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.

Narcotics or Controlled Substances must be locked in the narcotics lock box.

The crashcart must be inspected on a monthly basis for outdates by an ASC staff member. Evidence of monthly checks must be documented.

Fire extinguishers are located within the ASC and must be checked on a monthly basis. Annually an approved vendor will recharge the fire extinguisher.

Ensure that you have the 2 copies of the manufacturers instructions at the site of the UPS. Test the UPS according to manufacturers instructions and test to the requirements of the accrediting organization.

Privacy Curtains must display the fire retardant tag. If you do not have one notify the company who installed the curtains and they will provide you with a certificate if the curtains are fire retardant.

You want to ensure that you have SDS sheets for every chemical and hazard item in the ASC. Also you must form a list of all chemicals inside the ASC. This list must be approved by the Governing Board.

Emergency pull cord must be easily accessible to patients and will be fully functional.