Preparing the older center for survey

In the last ten years, and most especially the last four or five years, surveyors are casting a hard look at the condition of older ambulatory surgery centers from the parking lot to the medical gas closet. If you are the owner of one of these older centers built in the eighties or nineties, you need to proactive in preparing your center for a positive survey. That may prove to be a challenge.

In preparing to write this article, I am relying on the results of many surveys conducted in the last three years as my source. We were warned as long ago as nine years that CMS was going to be looking long and hard at these older centers, and that it was unclear what regulations would be enforced versus grandfathered. We have enough data, now, to be able to point out areas needing addressed.

Maintenance of your center should be a very high priority; however, experience shows that this is not being the case. It is most common that, in many cases, how the center looked and worked then, is how it looks and works now excepting, perhaps, some new and innovative equipment and instrumentation.

In assessing your center it is imperative that you step back and look at it as a “shopper”, or, if you cannot be objective, and find your self waffling and using words like “that will get by’, you may want to hire an outside person to do a thorough and objective assessment using not just what is visible, but also, the rules and regulations.

Let’s start with the parking lot. Remember, first impression ARE LASTING! Is your parking lot full of pot holes? Even one can prove to be an economic disaster, as it poses a huge risk to fall for everyone. Is the parking lot crumbling? Is grass growing up through the cracks in the asphalt or concrete? Are there safety stops? If yes, are they painted an obnoxious blue or yellow to draw attention to them and, thus, prevent someone from falling over them? In one center, a grandmother was carrying her 8 month old grand daughter when she stumbled over a disintegrating guard, twisted her ankle then fell over the guard while holding the baby. She managed to cradle the baby’s head, but twisted her knee badly. Luckily, this was the mother of one of the nurses and did not sue the center, practice, physician owners, etc. Is your parking lot striped? Is the striping clear? If needed, are there clear arrows identifying the traffic route? Parking lot fender benders are the most common call to police regarding traffic accidents.

Is signage clear as to the entrance? Is there signage on the entrance door identifying the hours, the emergency number and where to go in the event of an emergency?

If you live where inclement weather is routine, are parking lots and sidewalks sanded or salted adequately, or is it a “lick and a promise”? What is the walkway into the building? If it is marble, this will pose a fall hazard. If you use mats, make certain they are not a tripping hazard.

Scrutinize the landscape and shrubbery. Is it trimmed and neat or scraggly and all over the place, or, worse yet, dead? Are there weeds in the beds up to your knees? Is new mulching needed? One recent center was cited for the deplorable condition of the sidewalks and shrubbery identifying them as patient hazards. Be careful, too, of the mulching for it can catch on fire, as has happened in several centers thanks to cigarettes thrown into it. Put out sand filled pots for burning ashes and empty these regularly.

Look at the outside of your building surrounding the entrance. At the beginning of one recent survey, the surveyor was accosted by a swarm of wasps who were nesting in the corner by the top of the entry door. Peeling paint, damaged stucco all point to a lack of maintenance on the part of the owners. One surveyor identified to the physician owner that if he walked up to this center as a patient about to undergo surgery he would turn around and walk away. He admonished the physician owner telling him that he would have a hard time believing that he was “high tech” and safe in the performance of the surgical procedure scheduled.

The waiting room can be that moment that hits the visitor, and surveyor, square in the eyes, as they walk in and are surround by the mauve and teal color scheme of the eighties. The mauve upholstered chairs in the waiting room long ago lost their padding and are as hard as concrete to sit on. The fabric on the backs and seats of the chairs is stretched. The carpet is stretched and hooved up in some areas. At one time it was mauve, but it now has a clear dirty gray traffic pattern down the middle of the room. The formica on the reception desk is chipped posing a sharp edge on which patients can cut themselves and an impossibility to clean.

And, the final straw is the nearly dead plant perched on the reception desk.

Proceeding into the Preoperative area the surveyor notices the floor seams have separated and dirt has accumulated in the cracks to be waxed over. Upon seeing this issue, the surveyor announces that he is going to declare the center “a center that puts patients’ safety at risk for infection, and, even tho’ the center had bids for a new floor, in so far as the floors HAD NOT been replaced at the time of the survey, the center would be cited. Recommendation was to close the center until repairs were made and to deny accreditation.

Gone are the days when a center representative can call a vendor and ask them to send over the report on the job that was done a few days or weeks ago. CMS expects the reports to be on site immediately. You must have at least a preliminary and in depth interim report on site when asked for by the surveyor.
In many centers the same furniture that was in place when the center opened is what you got today. Repairs to “leather” upholstery on chairs or recliners may utilize electrical tape to cover the tears. Again, this is a patient hazard, as the chair cannot be thoroughly cleaned between patients.

