On a monthly basis you must review and check for expired supplies and medications inside the anesthesia cart. Outdated medications are removed and destroyed in accordance with federal, state and local pharmacy regulations.

Each patient care bed, the operating room, patient restroom and procedure room must be equipped with Code Blue / Nurse Call alert system.

If potential malignant hyperthermia triggering agents such as isoflurane, sevoflurane and desflurane and the depolarizing muscle relaxant succinylcholine are ever used, or present in the facility you must have the supplies for treating malignant hyperthermia and all staff must perform a malignant...

Requirements must be met to provide patient care in the surgery center. The governing body must have approved processes for initial appointment and re-appointment of the medical staff.

Follow instructions for use for properly cleaning laryngoscope blades and handle. The operating room is equipped with a laryngoscope that is functional and is cleaned as appropriate, high level disinfection or sterilized.

You must ensure that you are storing supplies and products accordingly to written manufacturers storage instructions. Document daily the temperature of the warming cabinet. Forced air warmers are used to maintain the patients temperature.

The staff of the surgery center must have state required immunizations or tests, inoculations or refusals. You must have present in the file a copy of health clearance, TB Test, TB Questionnaire, Influenza Vaccination or refusal, Hepatitis or waiver and COVID-19 vaccination. Some states require...

416.41 The Governing Body determines the missions, goals and objectives of the ASC. The Governing Body has oversight and accountability for the quality assessment and performance improvement program, ensures the facility policies and programs are administered so as to provide quality healthcare ...

If you have or are seeking Accreditation with QUAD A / AAAASF, you must have posted in a prominent area a copy of their specific Patient Rights and Responsibilities which you can download from https://www.quada.org/it/patients.

A complete copy of the current ACLS algorithm must be available on the emergency cart.

All staff members are instructed in fire and evacuation safety procedures and devices. Fire Drills are conducted on a quarterly basis. Preparation of drills include job description, evacuation route, area of safety outside the building, extinguishing of fire, drill scenario and evaluation check...

A list of high alert and look alike sound alike medications are present in the facility. Processes are in place to prevent errors from administration of these medications.

The Governing Body assumes full legal responsibility and has oversight for the quality improvement program, policies and procedures, developing and maintaining a disaster preparedness plan, contract services and establishing strategic direction & supporting its accomplishments.

Procedures are in place for obtaining, identifying, storing and transporting specimens.

The patient who leaves the surgery center after the surgical intervention is physically stable, has received post-operative teaching, and is accompanied by a responsible adult companion.

Nurse call system is an immediate alert response device. It provides an audible noise to the exact location of the patient.

You want to inspect the operating room flooring at periodic intervals for wear and tear. You can be cited if the flooring shows signs of deterioration, cracks and tears in the flooring.

Form an instructions for use (IFU) library for the medications inside your refrigerator. Make sure you know the storage requirements and the temperature parameters. Have a discussion with your inspector regarding what is inside the refrigerator.

This is a brief overview of the shelf life of the glucose control solutions and testing strips. Also read the manufacturer's instructions on how to clean the glucose meter.

Each Day the crash cart must be checked to ensure that there was no tampering of the medications and supplies. Make sure to check that the defibrillator and suction can run on battery and that they are working. Make sure you have a full E-cylinder of Oxygen. Always have available the latest AC...

You must document / record all patient surgery's in a log book or ledger.

Sharps waste is a form of biomedical waste composed of used "sharps", which includes any device or object used to puncture or lacerate the skin. Sharps waste is classified as biohazardous waste and must be carefully handled. Make sure you know the frequency of biohazardous pickup at your ASC.

Each day it is important to check all of you patient care equipment. This is mandatory. During the inspection process a surveyor will turn on equipment to ensure that it is functioning.

Preventative maintenance inspections on equipment by a qualified individual is vital to the performance of the equipment. It is also mandatory. You must document the frequency of testing and ensure that all of your equipment has been appropriately tagged by the biomedical engineer.