Common Citations in ASCs

Q: What is one of the main reasons that ambulatory surgery centers (ASCs) get cited for deficiencies in relation to testing, inspection, and maintenance activities for Life Safety equipment?

A: I have found that ASCs often make the mistake of assuming that outside vendors for the inspection, testing, and maintenance of the ASC’s medical gas, back-up generator, fire alarm, and fire sprinkler systems are adhering to the required NFPA standards. When educating ASC staff on the deficiencies that I find, they often ask, “Well, shouldn’t the vendor know what is required by NFPA?” That’s a great question, but does the vendor know that your facility has to follow the NFPA standards? Not every one of their clients does. The vendor usually knows exactly what is required by the standards, but they will only perform the tasks that are spelled out in the service contract that they have with the ASC or building management.

One of the main issues is that the ASC staff does not know what is required by the NFPA standards. The best way to solve the problem is through education; taking the time to review the standards and getting to know the requirements is very beneficial for anyone who is responsible for making sure that the ASC’s utilities are properly maintained. A basic internet search for testing, inspection, and maintenance requirements for the specific utility systems leads to many resources. Even contact with the vendor can be enlightening. It is also a good time to make sure that the vendor is aware of standards the ASC has to follow and if the vendor has a good grasp on what is required by those standards.

Another issue is that ASC staff does not really review the contracts to make sure that all required elements of the standards are covered. If it is not in the contract, it probably doesn’t get done. Over the years, as ASC personnel change and new individuals are responsible for the care of the ASC utilities, they often assume that whoever approved the service contracts in the past actually read them and made sure that the contracts included all the required tasks. Requirements also change over the years and the changes need to be reflected in the contract; therefore, service contracts should be reviewed periodically and they should especially be reviewed when they have reached their end and a new contract is going to be signed.

Scott Furgason, CFPS, CFI, CFPE

As a life safety surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC), Scott has conducted hundreds of accreditation surveys for healthcare organizations throughout the United States.

With expertise in policy development, risk assessments, personnel management, fire inspections, fire plan review, and fire prevention, Scott is a knowledgeable asset for his clients. He currently performs survey readiness services across the United States for healthcare organizations, with a particular emphasis on ambulatory surgery centers.