Title Page

  • Conducted on

  • Prepared by

  • Location

Nursing Service The nursing services of the ASC must be directed and staffed to assure that the nursing needs of all patients are met.

  • The ASC must have documentation that it has designated an RN to direct nursing services.

  • There must be sufficient nursing staff with the appropriate qualifications to assure the nursing needs of all ASC patients are met

  • Do nursing staff have the appropriate qualifications for the tasks they are asked to perform?

Organization and Staffing Patient care responsibilities must be delineated for all nursing service personnel. Nursing services must be provided in accordance with recognized standards of practice. There must be a registered nurse available for emergency treatment whenever there is a patient in the ASC.

  • job descriptions would suffice for a general articulation of the responsibilities for each nurse.

  • Individual patient assignments on a given day must be documented clearly in the assignment sheet.

  • An RN with specialized training or experience in emergency care must be available to provide emergency treatment whenever there is a patient in the ASC.

  • Ask the nursing staff to explain what their duties for the day of the survey are; can they articulate clearly what their patient care responsibilities are?

  • Ask the ASC to explain how it evaluates the nursing care provided in the ASC for conformance to acceptable standards of practice.

  • Ask the ASC to identify the RN(s) who are available for emergency treatment. Is there documentation of their qualifications to provide emergency treatment? Do staff in the ASC know which RN(s) (as well as medical staff) to call when a patient develops an emergency?

  • Ask the ASC for evidence that one or more RN(s) are readily available to provide emergency treatment. How do they assure that an RN can leave their current task to respond to the emergency without putting another patient at risk of harm?

Medical Records - The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care.

  • The ASC must have a complete, comprehensive and accurate medical record for each patient.

  • The ASC must use the information contained in each medical record in order to assure that adequate care is delivered to each ASC patient.

  • the ASC must ensure the confidentiality of each patient’s medical record.

Organization. The ASC must develop and maintain a system for the proper collection, storage, and use of patient records.

  • Review the ASC’s medical record policy and interview the person responsible for the medical records to ascertain that the system is structured appropriately.

  • If the ASC employs a fully or partially electronic medical record system, ask clinical personnel to demonstrate how they use the system in order to determine whether they are able to make entries and access needed information in order to support the provision of care.

  • Determine that closed records are retained in accordance with applicable State law.

  • Review a sample of active and closed medical records for completeness and accuracy in accordance with Federal and State laws and regulations and ASC policy. If patient records are not collected in a systematic manner for easy access, annotate this on the survey report form.

Form and Content of Record 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:

  • Patient identification;

  • Significant medical history and results of physical examination;

  • Pre-operative diagnostic studies (entered before surgery), if performed;

  • Findings and techniques of the operation including a pathologist’s report on all tissues removed during surgery, except those exempted by the governing body;

  • Any allergies and abnormal drug reactions;

  • Entries related to anesthesia administration;

  • Documentation of properly executed informed patient consent; and

  • Discharge diagnosis.

  • The identity of the patient must be clear through use of identifiers such as name, date of birth, social security number, etc.

  • A comprehensive medical history and physical assessment (H&P), completed and entered into the medical record in accordance with the requirements at §416.52, as well as the results of the pre-surgical assessments specified at §416.42 and §416.52.

  • If pre-operative diagnostic studies were performed, they must be included in the medical record prior to the start of surgery.

  • An operative report that describes the surgical techniques and findings.

  • A pathologist’s report on all tissues removed during surgery must also be included, unless the governing body has adopted a written policy exempting certain types of removed tissue from this requirement.

Pharmaceutical Services The ASC must provide drugs and biologicals in a safe and effective manner, in accordance with accepted professional practice, and under the direction of an individual designated responsible for pharmaceutical services.

  • The ASC must designate a specific licensed healthcare professional to provide direction to the ASC’s pharmaceutical service. That individual must be routinely present when the ASC is open for business,

  • Is there a contracted Pharmacists for the ASC?

