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CMS Updates Interpretive Guidelines For ASC’s

Centers for Medicare and Medicaid Services

We are in a new year and its time to review your ASC policies and procedures to ensure that you are in compliance with the new changes especially if you are up for surgery center re-accreditation or if this will be the year you start your brand new ambulatory surgery center and apply for initial accreditation or surgery center Medicare certification.

CMS has released updates to the Interpretive Guidelines related to:

Radiologist Requirement:

416.49(b)(2) If radiologic services are utilized, the governing body must appoint an individual qualified in accordance with State law and ASC policies who is responsible for assuring all radiologic services are provided in accordance with the requirements of this section.

Emergency Transfers:

The ASC is required to:

Have a written transfer agreement that is in force with a hospital that meets the requirements at §416.41(b)(2); or Ensure that every physician performing surgery at the ASC has admitting privileges at a hospital that meets the requirements of §416.41(b)(2)

Fully Equipped Surgery Center Operating Room
Surgery Center Operating Room must be fully equipped and meet applicable design standards.

Physical Environment:

Verify the ASC’s ORs meet applicable design standards.

Verify the ASC has the right kind of equipment in the ORs for the types of surgery it performs.

Verify the ASC has enough equipment, including surgical instrument sets, for the volume of procedures it typically performs.

Verify the ASC has evidence, such as logs on each piece of electrical or mechanical equipment, indicating that it routinely inspects, tests, and maintains the equipment.

Verify who within the ASC is responsible for equipment testing and maintenance.

Considering the size of the OR and the amount and size of OR equipment, verify there is sufficient space for the unobstructed movement of patients and staff.

Review the ASC’s temperature and humidity records for ORs, to ensure that appropriate levels are maintained and that, if monitoring determined temperature or humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels.

Patient Rights:

Ensure that patients must be fully informed about a treatment or procedure and the expected outcome before it is performed.

Patient Rights notice in ASC must include the name, address, and telephone number of a representative in the State survey agency to whom patients and/or their representatives can report complaints.  The notice must also include, with respect to ASC patients who are Medicare beneficiaries, the Web site for the Office of the Medicare Beneficiary Ombudsman.

Surgical Services Discharge Requirement:

Ensure each patient has a discharge order, signed by the physician who performed the surgery or procedure in accordance with applicable State health and safety laws, standards of practice, and ASC policy.

Download the copy here. 

Here’s to your success,

NB

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Infection Control: Ebola Virus

Functional and Sanitary ASC
You want to ensure that you have a functional and sanitary ASC

Would you be prepared to treat an Ebola case at your surgery center? An Ebola case happening at a surgery center is remote, but if it does happen AAAHC would like to know if your staff would know what to do and are they adequately trained? Do you have policies in place to handle this type of emergency?

You want to make sure that you have surgery center policies and procedures in place for the isolation or immediate transfer of patients with communicable diseases. Make sure you have a copy of your state department of public health list of reportable communicable diseases, contact information and forms for help and guidance.

Review your infection control program plan. Make sure your program is based on and follows a nationally recognized program such as CDC and make sure that the program is under the direction of a designated and qualified individual who has documented annual training in infection control. The CDC has a great deal of information on their website for you to plan your next mandatory infection control in-service education.

Immediate Transfer of Patient with a communicable disease
You want to ensure that you have a policy for the immediate transfer of a patient with a communicable disease

Here’s to your success,

NB

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