MNASCA Online Education Session: Are You Ready for Your Next Survey?

Some insight, proper preparation and survey prep tips can help you approach your next survey with confidence, knowing that your center is in compliance, and you are prepared for whatever questions your surveyor might ask. This session, held on April 26, looked at how state, Medicare and accreditation surveys vary and what you can expect during each type. Our presenter shared helpful hints on how to achieve and maintain survey readiness every day and discussed survey citations and how you can prevent them from happening to your ASC.

Review the Session Slides

Presenter: Mary K. Ryan, MBA, BSN, RN, CAIP, CASC

Mary Ryan learned to scrub while in Nursing school and has remained in the perioperative field ever since. Early in her nursing career, she was appointed the Director of Nursing for a startup surgery center. In addition, Mary held positions such as Administrator, Group Administrator, Regional Manager, Group Clinical Director and Clinical Consultant. She has assisted many start-up centers as they became certified and helped others achieve or maintain accreditation. She currently is a Senior Consultant for Amblitel. Mary was one of the founding members of the Iowa ASC Association and served as the first President. Mary has served on the Board of Ambulatory Surgery Certification (BASC) and frequently speaks at the ASCA Annual Conference. She has been one of the three main presenters for the Management Essentials for ASC Administrator course for many years.

Learning Objectives:

Explain the difference between license, certification, and accreditation.  

• Share the ASCA resource page and where to find state specific information (will tailor this information to Minnesota)
• Medicare certification: Review the documents needed, where to find the current form, and discuss the survey process in general
• Accreditation: Review the AO's that Medicare has selected to perform deemed status

 Provide guidance on prepping for a survey

• Walk through how to be prepared every day for a survey
• Share tips and tools to implement
• Walk through a typical survey and what to expect 

 Identify common deficiencies cited recently from accreditation organizations 

• Share data from the various accreditation organizations from the past year and opportunities to not get cited

Continuing Education Credit 
This program is approved for up to 1.0 hour of AEUs by BASC Provider #6240 for the content area: Regulatory and Legal Issues. For more information, please review the BASC Approval Letter and Content Breakdown.

Resources

• ASCA Resources
• Code of Federal Regulations, Part 416-Ambulatory Surgical Services
• CMS Ambulatory Surgical Center Infection Control Surveyor Worksheet
• Updated Guidance for Ambulatory Surgical Centers – Appendix L of the State Operations Manual (SOM)
• CMS SOM for ASCs Appendix I
• CMS SOM for ASCs Appendix Z
• CMS SOM - Appendix Q
• ASC Focus, The ASCA Journal.  “Accreditation Agencies Release ASC Top Deficiencies List” by Sahely Mukerji, June 2023
• 2023 AAAHC Quality Roadmap
• Surveyor Accreditation Commission for Health Care Volume 2023 No. 2. “Frequent Deficiencies in Ambulatory Surgery Centers”
• Top 5 most challenging requirements for 2023 (Full-Year 2022 Top Standards Noncompliance from the Joint Commission. Joint Commission Perspectives, April 2023, Volume 43, Issue 4.)

We are launching a survey preparation listserv ([email protected]) where members can share questions and resources relating to surveys. To sign up for this listserv, please follow these instructions:

1. Log into your MemberClicks profile.
2. Click on the My Features button to view the drop-down box, then click on E-lists.
3. Toggle on the Subscribed and Email Delivery buttons to join the Surveys list.

Questions? For more information please contact:

Laura Harris, MNASCA Executive Director
[email protected]