Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
CHAPTER 01: GOVERNING BODY 01.02.01 Contract Services Frequency of the citation: 39%
CHAPTER 02: ADMINISTRATION AND HUMAN RESOURCES 02.01.05 Personnel Records Frequency of the citation: 33% Overview of the requirement: The ASC maintains documentation that includes evidence of qualification, current licensure/ certification/registration, and orientation/training/assessments for all employees and providers. Comment on deficiencies: This standard is evaluated through review of documentation. No deficiencies reflected a failure to maintain personnel records, but Surveyors noted specific required items missing from the files. In most cases, content was missing in a subset of files rather than all files reviewed. Examples of ACHC Surveyor findings: ■ Files lacked current BLS/ACLS certificates as required by the organization’s policy. ■ Four of eight files reviewed lacked a completed initial orientation checklist. They were missing signatures and dates of completion. ■ Two files reviewed lacked an annual evaluation for the past two years. ■ Annual evaluations lacked signatures of the reviewer, the individual reviewed, and the date. ■ Files lacked annual competency evaluations in four of 16 files. ■ All files were missing annual training documentation for ethics and corporate compliance, assessment of patient’s risk for self-harm, management of an incapacitated or impaired provider, and communication with outside entities. ■ The employee handbook requires a 90-day evaluation for all employees. However, the human resource policy only requires an annual evaluation. All but one personnel records included a 90-day evaluation. The citation is based on evidence of accepted practice within the organization.
Overview of the requirement: The quality of all contracted services provided by the ASC are the responsibility of its governing body. All contracts must include metrics defining expectations for service delivery. These are incorporated into the ASC’s QAPI Program with results reported to the governing body. Comment on deficiencies: Compliance is evaluated through observation, interviews, and document review. Most deficiencies resulted from services that were not measured for quality and reported to the governing body and others that were not included in the QAPI Program. Examples of ACHC Surveyor findings: ■ Contracted services are not being evaluated by the governing body. The organization had no evidence of meeting minutes for the past year. ■ Although the governing body reviews contracted services annually, they are not incorporated into the ASC’s QAPI Program. ■ Metrics have not been used to assess/approve the continued services of the contracted companies. ■ The following contracts were missing from the list of contracted services and the review process: ٝ Accounting service. ٝ Property management services.
ٝ Biomedical services. ٝ Laboratory services.
Compliance tips for:
The ASC’s governing body holds responsibility for any service provided by or for the organization. For each contracted service, metrics define acceptable performance and these are trended through the QAPI Program, reported to the governing body, and used to make decisions about continuing, altering, or discontinuing the relationship. ■ Create and maintain a list of all contracted services. ■ Audit QAPI committee meeting minutes to ensure inclusion of data from all contractors in reports to the governing body. ■ Create a policy and procedure for inclusion of performance metrics in all contracts for services. ٝ Ensure that the QAPI committee establishes the means and frequency of data collection.
Nerd Newbies (understand the requirement)
Compliance tips for:
The intent of this standard is to ensure an individual file is created and maintained for each employee and contracted provider. Six categories of documentation must be included for a complete file. Surveyors focus on the presence of required documentation from each category when assessing completeness of personnel files.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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