Administration of Drugs - Drugs must be prepared and administered according to established policies and acceptable standards of practice

  • Is there evidence in the medical records reviewed that there is an order, signed by a physician or other qualified practitioner, for every drug or biological administered to the patient?

  • Are drugs or biologicals administered only by nurses or other qualified individuals, or under the supervision of nurses or other qualified individuals, as permitted under Federal or State law and the ASC’s policy?

  • Determine whether medications are properly labeled, stored, and have not expired.

  • Using the infection control survey tool, determine whether the ASC employs safe injection practices.

  • If the ASC uses scheduled drugs: Determine if there is a record system in place that provides information on controlled substances in a readily retrievable manner.

  • Review the records to determine that they trace the movement of scheduled drugs throughout the ASC.

  • Determine if there is a system, delineated in policies and procedures, that tracks movement of all scheduled drugs from the point of entry into the ASC to the point of departure, either through administration to the patient, destruction or return to the manufacturer.

  • Determine if the licensed health care professional who is in charge of the ASC’s pharmaceutical services is responsible for determining that all drug records are in order and that an account of all scheduled drugs is maintained and periodically reconciled.

  • Is the ASC’s system capable of readily identifying loss or diversion of all controlled substances in such a manner as to minimize the time between the actual losses or diversion to the time of detection and determination of the extent of loss or diversion?

  • Determine if facility policy and procedures minimize scheduled drug diversion.

Administration of Drugs - Adverse Reaction

  • Adverse reactions must be reported to the physician responsible for the patient and must be documented in the record.

  • All adverse drug reactions experienced by patients while in the ASC must be documented in the patient’s medical record.

  • The ASC’s policies and procedures must incorporate these requirements and ASC staff must be aware of and comply with them.

  • Interview clinical staff to ask them what steps they would take if a patient experiences an adverse reaction to a drug? Are staff aware of the requirement to promptly report this information to the physician on the ASC’s medical staff who is responsible for the patient?

  • Look for documentation of adverse drug reactions in the sample of records selected for review. If no adverse drug reactions are noted, ask ASC staff whether they recall any patients having adverse drug reactions, and if so, whether they could pull a medical record containing documentation of an adverse drug reaction.

  • Determine whether the ASC’s policies and procedures address adverse drug reactions and are consistent with the regulatory requirements.

Administration of Drugs - Blood

  • Blood and blood products must be administered only by physicians or registered nurses.

  • The ASC’s policies and procedures must specifically address this requirement, unless the ASC does not keep blood or blood products on hand and never administers such products to ASC patients.

Administration of Drugs - Orders

  • Orders given orally for drugs and biologicals must be followed by a written order and signed by the prescribing physician.

  • Does the ASC have policies and procedures addressing verbal orders? Does it require the prescribing practitioner to sign, date, and time a written order as soon as possible after issuing the verbal order?

  • Do the ASC's policies and procedures for verbal orders include a "read back and verify" process where the nurse who receives the order repeats it back to the prescribing physician to verify that the order was understood accurately?

  • Ask ASC nursing staff how they handle verbal orders. Does their practice conform to the regulatory requirements? Do they use a read-back and verify process?

  • Is there evidence in the medical records reviewed that each verbal order was followed by a written order signed by the prescribing physician?

Laboratory and Radiologic Services - Lack of substantial compliance with either the laboratory or the radiologic standard within this condition could provide a basis for citing a condition-level deficiency.

Laboratory Services

  • If the ASC does not provide its own laboratory services, it must have procedures for obtaining routine and emergency laboratory services from a certified laboratory in accordance with Part 493 of this chapter

  • ASC policies and procedures should list the kinds of laboratory services that are provided directly by the facility, and services that are provided through a contractual agreement.

  • The ASC procedures must include the following: A well-defined arrangement (need not be contractual) with outside services;

  • Laboratory services that are provided by the ASC;

  • Routine procedures for requesting lab tests; and

  • Language that requires the incorporation of lab/radiological reports into patient records.

  • Review the contractual agreements and determine if the referral laboratory is a CLIA-approved laboratory.

  • When laboratory tests are performed prior to admission, the results should be readily available to the attending physician in the ASC.

