Quality report reveals top 7 ASC citations: Dust, rust and dead insects were issues

ASCs were most frequently cited for deficiencies in patient care and safety and the environment during 2017 surveys, according to Healthcare Facilities Accreditation Program's 2018 Quality Review.

Here are the top-cited deficiencies.

1. Infection control standard 12.00.02. This was by and large the top-cited deficiency for ASCs. The standard requires centers to maintain a functional and sanitary environment for surgical services in all areas of the facility "to avoid sources and transmission of infections and communicable diseases."

Reasons behind citations issued in relation to standard 12.00.02 included:

  • Dust and dead insects were present on gas valves.
  • Procedure table frames showed large areas of rust.
  • Hand hygiene practice as observed was inconsistent with ASC policy.

2. Patient admission, assessment and discharge standard 13.00.03. The second most-cited deficiency for ASCs stipulates a patient's medical record must include documentation that a physician completed a pre-surgical assessment. Deficiencies resulted from missing elements, such as allergy documentation, admitting history and physical updates.

3. Medical staff standard 06.00.03. This standard requires the governing body to grant medical staff privileges and organizations to follow a reappointment process at least every 24 months. Deficiencies demonstrate a failure to implement a continuous, cyclical process.

4. Surgical services standard 03.00.02. A CMS condition for coverage, this standard requires that surgical procedures are performed by qualified physicians who were granted privileges by the governing body.

Standard 06.00.03 frequently correlates with standard 03.00.02 — without a reappraisal process in place, procedures may be performed by physicians who don't have current peer review and an application for reappointment in their credentialing file, making it difficult to confirm compliance.

5. Condition for coverage/condition of participation standard 05.00.01. This standard determines compliance with systems for building safety, building security, hazardous materials and waste, fire safety, medical equipment management and utility systems management.

6. Environment standard 05.00.05. This Health Care Facilities Code standard relates to requirements for building systems including medical gases, electrical, HVAC, gas equipment and hyperbaric facilities. Organizations that fail to perform a risk assessment for the required systems were cited.

7. Environment standard 05.01.01. The fire safety standard says buildings with construction completed after July 5, 2016, must meet the chapter 20 requirements of the 2012 NFPA 101: Life Safety Code. Buildings or portions of a building approved on or before July 5, 2016, must meet chapter 21 requirements.

In 2017, surveyors cited facilities for a fire-rated door held open with a door stop mounted to the bottom of the door and multiple unsealed penetrations present in fire-rated barriers.

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