Outpatient Facility Coding Alert

Survey Strategies:

ASCs: 4 Survey Vulnerabilities You'll Want to Address

Published on Tue May 02, 2017

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Train well in these areas and ace your next survey.

Where surveys are concerned, an ounce of prevention is certainly worth a pound of cure. Clearly, all your staff need to be prepped for surveyor visits, and there are certain key members who need to be extra prepared, given their high-profile status in Medicare’s Conditions for Coverage for ASCs.

First step: Appoint a training manager to get your staff ready for surveys. “Everybody on your staff is fair game, so you had better make sure everybody is well versed in what those roles and responsibilities are, what your relevant policies are, and the relevant regulations that impinge on those activities,” surgery center regulatory and operations consultant Regina Boore, RN, Principal of Progressive Surgical Solutions, told attendees at the “ASC Staffing” session of the Outpatient Ophthalmic Surgery Society’s Symposium 2016.

Ounce of prevention: Taking the extra time to prep these key staff members for scrutiny in some key areas will serve your surgery center well when surveyors come knocking:

Instrument Techs: Can They Take the Heat?

Surveyors really love to scrutinize instrument technicians. “These people get hammered” by surveyors during interviews, because instrument processing is such a vital function, “so it’s very important that they’re well-trained,” says Boore. They don’t need to be certified, but they do need to have full competency and training in instrument decontamination and sterilization procedures and the care, handling, and maintenance of instruments and be thoroughly knowledgeable about every kind of sterilizer you have.

Infection Coordinator: Job Description in the File and Time Documented?

“Your infection control coordinator will also be the focus of a lot of survey attention. Not only will surveyors be checking the coordinator’s personnel file for the infection control coordinator job description, but the coordinator can count on questions like how many hours per week does s/he spend on infection control activities,” says Boore. The coordinator needs to be prepared to answer that.

Tip: Document those hours and have that information ready to show.

QAPI Coordinator: Ready with Program Details?

You know you need a QAPI (Quality Assurance and Performance Improvement) coordinator and you’ve appointed one, but have you taken the steps that surveyors expect you to take to show that you’ve done this officially? You need a job description for that position and you need to ensure that that document is in the QAPI coordinator’s personnel file, advises Boore.

Also: “You also should be prepared to respond to questions about how much time, support, and allocation of resources you are providing to get your QAPI program implemented,” Boore says.

RN Circulator: On Board?

Surveyors will be interested in feedback from your RN circulator. The RN circulator not only serves as a patient advocate, but can improve patient safety and outcomes by leading the team in preventing surgical site infections, medication errors, wrong-site/wrong-patient/wrong-procedure surgeries, as well as retained surgical items, advises Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president of the consulting firm SLG, Inc., in Raleigh, N.C.

Surgical Techs: Properly Credentialed?

With 26 states requiring specific certifications for surgical techs and more states adding regs, you need to make sure that anyone stepping into a surgical tech role in those states is appropriately certified.

Watch out. Ophthalmologists, for instance, like to take good COAs and COTs and train them into surgical tech roles.

If yours is a practice-owned facility, you’ll be thinking about sharing resources with the ASC, as this seems natural. Be careful. An ASC, according to the CMS Conditions for Coverage, needs to be a distinctly separate entity physically, operationally, and in terms of their governance structure. It’s fine that you have people from the practice that work in the surgery center, but COA (Certified Ophthalmic Assistant) and COT (Certified Ophthalmic Technician) are not “positions” in the ASC.

Reg alert: If you have a COA or COT who comes over to the ASC from the practice to work with your doctors, you need to have an ASC-specific job description in their surgery center personnel file. They need to function under a job description that is appropriate and that is part of the surgery center staffing pattern, says Boore. Furthermore, they can’t administer drugs over in the ASC as they might be able to over in the practice.

A lot of things they can do in the practice, they just can’t do in the surgery center, says Boore. So when surveyors see that going on, it opens the door for a lot more questions and scrutiny.

Resource: To download the CMS’ State Operations Manual, Appendix L, Guidance for Surveyors: Ambulatory Surgery Centers, go to: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf