WAC 246-330-025   Department responsibility -- On-site survey and complaint investigation.  This section outlines the department's on-site survey and complaint investigation activities and roles.

     (1) Surveys. The department will:

     (a) Conduct on-site surveys of each ambulatory surgical facility every eighteen months or more often using the health and safety standards in this chapter and chapter 70.230 RCW;

     (b) Accept, in accordance with RCW 70.230.100(2), as a substitute for the department's eighteen months on-site survey, on-site surveys conducted by the Joint Commission, Accreditation Association for Ambulatory Health Care, American Association for Accreditation of Ambulatory Surgery Facilities or the Centers for Medicare and Medicaid Services as substituting for the eighteen month state survey requirement once every three years;

     (c) Notify the ambulatory surgical facility in writing the survey findings following each on-site survey;

     (d) Require each ambulatory surgical facility to submit a corrective action plan addressing each deficient practice identified in the survey findings; and

     (e) Notify the ambulatory surgical facility when their submitted plan of correction adequately addresses the survey findings.

     (2) Complaint investigations. The department will:

     (a) Conduct an investigation of every complaint against an ambulatory surgical facility that concerns patient well-being;

     (b) Notify the ambulatory surgical facility in writing of complaint investigation findings following each complaint investigation;

     (c) Require each ambulatory surgical facility to submit a corrective action plan addressing each deficient practice identified in the complaint investigation findings; and

     (d) Notify the ambulatory surgical facility when the facility submitted plan of correction adequately addresses the complaint investigation findings.

     (3) The department may:

     (a) For the purpose of meeting the every eighteen month survey requirement in RCW 70.230.100(2), allow an ambulatory surgical facility to conduct a self-survey once every three years if the previous three department inspections did not reveal any significant deficient practice;

     (b) Direct an ambulatory surgical facility on how to implement a corrective action plan based on the findings from an on-site survey or complaint investigation; or

     (c) Contact an ambulatory surgical facility to discuss the findings of the Joint Commission, Accreditation Association for Ambulatory Health Care or American Association for Accreditation of Ambulatory Surgery Facilities on-site accreditation survey.



[Statutory Authority: Chapter 70.230 RCW. 09-09-032, § 246-330-025, filed 4/7/09, effective 5/8/09.]