SOM Q261 Som107ap L Ambulatory

User Manual: Q261

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State Operations Manual
Appendix L - Guidance for Surveyors: Ambulatory
Surgical Centers
Table of Contents
(Rev. 137, 04-01-15)
Transmittals for Appendix L
Part I - Ambulatory Surgical Center Survey Protocol
Introduction
Regulatory and Policy References
Tasks in the Survey Protocol
Task 1 – Off-Site Survey Preparation
Task 2 – Entrance Activities
Task 3 – Information Gathering/Investigation
Task 4 – Preliminary Decision Making and Analysis of Findings
Task 5 – Exit Conference
Task 6 – Post-Survey Activities
Part II - General Provisions and Definitions; General Conditions and
Requirements
§416.2 - Definitions
§416.25 Basic Requirements
Specific Conditions for Coverage
§416.40 Condition for Coverage: Compliance With State Licensure Law
§416.41 Condition for Coverage: Governing Body and Management
§416.42 Condition for Coverage: Surgical Services
§416.43 Condition for Coverage: Quality Assessment and Performance Improvement
§416.44 Conditions for Coverage: Environment
§416.45 Condition for Coverage: Medical Staff
§416.46 Condition for Coverage: Nursing Service
§416.47 Condition for Coverage: Medical Records
§416.48 Condition for Coverage: Pharmaceutical Services
§416.49 Condition for Coverage: Laboratory and Radiologic Services
§416.50 Condition: Patient Rights
§416.51 Condition: Infection Control
§416.52 Condition: Patient Admission, Assessment and Discharge
Ambulatory Surgical Center Survey Protocol
Introduction
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
Ambulatory Surgical Centers (ASCs) are required to be in compliance with the Federal
requirements set forth in the Medicare Conditions for Coverage (CfC) in order to receive
Medicare/Medicaid payment. The goal of an ambulatory surgical center (ASC) survey is
to determine if the ASC is in compliance with the definition of an ASC, ASC general
conditions and requirements, and the conditions for coverage (CfCs) at 42 CFR 416
Subparts A through C.
Certification of ASC compliance with the regulatory requirements is accomplished
through observations, interviews, and document/record reviews. The survey process
focuses on an ASC’s delivery of patient care, including its organizational functions and
processes for the provision of care. The ASC survey is the means used to assess
compliance with Federal health, safety, and quality standards that will assure that patients
receive safe, quality care, and services.
Regulatory and Policy References
• The Medicare definition of an ASC is found at 42 CFR 416.2 Subpart A.
• General conditions and requirements for Medicare-participating ASCs are found at
42 CFR 416 Subpart B
• The CfCs for ASCs are located at 42 CFR 416 Subpart C.
• Survey authority and compliance regulations can be found at 42 CFR 416 Subpart
B and at 42 CFR Part 488 Subpart A.
• Should an individual or entity (ASC) refuse to allow immediate access upon
reasonable request to either a State Agency (SA) or CMS surveyor, the
Department of Health and Human Services Office of Inspector General (OIG) may
exclude the ASC from participation in all Federal healthcare programs in
accordance with 42 CFR 1001.1301. If a surveyor intends to make a request for
immediate access with the threat of possible exclusion for non-compliance, the SA
must first contact the CMS Regional Office, which must then contact the OIG
Administrative and Civil Remedies Branch at 202-619-1306.
• The CMS State Operations Manual (SOM) provides CMS policy regarding survey
and certification activities.
All ASC surveys are unannounced. Do not provide the ASC with advance notice of the
survey.
Tasks in the Survey Protocol
The tasks included in a survey protocol for an ASC are:
Task 1 Off-Site Survey Preparation;
Task 2 Entrance Activities;
Task 3 Information Gathering/Investigation;
Task 4 Preliminary Decision-Making and Analysis of Findings;
Task 5 Exit Conference; and
Task 6 Post-Survey Activities.