You must have a complete set of working drawings (blueprints) on site and readily available for the Life Safety engineer to review, as he goes poking about up in the ceiling and down below identifying fire and smoke walls.

Prior to your anticipated survey, get a contractor out to inspect your fire wall. One physician-owner whose center had been open for 25 years ,thus going through many surveys, was completely flamoxed when he was told during his last survey that there was no fire wall! He had to close the practice and ASC long enough to build an adequate fire wall---25 years after the fact!

You want this contractor to verify the presence of the fire wall and it’s intactness. Over the years it is not uncommon for telephone/computer lines, etc. to be run through your fire wall without the adequate sealant. Be proactive and get these repairs done before they join a long list of other items jeopardizing your survey’s success!

Hire a company to come in and inspect for mold. This contractor should be checking all around the HVAC system, but also the floor and walls, especially if you have had any water intrusion such as flooding, either internal or external. This could be from an overflowing toilet, hot water tank defect, etc., or from the outside due to large downpours. Not only is mold a huge health risk, but will surely cost you during a survey. Make repairs, and make them correctly. You must cut out the previously wet, now moldy, drywall and replace it. You will have to tear out the molded flooring/tile treat the underlying floor, and replace the flooring. Be prepared to show any work orders for any and all of this.

Conduct your annual air tests in the sterile, OR and soiled workrooms for proper turnover and positive and negative pressures.

Look at your ceiling tile. Those gross yellow water stains harbor aspergillus and are hazardous to patients and staff. Replace them. Also replace any that are ill-fitting and gaping. These must fit the grid tightly preventing dust and vermin from entering. Look for holes in the ceiling, inside cupboards, and under and around sinks.

Send your staff throughout the center looking for rust. Rust harbors bacteria and will surely be cited in the survey. There are companies that remove and repair rusted items from stretcher beds, OR tables, IV standards, scrub sinks, handwashing sinks, etc. Also, remove and replace any and all corroded sink handles where the corrosion cannot be removed with, say, CLR.

Check out the generator and your riser. Is there rust there? Time to paint!

Again, replace chipped formica. There are flooring companies that will repair the formica rather than having to replace entire spans of counters, desks, etc.

Inspect all your floor seams. You may not have to replace all the floors. Look for companies that will carve out the separated seams and make a new-looking floor with swirls and designs.

Look at your smoke alarms. These should not be any closer to an air vent than 3’. Over the years, this standard may have become contaminated by other construction, etc.

Check out the coving. Has it pulled loose? Get it replaced if re-gluing won’t work.

Remove the covers and clean all those overhead lights free of accumulated bugs and debris.

Look at labels and signage. Contact your electrician and have him come out and label the various electrical panel boxes and switches.

Make a Locator Map showing all the life safety equipment such as exit lights, fire alarms, smoke alarms, fire extinguishers, overhead lights, turn off valves for the utilities and hang this in the corridor and with your logs, too!

Walk through the center opening every door to include the medical gas closet. Are your tanks secured to prevent their falling? If copper tubing, is this inspected and replaced as needed, at least every five years? Are empty and full tanks separated in storage and labeled? Is the room clean? Is it free of extraneous storage? Is the door to the closet labeled with the proper, current signage?

Inspect the maintenance closet/room. Is it clean? Are items labeled as required?

Check out the vacuum closet. No storage here! No paint cans here or in either of the above….also no lawn fertilizer, etc.

When was the last time you looked inside your sterilizers? Have they grown barnacles? Is the surface gone thus laying down minerals on your instruments every time they are sterilized? This is an infection hazard for which you will be cited. That sterilizer most likely was the one purchased for the center when it was opened. Most likely, the shelf life has been exceeded, and then some! Again inspect the sterile and soiled work areas for chipped formica, broken doors and drawers.

Evaluate the status of center security. Strange as it sounds in this day and age, you should have a sound security system with not just your overall alarm, but keyless entry doors into patient care areas and staff dressing etc. There should be a panic/banker’s button at the front desk and at least a peep hole at the back/delivery door which should be kept locked. A doorbell is used here to alert staff that the vendor, who has previously signed in at reception, is now at the back door and needs entry. Staff should be checking the vendor prior to unlocking the door for his entry.

Finally, when discussing the state of the physical plant, it is crucial that paint and paper be replaced. Loose, hanging paper, torn paper, chipped paint all are a “no pass” where surveyors are concerned. First, tho’, go to every nook and cranny, especially around your doors and clean, clean, clean all that gunk that has accumulated around the door bottoms and frames, thresholds, corners, and the edges of the coving. Use the white glove test and get rid of all dust EVERYWHERE!

Presenting a spit and polished center reflective of the kind of care you deliver to your patients will go a long way towards a successful survey regardless of the age of the center!

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