Radiology Services

  • An ASC may only provide radiological services as an integral part of the surgical procedures it performs. ie, imaging services performed immediately before, during or after the procedure that are medically necessary to the completion of the procedure

  • Does the ASC provide, either directly or under arrangement, radiologic services? If yes, verify that it performs only those radiologic services that are integral to its surgical services?

  • The scope and complexity of radiological services provided within the ASC, either directly or under arrangement, as an integral part of the ASC’s surgical services must be specified in writing and approved by the governing body.

  • ASC complies with the hospital radiologic services requirements at § 482.26(b), (c)(2), and (d)(2), regardless of whether the service is provided directly by the ASC or under arrangement.

Safety for Patients and Personnel

  • The ASC must adopt and implement policies and procedures that provide safety for patients and personnel.

  • The hospital policies must contain safety standards for at least:

  • Adequate shielding for patients, personnel and facilities;

  • Labeling of radioactive materials, waste, and hazardous areas;

  • Testing of equipment for radiation hazards;

  • Maintenance of personal radiation monitoring devices;

  • Proper storage of radiation monitoring badges when not in use;

  • Storage of radio nuclides and radio pharmaceuticals as well as radioactive waste; and

  • Disposal of radio nuclides, unused radio pharmaceuticals, and radioactive waste.

  • Methods of identifying pregnant patients.

  • The hospital must implement and ensure compliance with its established safety standards. Verify that patient shielding (aprons, etc.) are properly maintained and routinely inspected by the hospital.

  • Verify that hazardous materials are stored properly in a safe manner.

  • Observe areas where testing is done for violations in safety precautions.

  • Periodic inspection of equipment must be made and hazards identified must be properly corrected.

  • The hospital must ensure that equipment is inspected in accordance with manufacturer’s instructions, Federal and State laws, regulations, and guidelines, and hospital policy.

  • The hospital must be able to demonstrate current inspection and proper correction of all hazards.

  • Radiation workers must be checked periodically, by the use of exposure meters or badge tests, for amount of radiation exposure.

  • Verify that the personnel are knowledgeable about radiation exposure for month, year, and cumulative/entire working life.

  • Observe that appropriate staff have a radiation-detecting device and that they appropriately wear their radiation detecting device.

  • • Review records to verify that periodic tests of radiology personnel by exposure meters or test badges are performed.

Radiologic services must be provided only on the order of practitioners with clinical privileges or, consistent with State law, of other practitioners authorized by the medical staff and the governing body to order the services.

  • Review medical records to determine that radiological services are provided only on the orders of practitioners with clinical privileges and to practitioners outside the hospital who have been authorized by the medical staff and the governing body to order radiological services, consistent with State law.

Only personnel designated as qualified by the medical staff may use the radiologic equipment and administer procedures.

  • Determine which staff are using differing pieces of radiological equipment and/or administering patient procedures. Review their personnel folders to determine they meet the qualifications established by the medical staff for the tasks they perform.

  • There should be written policies, developed and approved by the medical staff, consistent with State law, to designate which personnel are qualified to use the radiological equipment and administer procedures.

  • The hospital must maintain the following for at least 5 years: Copies of reports and printouts

  • Films, scans, and other image records, as appropriate.

  • Verify that radiology records are maintained in the manner required by the Medical Records

  • If radiologic services are utilized, the governing body must appoint an individual qualified in accordance with State law and ASC policies who is responsible for assuring all radiologic services are provided in accordance with the requirements of this section.

  • Interview the individual designated responsible for assuring compliance with this CfC and review related documentation to assess how these responsibilities have been implemented in the ASC.

  • What steps are available to this individual to remedy the situation if there is evidence of noncompliance with any of the requirements?

  • Under the medical staff credentialing and privileging requirements at §416.45, the ASC’s governing body will continue to be required to ensure that the operating surgeon is competent both to perform the surgical procedures for which privileges have been issued by the ASC and to appropriately and safely use the imaging modalit(ies) that are integral to the procedures s/he performs.