Task 1 – Off-Site Preparation
General Objectives
The objectives of this task are to determine the size and composition of the survey team
and to analyze information about the provider/supplier in order to identify areas of
potential focus during the survey. Review of information about the ASC allows the SA
(or RO for Federal teams) to develop a preliminary survey plan.
A full or standard survey will be conducted if the purpose of the survey is for initial
certification, recertification, or validation of an accreditation organization survey.
Surveys in response to a complaint or multiple complaints, or as a revisit to see if a
previously cited problem has been corrected, will be focused on the CfCs related to the
complaint or on the CfC for which deficiencies were previously identified. This does not
preclude the scope of a complaint or revisit survey being expanded, if surveyors observe
deficient practices related to other CfCs while on site. (See State Operations Manual,
§§5100.1 and 5200.1.)
Types of Surveys
Standard or Full surveys: Initial certification, recertification, and representative sample
validation surveys require assessment of the ASC’s compliance with all Conditions for
Coverage, including the Life Safety Code standards.
• Initial surveys are conducted when an ASC first seeks to participate in the
Medicare program.
• Recertification surveys are required to reconfirm at periodic intervals the ASC’s
ongoing compliance.
• Representative sample validation surveys are conducted to support CMS’
oversight of national accreditation organizations (AO) whose ASC programs have
been recognized by CMS as suitable for deeming an accredited ASC as meeting
the Medicare CfCs. CMS selects the ASCs for this type of validation survey, and
the SA must complete its survey no later than 60 days after the AO’s survey.
Although the primary purpose of the survey is to validate the AO’s oversight, if
substantial noncompliance is found by the SA and the RO concurs, the RO
initiates appropriate enforcement action. SAs may only survey a deemed ASC
when authorized to do so by the CMS Regional Office.
Complaint, Substantial Allegation Validation, or On-site Revisit Surveys: Generally,
these types of survey are more narrowly focused than a full standard survey.
• A complaint is an allegation of noncompliance with Medicare health and safety
standards. The purpose of a complaint survey is to determine the validity of the
allegation and assess the current compliance of the ASC with those CfCs that are
relevant to the substance of the allegation that triggered the survey.
• The purpose of the on-site revisit survey is to determine the ASC’s current
compliance with CfC requirements that the ASC was previously cited for
noncompliance.
• The second type of validation survey is the substantial allegation validation. A
complaint that alleges substantial noncompliance on the part of a deemed ASC
with the Medicare health and safety standards may result in RO direction to the SA
to conduct a substantial allegation validation survey. The SA uses the same
methodology as for a complaint survey of a non-deemed ASC. The CMS
Regional Office must authorize the State Survey Agency to conduct a substantial
allegation validation survey and will specify the CfCs to be assessed.
Generally, complaints received by the SA or CMS concern specific cases or incidents that
occurred in the past. However, CMS evaluates ASCs only for their current compliance or
noncompliance at the time of the survey. Nevertheless, if an investigation of a complaint
substantiates a violation in the past of one or more of the CfC requirements, and there is
no evidence that the ASC subsequently implemented effective corrective action, then the
findings substantiating the violation are documented on the Form CMS- 2567, Statement
of Deficiencies and Plan of Correction as evidence of current noncompliance. On the
other hand, if an allegation of a violation is substantiated, but the ASC subsequently
implemented effective corrective action and the survey reveals no current noncompliant
practices, then the ASC is in current compliance and is not cited for a deficiency based on
the past noncompliance.
A revisit survey will focus on assessing the ASC’s current compliance with the CfCs
where deficiencies were cited on the previous survey. The SA must receive an
acceptable plan of correction from the ASC before it conducts a revisit survey.
Survey Team Size and Composition
The SA (or the CMS RO for Federal teams) decides the composition and size of the team.
