Uncover ASC Safety Gaps with Regular Rounding

By Cyndi Newman, MSHL, BSN, RN, Senior Clinical Review Specialist

Cyndi Newman is an ACHC Senior Clinical Review Specialist for office-based surgery and ambulatory surgery centers. She has over 30 years of experience as a registered nurse, surveyor, and risk manager. Cyndi is passionate about quality patient care and the collaborative nature of accreditation.

Posted: May 12, 2026

Environmental rounding in ambulatory surgery centers (ASCs) is critical to patient safety, infection prevention, and regulatory compliance. Rounding helps identify physical hazards, needed repairs, and potential sources of infection.

Findings based on observation

Proof of the importance of regular rounding is evident in the following examples of deficiencies noted by ACHC Surveyors:

  • Chipped paint on walls.
  • Compromised integrity of operating room doors.
  • Waste on the floor instead of being contained in a receptacle.
  • Overflowing linen carts or carts without a lid.
  • OR mattress pad with tears, exposing the foam.
  • Rust on OR equipment.
  • Dirty or stained cubicle curtains.
  • Clutter in hallways and corridors.
  • Stained and broken ceiling tiles.
  • Corrugated boxes.
  • Expired patient supplies.
  • Water intrusion.
  • Food/drink in clinical areas.

Each of these items is directly observable and therefore avoidable. Rounding is an opportunity to make proactive improvements that minimize risk and should be an integral part of your routine monthly processes throughout 2026.

Although CMS (Centers for Medicare & Medicaid Services) and ACHC Ambulatory Surgery Center Accreditation Standards do not dictate a requirement for the frequency of rounding inspections, both require organizations to provide a functional and sanitary environment for the provision of surgical services.

Relevant standards

05.00.06 Sanitary Environment (§ 416.51)

The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.

The ASC’s environment for services is maintained so as to avoid sources and transmission of infections and communicable diseases. All areas of the ASC must be clean and sanitary.

15.00.00 Environment

The organization must have a safe and sanitary environment, properly constructed, equipped, and maintained to protect the health and safety of patients.

Note: This is a CMS condition level requirement. § 416.44

The organization must comply with requirements governing the construction and maintenance of a safe and sanitary physical plant, safety from fire, emergency equipment, and emergency personnel.

15.00.01 Physical Environment

The organization must provide a functional and sanitary environment for the provision of surgical services.

The organization must be designed and equipped to provide safe, efficient, high-quality ambulatory healthcare services.

The physical premises of the organization and the surrounding areas used by patients (including at least all stairwells, corridors, and passageways) must meet the functional requirements listed in this chapter.

15.03.03 Clean and Orderly Facility Maintenance

The interior of the ASC, the exterior of the physical structure housing the ASC, and the exterior walkways and parking areas must be clean, orderly, and free of any defects that are a hazard to patients, personnel, and the public.

Key benefits of environmental rounding

  • Infection prevention: Regular rounding helps identify potential sources of infection, such as mold, dust, rust, expired supplies, improper storage of sterile equipment, and inadequate disinfection of high-touch surfaces.
  • Risk reduction: Environmental rounding identifies structural hazards, damaged equipment, or safety issues that could harm patients or staff.
  • Regulatory compliance: Rounding ensures your organization is prepared for surveys by ensuring ongoing compliance with standards.
  • Staff compliance and education: Regular rounding allows for real-time assessment of staff practices, including infection control, hand hygiene, PPE, and handling of patient supplies.
  • Patient satisfaction: A patient’s perspective on the cleanliness and condition of the organization directly correlates to better patient satisfaction surveys.

Tips for compliance

  • Set aside time for routine rounding.
  • Use a checklist.
  • Take notes and manage corrective actions.
  • Ensure staff have access to and are familiar with environmental and infection control policies and procedures.
  • Share findings with the QAPI team and the governing body.
  • Include staff in rounding; infection prevention is everyone’s job.

Resources

Resources that you may find helpful to support your environmental rounding plan and ICP program include:

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