On my March 18, 2012 post Fire Safety and Emergency Drills I briefly talked about fire drills and the necessary drills that have to be documented to maintain your surgery center accreditation, certification and/or licensure.  I would like to take the time now to go into more detail about the Disaster Preparedness Plan.  This is a condition that has to be met for your Medicare certification or licensure.

This is a separate plan or policy apart from your Fire Safety policy, procedure and drill.  To reiterate that yes the surgery center must perform on a quarterly basis the necessary fire drills, but if you are seeking or have certification or licensure you must perform annually a Disaster Preparedness drill and coordinate the plan or policy with state and local authorities.

As per Medicare Interpretive Guidelines state, “A wide range of events could occur such as fire, flood, mass release of a biochemical hazard, electrical failure, failure of water supply, etc.  You must identify hazards that are specific to the operatory environment of the surgery center as well as hazards that may affect the community in which the surgery center operates. “

Your plan or policy should include developing a process to address how the surgery center will meet the needs of the patient, staff, and others present if essential services break down as a result of the disaster.  The regulation requires that the surgery center must coordinate its Disaster Preparedness Plan with state and local authorities that have responsibility for emergency management within the state.  The surgery center must require the response from that community agency or fire department.

Now, Medicare Interpretive Guidelines goes on to state, “the regulation does not require that the surgery center be integrated into state and local emergency preparedness plans to address threats that extend beyond the premise of the surgery center since it will ultimately be the decision of the state and local officials whether and how they might utilize the surgery center in a response to an emergency event.”

During your inspection for Medicare certification or licensure, the surveyor may ask you to briefly summarize your Disaster Preparedness Plan.  The surveyor may also ask for confirmed documentation that you made communications with the state and local officials.  You will be asked to show a written evaluation of the drill.

The administrator or the medical director of the facility can call your local city hall for the city official and you will be transferred to the appropriate individual to start you on your way to meeting this condition.  You will most likely be transferred to the local or county emergency coordinator.  The feedback I receive is that you can coordinate at your surgery center a disaster preparedness drill with the fire marshal or attend a CERT meeting or class.  CERT stands for community emergency response team.  At these training sessions you will meet the fire department, police officers, your neighbors, and other medical officials.  CERT meetings and classes are available nationwide.  For questions about CERT email cert@dhs.gov or contact your local or state emergency coordinator to request the dates of the next CERT meeting in your area.

Heres to your success,

NB

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There are key signage postings surveyors look for upon entering into your surgery center on survey day.  These postings should be in a visible area in your lobby/waiting room.  You should have postings of Patient Rights and Responsibilities, Notice of Privacy Practices, Advance Directive, Grievance and Ownership Disclosure. Those of you who operate a C-Arm or have any X-ray equipment on site must post notices alerting patients of the risks of such equipment.  Some states such as California in reference to the California Medical Board enforce that you need to have visible a sign that states “medical doctors are licensed and regulated by the Medical Board of California” and to include website and phone number.  You also need to post a copy of the business license and CLIA waiver (optional, you can post in recovery if you wish). Most of these items are self-explanatory but I would like to provide you with a little more detail here on Advance Directive and Grievance.

Advance Health Care Directives is a set of processes which decisions can be made for a person who for some reason is not currently able to make important health decisions for themselves.  This is a legal document that has usually been made with an attorney.

You will need to inform the patient and accompanying witness whether you honor Advance Directives or not.  Does your surgery center honor Advance Directives?  Whether you do or don’t please remember to make a sign visible for patients to see.

If patients have complaints or concerns in regard to their care it should be encouraged to notify either the medical director, administrator or office manager.  There must be a protocol in place to address such grievances.   All complaints require administrative follow-up.  Patients can either fill out a form the surgery center provides or report directly to the accrediting agency, licensing agency, and the Medicare Ombudsman.

Keep in mind that signage postings are completely different from the actual policy.  For example you may have a basic statement in your lobby signage referring to Grievances as ”If patients have complaints or concerns in regard to their care at the surgery center they are encouraged to notify the medical director and fill out a grievance form.  Consumer complaints can be made at…” BUT your policy needs to address the following:

●Steps taken to investigate the grievance

●The result of the grievance

●How you will notify the patient

●The time-frame in which the grievance process was completed

Take a moment now to view what postings are in your lobby.

Here’s to your success,

NB

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