10 deficiencies AAAASF cites most & how to correct them — No. 2: Universal Precautions, ASC standard 800.42.12

The American Association for Accreditation of Ambulatory Surgery Facilities compiled its 10 most commonly cited deficiencies and provided solutions on how to address them.

AAAASF Interim COO Thomas Terranova spoke with Becker's ASC Review about the organization's second most cited deficiency which relates to Universal Precautions, ASC standard 800.42.12.

Here's what you should know about the second most cited standard and what you need to do to fix it:

Thomas Terranova: The second most cited deficiency is related to the need to document evidence of training of Universal Precautions, ASC standard 800.42.12.

In this standard, records for all operating room personnel are required to contain evidence of training. The instruction must be current, meaning within the last year, and clearly documented. We tend to see inconsistent documentation, particularly at time of hire. If the employee does not have the needed training, the ASC may opt to hold an in-service or have them complete online education prior to their start date.

Facilities should pay particular attention to medical staff. Often, deficiencies are cited because facilities believe the physicians’ status on staff at a hospital implies they have received instruction in universal protocols. While this may be true, hospital privileges do not constitute adequate proof of training in this area. It is acceptable for the facility to obtain the practitioners’ certificates or other proof from the hospital, but the facility must maintain its own record in its personnel files.

Per diem nursing staff and itinerate anesthesia personnel must also have documentation of adequate training. Typically, this can be proven out by their service contract or in the file they bring onsite when providing care.

It is also important to be aware of potential gaps in compliance due to staff turnover and current staff training expiration dates throughout the year. When staff training is not conducted internally, expirations are not synchronized and require diligent oversight.

An annual review of the personnel files is recommended to ensure that instruction is current and applicable to the current standards of care related to universal precautions. Conducting regular reviews prior to a survey will help ensure that all required elements are accounted for.

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