Are You Survey Ready? Lessons Learned and Compliance Tips
Are You Survey Ready? Lessons Learned and Compliance Tips
Having been the recipient of a call from the front desk letting me know that a surveyor had entered the building, I was immediately filled with anxiety no matter how ready I thought I was. Even with announced surveys and significant prep time, survey days felt similar to taking Nursing Boards due to both the intense scrutiny and hoping for a good outcome.
Since starting our business, we have had the unique opportunity to be on the sidelines for many recent surveys and have gleaned insight into some survey expectations. Here are some lessons learned, and tips to help you hopefully be less anxious and better prepared for your next survey.
Staff: Are They Fully Oriented and Educated?
Surveyors will often verify that all staff members are properly oriented to their roles within 30 days of hire and familiar with facility policies initially and when new policies or edits are introduced. They will also verify that all staff are trained initially and annually on all required elements. Surveyors will also want to see that staff have been regularly evaluated on staff performance related to their job description.
Compliance Tip: Have staff sign an Orientation Plan checklist that includes a policy review line item. When new policies are introduced, attach a copy to an in-service form for staff review and attestation. Make sure staff members complete any necessary education for their roles.
Use a calendar to track staff performance reviews, and make sure appraisals are done annually. Review the evaluations with staff to gather feedback and understanding. Have them sign the appraisal and keep it in their file.
What we offer: Check out our Orientation Checklist and In-Service form in our ASC Solutions Library. You can find our online training at ASC Solutions Academy.
If you’re looking for an efficient tool to keep up with staff and credentialing file documents, check out our tracking tool: SimplyCRED
Infection Control: Are Your Logs in Order?
Surveyors typically inspect procedure room temperature and humidity logs, as well as fridge and freezer logs. They will check to ensure these logs are updated every procedure day and that out-of-range results and interventions are properly documented. Additionally, they’ll verify that fridge and freezer thermometers offer 24-hour monitoring.
Compliance Tip: Teach staff about the importance of accurate documentation, including handling out-of-range results. Consider conducting monthly audits of your logs to ensure everything is documented correctly before the surveyor checks.
What we offer: You can find our logs and other forms in our ASC Solutions Library.
Safety and Security: Is Your Facility Secure?
One of the main things surveyors will evaluate is whether the facility is safe and secure. This includes checking that doors are secured from unauthorized entry, egresses are clear, and items are stored properly.
Compliance Tip: Have your Safety Officer conduct a monthly walkthrough to ensure the facility is safe and secure. Document the process to show you’re proactive about safety and security.
What we offer: You can find our Safety Survey form in our ASC Solutions Library.
Medication Safety: Are You Staying on Top of Medication Management?
Surveyors will inspect medication management processes, including Confused Name and High Alert medication identification, and that reversal agents are stored near the medications they support. They will also inspect narcotic logs, prescription pad security, and will check for any expired medications.
Compliance Tip: Review your Confused Name and High Alert medication lists and highlight the medications on the list your facility has in stock. Use color-coded stickers to identify these medications wherever they are stored. Conduct routine audits to verify that medications are in-date and that logs and prescription pads are logged and tracked. Here is a link to the IMSP website.
What we offer: You can find our Medication Safety audit form in our ASC Solutions Library.
Life Safety: Are you testing your systems appropriately?
Ensure that all Life Safety testing is being done per regulatory requirements. The testing includes:
- Electrical receptacle testing annually
- Fire damper testing every four years
- Four-hour full load generator testing every 36 months
- Weekly generator verification
- Monthly generator transfer testing (all required elements)
- All fire extinguishers checked monthly, certified annually
- Fire alarm signal tested/coordinated with fire drill-results documented on drill record
Compliance Tip: Work with your Life Safety vendors to coordinate testing and documentation needs.
CLIA Waived Testing: Is Everything Documented?
Surveyors will also check that the CLIA waiver is visible in the facility and that testing logs are completed correctly. They will ensure that competencies for staff performing tests are documented and that controls are carried out according to the manufacturer’s instructions.
Compliance Tip: Ensure your CLIA waiver is posted in the lobby, and that staff competencies and testing logs are completed as required. Don’t forget to make IFUs (Instructions for Use) available for reference by staff.
Governance: Are Your Governance Practices in Compliance?
Surveyors will review Governing Body meeting minutes to confirm that meetings occur as defined in the facility by-laws (at least annually), and that the agenda covers key regulatory functions. These include reporting on all compliance subjects, compliance with regulatory requirements, policy reviews, and appointments.
Compliance Tip: Regularly check your Governing Body minutes to ensure they are up-to-date and comprehensive. If any meetings are missed, document the reasons for the delay.
What we offer: You can find our template Governing Body agenda in our ASC Solutions Library.
Labs: Do You Track All Lab and Pathology Results?
Surveyors will want to verify that all labs and pathology ordered are tracked and that results are signed off by the appropriate staff.
Compliance Tip: Assign a designated staff member to be responsible for lab tracking. Audit the log monthly to ensure the process is functioning smoothly.
What we offer: You can find our tracking form template in our ASC Solutions Library.
Credentialing: Are Your Staff Files Up to Date?
Surveyors will check the Delineation of Privileges (DOP) list and ensure that peer reviews are included in the re-credentialing process. They will also check that credentialed staff have agreed to abide by the facility’s bylaws.
Compliance Tip: Track and review credentialing files regularly to ensure they are complete and up-to-date.
What we offer: Looking for a tool to streamline credentialing management? Click here to learn more about SimplyCRED.
We get the challenges in ensuring that your facility remains prepared for regulatory surveys. However, with the right processes in place, you can streamline these tasks and make compliance more simple.
Want to learn more how we can help? Check out our website to learn more, or reach out to learn more about becoming an ASC Insider Member with ALM Surgical Solutions.