either at the time of registration or at the time of preoperative assessment. ■ Based on observation, patient rights were reviewed orally during the pre-op call, but they were not provided a written copy. ■ Patients were provided with a written document but their rights were not reviewed verbally. ■ The written Notice of Rights provided to the patient contained the patients’ responsibilities; however, the notice lacked information on the patients’ rights. ■ The patient’s guardian required translation services and although this service was provided in- person, the registration forms requiring a signature from the guardian, were not translated in full.
■ Facility policy “Aseptic Technique,” states that after every procedure, the floor is cleaned using a lint- free cloth moistened with an EPA approved disinfectant solution. Observation of a room turnover revealed that the floor is only dry mopped between cases and not damp mopped per facility policy. ■ Rust was noted on IV poles and on tables, carts, and stools with casters.
Compliance tips for:
The ASC is expected to select and adopt nationally-recognized infection control practices, train its staff on infection control, and maintain active surveillance. The standard requires a program that requires at least, a sanitary environment, mitigation of healthcare-associated infections, screening for infection/immunization status, monitoring for compliance, and periodic program evaluation and revision. ■ Conduct regular infection control surveillance rounds for equipment and environmental issues like rust, surface flaws (divots, chips, separations), dust accumulation, etc., to promote a culture of cleanliness. ■ Establish a schedule for routine cleaning of surfaces, including under sinks, top of warmers, ice machines, and emergency carts. ■ Review room turnover procedures and conduct a “spot the error” training session. ■ Train staff to follow policies as written. ■ Create infection control quality goals related to environmental conditions.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Compliance tips for:
Surgical patients are in an inherently vulnerable position. The intent of this standard is to ensure that they understand that they have rights and a process to exercise these rights. The verbal and written communication do not have to be provided simultaneously, but both must be provided prior to the patient’s movement out of the pre-operative area at the latest. ■ Review your patient rights statement for inclusion of all required elements. ■ Review your patient intake/admission process to ensure both the verbal and written components are covered. ■ Define a process for communicating patient rights in both verbal and written formats. ■ Identify a translation service that can be called upon to assist when English is not the patient’s or their representative’s primary language. ٝ Based on your patient population, documents can be translated in advance for the most frequently needed languages.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
CHAPTER 06: PATIENT RIGHTS 06.00.03 Notice of Rights: Provided to the Patient Frequency of the citation: 31%
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: Prior to the start of a surgical procedure, the patient or their representative is provided with a verbal and written statement of patient rights in a manner that ensures they are understood by the patient or their representative. Comment on deficiencies: Compliance is assessed through observation, interview, and document review. Surveyors noted that either the verbal communication or the written communication was present, but not both. For patients or their representatives who need translation services, both elements (written and oral) are expected to be in a language they can understand.
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