ASC Regulatory Compliance Checklist: What To Complete and When

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Key Takeaways

ASC compliance checks are vital. Performing regular checks and compliance tasks ensures ambulatory surgery centers avoid financial penalties and minimize patient risk.
Compliance checklists help ASCs stay on track. By mapping out compliance tasks by day, week, month, and year, ASCs can embed compliance-related checks into their regular work.
Everyone is responsible for ASC compliance. No single person should be responsible for all compliance checks and tasks. Delegating responsibilities helps ensure things get done well and on time.

Industry expert and VP of ASC Solutions at SIS, Daren Smith, details regulatory requirements and compliance checklists for ambulatory surgery center staff.

Ambulatory surgery center (ASC) leaders, managers, and staff are tasked with significant regulatory burdens. Regulators — including CMS, state health departments, ASC accreditation organizations, OSHA, the CDC, local authorities, NFPA, CLIA, and others — each require or strongly recommend checking several operational elements for ASC compliance on a daily, weekly, or annual basis.

The consequences for non-compliance are serious: Failure to perform these checks in a prompt, appropriate manner can not only result in financial penalties but also raise patient and staff safety risks.

Here's a checklist that outlines many of the things you should check regularly to ensure ASC compliance. Consider printing this checklist or using it as a starting point for building your own ambulatory surgery center regulatory compliance guide.

Daily Checks

Inspect and clean medication refrigerators
Inspect blanket or fluid warmers
Ensure crash carts are readily available
Inspect malignant hyperthermia (MH) carts
Inspect emergency equipment
Ensure exits and corridors are obstruction-free
Inspect autoclaves

Weekly Checks

Inspect and clean eyewash stations
Ensure emergency generators are in working order
Ensure nurse call systems are in working order

Monthly Checks

Inspect exit lights
Inspect emergency lighting
Ensure generators are in working order
Inspect medications, specifically expiration dates, and dispose of expired medications
Ensure fire extinguishers are in working order
Inspect and stock interior contents of crash carts
Take pest control actions, if needed

Quarterly Checks

Inspect HVAC systems
Complete quality assurance and performance improvement (QAPI) committee notes, reports, and minutes — including information from the safety, infection prevention, and pharmacy coordinators — and review occurrence reports
Practice fire drill protocols
Inspect and clean ice machines
Send dosimeters for readings

Annual Checks

Review and revise safety plans
Summarize fire extinguisher checks and check fire alarm system, including smoke and fire dampers
Review and practice disaster drills
Inspect medical gas and vacuum systems
Review and revise policies and procedures
Count DEA narcotics
Conduct staff immunizations
Educate staff on OSHA, HIPAA, CEMP, and other ASC compliance requirements
Review contracts for quality, using this contract agreement evaluation tool
Inspect fire doors
Clean HVAC ducts
Inspect C-arms/lasers
Inspect and perform radiation safety protocols

At Least Annually

Evaluate personnel records for date-sensitive information
Complete competency requirements
Perform staff credentialing and re-credentialing
Perform peer review
Complete mandatory state reports and CMS quality indicators

Staying on Top of ASC Compliance Requirements

Who in your ambulatory surgery center is responsible for performing these checks? Not just the administrator! This is simply too much for one person to tackle on their own, and expecting one person to handle it all increases the likelihood of errors or missed compliance requirements.

Delegate the work to other managers, leads, and staff, ensuring multiple people know how to perform each check and task. Outside vendors can also support ambulatory surgery center compliance checks.

It’s important to hold people accountable for their tasks and create tools to simplify the process for everyone involved. If you fall behind even slightly, catch up quickly, and identify what needs to happen to ensure you stay on top of requirements and timelines going forward. Anticipate the unexpected, whether it be the absence of a leader or a major event, like a natural or manmade disaster. And most of all, take good care of your employees — they can and will help ensure your ambulatory surgery center maintains year-round compliance.

Frequently Asked Questions (FAQ)

1. What are ASC compliance checks?

ASC compliance checks are tasks either required or strongly recommended by regulators such as CMS, state health departments, ASC accreditation organizations, OSHA, the CDC, and others. The checks range from inspecting equipment to ensuring staff credentialing to reviewing protocols.

2. Why is it important for my ASC to perform regulatory compliance checks?

Staying on top of required or recommended compliance checks helps ASCs avoid financial penalties from regulatory organizations. Performing regular compliance tasks can also help ASCs ensure their equipment and protocols are up to date, thereby minimizing the risk to patients and staff.

3. How often should my organization perform ASC compliance checks?

The frequency with which an ASC should perform compliance checks depends on the task itself. ASCs should inspect and maintain their immediate equipment daily, for example, but can plan to review safety procedures and inspect higher-level equipment monthly or annually.

4. Who should perform ASC compliance checks?

Compliance tasks shouldn’t fall on administrators alone. Instead, everyone should be responsible for ASC compliance, and leaders should delegate tasks to various staff members.

5. How can a compliance checklist help my ASC stay on top of required tasks?

Using templated compliance checklists can help leaders hold staff accountable to completing their tasks in a timely manner. Checklists can provide details on specific tasks and a calendar for when tasks should be completed.