In general, a survey team for a standard, i.e., full, survey should include two health
standards surveyors and one Life Safety Code (LSC) surveyor, who are on-site for 2
days, but individual circumstances may call for a smaller or larger team, or a shorter or
longer period of time on-site. The following factors are considered when determining
survey team size and the scheduled length of the survey:
• Size of the ASC, based on its number of operating or procedure rooms (ORs),
hours of operation, and/or available information about its average monthly volume
of cases;
• Complexity of services offered, e.g., a single type of surgical service, such as eye
surgery, or multiple types, such as eye surgery, orthopedic surgery, endoscopies
and gynecological procedures;
• Whether the ASC has an historical pattern of serious deficiencies or complaints;
and
• Whether new surveyors are to accompany the team as part of their training.
For a complaint or on-site revisit survey, only one surveyor will usually be needed and
should be chosen based on their knowledge of the CfC(s) that will be reviewed during the
survey.
The ASC surveyors must have the necessary training and experience to conduct a survey.
Completion of the Principles of Documentation Training Course is required. Completion
of the Basic Ambulatory Surgery Survey Course is required for all health standards
surveyors, unless such training has not been offered by CMS in the previous 2 years. All
Life Safety Code (LSC) surveys must be conducted by surveyors who have completed
the Basic LSC Surveyor Course. All ASC survey teams must include at least one RN
with hospital or ASC survey experience who has the expertise needed to determine if the
facility is in compliance with the Conditions for Coverage. New surveyors may
accompany the team prior to completing the required training.
Team Coordinator
The SA (or the RO) usually designates a Team Coordinator when the survey team
consists of more than one surveyor. The Team Coordinator will be responsible for
assuring that all survey preparation and survey activities are completed within the
specified time frames and in a manner consistent with this protocol. Responsibilities of
the Team Coordinator include:
• Acting as spokesperson to the ASC for the team;
• Conducting the entrance and exit conferences,
• Providing other on-going feedback, as appropriate, to ASC leadership on the status
of the survey.
• Assigning team members specific survey tasks;
• Facilitating time management;
• Encouraging ongoing communication among team members;
• Evaluating team progress in completing the survey and coordinating team
meetings; and
• Coordinating the preparation of the Form CMS-2567, Statement of Deficiencies
and Plan of Correction, as well as all other reports/documentation required by
CMS.
Assembling Background Information
Surveyors must prepare for the survey offsite, in order to make efficient use of the time
onsite at the ASC. If the survey involves more than one surveyor, the Team Coordinator
will arrange an offsite preparation meeting. If necessary, this meeting may be by
conference call rather than in person. The type of background material to be gathered
from the SA’s files and/or CMS data bases includes:
• Basic characteristics of the ASC, including the facility’s ownership, hours of
operation, size, and types of surgical services offered. The most recent Form
CMS-377 “Ambulatory Surgical Center Request for Initial Certification or Update
of Certification Information in the Medicare Program”, shows what the ASC
indicates are the services it offers, but this form may be out of date. Other sources
of information may include the SA’s licensure file;
• Any additional information publicly available about the ASC, e.g., from its Web
site, media reports, etc.;
• Any available information on the physical layout of the ASC;
• Whether any Life Safety Code waivers have been issued and are still in effect;
• Survey history and results of previous Federal and State surveys. In the case of a
complaint survey, information on whether there were similar complaints
investigated in the past; and
• Directions to the ASC.
During the meeting, the team discusses:
• Any significant information identified from the background information
assembled;
• Whether there are CfCs requiring particular attention:
• In the case of a complaint survey, the SA or the RO (in the case of a deemed
ASC) identifies in advance of the onsite investigation which CfCs will be
surveyed for compliance;
• In the case of an on-site revisit survey, surveyors will focus on the ASC’s
current compliance with those CfCs where deficiencies were cited on the most
recent Form CMS-2567. Surveyors also review the ASC’s plan of correction
and will look for evidence while onsite that the plan was implemented.
(However, surveyors may not assume that implementation of the plan always
means that the ASC is in substantial compliance with the CfC. It is possible
that a plan of correction may be implemented, but is not sufficient to bring the
ASC into compliance.);
• Preliminary team member assignments;
• Any questions the team has about how they will evaluate the CfCs;
• Date, location, and time team members will meet to enter the facility;
• When daily team meetings will take place if needed; and
• The anticipated date and time of the Exit Conference.
