SDS Accreditation Update

For Medicare survey success, managers must strive for excellence

If ambulatory surgery center (ASC) managers want to ace the Medicare survey, they should make sure staff members understand what will be assessed and current best practices for the standards.

"Compliance with the standards isn't just about passing a survey, but to ensure a high level of quality care is being provided to patients. Once that is ensured, survey success follows," says Jan Allison, RN, CHSP, director of accreditation and survey readiness, Clinical Services Team, Surgical Care Affiliates in Birmingham, AL.

Managers should carefully examine surgery center protocols and procedures to make sure they are up to date with the most recent, commonly accepted medical practices, according to Thomas Hamilton, director of the Survey and Certification Group for the Office of Clinical Standards and Quality, Centers for Medicare & Medicaid Services (CMS) in Washington, DC. Also make sure staff receives adequate training in infection control, then examine their fidelity of execution, says Hamilton.

"Make sure staff is following the protocols," he adds.

To ensure high quality care is provided patients, assess clinical and quality needs periodically, and also assess also the competency of staff in critical areas, advises Lee Anne Blackwell, RN, BSN, EMBA, CNOR, group director of clinical services for Surgical Care Affiliates. Get direct feedback, and conduct competency and performance reviews. "Based on your findings, set up focused training," says Blackwell.

Managers need to perform their own mock surveys on a routine basis to ensure there are no deficiencies in center processes and teammate behaviors, says Allison. When problems are identified, put an action plan in place immediately, she advises. For example, if equipment is not being cleaned appropriately after it is used with patients, go through the cleaning process according to the manufacturer's recommendations.

Although surveyors will observe processes and behaviors in action to ensure safe delivery of patient care, it is still critical to have documentation in place to support ongoing compliance with many of the standards, adds Allison. For example, there needs to be current and complete governing body meeting minutes, policies and program plans, education and training documentation, medical records, credentialing and human resource (HR) files, quality improvement activities, and inspection and maintenance reports.

Keep up on program oversight

Many ASCs struggle during surveys with the quality assessment and performance improvement (QAPI) and infection prevention sections of CMS survey standards, says Beverly Kirchner, RN, CNOR, CASC, president of Genesee Associates, a Dallas-based independent consulting business working with ASCs and hospital systems with ASCs to improve quality of care, safety, and regulatory compliance.

Problems occur because they do not maintain the programs on a regular basis or they have done nothing but collect data and cannot show how it was used to improve quality of care, she adds. To maintain survey readiness, review the programs weekly or at least monthly, she advises.

Get organized, says Kirchner. "The more you organize your information, the better the survey will go," she explains. She suggests using binders, or some other method, to store data.

Also important are meeting minutes covering all required elements. "I suggest administrators set up a calendar of what month the reports will be discussed at meetings," says Kirchner. [See Kirchner's sample calendar inserted with the online issue of SDS Accreditation Update. For assistance, contact customer service at or (800) 688-2421.] Set up template agendas with the data or information that needs to be reported, so nothing falls through the cracks.

While quarterly meetings formerly were sufficient, it is easier to meet at least bimonthly now to address accreditation changes, she adds. Although it has been more than two years since CMS implemented an improved survey process that promotes better infection control practices, ASCs still struggle with some issues according to the experts.

For example, with infection control, hand hygiene still is problematic, says Allison. "A nurse can perform hand hygiene when she enters the patient's bay, but then she grabs the curtain and pulls it closed, then proceeds to touch the patient," she explains. (For details on how to better prepare for a survey, see article, below.)

Hamilton recommends that all ASC managers keep a copy of the article on the results of the initial pilot for new CMS survey practices that appeared in the June 2010 issue of The Journal of the American Medical Association (JAMA).1 "It has useful information in regard to particular types of problems that were identified in that pilot," he explains. (For a summary of the pilot target areas described in the JAMA article, see below.)

An infection control worksheet for hospital surveys is being tested in several states and is expected to be implemented in federal fiscal year 2012. While surveyors always have looked at infection control in the course of the larger hospital survey, the more comprehensive worksheet will increase the knowledge and sensitivity of the surveyor, says Hamilton.

While this worksheet is a work in progress, it is available for review on the CMS web site. In the meantime, outpatient surgery departments might find the ASC tool quite useful, says Hamilton. (To access these tools, see resources, below.)

In light of the upcoming change in hospital surveys, Kirchner says, "If I were a hospital leader, I would be working with the infection prevention team identifying issues and being proactive in changing practice before a surprise survey."


  1. Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. JAMA 2010; 303:2,273-2,279.


The link to the draft hospital worksheets found on the Centers for Medicare and Medicaid Services' web site:

The link to the ambulatory surgery center worksheet used by Medicare accreditation surveyors can be found at

A more thorough survey requires preparation

Create a team for complete coverage

In 2012, ambulatory surgery center (ASC) administrators can expect surveyors from the Centers for Medicare and Medicaid Services (CMS) to be very thorough, says Jan Allison, RN, CHSP, director of accreditation and survey readiness, Clinical Services Team, Surgical Care Affiliates in Birmingham, AL.

As surveyors become more experienced, they are able to expand their focus. The first year, surveyors focused on infection control and medication safety. While additional standards were assessed, it wasn't until the next year that more focus was placed on some of the new standards, such as ensuring there is a contracted radiologist in place to oversee the radiology services, says Allison.

