2024 CMS deficiencies for ASCs
The following is an excerpt from a 2025 IAQ newsletter for paying members.
CMS survey data from 2024 paints a clear picture for ambulatory surgery centers (ASC) on what to look out for: Persistent gaps in infection control, sanitation, documentation, and governance continue to trigger citations across the country.
Although the data stem from ASC reviews, the root causes and mitigation strategies have broader relevance—especially for hospital-based accreditation and quality leaders seeking to improve readiness and avoid repeat citations and deficiencies.
The most frequently cited CoP in 2024 relates to the basic requirement for ASCs to maintain a clean, functional, and sanitary environment for surgical services. While this sounds fundamental, the real challenge lies in execution and documentation.
Deficiencies were cited in areas such as:
- Ventilation and HVAC oversight in surgical suites
- Water quality monitoring
- Cleaning and disinfection processes
- Food handling and sanitation procedures
- Pest management programs.
Other areas where deficiencies were present include infection control programs, medication safety, documentation, and governance.
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