For surveys involving only one surveyor, that surveyor also needs to gather background
information and plan the strategy for the survey prior to arriving on-site.
NOTE: Conduct ASC surveys during the ASC’s normal business hours. All
surveys are unannounced. Do not provide the ASC with advance notice of the
survey.
Resources
The following resources are useful to bring on surveys:
• Appendix L – Guidance for Surveyors: Ambulatory Surgical Centers in the SOM;
• Appendix I – Survey Procedures and Interpretive Guidelines for Life Safety Code
Surveys in the SOM;
• Appendix Q - Immediate Jeopardy in the SOM;
• Several copies of the regulatory language at 42 CFR 1001.130 regarding the
consequences of failure to permit the survey team access to the facility;
• For deemed accredited facilities, Exhibit 37, Model Letter Announcing Validation
Survey of Accredited/Deemed Provider/Supplier, and Exhibit 287, Authorization
by Deemed Provider/Supplier Selected for Accreditation Organization Validation
Survey.
Task 2 – Entrance Activities
General Objectives
The objectives of this task are to explain the survey process to the ASC staff and obtain
the information needed to conduct the survey.
General Procedures
Arrival
The entire survey team should enter the ASC together. Upon arrival, surveyors must
present their identification. If the ASC denies entrance to the facility or otherwise tries to
limit required survey activities, explain the requirements under 42 CFR 1001.1301 and
present a hard copy of the regulatory citation. Explain that failure of the ASC to allow
access for an onsite survey could lead to exclusion of the ASC from Medicare.
If surveyors encounter any problems onsite, they should feel free to contact their SA
manager or the RO for guidance. For instance, if ASC staff will not let a surveyor into
the facility even after they’re informed of the possible sanctions that can be imposed for
restricting access to their facility, a call to the SA or RO would be appropriate.
Because the survey is unannounced, surveyors should anticipate that in some ASCs, e.g.,
a small ASC with one physician owner who performs all the ASC’s procedures, the
ASC’s leadership may at the time of entrance by the survey team already be involved in a
procedure and unavailable. If there would be a prolonged wait for the ASC’s leadership,
e.g., a wait exceeding 15 minutes, the team should conduct the entrance conference with
available ASC senior staff; a separate brief discussion can be held at a later mutually
convenient time with the ASC’s leadership.
The Team Coordinator (or the single surveyor for complaint or revisit surveys) will
announce to the ASC’s Administrator, or whoever is in charge, that a survey is being
conducted. If the Administrator (or person in charge) is not onsite or available, the Team
Coordinator asks that the Administrator or person in charge be notified that a Federal
survey is being conducted. Do not delay the survey because the Administrator is not
available.
Entrance Conference
The entrance conference sets the tone for the entire survey. Surveyors must be prepared
and courteous, and make requests, not demands. The entrance conference should be
informative, concise, and brief.
During the entrance conference, the Team Coordinator or single surveyor:
• Explains the purpose and scope of the survey (initial certification or recertification;
complaint investigation; validation; revisit);
• In the case of a validation survey – either representative sample or
substantial allegation (complaint) - of a deemed ASC, presents the letter
explaining the survey and has the Administrator sign the authorization for
the survey
(Exhibit 287)
• Briefly describes the survey process;
• Introduces the survey team members, including any additional surveyors who may
join the team at a later time, and discusses in general what the surveyors will do
and the various documents they may request;
• Clarifies that all areas of the ASC, including the OR(s) or procedure rooms may be
surveyed, but emphasizes that the survey team will not interfere with the provision
of patient care and will take all standard precautions to avoid any infection control
breaches; patients will be asked if they object to having their surgery observed;
• Explains that all interviews will be conducted privately with patients, staff, or
visitors, unless requested otherwise by the interviewee;
• Discusses how the facility will provide the surveyors in a timely manner
photocopies of material, records, and other information as needed;
• Obtains the names, locations, and telephone numbers of key ASC staff and their
responsibilities;
• Discusses the appropriate time, location, and possible attendees of any meetings to
be held during the survey; and
• Proposes a preliminary date and time for the exit conference.