Patient Rights

  • The ASC must inform each of its patients, or the patient’s representative or surrogate in the case of minor patients or other situations where there is a designated representative for the patient, of their rights as an ASC patient.

  • all of the ASC’s policies, procedures and actions must be consistent with the protection of the patients’ rights

  • the ASC must actively promote the patient’s exercise of their rights.

  • the ASC must ensure that the written notice of patient rights is posted in one or more places where it is likely to be seen by patients waiting for treatment, or the patient’s representative or surrogate, if applicable.

  • Review posted notices to determine if they contain the same information as the individual written notice provided to patients or their representatives/surrogates, as required under §416.50(a). Deficiencies related to posting of the notice are to be cited using tag -Q0219.

Notice of Rights

  • An ASC must, prior to the start of the surgical procedure, provide the patient, or the patient’s representative, or the patient’s surrogate with verbal and written notice of the patient’s rights in a language and manner that ensures the patient, the representative, or the surrogate understand all of the patient’s rights as set forth in this section.

  • The ASC’s notice of rights must include the address and telephone number of the State agency to which patients may report complaints, as well as the Web site for the Office of the Medicare Beneficiary Ombudsman.

  • Is the staff who are responsible for advising patients of their rights aware of the ASC’s policies and procedures for providing such notice, including to those patients with special communication needs?

  • Does the ASC have a significant number of patients with limited English proficiency? If so, are there written notice materials available for patients who have a primary language other than English?

Disclosure of physician financial interest or ownership

  • The ASC must disclose, in accordance with Part 420 of this subchapter, and where applicable, provide a list of physicians who have financial interest or ownership in the ASC facility. Disclosure of information must be in writing.

  • Does the ASC have policies and procedures in place to make the required disclosures to patients? Are the policies and procedures consistent with the regulatory requirements?

  • Does the ASC provide a written notice of disclosure to all patients prior to the start of the surgical procedure, including a list of physicians with financial interests or ownership in the ASC?

  • Interview ASC staff to assess their knowledge and understanding of the physician ownership notice requirements, including the ASC’s process for delivering the notice.

  • Interview patients to ask them whether they were aware that the ASC has physician owners/investors.

Advance Directives

  • Provide the patient or, as appropriate, the patient’s representative with written information concerning its policies on advance directives, including a description of applicable State health and safety laws and, if requested, official State advance directive forms.

  • Inform the patient or, as appropriate, the patient’s representative of the patient’s rights to make informed decisions regarding the patient’s care.

  • Document in a prominent part of the patient’s current medical record, whether or not the individual has executed an advance directive.

  • If the patient with an advance directive is transferred from the ASC to another healthcare facility, e.g., if there is an emergency transfer to a hospital, the ASC must ensure that a copy of the patient’s advance directive is provided with the medical record when the patient is transferred.

  • If the State has an official advance directive form, ask the ASC to demonstrate how it provides these forms upon request to patients.

  • Ask the ASC how it documents that required advance directive information is provided to the patient prior to the start of the surgical procedure.

  • Does the ASC advise patients, or the patient’s representative or surrogate, of their right to make informed decisions about their care in the ASC?

Submission and investigation of grievances

  • The ASC must establish a grievance procedure for documenting the existence, submission, investigation, and disposition of a patient’s written or verbal grievance to the ASC.

  • The following criteria must be met: The grievance process must specify timeframes for review of the grievance and the provisions of a response.

  • The ASC, in responding to the grievance, must investigate all grievances made by a patient, the patient’s representative, or the patient’s surrogate regarding treatment or care that is (or fails to be) furnished.

  • The ASC must document how the grievance was addressed, as well as provide the patient, the patient’s representative, or the patient’s surrogate with written notice of its decision.

  • The decision must contain the name of an ASC contact person, the steps taken to investigate the grievance, the result of the grievance process and the date the grievance process was completed.

  • A complaint from someone other than a patient or a patient’s representative or surrogate is not a grievance. A complaint that is presented to the ASC’s staff and resolved at that time is not considered a grievance; the grievance process requirements do not apply to such complaints. Billing issues are not usually considered grievances for the purposes of this grievance requirement.

