ASCs have been subjected to frequent regulatory surveys since a Las Vegas ASC was linked in 2008 to a cluster of hepatitis C cases.

  • It’s important for ASCs to create a well-written, well-detailed plan of correction (POC) in response to survey results.
  • The POC verifies that deficiencies have been corrected.
  • Read the surveyor’s cover letter carefully and follow those instructions when writing the POC.

If an ASC that treats Medicare patients has not been surveyed since 2015, it’s likely time to expect one. In recent years, state health departments — fueled by federal funding — have increased survey inspections.

Since 2009, there has been increased government funding to assess ASCs’ compliance with Medicare and other regulations. Most surgery centers will undergo a survey every three years, says Jan Allison, RN, CHSP, senior director of regulatory at AmSurg in Nashville, TN.

“Since 2009, the majority has been seeing a much larger increase in the volume of surveys taking place and the frequency with which they’re happening,” Allison says. “I worked for an [ASC] for 21 years, and state surveyors showed up twice during that time.”

That was before 2009 when the regulations changed. CMS began paying more attention to ASCs in 2008 after a Las Vegas ASC exposed patients to hepatitis C. Additional ASCs were found to be in violation of infection control regulations.1

In early 2008, Nevada public health officials identified a hepatitis C cluster — the largest recorded — among patients of an ASC in Las Vegas. In all, they found nine linked and 106 possibly linked HCV cases among patients who underwent surgery on the same day as HCV-infected patients believed to be the infection’s source.2

A Nevada state health division investigation determined that inappropriate syringe use caused the HCV cluster. Thus, Nevada increased its number of surveyors by one-third.1

State resources vary, so ASCs in some states will conduct fewer surveys. Also, there is the unpredictability of what will happen in the federal budget process this year. The president’s budget, if enacted along with plans to reduce regulations, could result in scaled-back surveys.

Each state can be different in its survey direction and focus, notes Allison, who assists AmSurg’s surgery centers in 38 states with their plans of correction (POCs). (See story on surveyors’ pet peeves in this issue.)

“In the past, surveyors were not as well trained as they are today in the level of detail and how they conduct surveys,” she says.

Following a survey, ASCs must respond to the findings, and they do this through the POC. CMS and state agencies use the POC to verify deficiencies have been corrected, and the plan of correction is a legal document that is accessible to the public. Therefore, it’s very important to write the POC well and accurately, Allison urges.

“If you look at the surveyor’s deficiency report, it’s very, very detailed,” she explains. “People tend sometimes not to provide enough detail in the [POC], when they need to respond with the same level of detail as the report provided.”

The short list of what to do to improve a plan of correction includes: “Identify and meet your deadlines. Identify staff responsible for oversight. Provide specific details. Have a monitoring plan,” Allison explains.

The following are additional suggestions for improving the POC:

1. Read the cover letter thoroughly.

The cover letter explains precisely what state surveyors want in the POC.

“Some states want the [POC] put into the report you received, and some might provide you with a form of their own,” Allison says.

The cover letter includes the findings in an attached 2567 report describing whether any deficiencies were found and, if any were found, describing those deficiencies.

Other information to glean from the cover letter includes:

  • Where and how do you submit the POC?
  • By what date do corrections need to be completed?
  • Who do you contact with questions?

2. Know the hot topics in deficiency reports.

While infection control issues are always big on surveyors’ lists, in recent years, the deficiencies have focused increasingly around environmental/life safety issues, Allison notes.

“It’s about the environment — that’s where more than half of the deficiencies are coming from,” she says. “If something hasn’t been done, then you get a contractor out there and make sure it’s done and not missed, going forward.”

Humidity monitoring was a chief focus two years ago. Now, the focus is on air flow, Allison says.

“Does an area require a positive or negative air flow environment, and is that being maintained?” she says. “Other problems we’ve seen in the last few years are related to life safety.”

Life safety surveyors will assess:

  • if the ASC is maintaining its generator appropriately;
  • if the facility has completed and documented all fire alarm system inspections and maintenance;
  • if smoke detectors have undergone required sensitivity tests.

3. Demonstrate how the ASC will measure success.

“Monitor to show your strategies are working,” Allison says. “Describe how you did something to improve compliance. That tells the surveyor you took this seriously and did something a step above and beyond just saying you will do a better job.”

For example, if a deficiency is noted in hand hygiene, it’s not sufficient to say, “We held an in-service on hand hygiene.” A better strategy is to meet with staff to solicit their input as to why they were not compliant, Allison says.

It could be the hand cleaning product causes skin to be dry and irritated. If this is a problem, then part of the solution would be to switch products. Other solutions would be to post hand hygiene posters at each sink and provide ongoing education and training, including instruction on use of specific products. Also, an ASC could reinforce good hand hygiene behavior through positive, ongoing feedback, she suggests.


  1. Harasimlas P. Deficiencies found at Nevada ambulatory surgical centers. Las Vegas Review-Journal, March 9, 2009. Available at: http://bit.ly/2n0oGuZ. Accessed March 27, 2017.
  2. Mathis S. Closing in on health care–associated infections in the ambulatory surgical center. J Leg Med 2012;33:493-528.