An ASC survey will always feel like a sneak attack—after all, they’re unannounced for a reason. Unfortunately, the results of your survey could be equally surprising. “There’s this nebulous cloud that hangs above us and it’s anyone’s best guess as to what surveyors are looking for,” says Judy Harless, MBA, CASC, who spoke to attendees at the Ambulatory Surgical Center Association’s 2017 annual meeting about what to do when surveyors come calling.
Official guidance for surveyors is so general—they’re called “Interpretive Guidelines” for a reason—that you could be caught off-guard even if your facility is well-prepared. If that’s the case, you may have received a statement of deficiencies (Form CMS-2567) to alert you of non-compliance in your ophthalmic ASC, along with your ASC survey report. Here’s a quick rundown on what you might see on that letter:
Standard Level Deficiencies:
These indicate noncompliance with a single requirement or multiple requirements within the same standard. They don’t negatively impact your center’s ability to provide proper patient care, and don’t affect the health and safety of your patients.
Note: Multiple standard level deficiencies within the same requirement can add up to a condition level citation.
Condition Level Deficiencies:
These indicate noncompliance with requirements in a single standard or several standards within a condition. They represent a definite health or safety concern, and have a 90-day termination track. If you don’t correct them, your ability to collect Medicare payments is at risk.
The Top 5 ASC Survey Deficiencies
In years past, a negative finding on an ASC survey report necessitated two or even three observations of noncompliance. But beginning in 2017, even one single observation of noncompliance results in a finding. The most commonly cited deficiencies involved these five Conditions of Coverage, according to Erin McCoy, MS, RN, ONC, who advised ASCA 2017 attendees on how to succeed at surveys:
- Sanitary Environment: i.e. cardboard shipping containers in the OR.
- Administration of Drugs: i.e. expired medications left in patient care areas.
- Infection Control Program: i.e. center not following/implementing its own written policies.
- Form and Content of Record: i.e. use of unapproved abbreviations on physician orders.
- Physical Environment: i.e. wear and tear that creates non-cleanable surfaces
ASC Survey Corrections: What to Do
Like any good ASC owner or administrator, you’re probably eager to correct any deficiencies, even minor ones. You must provide a Plan of Correction (a PoC) to your state survey agency within 10 calendar days—not business days— of receiving the statement. Time is not on your side, so follow these steps to get started:
Step 1: Ground Zero
Your statement of deficiencies was accompanied by a cover letter. Read it. Then read it again, emphasizes Jan Allison, RN, CHSP, who spoke to ASCA attendees about coping with less-than-stellar survey results. State requirements, ASC survey processes, and the surveyors themselves can vary quite a bit. Your cover letter will note any specific requirements, so don’t discard it—those requirements aren’t necessarily something you can look up later online.
The cover letter contains several key pieces of information you need to thoroughly understand, like:
- The “due date” for your PoC
- Submission instructions
- The types of deficiencies
- What needs to be addressed in the PoC
- How to document your PoC
- The date by which all corrections must be completed
Step 2: The Smoke Clears
Here’s where the real work begins. Form CMS-2567 is the basis for your PoC. It is also a public record of your survey. Since your PoC describes how you plan to correct the deficiencies listed in CMS-2567, you must have a deep understanding of the information on this form.
“Deficiencies have three components,” notes Allison. “A regulatory reference, a deficient practice statement, and relevant findings or evidence.” Each component is listed on the form:
1. The regulatory reference precedes each listed deficiency and helps you locate the specific regulation in Appendix L of the CMS State Operations Manual. The regulatory reference will usually begin with a Q or a K.
Example: Q-0064 §416.42 Condition For Coverage: Surgical Services
Surgical procedures must be performed in a safe manner by qualified physicians who have been granted clinical privileges by the governing body of the ASC in accordance with approved policies and procedures of the ASC.
2. The deficient practice statement notes that the standard was not met:
Example: The standard was not met based on observation and interview. The ASC failed to ensure that each surgical procedure is performed in a safe manner due to inappropriate use of liquid germicides as evidenced by…
3. The surveyor’s findings are his or her documented reasons for noncompliance. Findings describe the actions taken or not taken by staff, and the extent of those actions.
Example: During an observation in procedure room 2, the patient was draped before the alcohol-based skin preparation was completely dry. The clinical leader verified that there was no verbal confirmation that the solution had completely dried during the pre-operative “time out” as required by the ASC’s written policy.
Unfortunately, Form CMS-2567 simply describes the evidence of any deficiencies, not the cause. “To say that [CMS] is vague is an understatement,” Harless points out. It’s up to you to do the digging necessary to uncover and address the root causes of the deficiencies noted.
Step 3: The Heavy Lifting
Your PoC is a statement of how your center plans to address all deficiencies listed in on CMS-2567. Because these corrections will be verified, it’s important “to not submit a PoC that is not feasible for [your] facility to accomplish,” advises Allison. Additionally, avoid “band-aid” solutions. “Determine what happened and why the problem exists or occurred,” says Allison. “If the cause of the failure isn’t identified, the center likely will not succeed in correcting it.”
The required components of your PoC may vary depending on your state and surveyor, so be sure to refer to your cover letter. For best chances of State approval, Allison recommends that your PoC includes at these seven elements (plus any others your cover letter requires):
7 Essential Elements of a Plan of Correction
- The specific action you’ll take to correct the deficiency. Begin each with its corresponding regulatory reference tag (i.e. Q241).
- A description of how those actions will improve the processes that contributed to the deficiency
- The procedure you’ll use to implement the corrections (basically 1 and 2 in more detail)
- A specific completion date for each correction. Future plans aren’t allowed.
- A description of monitoring or tracking procedures you’ll put in place to ensure your facility will stay in compliance.
- The title of the person responsible for implementing the PoC (don’t list their name).
- The administrator’s signature and date (on page 1 of CMS-2567)
Need extra space? Download and print an official continuation page at cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2567.pdf
You must respond to each individual finding or instance listed on the form—not just each group of findings. For example, if your form showed three findings violating guideline Q241 (sanitary environment), you’d need to draft three individual responses, not just one.
Some states may designate another form to use or refer you to a website, but in most cases you’ll insert your PoC directly on the CMS-2567 form. When you’ve completed the PoC, make a copy for your records. Submit the original, along with any supporting documentation required, according to the instructions on the cover letter. Supporting documentation, document attachments, or references to attachments in the PoC are state and even sometimes surveyor-specific, warns Allison. If you have questions, don’t hesitate to contact your regional CMS office.
Step 4: The Aftermath
What happens after you’ve submitted the PoC? Again, that will vary, says Allison. In some states, you’ll receive written communication (an email or letter) stating that your PoC is acceptable. In other states, no news is good news—you’ll only hear back if your PoC falls short. Remember, if you responded to condition-level deficiencies, you can expect an on-site revisit. Surveyors perform revisit surveys when they noted condition level deficiencies the first time. During the revisit, the surveyor will verify that you’ve corrected those deficiencies.