Medicare’s Top Citations in 2018 ASCA 2019 will offer guidance for avoiding common pitfalls BY KARA NEWBURY

The Centers for Medicare & Medicaid Services (CMS) conducted 1,185 health surveys and 819 life safety surveys at 5,772 CMS-cer-

tified facilities in 2018. A look at the top citations CMS issued during those sur- veys can help provide insight into what surveyors focused on and identify areas where facilities failed to comply.


ASCs are required to meet the health and safety standards for ASCs, i.e, the Conditions for Coverage (CfCs), to achieve and maintain CMS certifica- tion. Each CfC includes at least one standard (identified by a “tag”) for which the facility can be cited for fail- ure to comply. Surveyors use “Q” tags for health surveys and “K” tags for life safety surveys. Emergency prepared- ness standards—identified with an “E” tag—can be used in both health and life safety surveys. When surveyors note non-compli- ance with a standard within the CfC, they determine whether the lack of compliance is at the standard or con- dition level. The condition level cita- tion is more serious than the standard level. The factors that surveyors take into consideration for determining the level of non-compliance include the potential or actual harm to patients and the extent of non-compliance. CMS provides the public with direct access to information on surveys for facilities that it certifies, including ASCs. The Quality, Certification and Oversight Reports (QCOR) application, https://, offers access to general information on facilities and spe- cific information on citations. The data- base gives individuals the ability to run

20 ASC FOCUS MARCH 2019| Infection Control

Sanitary Environment (Q0241) was the most cited tag in 2018 and has been the top health survey citation since 2013.”

— Kara Newbury, ASCA

a variety of deficiency reports. In addi- tion, there is a search function by facil- ity that shows the citations for that facil- ity’s most recent survey and the level of those citations. While the QCOR application does

not provide the exact reason for a cita- tion, information on the trends in cita- tions can aid facilities in their policy and procedure development and edu- cation efforts. The ASC citation fre- quency report under Deficiency Reports was used to compile the top 10 citations charts on page 21.


Visit ASCA’s website every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs. GovtAffairsUpdate

The Infection Control CfC states that an ASC must “maintain an infection control program that seeks to mini- mize infections and communicable diseases.” One of the key elements of an effective infection control pro- gram is maintaining a sanitary envi- ronment, and the CfCs state that an “ASC must provide a functional and sanitary environment for the provi- sion of surgical services by adhering to professionally acceptable standards of practice.” Sanitary Environment (Q0241) was the most cited tag in 2018 and has been the top health sur- vey citation since 2013.

Three of the top 10 health sur-

vey citations fall under the Infection Control Condition for Coverage. In addition to Q0241, surveyors cite the Infection Control Program (Q0242) tag third most frequently. This tag requires that facilities “maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addi- tion, the infection control and preven- tion program must include documen- tation that the ASC has considered, selected, and implemented nationally recognized infection control guide- lines. […]” Citations for the general Infection Control (Q0240) tag round out the top 10.

Environment Another CfC that surveyors often cite is Environment. This CfC is closely aligned with the Infection Control CfC, as it requires ASCs to “have a safe and sanitary environment, prop- erly constructed, equipped, and main- tained to protect the health and safety of patients.” Physical Environment

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