Most Common Deficiencies For AAAHC Chapter 4 “Quality of Care”
The most common deficiencies our surveyors see for Chapter 4 “Quality of Care” of the AAAHC Accreditation Handbook for Ambulatory Health Care:
All personnel assisting in the provision of health care services are appropriately qualified and supervised and are available in sufficient numbers for the care provided. Often, we see that providers are not privileged to supervise the CRNAs, AAs, PAs, FNPs and First Assists they are responsible for.
Medication reconciliation is performed. This is one of the most common deficiencies. This is a required standard but many centers have no documentation for medication reconciliation.
Specimens – Logging and tracking ensures results for each specimen are obtained. Results for each specimen are reported to the ordering health care provider. Ideally, the specimen log has the patient’s name or account number, the type of specimen, the location the specimen was taken from, the date, the ordering provider, and the lab it was sent to. Then, when the pathology report arrives, it should also be logged in. Once the provider has reviewed and initialed the pathology report, this would be logged in as well. Some centers do have an electronic system. Any type of system is sufficient as long as it serves as a method of checks and balances so that no specimens or reports fall through the cracks.
Many Chapter 4 requirements cross over with Standards in other chapters of the Handbook. Therefore, if you have a deficiency in a different chapter, and it is also required in Chapter 4, you will likely be cited for that deficiency in Chapter 4, resulting in two deficiencies for a single issue.
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*Sources:
“AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.
HealthCon Consultant survey experience