During the entrance conference, the Team Coordinator arranges with the ASC
Administrator or available administrative supervisory staff in his/her absence, to obtain
the following:
• A list of all surgeries scheduled for that day (and the next if a 2-day survey); the
list should include each patient’s name, age, type of surgical procedure scheduled
or performed, and the physician performing the procedure. The Team Coordinator
indicates that one surveyor will be following the progression of at least one patient
from initial registration through to discharge from the ASC (or at least through the
initial period in the recovery room), so it is essential that information on these
cases be provided as soon as possible, including the expected time between
registration and discharge.
• A list of:
• All surgeries from the past 6 months. In the case of a complaint survey
concerning a surgery that took place further in the past, be sure to request
a list that includes the month of the complaint case; and
• All cases in the past year, if any, where the patient was transferred from
the ASC to a hospital or where the patient died;
The list should include each patient’s name, age, type of surgical procedure
scheduled or performed, and the name of the physician performing the procedure.
The Coordinator explains to the ASC that, in order to complete the survey within
the allotted time, it is important the survey team is given this information as soon
as possible. The ASC should begin compiling this list as soon as the entrance
conference concludes. Generally an ASC should be able to provide this
information within 1 to 2 hours of the request.
• A location (e.g., conference room, an office not in use) where the survey team may
meet privately during the survey, and also conduct record reviews, interviews, etc.;
• A telephone, preferably in the team meeting location;
• A list including the names of the Director of Nursing, active Medical Staff, Allied
Health professionals, and all other staff providing patient care;
• A copy of the facility’s organizational chart;
• Selected ASC written policies and procedures;
• Selected ASC personnel records;
• Written documentation related to the ASC’s infection control program and its
program for ongoing self-assessment of quality;
• A list of contracted services; and
• A copy of the facility’s floor plan.
For initial or recertification surveys, arrange an interview with the administrative staff
member who will be providing information enabling the survey team to complete the
Form CMS-377, Ambulatory Surgical Center Request for Initial Certification or Update
of Certification in the Medicare Program. Note that for recertification surveys, the
ASC’s management is not required to sign this form, since certification is ongoing and
there is no requirement for the ASC to request recertification.
Task 3 – Information Gathering/Investigation
General Objective
The objective of this task is to determine the ASC’s compliance with the CfCs through
observations, interviews, and document review.
During the Survey
• Surveyors should always maintain a professional and calm demeanor;
• The SA and surveyors have discretion whether to allow, or to refuse to allow,
facility personnel to accompany the surveyors during a survey. However,
maintaining open and ongoing dialogue with the facility staff throughout the
survey process generally enhances the efficiency and effectiveness of the survey.
Surveyors should make a decision whether to allow facility personnel to
accompany them based on the circumstances at the time of the survey;
• Surveyors need to respect patient privacy and maintain patient confidentiality at
all times during the survey;
• Surveyors are not permitted to conduct clinical examinations or provide clinical
services to any of the ASC’s patients. Surveyors may direct the attention of the
ASC staff to address an immediate and significant concern affecting a patient’s
care. All significant issues or significant adverse events, particularly those that a
surveyor believes may constitute an immediate jeopardy, must also be brought to
the Team Coordinator’s attention immediately. Immediate jeopardy is defined as
a situation in which the ASC’s noncompliance with one or more CfCs has caused,
or is likely to cause, serious injury, harm, impairment or death to a patient. If the
Team Coordinator agrees that there is an immediate jeopardy situation, the team
will follow the guidance in Appendix Q of the State Operations Manual.