  • As part of its obligation to notify patients of their rights, the ASC must inform the patient and/or the patient’s representative or surrogate of the ASC’s grievance process, including how to file a grievance.

  • The ASC’s grievance policies and procedures must identify the person(s) in the ASC who have the authority to respond to grievances.

  • The ASC is expected to educate staff on their obligation to report all grievances, including whom they should report the grievance to.

  • Interview staff to see if staff is aware of the ASC’s grievance policies. Do staff know the difference between a complaint handled on the spot and a grievance?

  • The following criteria must be met: All alleged violations/grievances relating, but not limited to, mistreatment, neglect, verbal, mental, sexual, or physical abuse, must be fully documented.

  • All allegations must be immediately reported to a person in authority in the ASC.

  • Only substantiated allegations must be reported to the State authority or the local authority, or both.

  • All grievances alleging mistreatment, neglect or abuse that are submitted to any ASC staff member, whether verbally or in writing, must be reported immediately, i.e., as soon as possible, and at least on the same day, by the staff member to an ASC official who has authority to address grievances.

  • Interview staff to determine whether they are aware that the ASC may not discriminate against patients, or take punitive actions against any patient as a reprisal for some act on the patient’s part.

  • Review the ASC’s policies and procedures to determine whether it is clear that patients, or their representatives, or surrogates may exercise their rights without fear of reprisal.

  • Interview staff about how a patient who has filed a grievance or otherwise exercises his/her rights is treated. Is staff aware that they should not treat patients differently if the patient files a grievance?

  • The patient has the right to – Personal privacy.

  • Be free from all forms of abuse or harassment.

Informed Consent

  • The ASC’s surgical informed consent policy should describe the following: Who may obtain the patient’s informed consent;

  • The circumstances when a patient’s representative, rather than the patient, may give informed consent for a surgery (see guidance for §416.50(e)(2) & (3);

  • The content of the informed consent form and instructions for completing it;

  • The process used to obtain informed consent, including how informed consent is to be documented in the medical record;

  • Mechanisms that ensure that the informed consent form is properly executed and is in the patient’s medical record prior to the surgery; and

  • If the informed consent process and informed consent form are obtained outside the ASC, how the properly executed informed consent form is incorporated into the patient’s medical record prior to the surgery.

  • Verify that there is a policy addressing the exercise of rights on behalf of a patient judged legally incompetent.

  • Verify that there is a policy addressing the delegation by a patient of the exercise of rights to a representative.

Safe Environment

  • Review and analyze patient and staff incident and accident reports to identify any incidents or patterns of incidents concerning a safe environment. Expand your review if you suspect a problem with safe environment in the ASC.

  • Review safety, infection control and security documentation to determine if the ASC is identifying problems, evaluating those problems, and taking steps to ensure a safe patient environment.

  • Observe the environment where care and treatment are provided.

  • Review policy and procedures to see what steps the facility takes to curtail unwanted visitors and/or contaminated materials.

  • Interview staff and patients to see if either have any concerns about the safety of the setting.

Confidentiality of Clinical Records

  • The Privacy Rule requires ASCs that are HIPAA Covered Entities to engage in activities such as:

  • • Notifying patients about their privacy rights and how their information can be used;

  • • Adopting and implementing privacy procedures for the ASC;

  • • Training employees so that they understand the privacy procedures;

  • • Designating an individual to be responsible for seeing that the privacy procedures are adopted and followed within the ASC; and

  • • Securing patient records containing individually identifiable health information so that they are not readily available to those who do not need them.

  • What policies and procedures does the ASC have in place to prevent the release or disclosure of individually identifiable patient information?

  • • Observe whether patient information is visible in areas where it can be viewed by visitors or other patients? How likely is it that an unauthorized individual could read and/or remove a patient’s medical record?

  • • What security measures are in place to protect the patient’s medical records?

Infection control - The ASC must maintain an infection control program that seeks to minimize infections and communicable diseases.

