Michon Villanueva, assistant director, accreditation services, for the Accreditation Association for Ambulatory Health Care, identifies the following AAAHC and Medicare standards as 10 of the most often found to be out of compliance during surveys of ambulatory surgery centers. Note: Comparable AAAHC standards and Medicare requirements are identified together when applicable.
1. 416.44 (b)(1) (Medicare requirement) — Except as otherwise provided in this section, the ASC must meet the provisions applicable to Ambulatory Health Care Centers of the 2000 edition of the Life Safety Code of the National Fire Protection Association, regardless of the number of patients served.
"Life Safety Code deficiencies are the number-one cited Medicare deficiency for Medicare-certified ASCs or those seeking Medicare certification through deemed status," says Ms. Villanueva.
2. 416.43 (Medicare requirement) — Condition for Coverage: Quality Assessment and Performance Improvement.
3. 416.47 (Medicare requirement) — Condition for Coverage: Medical Records.
Ms. Villanueva says the top two conditions cited on Medicare surveys are 416.43 and 416.47.
4. 2.II.D (AAAHC standard) — Privileges to carry out specified procedures are granted by the organization to the healthcare professional to practice for a specified period of time. These privileges are granted based on an applicant's qualifications within the services provided by the organization and recommendations from qualified medical personnel. / 416.45 (a) (Medicare requirement) — Members of the medical staff must be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges granted. The ASC grants privileges in accordance with recommendations from qualified medical personnel.
"This deficiency is usually related to missing privileges for a specific area; for example, no privileges for local anesthesia, supervision of RNs providing conscious sedation, specific laser device, etc.," says Ms. Villanueva.
5. 10.I.D (AAAHC standard) — An appropriate and current health history must be completed, with a list of current prescription and non-prescription medications and dosages, when available; physical examination; and pertinent pre-operative diagnostic studies incorporated into the patient’s clinical record within thirty (30) days, or according to local or state requirement, prior to the scheduled surgery/procedure. / (416.47 (b)(2) (Medicare requirement) — The ASC must maintain a medical record for each patient. Every record must be accurate, legible, and promptly completed. Medical records must include at least the following: Significant medical history and results of physical examination
"History and physical deficiencies vary, but typically relate to missing medication documentation or missing H&Ps in some cases," says Ms. Villanueva.
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6. 7.I.B-3 (AAAHC standard) — The infection prevention and control program includes documentation that the organization has considered, selected, and implemented nationally-recognized infection control guidelines. The program is: Under the direction of a designated and qualified healthcare professional who has training and current competence in infection control. / 416.51 (b)(1) (Medicare requirement) — The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevention program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines. The program is: Under the direction of a designated and qualified professional who has training in infection control.
"The standard stipulates that the infection control program is under the direction of a designated and qualified healthcare professional who has training and current competence is infection control," says Ms. Villanueva. "Some organizations are found out of compliance due to lack of evidence of training and current competence of this individual."
7. 9.F (AAAHC standard) — Anesthesia is administered by anesthesiologists, other qualified physicians, dentists, certified registered nurse anesthetists, or other qualified health care professionals approved by the governing body pursuant to Chapter 2.II. Other qualified health care professionals must be directly supervised by a physician or dentist who has been privileged for such supervision.
ASCs are often out of compliance due to lack of privileges for supervision of anesthesia, says Ms. Villanueva.
8. 11.L (AAAHC standard) — If look-alike or sound-alike medications are present, the organization identifies and maintains a current list of these medications, and actions to prevent errors are evident.
"Not all organizations have developed such lists," says Ms. Villanueva.
9. 6.K (AAAHC standard) — The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistent location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified. / 416.47 (b)(5) (Medicare requirement) — The ASC must maintain a medical record for each patient. Every record must be accurate, legible, and promptly completed. Medical records must include at least the following: Any allergies and abnormal drug reactions.
"The documentation of allergies/reactions continues to be an area of inconsistency for organizations," says Ms. Villanueva. "Verification at each encounter is not always consistent."
10. 6.I (AAAHC standard) — Reports, histories and physicals, progress notes, and other patient information (such as laboratory reports, x-ray readings, operative reports, and consultations) are reviewed and incorporated into the record in a timely manner. / 416.47 (b)(2) (Medicare requirement) - The ASC must maintain a clinical record for each patient. Every record must be accurate, legible, and promptly completed. Clinical records must include at least the following: Significant medical history and results of physical examination.
"The documentation of histories and physicals continues to be an area of deficiency for organizations," says Ms. Villanueva.
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