• Informal conferences with facility staff may be held in order to inform them of
preliminary survey findings. This affords facility staff the opportunity to present
additional information or to offer explanations concerning identified issues;
• The survey team should meet at least daily in order to assess the status of the
survey, progress of completion of assigned tasks, and areas of concern, as well as
to identify areas for additional investigation. If areas of concern are identified in
the discussion, the team should coordinate efforts to obtain additional
information. Additional team meetings can be called at any time during the survey
to discuss crucial problems or issues; and
• Surveyors should maintain their role as representatives of a regulatory agency.
Although non-consultative information may be provided to the ASC upon request,
the surveyor is not a consultant and may not provide consulting services to the
ASC.
Observations
Observations provide direct knowledge of the ASC’s practices, which the surveyor must
compare to the regulatory requirements in order to determine whether the ASC is in
compliance with the requirements. The interpretive guidelines for each of the CfCs
provide detailed guidance as to what the regulations require, as well as tips for surveyor
activities to determine compliance.
Case Observation
The Team Coordinator should make it a priority at the beginning of the survey to select
one or more surgical cases scheduled for observation during the survey. To form a more
accurate picture of the ASC’s routine practices, it is preferable to observe a case on the
first day of the survey. ASC patients remain in the ASC up to a maximum of 24 hours;
therefore, following individual cases from start to recovery or discharge is an effective
tool for assessing the ASC’s compliance with the CfCs. The number of cases selected
will depend on the size of the team, the scheduled length of the survey, and the expected
duration of the surgical case. Depending on the timing of the case selected, a surveyor
may begin a case observation immediately.
The surveyor could follow the patient from pre-operative preparation and assessment to
discharge (but at least through post-anesthesia recovery). For larger ASCs, i.e., those
with more than 2 ORs or procedure rooms, or for multi-specialty ASCs, surveyors should
consider following two cases.
In selecting cases to follow, surveyors should choose more complex cases, based on the
type of procedure or patient age or patient co-morbidities. It may also be useful to avoid
selecting cases where surveyors anticipate that patient modesty concerns may make it
harder to obtain the patient’s consent. As a general practice, to make efficient use of
onsite time, surveyors should not select cases where the operative time is expected to
exceed 90 minutes. Surveyors may opt not to observe the whole surgery from start to
finish; however, in such cases they must assure they are in the OR when the patient is
brought in, in order to observe the start of the surgery, and they must return to the OR
before the case concludes. It may be useful for a surveyor to remain in the OR after the
patient leaves, in order to observe how the OR is cleaned and prepped for the next case.
In such cases the team should arrange for another surveyor to pick up the observation of
the patient’s care after the first surveyor leaves the OR.
In following the case(s) surveyors will look for evidence of compliance related to the
various CfC requirements, e.g., infection control, physical environment, medication
administration, assessment of anesthesia and procedure risk as well as the required pre-
operative update assessment of changes from the history and physical, provision of
surgical and anesthesia services, post-surgical assessment, recovery from surgery and
anesthesia, and discharge orders.
ASC Tour
The tour may be accomplished before case observation, or surveyors who are not
following a case may tour the ASC while the ASC staff is assembling the information
requested during the entrance conference. The purpose of the tour is to get an overview
of the whole ASC and to begin making findings about its compliance with the Cf C
governing an ASC’s environment, 42 CFR 416.44. The amount of time spent on the tour
will depend on the size of the ASC, e.g., the number of ORs/procedure rooms, recovery
rooms, etc. For revisit surveys, a tour of the whole facility is generally not necessary.
Observation Methods
When making observations, surveyors attend to the following; specific areas or activities
to observe are discussed in the guidance for each CfC requirement.
• Building structure and layout, general appearance of cleanliness, odors;
• Staff-patient interactions, both clinical and non-clinical. For example, what
happens to patients from the time they arrive at the ASC until the time they leave?
Are their privacy and other rights protected? Is care provided by appropriate,
qualified staff? Is patient identity verified by each staff member before care is
provided?; and
• Other staff activities. For example, how do staff protect the confidentiality of
medical records? Are infection control precautions observed? Are staff aware of
regulatory requirements pertinent to their activities?
