Medicare surveys change under new Conditions for Coverage

Ambulatory surgery centers (ASCs) undergoing Medicare accreditation surveys under the new Conditions for Coverage (CfCs) that took effect in May 2009, are reporting that the surveys are longer than in the past, have more surveyors, and put a much stronger emphasis on infection control.

At North Shore Surgical Center in Lincolnwood, IL, a recent survey took three days, although it originally was scheduled for two, says Kim Zidonis, RN, administrator. "There was so much information that they needed input on, it took a whole additional day," she says.

The Centers for Medicare & Medicaid Services (CMS) has just approved a process change for ambulatory surveys seeking deemed status from The Joint Commission (TJC), according to Michael Kulczycki, MBA, executive director of ambulatory care accreditation at TJC. TJC will "sample" closed patient records and credentialing/privileging files of surgeons on staff, Kulczycki says. "This is critical in passing along to TJC customers the 'efficiencies' of this process vs. relying on state survey processes in which they may allocate two, three, or four additional days of survey activity," he says.

Another change to the Medicare surveys under the new CfCs is that instead of one surveyor, there are two or three, says Monica Daniel, principal with AXIOM Integrated Services, a Chicago-based consulting group for ambulatory health care organizations. Their primary focus is infection control, especially sterilizers, Zidonis reports. [A "Checklist for Medicare Survey — Infection Control (Excerpt) is included.] The surveyors are using the new infection control worksheet, she says. One surveyor must complete the form, but it includes input from the survey team, says Michon Villanueva, assistant director of accreditation services for the Accreditation Association for Ambulatory Health Care (AAAHC). The form is completed based on direct observation and interviews with the staff. Instead of talking with administrators, surveyors will "ask the appropriate individual as to how they perform their task," says Villanueva, who spoke about accreditation to the most recent meeting of the Texas Ambulatory Surgery Center Society.

Quality data, education are two focuses

The Medicare surveys formerly were policy- and procedure-driven, Daniel says. "Now it's gearing into a lot of leadership, education, as well as still looking at policies and procedures and how it correlates, but also looking hard at quality data," she says. Specific items examined include how infection control relates to your quality; how your program educates staff, physicians, and any outside staff; and how you incorporate infection control into education.

At North Shore, surveyors hit on the topic of infection control "very, very hard," Daniel says. Now, she says, surveyors will ask, "What are your quality indicators for infection control, and how are you monitoring them and how are they reported to the board?"

Zidonis said she had to educate surveyors on the difference between steam sterilizers, liquid sterilizers, and gas sterilizers. "There was a lot of time training the inspectors, in a sense," she says. The surveyors wanted to ensure the center was following manufacturers' instructions for the sterilizers, Zidonis says.

Consider putting all of your infection control information into one binder as a one-stop shop, says Daniel, who said they provide this service for their clients.

"When you sit in front of a surveyor, and they say, 'Tell me about your infection control program,' you think, 'Where do I start?'" she says. "If you can show them what your infection control program encompasses, it makes it easier for surveyors. If you make it easy for them, they'll be out of your center faster."

Here are additional survey changes:

Multidose medications.

Surveyors will want a list of all multidose medications at your facility, Daniel warns. They want the names of the medications and the average number for patients per vial or container, she says.

"If you have number of multidose medications, and list isn't completely ready, staff can be caught off guard, because that's a lot of calculations for lots of medications," Daniel says. Have a complete list of medications and any product inserts ready for surveyors, she advises.


Observing a procedure wasn't previously required for a Medicare survey, says Villanueva. "The new survey protocol outlines the expectation that the surveyor that observes the procedure is there from pre-op to post-op, and follows the patient throughout," she says.

At least one procedure will be selected, and it should be one that isn't expected to exceed 90 minutes, Villanueva says. Surveyors will be looking at "not just what happens with the patient, but all staff activity," she says. For example, they will determine whether staff members are following appropriate sterile techniques and whether they are adhering to policies and procedures, Villanueva says. In addition to infection control, other areas that will be examined include the physical environment, medication administration, assessment of anesthesia and procedure risk, pre-op update assessment of changes from the history & physical, provision of surgical and anesthesia services, the post-surgical assessment, recovery, and discharge orders.

For example, surveyors want to ensure all patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician, according to a memo sent by AXIOM to its clients.1 AXIOM recommends that you review your policies for those patients who don't mandate a ride home. The regulations state "exemptions must be specific to individual patients, not blanket exemptions to a whole class of patients," according to AXIOM. Ensure that each patient has a discharge order, signed by the physician who performed the surgery or procedure, it advised.

