In this episode of the ASC Podcast with John Goehle we discuss the latest news, review common infection control and sanitary environment issues in ASCs and in our focus segment, discuss Navigating the Complexities of ASC Billing and Coding with Bob Lathrop from SIS.
This episode is sponsored by Surgical Information Systems,
Notes and Resources from this Episode:
Cost pressures that battered ASCs in 2025:
https://www.beckersasc.com/asc-transactions-and-valuation-issues/the-cost-pressures-that-battered-ascs-in-2025/?origin=ASCE&utm_source=ASCE&utm_medium=email&utm_content=newsletter&oly_enc_id=5567B4088734C3Z
Focus on Sanitary Environment and Infection Prevention & Control (IPC) in ASC Surveys
Sanitary environment and IPC issues consistently rank among the top deficiencies in ambulatory surgery center (ASC) accreditation and certification surveys, making this a critical "hot issue" for 2025 and beyond. These citations directly impact patient safety by increasing risks of healthcare-associated infections (HAIs), and they appear frequently across major accreditors like CMS, AAAHC, and ACHC. For context:
In AAAHC's 2025 Quality Roadmap (released September 2025), IPC remains a persistent top challenge, with deficiencies cited in nearly 90% of surveys for ASCs and office-based surgery settings.
ACHC's November 2025 survey data highlights sanitary environment lapses (e.g., sanitation issues, incomplete policies) as a leading deficiency, often tied to inconsistent implementation of hand hygiene, glove techniques, and environmental cleaning.
Historical CMS data shows patterns holding into recent years, with "Sanitary Environment" and "Infection Control Program" among the most cited, stemming from failures in basic practices like cleaning, sterilization, and safe injection protocols.
These issues often arise from documentation gaps, staff inconsistencies, or overlooked details during busy operations, even in high-performing centers.
Key Regulatory Requirements
The foundation for sanitary environment and IPC in ASCs is CMS Conditions for Coverage (CfC) at 42 CFR § 416.51, which applies to Medicare-certified ASCs and influences other accreditors (deemed status via AAAHC, ACHC, etc.).
Standard: Sanitary Environment (§ 416.51(a)): The ASC must provide a functional and sanitary environment for surgical services, avoiding sources and transmission of infections by adhering to professionally accepted standards (e.g., CDC, AORN, APIC guidelines).
Standard: Infection Control Program (§ 416.51(b)): Maintain an ongoing, coordinated program to prevent, control, and investigate infections/communicable diseases. This includes:
Designation of a qualified professional (e.g., infection preventionist) to oversee the program.
Annual risk assessment to identify infection risks.
Integration of nationally recognized guidelines (CDC core practices are mandatory if no other evidence-based standards apply).
Policies for hand hygiene, environmental cleaning, sterilization/high-level disinfection (HLD), safe injection practices, and point-of-care devices.
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