At the 20th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 25, three ambulatory surgery center administrators discussed preparing their centers for surveyors and Medicare inspections.
Marti Potter, administrator with Jersey Shore Ambulatory Surgery Center in Somers Point, N.J., Marcy Sasso, director of compliance and development with Facility Development and Management in Orangeburg, N.Y., and Regina Robinson, administrator of the Toledo (Ohio) Clinic — Outpatient Surgery participated in the roundtable. The discussion was moderated by Melissa Szabad, JD, partner with McGuireWoods.
Here is an excerpt of the panel discussion, lightly edited for clarity and style.
Ms. Szabad: Can you share some of your experiences with surveyors?
Ms. Potter: I find folks from the Accreditation Association for Ambulatory Health Care are [more] likely to act collegially than those who come from the state. The AAAHC is much more amenable. For the most part, they'll give you the opportunity to make a correction.
Ms. Sasso: [This is] the way I look at CMS [inspections]: There is black and white but not as much gray. For recertification, they look at you differently. They are definitely going to hold you a little more accountable. You better not have any repeat outstandings.
Ms. Robinson: For one survey, I had three surveyors [at the ASC] for three days. Fortunately they found small things. At the end, I said, "Did we do anything right?" And the surveyor said, "Oh, you did a lot of things right. We just don't talk about that. CMS is a negative survey." Their job is only to find things that are wrong.
Ms. Szabad: What do you do to plan for initial or recertification? Can you discuss and maybe key areas you focus on and how much time you allocate to those?
Ms. Robinson: The one thing that can probably trip you up the easiest is when they do tracers, following patients from admission to discharge. They'll hit all areas [of the patient's experience], so it's a challenge. Have mock audits, perhaps, or at every staff meeting have a topic you'll discuss. I've actually had mock surveyors come in, which is helpful. We always work toward a state of readiness. Keep track of infection rates and make it part of monthly staff meetings. Keep the staff directly involved.
Ms. Sasso: Part of my job as a consultant is to perform mock surveys for many clients. I actually walk around and talk to staff as if I were a surveyor. Surveyors want to see per diem staff records, not just [those for] the administrator and director of nursing. You need a fresh set of eyes [to notice potential errors]. You might walk by a garbage can missing its lid 50 times a day and not notice it.
Ms. Potter: Most surveyors do come in and speak to staff. Staff needs to know not to b-s them. The surveyor knows right away if a person is involved [in compliance], or if they're making it up as they go. [If they're asked a question they don't know the answer to,] all staff need to say is they're not sure but they know where to find the answer. It's also important to make sure you have physician involvement. Surveyors also want to speak to your docs, especially as they do a tracer. You want to make sure physicians have the basic answers.
More Articles on Medicare Inspections:
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Marti Potter, administrator with Jersey Shore Ambulatory Surgery Center in Somers Point, N.J., Marcy Sasso, director of compliance and development with Facility Development and Management in Orangeburg, N.Y., and Regina Robinson, administrator of the Toledo (Ohio) Clinic — Outpatient Surgery participated in the roundtable. The discussion was moderated by Melissa Szabad, JD, partner with McGuireWoods.
Here is an excerpt of the panel discussion, lightly edited for clarity and style.
Ms. Szabad: Can you share some of your experiences with surveyors?
Ms. Potter: I find folks from the Accreditation Association for Ambulatory Health Care are [more] likely to act collegially than those who come from the state. The AAAHC is much more amenable. For the most part, they'll give you the opportunity to make a correction.
Ms. Sasso: [This is] the way I look at CMS [inspections]: There is black and white but not as much gray. For recertification, they look at you differently. They are definitely going to hold you a little more accountable. You better not have any repeat outstandings.
Ms. Robinson: For one survey, I had three surveyors [at the ASC] for three days. Fortunately they found small things. At the end, I said, "Did we do anything right?" And the surveyor said, "Oh, you did a lot of things right. We just don't talk about that. CMS is a negative survey." Their job is only to find things that are wrong.
Ms. Szabad: What do you do to plan for initial or recertification? Can you discuss and maybe key areas you focus on and how much time you allocate to those?
Ms. Robinson: The one thing that can probably trip you up the easiest is when they do tracers, following patients from admission to discharge. They'll hit all areas [of the patient's experience], so it's a challenge. Have mock audits, perhaps, or at every staff meeting have a topic you'll discuss. I've actually had mock surveyors come in, which is helpful. We always work toward a state of readiness. Keep track of infection rates and make it part of monthly staff meetings. Keep the staff directly involved.
Ms. Sasso: Part of my job as a consultant is to perform mock surveys for many clients. I actually walk around and talk to staff as if I were a surveyor. Surveyors want to see per diem staff records, not just [those for] the administrator and director of nursing. You need a fresh set of eyes [to notice potential errors]. You might walk by a garbage can missing its lid 50 times a day and not notice it.
Ms. Potter: Most surveyors do come in and speak to staff. Staff needs to know not to b-s them. The surveyor knows right away if a person is involved [in compliance], or if they're making it up as they go. [If they're asked a question they don't know the answer to,] all staff need to say is they're not sure but they know where to find the answer. It's also important to make sure you have physician involvement. Surveyors also want to speak to your docs, especially as they do a tracer. You want to make sure physicians have the basic answers.
More Articles on Medicare Inspections:
Medicare Inspections Abound … Is Your Center Ready?
Inside the Medicare Accreditation Process: 5 Crucial Points From ASC Inspector Dr. David Watts
5 Mistakes to Avoid During Medicare Accreditation