A surveyor must take detailed notes of all observations, identifying the regulatory
standard(s) to which the observations relate to. For example, one set of observations
might support findings related to multiple standards, or some surveyors may find it
convenient to use interpretive guidance “tag” numbers as a convenient shortcut for
identifying the applicable standards. When such tags are used, the surveyor must always
recall that tags are just a filing/sorting device, and that the regulatory authority is always
based on the specific regulatory language. With the approval of the SA, surveyors should
also feel free to use templates or worksheets that will help record their survey findings.
Surveyors must attempt to obtain verification of the factual accuracy of their observations
by the patient, family, facility staff, other team member(s), or by another means, as
appropriate. For example, when finding an outdated medication on the anesthesia cart,
surveyors can ask the ASC staff member who has responsibility for anesthesia to verify
the drug’s expiration date.
Surveyors must first obtain the permission of the patient or the patient’s representative in
order to observe the delivery of care to that patient. The privacy and dignity of the
patient must always be respected, along with the patient’s right to refuse to allow the
surveyor to observe his/her care. For observation of a surgical case, the patient’s consent
to the surveyor’s observation must be included/added to the patient’s informed consent.
It is at the surveyor’s discretion whether he or she prefers ASC staff to first approach a
patient about the possible observation of his or her procedure, or whether the surveyor
approaches the patient directly to seek permission. In all cases, the surveyor must speak
directly with the patient to obtain consent.
The surveyor is not required to obtain the consent of the operating physician prior to
observing a surgical procedure. The surveyor may observe any and all cases and
activities upon request as needed in order to assess compliance with the Medicare ASC
CfCs. An ASC may not condition a surveyor’s ability to observe patient care by, for
example, requiring a surveyor to sign any written documents or to present proof of
vaccinations. The surveyor, however, must ensure that his/her observation protects
patient safety and does not interfere with the operating physician or the surgical
procedure.
If a facility denies a surveyor access to ASC activities which must be evaluated to
determine compliance with the Medicare ASC CfCs, then the facility has failed to
provide evidence of compliance and must be cited accordingly. In addition, the ASC
may be subject to exclusion from participation in all Federal healthcare programs in
accordance with 42 CFR 1001.1301. See “Regulatory and Policy References” section in
this Appendix.
For each observation, the surveyor should document:
• The date and time of the observation(s);
• Location within the ASC;
• Patient and staff identifiers. A key containing identifiable information for patients
must be kept on a separate identifier list. The ASC/surveyor may not use medical
record numbers, Social Security numbers, or billing record numbers to identify
patients, or the names or position numbers to identify staff members;
• Individuals present during the observation;
• Activity/area being observed (e.g., observation of sterile technique in the operating
room, operative instrument cleaning and sterilization, recovery room care, etc).
Use of Infection Control Tool
CMS has developed, with the assistance of the Centers for Disease Control and
Prevention (CDC), a comprehensive survey tool to assist surveyors in evaluating the
infection control practices of an ASC. The tool may be found at Exhibit 351 of the State
Operations Manual. One surveyor must be assigned to complete this tool during the
survey, but all surveyors should be alert to breaches of standard infection control
practices and share such observations with the surveyor completing the tool. The tool
utilizes a combination of direct observations and interviews in order to document the
ASC’s infection control practices.
Document Review
ASCs maintain a variety of documents that provide evidence of their compliance/non-
compliance with the regulations. Review of documents is a key component of the
survey; however, it is important to note that the review must always be supplemented by
surveyor observations and interviews. In particular, it is never sufficient to determine
compliance by merely verifying that an ASC has an appropriate written policy and
procedure in place. Surveyors must use a variety of means, including review of other
documents, such as patient medical records, personnel files, maintenance records, etc., to
confirm that the ASC actually follows its policies and procedures in its daily operations.
