CMS Inspection Surveys: Is Your ASC Ready?

At the 18th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 28, Tracy Heoft-Hoffman, Administrator, Hastings (Neb.) Surgery Center, shared key tips for preparing for CMS surveyor visits.

To prepare for unannounced CMS surveys, Ms. Heoft-Hoffman said "constant preparation" is key. Constant preparation means knowing CMS and state policies, ensuring written regulations meet these policies and keeping all documentation that will be requested from CMS up-to-date and in one, easy-to-find place. Items that will be requested include board meeting minutes, the ASC's organizational chart, a list of active employees with credentials and copies of the ASC's grievance policy, among many other documents. Ms. Heoft-Hoffman said she keeps all documents in a single CMS survey "manual," adding it's important for other employees to know where this is located in case the survey occurs when the administrator is out. For a full list of items Medicare surveyors will request, click here.

Ms. Heoft-Hoffman provided the following additional tips survey success:

  • Use surveyor worksheets to assess the center. "It's like having the answers to the test," she said.
  • Perform mock surveys. Hire a consultant or use your management company to perform this.
  • Network with peers. Utilize your state's ASC association, management company and conferences to meet colleagues at other centers.
  • Benchmark. Compare your ASC's performance on quality metrics with other centers.
  • Know the most common deficiencies for ASCs in your state. Ensure your ASC is compliant.
  • Prepare staff and physicians for surveys through education. Discuss survey issues at monthly staff and board meetings.
  • Treat surveyors well. They are there to help improve the center.
  • Expect one or more deficiencies.
  • Submit a correction plan, if required, on time and "do what you say you're going to do," said Ms. Heoft-Hoffman.

Related Issues on ASC Accreditation:

15 Questions to Ask to Ensure an Effective, Compliant Quality Program
14 Questions to Ask to Ensure Effective Patient Identification
20 Questions Surgery Centers Should Ask to Ensure an Effective Safe Medication Management Program

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