  • The ASC’s infection control program must: Provide a functional and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases;

  • • Be based on nationally recognized infection control guidelines;

  • • Be directed by a designated health care professional with training in infection control;

  • • Be integrated into the ASC’s QAPI program;

  • • Be ongoing;

  • • Include actions to prevent, identify and manage infections and communicable diseases; and

  • • Include a mechanism to immediately implement corrective actions and preventive measures that improve the control of infection within the ASC.

  • One surveyor is responsible for completion of the Infection Control Surveyor Worksheet, Exhibit 351,

Sanitary Environment The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.

  • Policies and procedures for a sanitary and functional environment should address the following: Ventilation and water quality control issues, including measures taken to maintain a safe environment during internal or external construction/renovation;

  • Maintaining safe air handling systems in areas of special ventilation, such as operating rooms;

  • Techniques for food sanitation if employee food storage and eating areas are provided;

  • Techniques for cleaning and disinfecting environmental surfaces, carpeting, and furniture;

  • Techniques for disposal of regulated and non-regulated waste; and

  • Techniques for pest control.

  • Observe throughout the ASC the cleanliness of the waiting area(s), the recovery room(s), the OR/procedure rooms, floors, horizontal surfaces, patient equipment, air inlets, mechanical rooms, supply, storage areas, etc.

  • • Interview staff to determine whether cleaning/disinfection takes place at the appropriate frequencies, using suitable EPA-registered agents. Ask for supporting documentation to confirm what staff say in interviews.

  • • Determine whether the ASC has a procedure for decontamination after gross spills of blood or other bodily fluids.

  • • Determine whether used sharps are disposed of properly.

  • • Determine whether the ASC re-uses devices marketed for single use, and if so, does it send them to an FDA-approved vendor for reprocessing?

Infection control program

  • 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.

  • As part of this ongoing program, the ASC must have an active surveillance component that covers both ASC patients and personnel working in the facility.

  • Surveillance includes infection detection through ongoing data collection and analysis.

  • Maintenance of a sanitary ASC environment (see requirements of §416.51(a));

  • • Development and implementation of infection control activities related to ASC personnel, which, for infection control purposes, includes all ASC medical staff, employees, and on-site contract workers (e.g., nursing staff employed by associated physician practice who also work in the ASC, housekeeping staff, etc);

  • • Mitigation of risks associated healthcare-associated infections:

  • • Identifying infections;

  • • Monitoring compliance with all policies, procedures, protocols and other infection control program requirements;

  • • Program evaluation and revision of the program, when indicated;

  • Evaluating ASC staff immunization status for designated infectious diseases, for example, as recommended by the CDC and its Advisory Committee on Immunization Practices (ACIP);

  • • Policies articulating the authority and circumstances under which the ASC screens its staff for infections likely to cause significant infectious disease or other risk to the exposed individual, and for reportable diseases, as required under local, state, or federal public health authority;

  • • Policies articulating when infected ASC staff are restricted from providing direct patient care or required to remain away from the facility entirely;

  • • New employee and regular update training in preventing and controlling healthcare-associated infections and methods to prevent exposure to and transmission of infections and communicable diseases; and

  • • Methods to evaluate staff exposed to patients with infections and communicable diseases.

Surgery-related infection risk mitigation measures:

  • Implementing appropriate prophylaxis to prevent surgical site infection (SSI), such as protocol to assure that antibiotic prophylaxis to prevent SSI for appropriate procedures is administered at the appropriate time, done with an appropriate antibiotic, and discontinued appropriately after surgery; and

  • Addressing aseptic technique practices used in surgery, including sterilization or high-level disinfection of instruments, as appropriate.

  • Other ASC healthcare-associated infection risk mitigation measures:

  • Promotion of hand hygiene among staff and employees, including utilization of alcohol-based hand sanitizers;

  • Measures specific to the prevention of infections caused by organisms that are antibiotic-resistant;

  • Measures specific to safe practices for injecting medications and saline or other infusates;

  • Requiring disinfectants and germicides to be used in accordance with the manufacturers’ instructions;

  • Appropriate use of facility and medical equipment, including air filtration equipment, UV lights, and other equipment used to control the spread of infectious agents;

  • Educating patients, visitors, and staff, as appropriate, about infections and communicable diseases and methods to reduce transmission in the ASC and in the community.

