During inspections of ambulatory surgery centers (ASCs), the Centers for Medicare & Medicaid Services (CMS) commonly identify several areas where these facilities often fail to meet regulatory standards. These deficiencies typically relate to infection control, patient safety, and adherence to CMS guidelines. Here are the most common areas of failure: (as current as 9/10/24)
1. Infection Control Violations
Infection control is a critical area in surgery centers, and CMS frequently cites deficiencies in this area. Common issues include:
Failure to adhere to proper sterilization protocols for surgical instruments.
Lapses in hand hygiene by staff can lead to contamination.
Improper cleaning of operating rooms or patient care areas.
Inadequate storage and handling of sterile supplies, leading to potential contamination.
Forgetting MIFU both look up and communications. example: the Glucometer controls (after opening are only good for 60 days)
Failure to follow CDC guidelines for infection control practices such as the use of personal protective equipment (PPE).
2. Improper Medication Management
Medication management and administration are often scrutinized during inspections. Common violations include:
Failure to properly label medications, particularly those that are drawn into syringes.
Inadequate tracking of controlled substances or failure to secure medications properly.
Improper storage of medications, including not maintaining correct temperature control.
Failure to follow protocols for medication administration, leading to dosing errors or misuse.
3. Patient Safety Protocols
ASCs often fall short in adhering to CMS’s patient safety standards. Examples of common deficiencies are:
Failure to conduct proper time-outs before surgery to confirm patient identity, procedure, and surgical site (part of the Universal Protocol for preventing wrong-site surgeries).
Lack of proper emergency preparedness plans or training for staff to handle medical emergencies.
Inadequate documentation of patient care and failure to maintain proper medical records.
Failure to assess and monitor patient conditions adequately, especially during and after surgery.
4. Physical Environment Standards
CMS also inspects the physical environment of ASCs to ensure patient safety and adherence to guidelines. Common issues include:
Failure to maintain safe and clean facilities, such as improper disposal of biohazard waste.
Inadequate maintenance of medical equipment or failure to properly calibrate machines.
Failure to meet fire and life safety codes, such as improper exits or lack of emergency lighting.
5. Staffing and Credentialing Issues
Another frequent area of deficiency involves staffing and credentialing:
Failure to ensure that all staff members are properly credentialed, trained, and licensed to perform their duties.
Inadequate staff-to-patient ratios, which can impact patient safety and care quality.
Lack of staff training in emergency procedures, infection control, or proper use of equipment.
6. Patient Rights Violations
CMS also monitors ASCs for patient rights violations. Common failures include:
Failure to inform patients of their rights under CMS regulations.
Inadequate informed consent processes, where patients are not fully informed about the risks, benefits, and alternatives to a procedure.
Failure to provide appropriate post-operative care instructions and follow-up.
7. Documentation and Record-Keeping
Inaccurate or incomplete documentation is a frequent issue found during inspections:
Inadequate medical record documentation, particularly in relation to patient histories and informed consent.
Failure to document patient outcomes and follow-ups appropriately.
CMS inspections aim to ensure that surgery centers are compliant with federal standards designed to protect patient safety, and these common failures can lead to significant consequences, including fines, citations, or even loss of certification or accreditation.
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