An Introduction to ASC Surveys
An ASC survey is an evaluation of an ASC to determine the ASC ’s compliance with state rules and federal regulations. The survey evaluates the ASC on such areas as governing body, infection control, laboratory services, medical records, medical staff, patient care services, pharmaceutical services, and physical environment.
Pursuant to Indiana Code 16-21, ASCs must be licensed. The Indiana State Department of Health is the licensing authority and has adopted rules for the operation of ASCs. The state rules may be found at 410 Indiana Administrative Code 15.2. ASC surveys evaluate the ASC for compliance with these rules.
Medicare certification is under the authority of the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS). The federal regulations (Conditions of Coverage for ASCs) are found at 42 Code of Federal Regulations 416. Federal certification surveys and federal complaint surveys evaluate the ASC for compliance with these regulations.
Surveys of Indiana ASCs are conducted by public health nurse surveyors and medical surveyors from the Indiana State Department of Health (ISDH) Division of Acute Care. Surveyors from the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) will occasionally participate in or conduct a survey. A majority of the ASC surveyors are registered nurses. Surveyors are experienced medical professionals and receive extensive training in ASC rules and regulations. Surveyors complete a CMS training program on survey principles and procedures. Surveyors receive additional training throughout the year on the latest medical advances and updates to rules and regulations.
The Survey Process:
The survey process varies depending on the type of survey. Surveys may take only a few hours or several days. All surveys are unannounced. Surveys generally include surveyor visits to the licensed ASC. During a survey, ISDH surveyors will tour the ASC, interview staff, and review patient records and other documents to determine compliance with state rules.
At the conclusion of the survey, surveyors prepare a report of their findings. A separate survey report is prepared for state and federal surveys. The survey report lists and describes all violations of state rules or federal regulations.
If deficiencies are cited on a survey, the ASC may be requested to complete a plan of correction on how and when they will achieve compliance with each deficiency and who will be responsible to ensure the corrections are made and will not reoccur in the future. The ASC submits the plan of correction to the ISDH within fifteen (15) days of the issuance of the survey report. The ISDH reviews and approves the plan of correction.
Types of Surveys:
There are numerous types of ASC surveys. These include:
• state licensure surveys
• state and federal complaint surveys
• accreditation surveys
• federal Medicare certification surveys
• post-survey revisit surveys
• preoccupancy surveys
• initial surveys
• life safety code survey
The following is a brief description of a few of the common ASC surveys.
State Licensure Surveys
Indiana Code 16-21 requires that every Indiana ASC be licensed. The Indiana State Department of Health (ISDH) is designated as the licensing authority. The ISDH conducts a state licensure survey at each licensed ASC approximately once per year.
The licensure survey is a comprehensive review of the ASC and the ASC’s compliance with state rules (410 Indiana Administrative Code 15.2). State licensure surveys are conducted by a team of ISDH surveyors. The survey is unannounced. A state licensure survey is usually completed in one to two days. The survey includes surveyor visits to the licensed ASC and off-site locations under the ASC license. During the licensure survey, ISDH surveyors will tour the ASC, interview staff, and review patient records and other documents to determine compliance with state rules.
Many ASCs voluntarily submit themselves for accreditation by an ASC accreditation association. If an ASC is accredited, the ASC may substitute the accreditation survey for the state licensure on-site survey. In years when an accreditation survey is performed, there may not be a state licensure survey conducted by the ISDH.
Federal and State Complaint Surveys
Any person may file a complaint with the ISDH about an ASC. The ISDH investigates all complaints. Complaints may be filed in person at the ISDH, in writing, by telephone, or by email. The toll-free complaint number is 1-800-246-8909. Instructions for submitting a complaint by email are found in the ISDH Regulatory Services Web site under “contact us.” Complaints are prioritized and scheduled for investigation based on their potential to place the health and safety of patients at risk. Complainants are informed (except anonymous complainants) upon receipt of the complaint by the surveyor and at closure of the complaint of the findings of the investigation.
A complaint survey is a focused survey reviewing the specific allegations of the complaint. The purpose of a complaint survey is to determine if the ASC is compliant with the state licensure rules (410 Indiana Administrative Code 15.2) and/or Conditions of Coverage for ASCs (42 Code of Federal Regulations 416). A complaint survey is unannounced and the name of the complainant is not disclosed to the ASC. During the course of a complaint survey, surveyors may expand the scope of the survey if additional problems are observed. Complaint surveys are generally completed by only one or two surveyors and last a few hours to a day. Similar to the licensure survey, surveyors will visit the ASC, interview staff, and review records to determine compliance with state rules and federal regulations.
If in the course of investigating the complaint allegation a violation of state or federal rules or regulations is found by surveyors, the complaint is said to be “substantiated with findings.” These findings would be reported on the survey report issued at the conclusion of the survey.
While state rules do not require ASCs to be accredited, many ASCs voluntarily apply for accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC), American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Joint Commission for Healthcare Organizations (JCAHO), or the American Osteopathic Association (AOA). Accreditation surveys are performed by the accreditation association once every three years. Accreditation is granted to the ASC if the ASC meets the standards of a private accreditation organization.
Section 1865(b)(2) of the U.S. Social Security Act allows institutions accredited as ASCs by the AAAHC, JCAHO, AAAASF, and AOA to be deemed to meet the Conditions of Coverage for ASCs. The ISDH also accepts the AAAHC, AAAASF, JCAHO, or AOA inspection report in lieu of a state licensure on-site survey. In years when an accreditation survey is performed, there may not be a state licensure survey conducted by the ISDH.
Federal Certification Surveys
Federal Medicare certification surveys are conducted to determine ASC compliance with the Federal Conditions of Coverage for ASCs. For non-accredited federally certified ASCs, a federal Medicare certification survey is completed once every three years. A federal certification survey may also be completed if the Center for Medicare and Medicaid Services (CMS) finds the ASC to be out of compliance with a federal condition of Coverage and CMS requests that a certification survey be completed.
In the case of a ASC that is accredited, an ASC that meets accreditation standards is deemed to have met the Federal Conditions of Coverage based on the accreditation survey. In that situation, the accreditation survey replaces the federal certification survey. Accredited ASCs will therefore likely not have a federal certification survey. If the ASC Consumer Report indicates that the federal certification survey was “not applicable,” this indicates that the ASC is accredited and an accreditation survey was performed in lieu of a federal certification survey.
If a federal certification survey is performed, it is very similar to the state licensure survey except that it evaluates the ASC on federal regulations rather than state rules. During a federal certification survey, the surveyors will tour the ASC, interview staff, and view patient records and other documents to determine compliance with the Conditions of Coverage for ASCs. Noncompliance with the Conditions of Coverage for ASCs will result in issuance of a survey report specifying that the ASC did not meet a specific regulation.