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The ASC Plan of Correction: A Practical Guide

By: Rommie Johnson, MPH, PMP
Program Director

Posted:August 22, 2025

Every ACHC ambulatory surgery center survey that yields a citation triggers the need for a plan of correction (POC). A post-survey summary of findings is typically sent within 10 business days of the final survey day, and your organization then has 10 calendar days to detail how and when you will correct each area of noncompliance. Missing this deadline causes delays and jeopardizes your center’s accreditation. Using the online ACHC POC form simplifies and speeds your process.  

Key POC elements 

A strong POC addresses the following four elements. The ACHC POC template makes it easy to ensure that each requirement is addressed. 

 
Part A: Taking action

The focus on action involves two categories: interim fixes to immediately eliminate potential harm and longer‐term solutions that prevent recurrence. For example, suppose your surveyor noted: “Patient discharge instruction sheets for 3 of 20 medical records lacked the patient’s signature.” 

Your POC might state: 

  • Immediate action: On the day the finding was identified (8/1/2025)—this could be during the survey or when the summary of findings was received—charge nurse Jackson implemented a “no discharge without signature” protocol. Any patient chart missing a signature now triggers an immediate electronic alert in the EHR, preventing the chart from closing until the signature line is completed.
  • Extended action: On 8/3/2025, Quality Coordinator Martinez worked with IT to update the EHR template so that discharge instruction fields are auto flagged if unsigned. Additionally, the “Discharge Protocol” policy was rewritten to emphasize the nurse’s role in verifying signatures before patient release.

Specifying who completed each action and when gives ACHC reviewers confidence that the deficiency was corrected and that ongoing systemic safeguards have been built in. 

Part B: Documenting Internal Approval

ASCs often involve multiple leaders—medical directors, nurse managers, and QI committees. Knowing who assumed responsibility for a specific process change is critical for tracing the flow of information. For our discharge form example, your POC might state: 

  • Nursing leadership approval: Nurse Manager Alvarez reviewed and endorsed the “no discharge without signature” protocol on 8/1/2025.
  • Medical director sign‐off: Dr. Patel approved the updated Discharge Protocol policy on 8/7/2025.
  • Quality improvement committee:The QI Committee signed off on the EHR template changes during the monthly meeting on 8/15/2025.

Concise email threads, meeting minutes, or electronic signature logs save time and ensure that each Part A action was officially sanctioned. Include each approver’s name, role, and approval date to eliminate ambiguity. 

Part C: Building shared knowledge

Education in an ASC often takes the form of brief in–service meetings, huddles, or e‐learning modules. Craft Part C of your POC to cover who was trained and what was taught. Continuing our discharge‐form scenario: 

  • Who was educated: All RNs and LPNs who staff ORs and post‐op recovery.
  • Training provided: A 20-minute, in‐service meeting on 8/8/2025 demonstrated the updated EHR discharge workflow, followed by a short virtual refresher for alternate shift nurses.
  • Supporting documentation: Upload any relevant slide deck or instructional material along with a roster showing signatures from the attendees.

With ACHC’s customer platform, you can store attendance rosters, slide decks, and even short video snippets of training sessions inside the POC folder. If your planned training session(s) occur beyond the 10-day window for submission of the POC, indicate the expected date in the template and upload final documentation as soon as it becomes available. This way, ACHC’s clinical review team can see tangible proof that your staff has been trained on exactly what to do and why. 

Part D: Making it important—monitoring

This section of the POC outlines how you will track compliance over time. Without a robust monitoring plan, immediate fixes can unravel. As an example, your monitoring might include: 

1. Chart audits: Beginning 8/7/2025, the Quality Coordinator will audit 10 randomly selected discharge records every week for signature completion.

2. Benchmark thresholds: The ASC will aim for 95% signature compliance for six consecutive weeks. If the rate drops below 90% in any given week, the Quality Coordinator will convene a focused huddle to identify root causes.

3. Reporting structure: The Quality Coordinator will present compliance percentages and trend graphs to the ASC’s Quality Improvement Committee at each monthly meeting.

Specify who performs each monitoring action, the frequency, and the compliance threshold. You can set an end date or reduce monitoring frequency once compliance is well established. This demonstrates that monitoring is not a limited activity but a sustained priority. 

Leveraging ACHC tools to simplify your POC

ACHC’s customer platform equips you with audit templates, secure document upload, and automated reminders for POC deadlines. A few practical tips: 

  • Uploading policies: Label them clearly—e.g., “DischargeProtocol_REVISED_08102024.pdf”—so the review team can easily compare changes.
  • Track approval emails: Forward any approval emails into the platform’s POC workspace. This avoids hunting through your inbox when deadlines loom.
Remember

When your ASC survey uncovers deficiencies, it can feel like a setback. More effectively, you can see these as opportunities to strengthen systems, protect patients, and demonstrate your commitment to continuous improvement.  

A complete, thoughtful POC turns survey feedback into an action plan. Structuring your POC via Parts A–D keeps the documentation succinct and positions your ASC for fewer requests for revision from the review team.  

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