Why More Surgery Centers Are Failing Accreditation

Accreditation isn’t optional—it’s your license to operate.
Yet, with QUAD A tightening their inspection process, more centers are failing to meet compliance in key areas like infection control and documentation.
If you’re relying on outdated forms or old survey prep methods, you’re putting your accreditation—and revenue—at risk.
This post outlines the top reasons facilities are failing inspections in 2025—and what to do now to stay survey-ready.

Inadequate Infection Control Practices

The problem: Lapses in hand hygiene compliance, sterilization tracking, or environmental cleaning protocols can lead to immediate citations—or even shutdowns.

What to do:

Assign a designated Infection Control Coordinator

Train all staff annually (and upon hire) with signed documentation

Surgical Techs must have evidence of sterilization competency and high level disinfection competency

Use checklists and logs to verify daily compliance (and keep them inspection-ready)

Weak Emergency Preparedness & Fire Drill Compliance

The problem: Missing fire drill reports, missing code blue drills, expired emergency contact lists, lack of recent staff drills, or no documentation of tabletop exercises.

What to do:

Schedule and document all emergency drills in your compliance calendar

Review and update your Emergency Operations Plan annually

Train staff using real scenarios—and keep signed attendance sheets

Credentialing & Privileging Gaps

The problem: Expired or missing documents in physician or provider files (licenses, DEA, malpractice insurance, board certifications, health records).

What to do:

Maintain a credentialing matrix for due dates and expiration tracking

Conduct a quarterly audit of all provider files

What To Do NOW To Stay Survey Ready:

Consult with Nicole Brown, owner of Accredia Surgery Center Inspection Preparation.

Purchase accredia.shop ready to download policies and procedures, drill templates and forms.

Subscribe to accredia TV inspection preparation channel and watch surgery center accreditation preparation videos streaming 24 hours a day.

Here’s to your success,

The ambulatory surgery center or office based surgery center must adopt, employ, and regulate policies and procedures of the center. This process will be in the form of what is called the Policy and Procedure Manual. The surgery center policy and procedure manual must have a written policy that dictates the procedure for all aspects of the center. This manual will be considered the nucleus of the center. The surgery center policy and procedure manual will describe characteristics and functions of the center and compliancy to situations to the attainment of quality patient care.

Surgery center policies and procedures are never ending. When you purchase your accreditation organization of choice standards manual, in it you will be provided with the core standard chapters in which you have to meet. While viewing the core standard chapters you get an idea of what policies your surgery center will need to adopt. Unfortunately I wish at the back of the standards manual they provide you with a list of each and every policy you need to have, but they don’t. Accredia.shop has prepared all of the ASC Policy and Procedures that are easily downloadable. The good news is when you are reading the core standard chapters or the Medicare Guidelines; you can get a good feel for the policies you need to adopt. Also refer to the index portion of the accreditation standards manual; I look at the index as a baseline for what you need and I prepared it in an easy download. Accredia’s has every policy and procedure that is current. In some circumstances the standards manual and Medicare Guidelines do mention some policies you need to have. Remember when they mention a policy make sure you have policies that cover all aspects of the subject. This way it will equip you with information you need to have written on hand and available to show.

Here’s to your success,

Tag: ASC guidelines