Eye Care Leaders detailed the accreditation survey deficiencies most common for ASCs, and what centers can do after a survey to correct mistakes.
Here are the key details to know:
Top survey deficiencies:
1. Sanitary environment. ASCs not creating a sanitary environment in the operating room, such as having cardboard boxes lying around was the top deficiency for ASCs.
2. Drug administration. Problems with drug administration include expired medications left in patient care areas.
3. Infection control program. ASCs that don't follow their own infection control policies are deemed noncompliant.
4. Form and content of record. Violations include the use of unapproved abbreviations of physician orders.
5. Physical environment. This includes wear and tear that results in surfaces that can't be properly cleaned.
How to correct deficiencies:
1. Determine the exact due date of the plan of corrections, as well as what needs to be addressed and how to document the changes.
2. ASC staff should read and understand the CMS-2567 form that documents the deficiencies found during the survey when drafting the plan of corrections.
3. The essential elements each plan of correction should include are:
● The specific actions the ASC will take to correct the deficiencies
● How the actions will improve ASC processes
● How the ASC will implement the actions
● The specific date each correction was put in place
● How the ASC will monitor that the corrections will continue to be put in place to ensure corrections will continue to be enforced
● The title of the person in charge of implementing the plan of corrections
● The ASC administrator's signature and date