ASCs easily can avoid some of the more common problems encountered when writing a POC in response to citations.
A simple solution is to sign the report, says Jan Allison, RN, CHSP, senior director of regulatory at AmSurg.
The bottom of the report might list “laboratory director” or some other title, but that’s because the same survey reports are used for various healthcare facilities. Just sign the report and date it, Allison says.
The following are some other do’s and don’ts:
- Give separate answers for each item in one system citation.
The survey citation will list findings, but some of these will not be one-off problems. They’ll be related to a system issue, and this should be explained, including why it happened, Allison says.
“A facility could receive a sanitary environment citation based on surveyors finding dust, not cleaning beds according to manufacturer’s instructions, and not maintaining an autoclave,” she says. “When someone writes the correction, write a separate correction for each of those observations, if they’re different.”
- Note who is responsible for inspections, but don’t use actual names.
“You don’t put in people’s names, only their titles,” Allison says. “It’s the same for listing vendors.”
If an ASC has contracted with a fire alarm vendor, don’t include that company’s name in the POC, she advises.
“The [POC] is public information,” she explains. “Anyone can request a copy from the state for review, or, in some cases, find it on the internet via a search engine.”
Plus, surveyors don’t want to know the name — they just want to know the role and title, Allison adds.
- Ensure leadership is involved.
ASC leaders ultimately are responsible for every correction and monitoring results. Each finding during internal monitoring should be reported to a committee, such as a quality committee, as well as to leadership, Allison says.
- Watch deadlines.
“Make sure deadlines listed on [the] POC are not too soon and can’t be met,” Allison says. “Don’t say, ‘I can have that done next week,’ because what if there is a snowstorm and the ASC didn’t get to have the in-service?”
Instead, provide a realistic deadline with a built-in time cushion that still meets the deadline established by the state.
- Include attachments, if surveyor wants them.
Submitting attachments with a POC can be supportive evidence. For instance, if an in-service already was conducted on a citation issue, then the sign-in form with the in-service topic could be attached. Likewise, an organization could attach an invoice showing that a problem area was repaired, Allison suggests.
Just remember that some states do not want an attachment; the cover letter will provide that information.
“Most states are fine with that,” she says. “But others say, ‘Take that reference out of there.’”
- Be prepared for detailed questions.
Some surveyors will dig into the details. For example, a surveyor might note that a firewall has an unsealed penetration hole in it. The hole might have been the result of installation of cables. Provide details in the POC to indicate what kind of product was used to caulk the hole, Allison says.
“Was it a commercial, fire-rated substance?” she says. “Keep it simple, but still provide details like these in the [POC].”
Most important: Sign the report.
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