Top 10 Areas CMS Surveyors Are Probing in ASC's for Deficiences

Many of my surgery center clients have shared their experiences in 2016 / 2017 regarding surveys. Coincidentally, we recently attended a State ASC Association meeting where a representative for AAAHC was speaking. This person hit upon many of the same Top 10 and thus the basis for developing our Top 10 list.

Click underlined links for my solutions.

1. Sterilization of Instruments – Are You Following Manufacturer’s Instructions For Use (IFU’s)? Are you staff using proper sterilization procedures?

   WISH: Wash, IUSS, Sterilization  and HLD 

   Why Are My Surgical Instruments Dirty? Part One 

   Why Are My Surgical Instruments Dirty? Part Two

2. Endoscope Reprocessing, Storage and Handling; Again MIFU’S!

   Is that Scope Safe? Flexible Endoscope Cleaning

   Reprocessing Flexible Endoscopes Best Practices 

   Best Practices for Sterilization and HLD of Reusable Medical Devices

3.  Emergency Preparedness Rule & Operations Plan        

  Emergency Preparedness Rule / Emergency Operations Plan

4.  How to Complete an Infection Control Risk Assessment

   Completing the Infection Prevention Risk Assessment - Part 1 and Part 2

5.  Credentialing

  Dispelling the Mystery of Credentialing

6. Life Safety Code

   Life Safety Compliance as It Relates to Infection Prevention in the Ambulatory Surgery Center

   Life Safety Codes & Emergency Preparedness for ASC’s

   2012 Life Safety Code for Existing ASC's - Effective July 5, 2016

7. Completing the Infection Control Worksheet

  Completing the Infection Control Worksheet

8.  Following USP797 Guidelines and Safe Injection Practices

   Infection Prevention Strategies for the ASC Pharmacy

9.  Quality Assurance / Performance Improvement Program; Are You Conducting Quality Pertinent QAPI Studies?



  Root Cause Analysis

10.  Policies & Procedures: Do you Manage Your Facility According to Your Policies; Does your Policies Reflect Recognized Guidelines & Best Practices; and Is Your Governing Body Involved In Approving Your Policies.

   CMS Regulations 2015 - Session #1

   CMS Regulations 2015 - Session #2 

   Infection Prevention Policies & Procedures


If you discover that you are interested in many of our training solutions, you might want to consider joining our ALL VIDEO EMEMBERSHIP program.  For instance there are three more Sterilization training topics in the emembership library of over 100 total presentations. 

  • Frequently Asked Questions About Sterilization
  • Is It Sterile or Did It Just Get Hot!
  • Sterilization 101

The program is spread out on a monthly basis and you have access to over 100 presentations and respective documents and thus reducing the cost of each presentation in the $16.00 range as compared to $139 when purchased individually.  All nursing staff are eligible for Contact Hours and Certificates of Participation.

CLICK HERE to learn more about emembeship.