"Many centers may have the CMS Conditions for Coverage standards covered very well, only to find they neglected ensuring compliance with life safety [requirements]," says Allison. Top issues with life safety are penetrations in smoke barrier walls, lack of appropriate latching of the fire doors, and lack of conducting fire drills each quarter or with no varying scenarios or physician participation. Also it is important to ensure that the location of equipment, carts, and other items does not impede access to the fire exits, she explains.

Team approach best

To prepare effectively for a Medicare survey, select staff for the preparation team from all areas of the ASC to include direct patient care, instrument processing, the environment, quality program, and registration.

"A center should never lean on one person to drive the compliance when all the teammates should be engaged," says Allison.

However administrators should note that the team members will need time to focus on survey preparation outside of their patient care duties. In these tough economic times, it has been challenging for administrators to efficiently allot time to research, documentation, education. competencies, and audits, Allison adds.

All areas must be assessed. For example, infection control practices of the anesthesia providers must be observed such as cleaning medication vials and IV ports with an alcohol swab. "In addition, teammates should be observed to ensure they are referencing the manufacturer's directions for cleaning agents and appropriate disinfection or management of the equipment," says Allison.

Physicians need to understand what constitutes a comprehensive history and physical (H&P) and that every patient must have one regardless of how minor the procedure. Also physicians must understand that the update note does not make an H&P older than 30 days current, says Allison.

Some surgery centers struggle with environment of care standards, says Beverly Kirchner, RN, CNOR, CASC, president of Genesee Associates in Dallas, an independent consulting business working with ASCs and hospital systems with ASCs.

"Keeping records on maintenance of equipment and safety checks is important," Kirchner explains. (To learn how to respond to compliance issues, see article, below.)

Mock surveys are helpful in preparing; however, someone outside the surgery center should conduct the survey, says Kirchner. Outside eyes are helpful because staff members in the center are comfortable with their processes, which might have flaws, she explains.

"If you are not sure how to meet a CfC [Condition for Coverage] or any other regulations, do not hesitate to contact an organization to help you," advises Kirchner. These organizations might include the state health department, the Centers for Disease Control and Prevention, the Association of periOperative Registered Nurses (AORN), American Society of PeriAnesthesia Nurses (ASPAN), and the Occupational Safety and Health Administration (OSHA), she says.

"Network and find peers that complement your skills," adds Kirchner. "Use each other as resources."

JAMA article highlights infection control lapses

An article1 published in The Journal of the American Medical Association with the results of the pilot for the new Medicare accreditation survey process provides good background information for administrators at ambulatory surgery centers (ASCs) on types of problems surveyors found, says Thomas Hamilton, director of the Survey and Certification Group for the Centers for Medicare and Medicaid Services, Office of Clinical Standards and Quality.

Twenty-eight percent of ASCs participating in the pilot were cited for using medications in single-dose vials for multiple patients. According to the JAMA article, two-thirds of the pilot ASCs had lapses in infection control identified during the inspections and 18% of the centers had lapses extending across three or more areas of infection control. Surveyors evaluated the following:

  • hand hygiene;
  • whether gloves were exchanged before each new task;
  • the use of new sterile needles and syringes for each patient and each entry into medication vials that were used for multiple patients;
  • the preparation of injections in a clean work area;
  • whether single-dose medications were dedicated to one patient;
  • the pre-cleaning of equipment prior to sterilization or high-level disinfection;
  • whether facilities followed manufacturer instructions for reprocessing equipment and storing after reprocessing;
  • whether facilities used disinfectants registered by the Environmental Protection Agency to clean operating and procedure areas between patients;
  • whether blood glucose meters were cleaned and disinfected after each use;
  • whether spring-loaded lancing penlet devices were used for multiple patients. [The Association of periOperative Registered Nurses (AORN) has just released a new medication standard. For more information, see Same-Day Surgery Weekly Alert, Jan. 19, 2012. To subscribe to this free publication, go to, or contact or call (800) 688-2421.]


  1. Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. JAMA 2010; 303:2,273-2,279.

Back disagreements on findings with fact

During a Medicare accreditation survey, do not argue with the surveyors while they are onsite if you feel their assessment of compliance is inaccurate, advises Beverly Kirchner, RN, CNOR, CASC, president of Genesee Associates in Dallas, an independent consulting business working with ambulatory surgery centers (ASCs) and hospital systems with ASCs.

"If you disagree with the way a surveyor judged compliance for a condition of coverage, standard, or regulation, you have the right to appeal," says Kirchner.

Be sure you have all of the facts in hand and proof of compliance to present with your letter of complaint to the head of the organization that surveyed your facility, whether Centers for Medicare and Medicaid Services (CMS), the state health department, The Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC). Even if you disagree with the surveyor, you must write a plan of correction, and you must implement the plan as stated.

Once the plan is submitted to CMS, staff at surgery centers must work with the processes for correction. If for some reason the process change does not work, then administrators must be prepared to show through process improvement (PI) that the process did not work and what they have done to ensure compliance to the Condition for Coverage (CfC) for which the center was cited in the survey, says Kirchner.

If the surveyors come back, and you have not done what you said, CMS certification can be terminated, Kirchner warns.