REGULATORY REVIEW


(Q0101), Safety from Fire (Q0104) and the general Environment (Q0100) tag all made the top 10 citation list in 2018. Many of the compliance issues under Environment could be identi- fied in a life safety survey, as well.


ASCA 2019 Regulatory Compliance Sessions The ASCA 2019 Conference & Expo in Nashville, Tennessee, May 15–18, will feature an Infection Prevention track with sessions such as “A How- to Guide for Infection Control Risk Assessment” and “Use Medicare’s ASC Infection Control Surveyor Worksheet to Improve Compliance and Patient Care.” These sessions will allow participants to better equip their facilities with the tools they need to avoid these citations in the Infection Control CfC. Many of the same infection con- trol sessions also will help facilities comply with the Environment CfC. In addition, ASCA 2019 will offer a presentation in the Advanced Session track, “Simple Steps to DIY Compli- ance with NFPA 99’s Required Risk Assessments,” that will help facilities prepare for health surveys and life safety surveys.


ASCA 2019 also will provide sessions on quality assessment and performance improvement and emer- gency preparedness. Attendees can wrap up their regulatory education with a breakout session on “Medi- care Survey Trends and Strategies for Compliance” on Saturday morning, May 18. To see the entire ASCA 2019


schedule, go to ascassociation.org/ annualconference/schedule. For more information on CMS


regulations or how to use the QCOR application, write Kara Newbury at knewbury@ascassociation.org.


Kara Newbury is ASCA’s regulatory counsel. Write her at knewbury@ascassociation.org.


Top 10 Health Survey Citations Tag #


Tag Description Q0241 Sanitary Environment


Q0181 Administration of Drugs


Q0242 Infection Control Program


Q0162 Form and Content of Record


Q0101 Physicial Environment Q0104 Safety From Fire


Q0141 Organization and Staffing


Q0240 Infection Control


# of citations


323 284 229 167


131 123


106 92 Q0261 Admission Assessment 86 Q0100 Environment 84


Top 10 Health Survey Citations Tag #


Tag Description K0353 Sprinkler System—Maintenance and Testing


% of surveys (out of 1185)


27.30% 24.00% 19.30% 14.10%


11.10% 10.40%


8.90% 7.80% 7.30% 7.10%


Condition for Coverage


Infection Control


Pharmaceutical Services


Infection Control Medical Records


Environment Environment


Nursing Services Infection Control


Patient Admission, Assessment and Discharge


Environment


# of citations


171


K0918 Electrical Systems—Essential Electric System 167 K0345 Fire Alarm System—Testing and Maintenance K0712 Fire Drills


K0291 Emergency Lighting


K0321 Hazardous Areas—Enclosure K0131 Multiple Occupancies


K0920 Electrical Equipment—Power Cords and Extensions


K0372 Subdivision of Building Spaces— Smoke Barriers


K0211 Means of Egress—General Source: Centers for Medicare & Medicaid Services ASC FOCUS MARCH 2019| ascfocus.org 21


162 134 108 96 82


58 53 48


% of surveys (out of 819)


20.90% 20.40% 19.80% 16.40% 13.20% 11.70% 10.00%


7.10% 6.50% 5.90%


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30