  • The ASC must conduct monitoring activities throughout the entire facility in order to identify infection risks or communicable disease problems.

  • The ASC should document its monitoring/tracking activities, including the measures selected for monitoring, and collection and analysis methods.

  • Are staff washing their hands prior to providing care to patients?

  • Do personnel who prepare injections comply with all pertinent protocols?

  • Is equipment properly sterilized or disinfected? Is the facility clean?

  • The ASC must demonstrate that it has a process in place for regularly assessing infection control compliance.

  • Under the direction of a designated and qualified professional who has training in infection control;

  • An integral part of the ASC’s quality assessment and performance improvement program; and

  • Plan evaluation and revision of the plan, when indicated;

  • Coordination as required by law with federal, state, and local emergency preparedness and health authorities to address communicable and infectious disease threats and outbreaks; and

  • Compliance with reportable disease requirements of the local health authority.

  • Ask the infection control professional to describe actual examples of how, as a result of the action plan, infection control issues were identified and corrective or preventive actions were taken.

  • • Ask for documentation of how those actions were evaluated to assure that they resulted in improvement.

  • • Ask the infection control professional to review the ASC’s infection control plan of action with you, explaining how it addresses the fundamental elements of an infection control program.

  • • Does the plan address all the basic elements of infection control?

  • • Ask the ASC’s leadership how it tracks infections among patients and staff.

  • • Ask for documentation of this tracking – is there tracking of all patients?

  • • Ask the ASC’s leadership what diseases are reportable to the State to verify the ASC’s awareness of applicable reporting requirements.

  • • Ask the ASC if it has ever reported a reportable disease to the State. If yes, review the ASC’s documentation of the case.

Patient Admission, Assessment and Discharge

  • The core objectives of this condition are to ensure that:

  • • The patient can tolerate a surgical experience;

  • • The patient’s anesthesia risk and recovery are properly evaluated

  • • The patient’s post-operative recovery is adequately evaluated;

  • • The patient received effective discharge planning; and

  • • The patient is successfully discharged from the ASC

  • Determine whether the ASC has a policy requiring that a H&P no more than 30 days prior to admission,

  • Does the ASC’s policy address who may perform the H&P

  • Upon admission, each patient must have a pre-surgical assessment completed by a physician or other qualified practitioner in accordance with applicable State health and safety laws, standards of practice, and ASC policy that includes, at a minimum, an updated medical record entry documenting an examination for any changes in the patient’s condition since completion of the most recently documented medical history and physical assessment, including documentation of any allergies to drugs and biologicals. Update to H&P within 24 hours of surgery

  • The patient’s medical history and physical assessment must be placed in the patient’s

  • medical record prior to the surgical procedure.

Discharge Assessment

  • The patient’s post-surgical condition must be assessed and documented in the medical

  • record by a physician, other qualified practitioner, or a registered nurse with, at a minimum, post-operative care experience in accordance with applicable State health and safety laws, standards of practice, and ASC policy.

  • Post-surgical needs must be addressed and included in the discharge notes.

  • Provide each patient with written discharge instructions and overnight supplies.

  • When appropriate, make a follow-up appointment with the physician, and ensure that all patients are informed, either in advance of their surgical procedure or prior to leaving the ASC, of their prescriptions, post-operative instructions and physician contact information for follow-up care.

  • Ask the ASC when and how it schedules follow-up appointments with the physician for patients.

  • Ask the ASC what types of supplies it typically provides to patients upon discharge. Observe whether patients being discharged during the survey are provided any supplies to cover their overnight needs.

  • Ensure each patient has a discharge order, signed by the physician who performed the surgery or procedure in accordance with applicable State health and safety laws, standards of practice, and ASC policy.

  • Ensure all patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.