Surgery centers can expect more challenging survey findings in the next few years as Life Safety Code and other regulatory changes take effect, one surveyor predicts. “There have been some major changes over the years to those life safety codes,” says Sandra Jones, CASC, CPHRM, LHRM, chief executive officer of Ambulatory Strategies, Inc. of Dade City, FL. Jones is a surveyor for the Accreditation Association for Ambulatory Health Care. She also conducts mock surveys for clients accredited by The Joint Commission, the American Association for Accreditation of Ambulatory Surgery Facilities, and the Institute for Medical Quality.

For instance, ASC directors have been surprised at how much more they have to check for life safety code maintenance and drills, she adds.

Jones highlights these similar examples of hurdles and challenges ASCs face when surveyed:

  • Missing documentation.

“One of the things I see as a surveyor is that an ASC is not meeting requirements, and there’s no documentation that they’re taking action,” Jones says.

For example, the ASC keeps a log for its refrigerator temperature, and the log shows that the temperature fell below the acceptable range for a day or two. But the ASC does not document the actions it took after discovering that problem, she explains. Another example involves hand hygiene. The ASC’s data might show weakness in the facility’s processes. Again, the site might not document that an action plan was implemented. An action plan could include staff education, better new employee training, and adding a hand hygiene protocol.

  • Medication issues.

“I went to a surgery center, and they had a drug in the anesthesia cart that was backordered,” Jones says. “My question was, ‘What other suppliers did you try?’ They should do everything they can to solve the problem, look for other vendors and different supply chains,” she adds.

Medication shortages are a growing problem, and because of shortages, expired medications also can be an issue.

Surgery centers might keep expired medication in the anesthesia cart because they can’t get a new supply, but this is against regulations, Jones says.

ASCs should make sure they are following FDA and CDC guidelines about using expired products. The FDA requires all outdated prescription drugs to be quarantined and physically separated from other prescription drugs until they are destroyed or returned to the supplier.1

In some situations of critical shortages, such as IV solutions used in critical care, FDA told healthcare organizations that they may use the products beyond the labeled expired date. (

  • Head coverings.

When Jones assisted a surgery center with a mock survey, she saw employees wearing cloth head coverings. Staff might find these to be more decorative than caps that push down one’s hair, but cloth head coverings can be a problem depending on how these are maintained.

“The standards say that cloth can be worn as long as it is washed freshly each day, just like the scrubs are washed daily,” she explains. “If that doesn’t happen, and you let your staff wear cloth head covers, then they should wear a head cap over it.”

  • Expired supplies.

“On a real survey, I found expired hand sanitizer in several places,” Jones says. “These had been on a back shelf, and someone replaced the sanitizer and didn’t look at the date of expiration.” ASC staff always should check for expiration dates on supplies, as well as medication, she says. The surgery center’s policy could be to direct all employees to check all expiration dates before using the product, and this must be monitored and adhered to, even when people are in a hurry, Jones offers. “At one mock survey, I asked people how they checked supplies and medication for out of dates. The clinical director said, ‘We check them before we use them,’” Jones recalls. “So, I opened the cabinet door and picked out supplies. The first one I picked up had expired 18 months earlier.”

The ASC director was embarrassed, but the point was to show that the center didn’t take a systematic approach to checking dates.

Another ASC's system for checking expiration dates worked like this:

  1. The surgery center divided its floor plan into sections;
  2. Employees were assigned sections to check each month;
  3. Staff checkers were rotated each month to keep fresh eyes looking out for outdated supplies.

“All surveyors are looking at how you use products and whether you have a system to ensure products are used correctly,” Jones says. “Making sure products are not out of date is a focus for all surveyors.”

  • Disseminating staff education.

ASC administrators need to share knowledge throughout the surgery center team so one person isn’t responsible for everything, Jones says. Whenever knowledge is centralized, a problem could occur.

“What if that one person happens to not be at work when the surveyor shows up?” Jones asks. “Teach your staff what they’re responsibility is and what the rules are.” The hurdle is spreading knowledge throughout the organization and spending the time necessary to educate staff, she says.

It’s difficult for a surgery center to keep up with new regulations and guidance from various federal agencies. It takes time to write a policy based on the new guidance or regulation.

Then, an ASC director has to educate staff and implement the protocol, Jones says. “Meantime, you’re trying to run a business, worrying about supplies, billing, and staff showing up,” she adds. “You have to wear a lot of hats as a surgery manager.”


  1. Title 21 – Food and Drugs Chapter I – Food and Drug Administration, Department of Health and Human Services, April 1, 2017. Available at: Accessed May 2, 2018.