In terms of anesthesia services, surveyors will look at your use of certified registered nurse anesthetists (CRNAs) and their supervision, AXIOM said. If CRNAs or other allied health professionals are used, identify who has been granted authority for supervision, it advised. Ensure this information is documented in the privileges, AXIOM said.

Another change from past surveys is that managers formerly told members of their staff to respond only to what the surveyor is asking for, Daniel says. Now, surveyors are asking vague questions, and staff members should go through the answer in a detailed manner to ensure it's complete, Zidonis says.

"I suggest knowing everything step by step so you can give a good and complete answer," she says. "Make sure the staff understands it as well."


  1. AXIOM Consulting Group. Memorandum: CMS Conditions for Coverage 2009 — Updated 10/14/09. Issued Oct. 23, 2009.

Here are steps to prepare for accreditation survey

When preparing for your accreditation survey under the new Medicare Conditions for Coverage (CfCs), consider the survey to be an "open-book test," says Michon Villanueva, assistant director of accreditation services for the Accreditation Association for Ambulatory Health Care (AAAHC).

"I'm simply stressing to surgery centers that they have the ability to look at exactly what the state agencies and accrediting agencies are tasked to do, because they can look at the interpretive guidelines," Villanueva says. "It's an opportunity to educate themselves. Everything is out there to prepare for a Medicare survey."

For your survey, you'll need a list of surgeries from the past six months, says Michael Kulczycki, MBA, executive director of ambulatory care accreditation at The Joint Commission. You should have a list of cases in the past 12 months in which any patients were transferred to a hospital or the patient died, he says.

Have all documents related to your infection control program including, for example, a description of the program, policies and procedures, and surveillance data, he says.

Make sure you know your infection control equipment, and ensure the manufacturers' guidelines are followed in your policy, as well as your day-to-day practice, says Kim Zidonis, RN, administrator at North Shore Surgical Center in Lincolnwood, IL, which recently was surveyed.

Monica Daniel, principal with AXIOM Integrated Services, a Chicago-based consulting group for ambulatory health care organizations, says, "I can't reiterate it enough. You may think you know what staff is doing," Daniel says. For example, you've had a protocol for doing sterilizer testing in place, but you find that staff aren't following that protocol. Check with staff and verify what they're doing, she says.

Daniel has seen programs that had a change of personnel, and practices that were not in the policies and procedures were carried on by a new staff person. "So you might have known two months ago that everything was in place, but now there's a new person, and there's a state survey, and you say, 'We've always been doing leak test every day,' and all of a sudden they're not doing it," she says.

Patient rights handled differently from the past

When North Shore Surgical Center in Lincolnwood, IL, was surveyed recently under the new Medicare Conditions for Coverage (CfCs), the patient tracer was handled differently than in past surveys, says Kim Zidonis, RN, administrator.

Zidonis reports that during her survey, the surveyors were there when the patient checked in and checked to ensure the patient had received the center's bill of rights prior to coming in, as well as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) agreement and advance directives.

In a memo to its clients, AXIOM Integrated Services, a Chicago-based consulting group for ambulatory health care organizations, wrote that organizations should send the patient rights, which should incorporate all of the components outlined in the CfC, to the patients when they're scheduled.1

You might want to incorporate the patient rights into a "physician marketing packet" and ask the physician to provide this information to the patient when scheduled for surgery, AXIOM advised. Also, you can post the patient rights on your web site for patients to retrieve, it wrote.

AXIOM noted that the patient rights must be provided in a language and manner that the patient can understand, so this requirement might mean you need to translate the forms.

It wrote that providing the patient this notice for the first time on the day that the surgical procedure is scheduled to occur is not acceptable, unless:

  • the referral to the ASC is made on that same date;
  • the referring physician indicates, in writing, that this is medically necessary for the patient to have surgery on the same day, and that surgery in an ASC setting is suitable for the patient. The Centers for Medicare & Medicaid Services (CMS) would consider "medically necessary" to be emergency cases or when the patient's health/safety would be jeopardized if the surgery were performed one day later, according to AXIOM.


  1. AXIOM Integrated Services. Memorandum: CMS Conditions for Coverage 2009 — Updated 10/14/09. Issued Oct. 23, 2009