7 Survey Readiness Mistakes ASCs Make (and How to Fix Them Before Your Next Audit)

Survey day arrives. The surveyor walks through your doors: CMS, AHCA, or AAAHC. Your team scrambles. Binders get pulled. Staff freeze when asked basic compliance questions.

Sound familiar?

Most ASC citations stem from preventable gaps. Not negligence. Oversight. The difference between a clean survey and a corrective action plan often comes down to preparation that happens months before surveyors arrive.

Here are seven mistakes ambulatory surgery centers make repeatedly: and exactly how to fix them before your next audit.

Mistake #1: Credentialing Shortcuts

Why It Happens

Credentialing feels administrative. Busy ASCs treat it as checkbox work. Files get created, then forgotten.

What Surveyors Find

• Missing or outdated privilege forms

• Incomplete primary source verifications

• Absent peer review data

• Expired licenses, DEA registrations, or malpractice insurance

• No OIG/SAM exclusion checks

Why It Matters

Credentialing deficiencies signal systemic governance problems. CMS and accrediting bodies view incomplete files as patient safety risks.

The Fix

• Audit every provider file using a structured checklist

• Verify Governing Body approval for delineated privileges

• Include FPPE/OPPE documentation

• Run OIG/SAM checks monthly

• Set calendar reminders 90 days before expirations

Mistake #2: Infection Control Weaknesses

Why It Happens

Daily operations take priority. Environmental rounds get skipped. Logs fall behind.

What Surveyors Find

• Dust accumulation in high areas or behind equipment

• Expired supplies or disinfectants

• Incomplete sterilization logs

• Poor point-of-use instrument care

• Missing Safety Data Sheets

Why It Matters

Infection control ranks among the most-cited survey areas. A single expired disinfectant or incomplete log can trigger a deficiency.

The Fix

• Conduct weekly environmental rounding with documented checklist

• Standardize point-of-use cleaning protocols

• Review sterilization logs monthly with your infection preventionist

• Verify all disinfectants have current SDSs and correct contact times

• Train all staff on proper cleaning and sterilization procedures

Consider scheduling Infection Control Annual Training to keep your team current.

Mistake #3: Documentation Gaps in Medical Records

Why It Happens

Clinical staff focus on patient care. Documentation becomes secondary. Small omissions accumulate.

What Surveyors Find

• Missing or outdated history and physical updates

• Incomplete risk assessments

• Unsigned or non-specific informed consents

• Absent patient education documentation

• Sedation records missing vital signs or monitoring intervals

Why It Matters

Medical record deficiencies appear in nearly every survey. Each missing element represents a potential citation.

The Fix

• Audit minimum 10 records monthly

• Implement day-of checklist for pre-op nurses

• Ensure consents are procedure-specific, complete, and witnessed

• Verify post-op call documentation exists for every patient

• Create standardized templates for common documentation gaps

Mistake #4: Emergency Preparedness Plans Collecting Dust

Why It Happens

Emergency plans get created during initial licensure. They sit in binders. Years pass without updates.

What Surveyors Find

• Outdated Hazard Vulnerability Assessments

• Poorly documented or unrealistic drills

• No local emergency management contacts

• Staff unable to articulate their emergency roles

• Generic plans not customized to facility location or services

Why It Matters

CMS Emergency Preparedness requirements demand active, facility-specific planning. A binder on a shelf fails inspection.

The Fix

• Update HVA annually with current threat assessments

• Run and document tabletop drills yearly through QAPI

• Establish relationships with local fire department and EMS

• Train all staff on your specific emergency plan: not generic protocols

• Test communication systems quarterly

Need a compliant plan? Explore Comprehensive Emergency Management Plan services.

Mistake #5: QAPI Documentation That Doesn't Tell the Story

Why It Happens

Quality improvement happens informally. Meeting discussions never make it to paper. Data gets reviewed but not analyzed.

What Surveyors Find

• QAPI minutes lacking analysis or action items

• Incident follow-up not documented

• No evidence of benchmarking

• Missing root cause analysis

• Improvement activities without measurable outcomes

Why It Matters

Surveyors need to see your QAPI program working: not just existing. Undocumented improvement equals no improvement in survey terms.

The Fix

• Use standardized QAPI template capturing findings, analysis, actions, and outcomes

• Create QAPI calendar for monthly and quarterly reporting deadlines

• Link data trends to root cause analysis

• Document all training resulting from quality findings

• Track metrics over time to demonstrate improvement

Mistake #6: Time Out Process Without Documentation

Why It Happens

Surgical teams perform time outs routinely. The process becomes automatic. Documentation gets overlooked.

What Surveyors Find

• Time out performed but not documented

• Missing elements in documentation

• No verification of process from scheduling through surgery

• Inconsistent compliance across different surgical teams

Why It Matters

Wrong site surgery prevention requires documented proof. Verbal confirmation without written evidence creates citation risk.

The Fix

• Implement standardized time out checklist

• Require documentation signature from all participating team members

• Verify process begins at patient scheduling

• Audit time out documentation weekly

• Address compliance gaps immediately through staff education

Mistake #7: Reactive Instead of Proactive Compliance Culture

Why It Happens

Survey preparation happens when survey notification arrives. Compliance becomes an event, not a practice.

What Surveyors Find

• Staff unable to answer basic compliance questions

• Last-minute document preparation visible

• Inconsistent routine checks

• No evidence of ongoing internal auditing

• Training records clustered around survey dates

Why It Matters

Surveyors recognize reactive compliance immediately. It signals deeper organizational issues.

The Fix

• Train staff regularly on survey expectations year-round

• Conduct routine checks consistently: not just before surveys

• Run regular drills for fire, power outages, and emergencies

• Perform random internal audits monthly

• Build compliance into daily workflows

A Facility Mock Survey identifies gaps before surveyors do.

Quick Self-Audit Checklist

Use this monthly to maintain survey readiness:

Credentialing

• All provider files current and complete

• OIG/SAM checks documented

• Privileges match current scope of services

Infection Control

• Environmental rounding completed and documented

• Sterilization logs current

• No expired supplies or disinfectants

• SDSs accessible and current

Medical Records

• 10+ charts audited this month

• Consents complete and procedure-specific

• Post-op documentation present

Emergency Preparedness

• HVA updated within past 12 months

• Drill conducted and documented this quarter

• Staff can articulate emergency roles

QAPI

• Meeting minutes include analysis and action items

• Incidents documented with follow-up

• Data trends tracked with measurable outcomes

Time Out

• Documentation present in all charts

• All required elements captured

Organizational Readiness

• Staff training current

• Internal audits conducted

• Compliance integrated into daily operations

Build Survey Readiness Into Your Culture

Survey citations rarely result from intentional non-compliance. They stem from gaps that grow over time. Monthly attention prevents annual panic.

The goal: when surveyors arrive, your team responds with confidence: not scrambling.

Ready to Strengthen Your Survey Readiness?

The Mensah Group LLC partners with ASCs to build sustainable compliance programs. From mock surveys to staff training to emergency management planning, we help you prepare before surveyors arrive.

Schedule an Initial Consultation to identify your compliance gaps and create an action plan.

Visit The Mensah Group LLC to explore our full range of ASC consulting services.