Image by Andreas Breitling from PixabayThe Centers for Medicare & Medicaid Services (CMS) recently released the most frequently cited areas for ambulatory surgery centers (ASCs) in 2023.
The most cited issue was “Sanitary Environment,” cited 507 times. Following closely was “Infection Control Program,” cited 372 times.
The data, obtained by the Ambulatory Surgery Center Association (ASCA), was based on 3,023 ASC surveys from last year. The numbers show that infection control remains a predominant concern for operators, with three of the top five health survey citations linked to infection control programs.
“The increase in the number of citations is indeed noteworthy,” Charles Petrini-Poli, CEO of HUB Healthcare, told ASC News. “This rise can be attributed to several factors.”
HUB Healthcare, based in Raleigh, North Carolina, is a HIPAA-compliant platform that streamlines health care operations.
“Firstly, the inclusion of data from state agencies and accrediting organizations in the 2023 survey has likely contributed to the higher numbers,” Petrini-Poli said. “Additionally, the lack of updated data from CMS since 2022 may have impacted how ASCs managed their compliance efforts, potentially leading to a relaxation in adherence to standards.”
Petrini-Poli said that operators should implement strong internal monitoring systems to maintain compliance with CMS standards despite external updates, while also updating training programs regularly to educate staff on current compliance requirements. Conducting frequent internal audits and utilizing health care technology to streamline compliance tracking and reporting for maintaining consistently high standards can also help ASCs remain compliant, he added.
Other common areas for citations include “Environment,” “Administration of Drugs,” “Form and Content of Record,” and “Governing Body and Management.”
More on infection control and prevention
During a recent ASCA podcast, Debbie Mack, an infection prevention educator and consultant, said that new and experienced infection preventionists in ambulatory surgery centers should review their infection control plans to ensure they meet CMS appendix L requirements.
She said substantial educational training is important, recommending at least five to seven hours of continuous infection control training annually.
“There’s often some confusion about the type of educational training infection preventionists need. It is more than just one hour a year; it requires several hours,” she said. “Many of my colleagues who frequently speak on infection control believe that you need at least five to seven hours annually of continuous infection control training.”
Mack said common deficiencies noted by CMS are the lack of documented educational training in infection preventionists’ personnel files and the absence of approval by the governing board.
“These are two critical requirements that need to be addressed at the board level,” she said.
The best way to handle infection reporting and surveillance is by involving team members rather than doing it alone, she added.
“For example, you could have your business office send out the reports to the physicians and track that they return that surveillance report, because we’d like to keep that within 30 days,” she said. “And we want to make sure the physician is letting us know if they don’t pick up the phone and call us.”
Mack said it’s important for physicians to inform the center about any infections, even though they are rare, so proper investigations can be conducted. She said that in an ambulatory surgery center, where staff often handle multiple roles, it’s crucial to distribute the workload to prevent infections.
Also included in CMS’ top citations list were citations from Life Safety Code surveys.
For ASC facilities, building safety received 339 citations; with electrical systems, sprinkler systems, maintenance and testing, and fire alarm systems receiving the most citations.
