Surveyors can find deficiencies even when a surgery center believes its policies and procedures are in compliance.

  • If a surveyor sees an employee sterilizing equipment incorrectly or not following hand hygiene protocols, this could be a deficiency.
  • Teach staff to not reuse disposable items. This also could be a survey finding.
  • Syringes left on a tray must be labeled, or they cannot be used.

An ASC might follow processes that appear to be adequate or even best practices when it comes to infection prevention. Then, a surveyor visits, and a deficiency appears.

“If a surveyor sees you doing something wrong, they don’t know if that’s your norm,” says Marcy Sasso, CASC, principal and director of compliance for Sasso Consulting.

Sasso offers this example: An ASC employee began sterilizing equipment in the handwashing sink. The worker knew where she was supposed to sterilize equipment, but because the surveyor was there or for some other reason, she was flustered and broke with policy, Sasso explains.

“This was an immediate jeopardy,” she says. “They said, ‘We don’t feel like what you are doing is safe, so stop.’” The employee was fired, and someone else had to resterilize every piece of equipment. Such consequences can be even worse. An ASC could be closed for a week, she adds.

“If they find you have enough issues with patient safety, they can close you,” Sasso says.

Here are some common infection prevention issues that could result in survey deficiencies:

Watch the wipes. A good rule is to not reuse disposable items. For instance, suppose an ASC employee has a vial, pops off the rubber part, and takes an alcohol wipe to clean its top. Then, the employee picks up the second vial and uses the same alcohol wipe, repeating this several times. This could be a deficiency finding, Sasso says.

Label syringes. Anesthesia often is the area where surveyors find multiple deficiencies. For instance, an anesthesiologist might prepare syringes with medication in advance, and then leave them on a tray. If these syringes are left for any length of time, they must be labeled.

“If you are drawing up medication, using it on a patient, wiping down the vial, doing proper hand hygiene with an alcohol-based rub, but haven’t labeled the medication, it’s a deficiency,” Sasso says.

Each label must include the date and time the medication is drawn, medication, dose, and initials of the person who drew up the medication. If unlabeled syringes are left on a cart, they must be thrown away because there is no way to ensure what is in them, she adds.

“It’s an immediate jeopardy because the surveyor feels there is a threat to patient safety,” Sasso says. “You can’t prove what’s in the syringe, so the surveyor will make you stop, and write a plan of correction.”

The plan of correction might include directing a nurse to monitor before and after each case. This is an onerous task of tracking and monitoring that each syringe is labeled to ensure it doesn’t happen again. The regulatory agency might require this monitoring to take place for three months.

“It becomes a fix, but it’s easier to just not do it wrong the first time,” Sasso offers.

Refrigerator temperatures. ASCs must ensure their medication refrigerators maintain specified temperatures at all times. Placing a generator on site can help keep the temperature level in compliance, even during a short power outage. But there’s a catch: What if the power went out over the weekend? On Monday morning, staff can see that the power is on, the temperature is fine, yet the records show there was an outage.

“How do you know your medications are safe?” Sasso says. “Unless you have an alert system, how would you know whether or not you could use those medications?”

Years ago, staff would use a penny trick: freezing water and putting a penny on top. If on Monday morning the penny was at the bottom of the glass, then they knew the medications were compromised, Sasso recalls. That method is no longer acceptable to regulators. The only way an ASC can be sure the medication remains usable is through an alert system that lets someone know when the refrigerator’s temperature is out of range.

“If the director of nursing says, ‘I get an alert on my phone the minute it’s out of range,’ the surveyor will accept that answer because the nursing director could go to the surgery center and check on the medication refrigerator,” Sasso says.

Climate control. Power outages also could cause problems in a surgery center’s sterile supply room, where humidity and temperature must be maintained consistently.

“Say you’ve lost power on the weekend, and the room is now warm, with the humidity over 60%,” Sasso explains. “The products must be maintained in 20-60% humidity, and maybe you didn’t even know you had lost power.”

A surgery center could lose every item in that room because they were compromised, Sasso laments.

“You have to open every product’s label, and if it says the humidity cannot climb above 60%, then you have to throw away that item,” she says.

This could include implants and other costly sterile supplies.

Infection analysis. When an ASC learns a patient has developed a post-surgery infection related to the center’s care, then it must be documented. A root cause analysis should be conducted.

“Go to the sterile processing department, and say, ‘Please call up all of your sterilization records for this date,’” Sasso suggests.

Then, find answers to these questions: Were there any complications related to the surgery? Did a biological indicator return positive, indicating something was not executed properly? Who was in the operating room for this case? Was anyone in the room sick? Was new equipment used? Were any new supplies used?

One of these questions could solve the problem. For instance, the ASC might have just switched to a new prep that requires a three-minute drying time. The ASC employee might have not waited the full three minutes, and this could have led to the infection, Sasso explains. “Once you do your root cause analysis, you stop using the prep,” she adds.