Your ASC was cited for a standards deficiency — what next? 4 Qs with an HFAP expert

During 2017 surveys, ASCs had trouble with the same standards they've struggled with in previous years, according to Donna Tiberi-Blaszczyk, RN, BS, MHA, who serves on the Healthcare Facilities Accreditation Program's standards interpretation staff.

Ms. Tiberi-Blaszczyk spoke with Becker's ASC Review about what administrators can learn from HFAP's 2018 Quality Review and how to better prepare for surveys.

Note: Responses have been edited for length and clarity.

Question: Were any of the top-cited deficiencies for ASCs in 2017 surprising?

Donna Tiberi-Blaszczyk: To be perfectly honest with you, no. These continually appear. The frequency of citation may decrease, but it's the same issues: lack of training, lack of competency for staff, [cited centers] continue to not apply appropriate credentialing and privileging processes, they're not reviewed by the medical staff and the governing board. In terms of medication security, crash carts are not always checked as required, the anesthesia carts are left open. You have to remember, many of these organizations have turnover of qualified staff and leadership, and when that happens, some of these things fall on wayside.

Q: Why do you think infection control standard 12.00.02 was the top-cited deficiency?

DT: Infection control tends to always land in the top-cited standards because the facility may not have someone who's qualified to act as the infection control preventionist. That doesn't mean that person needs to be certified in infection control, but certainly they do need some quality and infection control training so they can develop an infection control plan based on their geographic area. Sometimes, organizations assume they're doing a good job, so they don't review things they commonly do on a daily basis and don't realize they're missing steps. When you don't designate at least two people to be trained in this area, mistakes can happen.

Q: What are the next steps for ASCs that have discovered deficiencies?

DT: When a surveyor brings something to your attention as a citation, you should always have a scribe — someone that can document that observation as a citation — so upon closure of that survey, you can immediately begin to develop a plan of correction. For credentialing and privileging, you should have some type of reminder file to make sure no data is missing and take a look at that every eight months or once a year.

Q: What tips do you have for ASCs trying to meet the toughest standards?

DT: It's always best to make a checklist of what you need to do in your facility. Focus on CMS regulations in terms of infection control, sterilization processes, high-level disinfection, competency, practitioners/surgeons' privileges. There's a list of things they can check on, whether it be monthly or quarterly. It's really good to incorporate staff and get them involved. Conducting mock surveys with your staff is very important because you will find things before a survey may occur that you can correct easily.

Educate staff on standards regardless of the accrediting organization. They need to know what the standards are and what they mean for them in their department. If they don't understand, then oftentimes, they don't feel they need to comply or that it's important. But it is. Depending on the citation, if there are multiple citations just in one chapter, for HFAP, it could result in a Condition for Coverage and would require additional review. We would have to return within 45 days to conduct another survey. You want to avoid that. Staff should be aware that when they don't understand, they need to seek advice and feel free to contact the accrediting organization, such as HFAP, to ask questions.

For questions about standards, ASCs can contact HFAP 312-202-8069 and 312-202-8346 or email questions to

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