ASD Management

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Avoid Medicare Surveyor Citations of Deficiency in Your Governing Body Minutes

by Sandra Jones
 Executive Vice President, ASD Management

This Q&A has been reprinted from its original publication by the Florida Society of Ambulatory Surgical Centers (, to which Sandra Jones is a regular contributor.


Question: After talking to fellow surgery center administrators, I learned some inspectors are citing deficiencies because of governing body minutes. What should I put in my minutes?

Answer: The state surveyors have spent time in training on the Medicare Conditions for Coverage. During inspections, the surveyors have been familiarizing themselves with your organizational structure, bylaws and policies. So a surgery center may receive a citation tied to a Medicare Condition for Coverage when the staff does not follow the organization’s own bylaws or policies. The surveyors seem to be looking at how they will find evidence of governing body activities within your organization. That does not mean they have less expectations for a small surgery center than for a large, high volume surgery center.

For a small surgery center with a few physicians handling all committee and governing body activities versus one with dozens of physicians serving on committees and governing body, the responsibilities are not different. So the documentation of the fulfillment of those responsibilities would not be different in the eyes of surveyors. As surgery center managers, we know a surgery center with a few physicians who are the only users and owners, the few physicians are the ones involved in quality assessment and performance improvement (QAPI) daily. And they are the governing body too. Regardless of the complexity of the organization, the same regulations apply and the same documentation needs exist.

By focusing on the Medicare Conditions for Coverage and the Interpretive Guidelines’ specific mention of the governing body, we can get a good idea of what should be put in minutes.

Medicare §416.41 Condition for Coverage, Governing Body and Management states “The ASC must have a governing body that assumes full legal responsibility for determining, implementing and monitoring policies governing the ASC’s total operation. The governing body has oversight and accountability for the quality assessment and performance improvement program, ensures that the facility policies and programs are administered so as to provide quality healthcare in a safe environment, and develops and maintains a disaster preparedness plan.”

Reading the Interpretive Guidelines assists in understanding what surveyors will look for in documentation of activities. The guidelines include statements such as:

  • Delegations of governing body authority should be documented in writing.
  • The governing body is not only responsible for adopting formal policies and procedures that govern all operations within the ASC, but also it must take actions to ensure that these policies are implemented.

The guidelines also list some items that surveyors are to research.

  • What are typical items on the governing body’s meeting agenda and how often do they meet?
  • Where is evidence of how the governing body monitors internal compliance with and reassesses the ASC’s policies?
  • Is there any evidence of data collected and submitted to the governing body related to specific ASC policies?

Let’s stop here for a minute and cite an example. You would have a policy on how instruments are processed. The governing body approves the policy. You implement it. You collect data that shows you have monitored the implementation and performance of the staff. You report to the governing body your findings. Perhaps the governing body members made a suggestion about modifications to the policy, or asked if you were following national guidelines from AAMI or another national organization. Maybe there was a question about training of staff and whether any had attended an outside education event or if there were reference materials available for staff. When you put in the minutes a summary of these activities and comments, demonstrating your governing body is active in oversight, quality assessment, and the administration of policies to provide quality healthcare in a safe environment, you have provided evidence to the inspectors of your governing body’s fulfillment of their responsibility.

In fact, in the Interpretive Guidelines for §416.41 it states, “The governing body is responsible for establishing the ASC’s policies, making sure that the policies are implemented, and monitoring internal compliance with the ASC’s policies as well as assessing those policies periodically to determine whether they need revision.” The preceding paragraph gives an illustration of how you document compliance to the governing body’s responsibility.

The Medicare Conditions for Coverage have several references to governing body responsibility. Some surveyors are closely reading minutes to look for documentation of credentialing and privileging activities and governing body approval. They are looking for more than “All reappointments are current” when reappointments are presented to the governing body. They are looking for more than “See attached minutes of the quality improvement committee.” Surveyors want to see some “meat” in the minutes, something that demonstrates the governing body is active in assuming their responsibilities.

One great thing about digital documents is that you can do a word search. Use word search to focus your learning of regulations and inspection expectations. Open the CMS Appendix L document and put governing body in the search cell. Read all the areas that mention governing body and make notes of the expected activity. Think about how your minutes, sign off on forms or reports, and on-going QAPI activities help you document your actions and the involvement of and oversight by your governing body. You will probably find you made a lot of notes and now have a better idea of what you need to put in minutes.

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