Survey Program

Inspection/Survey Process

The Department of Health (department) licenses more than 180 ambulatory surgical facilities (ASF) in Washington to provide outpatient surgical services within the minimum health and safety standards established by state law. In addition to state licensure, ASFs may choose to become Medicare-certified as an ambulatory surgery center (ASC), or accredited by a department-approved accrediting organization.

The department is required to conduct an on-site survey no more than once every 18 months for each licensed ASF. Surveys are unannounced. Facilities that receive a Medicare and/or accreditation survey are able to count either of these surveys as meeting one of the 18-month state surveys within the three-year licensing period (see notification requirement below). This provision reduces the burden on these facilities and eliminates unnecessary duplicative surveys.

Surveys are conducted by registered nurses and other health professionals who are trained to inspect ASFs to confirm compliance with state regulatory standards found in chapter 246-330 WAC and chapter 70.230 RCW. The survey process may examine all aspects and phases of the ASF operation necessary to determine compliance with applicable regulations. A surveyor's primary concern is system-wide deficiencies that pose patient safety risks. On-site surveys can last two or three days, depending on the size, practice type, and complexity of the ASF.

After the on-site survey is completed, the surveyor will verbally share with the ASF staff the initial findings, and will discuss any issues that require education or clarification. The surveyor will then produce a written statement of deficiencies (SOD) and send the SOD to the ASF. This is the official notice of deficiencies regardless of discussions occurring during or after the inspection. Once the ASF receives the SOD, it must develop a written plan of correction (POC) that will describe, in detail, how the deficiencies will be addressed and corrected. Surveyors will review the POC and either accept the plan as written or require the ASF to make additional modifications in order for the plan to be acceptable. The surveyor may request documents or other evidence of compliance as opposed to a rewrite of a POC.

Notifying the department of a recent survey

An ASF that receives a Medicare or accreditation survey must notify the department within two business days following the completion of the survey (WAC 246-330-105). Notice of the accreditation or Medicare certification decision must be submitted in writing within 30 calendar days of receiving the report from the accrediting organization. Please send your notifications to the department's Office of Health Systems Oversight. Notice is not required for a Medicare-certification survey conducted by the department.

Annual information update requirement

ASFs are required to submit to the department updated licensing information before December 31 of each year (WAC 246-330-100(2)). Updating facility information is important in order to keep licensing data accurate. This requirement is satisfied by completing the standard ASF licensing application with current facility information. Fees are not required when submitting annual update information. Please send your annual update to the address listed within the instructions of the application.

Inspection Tools

How to prepare for your survey

Most commonly cited deficiencies