Most common deficiencies for AAAHC-ASC

Most common deficiencies for AAAHC Chapter 2 “Governance”, Subchapter I “General Requirements” In order to avoid deficiencies for Governance I, the governing body must meet a minimum of once a year and keep documented minutes. Most centers have a board that meets and keeps minutes; however, the minutes must include an annual review of the items below. Minutes lacking this approved list is the most common deficiency surveyors see for Subchapter 2.I: 1. Rights of Patients 2. QI Management & Improvement Program 3. Infection Prevention and Control Program 4. Annual Safety Program 5. Policies and Procedures 6. Scope of Care 7. Job descriptions for officers such as Director, Administrator, and Medical Director These items are simple to add to the annual board minutes and also meet Standard G: Annual Review of AAAHC accreditation requirements. Another often deficient Standard is D that requires: “Within 15 Calendar days of significant organization ownership, operational, or quality of care events, the organization notifies AAAHC of the event in writing.” Some organizations fail to let AAAHC know when: 1. The name of the organization changes 2. Majority ownership changes 3. Re-location of the center or an addition in number of ORs 4. Anesthesia level change from MAC to General 5. Change from single specialty to multi-specialty 6. Change in management company or administrator Kristine Mighion