7 Mistakes You're Making with ASC Survey Prep (and How to Fix Them Before It's Too Late)

Survey day at your Ambulatory Surgery Center. Surveyors walk through the door. Your team freezes. The next few hours determine whether you pass, receive citations, or face temporary closure.

Most ASC administrators know this feeling. The stress. The uncertainty. The nagging thought that something got missed.

Here's the thing: survey failures rarely happen because of one catastrophic mistake. They happen because of small, preventable oversights that compound over time.

These are the seven mistakes we see most often: and how to fix them before surveyors arrive.

Mistake #1: Skipping Mock Surveys

The assumption: chart reviews and staff emails are enough preparation.

The reality: paper preparation doesn't reveal operational gaps.

Mock surveys expose problems that desk audits miss. One facility discovered a physician dictating cases before procedures were even performed: a major violation that would have triggered immediate citation during the actual survey.

The Fix:

• Schedule mock surveys with experienced consultants at least 90 days before your accreditation survey

• Ensure the consultant conducting your mock survey won't be your actual surveyor (this is prohibited)

• Treat mock surveys like the real thing: no special preparation announcements

• Document all findings and create corrective action plans

Mock surveys aren't optional extras. They're risk mitigation tools.

Mistake #2: Neglecting Hand Hygiene and Medication Handling

Hand hygiene remains one of the most consistently cited deficiencies. Year after year. Survey after survey.

Common violations include:

• Failure to scrub medication hubs

• Not allowing prep solutions adequate drying time

• Improper medication handling practices

• Inconsistent handwashing technique

These seem basic. Surveyors still catch them constantly.

The Fix:

• Create a "cheat sheet" listing commonly cited violations

• Distribute quick reference note cards to anesthesiologists, CRNAs, and physicians

• Post visual reminders at scrub stations and medication prep areas

• Conduct unannounced hand hygiene audits monthly

Staff know the protocols. They need reminders to execute them consistently under pressure.

Mistake #3: Disorganized or Inaccessible Documentation

Surveyor asks for your emergency preparedness plan. Staff scrambles. Five minutes pass. Ten minutes. The document appears: outdated and unsigned.

Disorganized documentation signals larger operational problems to surveyors. It also wastes precious survey time and increases scrutiny.

The Fix:

• Implement digital documentation systems with organized file structures

• Create a master binder (physical or digital) with all survey-critical documents

• Assign one staff member as documentation coordinator

• Review and update all policies quarterly

Documentation issues lead to compliance citations, expensive fines, delayed approvals, and in severe cases, temporary closure. Organization prevents these outcomes.

Need comprehensive policies for your ASC? Check out our Policies & Procedures Package for ready-to-customize templates.

Mistake #4: Incomplete or Inaccurate Surgical Records

Missing H&Ps in operative reports. Staff completing paperwork before cases conclude. Unsigned consent forms. Incomplete anesthesia records.

Each represents a documentation failure. Each triggers citations.

The most problematic: staff completing paperwork before procedures finish. This violates accreditation standards and suggests falsification of medical records.

The Fix:

• Use tracer methodology during internal audits to review documentation

• Observe direct patient care alongside chart review

• Verify all required documents are complete before patient discharge

• Enforce policies that prevent premature paperwork completion

• Conduct random chart audits weekly

Surgical records tell the story of patient care. Incomplete stories raise red flags.

Mistake #5: Environmental Safety Oversights

Crash cart not checked. Expired medications on the shelf. Dust on equipment. Biohazard containers overflowing.

Environmental issues are immediately visible to surveyors. They walk through your facility before interviews begin. They notice everything.

Common oversights include:

• Crash cart readiness failures

• Expired supplies on anesthesia carts

• General housekeeping deficiencies

• Outdated medications in storage areas

• Improper storage temperatures

The Fix:

• Establish daily crash cart verification protocols

• Implement monthly expiration date audits for all storage areas

• Create facility walkthrough checklists

• Assign environmental rounds to rotating staff members

• Document all inspections with dates and signatures

Environmental readiness reflects overall operational discipline. Surveyors know this.

Mistake #6: Unprepared Staff and Unavailable Resources

Surveyors arrive. The administrator is in surgery. The surgery schedule isn't printed. Nobody knows the Wi-Fi password. Key staff members are tied up with patients.

First impressions matter. Chaos signals poor planning.

The Fix:

Before survey day:

• Prepare printed copies of surgery schedules

• Have staff schedules immediately available

• Document Wi-Fi passwords and any system access credentials

• Identify which staff members surveyors will likely interview

• Assign those staff to minimal clinical duties during survey hours

• Designate a survey coordinator to manage surveyor needs

Surveys have time limits. Every minute spent locating resources is a minute not spent demonstrating compliance.

Mistake #7: Missing Patient-Centered Policies and Procedures

Patient rights documentation incomplete. Informed consent processes unclear. Privacy policies outdated. Patient education materials unavailable.

Patient-centered care isn't just clinical. It's documented. It's systematic. It's verifiable.

Surveyors evaluate:

• Patient privacy protections

• Informed consent procedures

• Communication of patient rights and responsibilities

• Availability of education materials

• Staff competency in addressing patient concerns

The Fix:

• Audit all patient-centered policies annually

• Ensure informed consent documents are procedure-specific

• Post patient rights in visible locations

• Stock patient education materials in pre-op and recovery areas

• Train staff on patient communication standards

• Document all patient education provided

Patient-centered policies demonstrate organizational values. Missing policies suggest those values don't exist.

For office-based practices needing comprehensive policy frameworks, explore our Office-Based Procedure Policies & Procedures.

The Bigger Picture

These seven mistakes share a common thread: they're all preventable with consistent preparation.

Survey readiness isn't a one-time event. It's an operational mindset. Facilities that pass surveys cleanly don't scramble in the weeks before. They maintain readiness year-round.

Survey prep checklist summary:

What Happens Next

Survey citations don't just mean failed inspections. They mean:

• Delayed Medicare certification

• Expensive corrective action plans

• Staff retraining requirements

• Potential temporary closure

• Reputation damage with referring physicians

The cost of prevention is always lower than the cost of correction.

Start with a gap assessment. Identify which of these seven areas needs attention. Build systematic processes to address each one.

Survey readiness is achievable. It requires consistent effort, not last-minute heroics.

Need help preparing for your next ASC survey? The Mensah Group provides consulting services, mock surveys, and ready-to-use policy templates for ambulatory surgery centers and healthcare facilities. Browse our ASC resources to get started.