Documents reviewed may be both written and electronic and include the following:
• Medical records (see discussion below);
• Personnel files to determine if staff members have the appropriate educational
requirements and training, and are licensed and credentialed, if required. The
ASC must comply with all CMS requirements and State law as well as follow
its own written policies for medical staff privileging and credentialing;
• Maintenance records to determine if equipment is periodically examined and to
determine whether the equipment is in good working order and whether
environmental and sanitary requirements have been met;
• Policy and procedure manuals. When reviewing policy and procedure
manuals, verify with the ASC’s leadership that the manuals are current; and
• Contracts and transfer agreements. Review to verify these are current.
Photocopies
Surveyors must photocopy all documents needed to support deficiency findings. The
surveyor requires access to a photocopier in the ASC in order to make these photocopies.
Generally surveyors must not rely upon ASC staff to make copies for them. However, if
the ASC insists that one of its staff must operate the copier, then a surveyor must observe
the copying process, in order to assure that changes or omissions do not occur. If
requested by the ASC, the surveyor will make an extra copy of the photocopied items for
the ASC’s benefit. All photocopies must be dated and timed by the surveyor to reflect
when they were photocopied. They must be properly identified, as appropriate, e.g.,
“ASC Recovery Room Policy – 10-25-07 or “Facility Surgical Instrument Sterilization
Policy – 10-25-07, or “Patient #3 Preoperative Anesthesia Assessment - 10-25-07.”
Medical Record Review
Closed Record Sample Size and Selection
After the ASC provides a log or some other record of closed cases from the past six
months, the team/surveyor will select a sample of the medical records for these cases to
review.
Sampling for Initial Surveys, Recertification Surveys, or Representative
Sample Validation Surveys
For recertification and representative sample validation surveys, the sample selected must
represent a cross section of the cases performed at the ASC (i.e., different surgical
specialties, types of surgery, surgical cases using different types of anesthesia, different
physicians, post-op infection, unplanned post-operative transfer, etc.) The sample must
include Medicare beneficiaries as well as other patients. All deaths and transfers to
hospitals should be included. At a minimum, the surveyor selects at least 20 records for a
facility with a monthly case volume exceeding 50. For lower volume ASCs, the surveyor
selects at least 10 records. The sample size may be expanded as needed in order to
determine compliance with the ASC CfCs, at the Team Coordinator’s discretion.
Initial survey closed record sample sizes should be chosen at the Team Coordinator’s
discretion, since the volume of closed cases may be small. The Team Coordinator
determines if there are enough patients on the current surgical schedule and patient
records (i.e., open and closed) for surveyors to determine whether the ASC can
demonstrate compliance with all CfCs for each specialty performed in the ASC.
Sampling for Complaint Surveys
CMS always assesses an ASC for its current compliance with the CfCs. Thus, it is not
sufficient to look only at the medical record for the complaint case in conducting a
complaint investigation. The surveyor must determine whether at the time of the survey
the ASC is in compliance with the CfCs selected for evaluation. If evidence of
noncompliance is found to have occurred in the past and the systems and processes that
led to the noncompliance remain unchanged at the time of the survey, this will be treated
as continuing current noncompliance.
The RO (for deemed ASCs) or the SA (for non-deemed ASCs) will determine in advance
of the survey which CfCs the surveyors will be evaluating in relation to the complaint.
Selection of the CfCs will be determined based on the nature of the allegation(s)
explicitly stated or implied by the complaint – i.e., an allegation of transmission of an
infectious disease will require review of the infection control CfC, and probably also of
the governing body CfC, while an allegation by a hospital that it received an emergency
transfer of a patient who had suffered a surgical complication that called into question the
safety and competence of the ASC would necessitate reviewing multiple CfCs, including
surgical services, medical staff, and governing body, at a minimum.
It will be necessary to review several closed records. The selection of the sample to
review will be dependent, in part, on the complaint allegations. Depending on the CfCs
to be surveyed for a complaint, it may also be necessary to observe an open case. If the
complaint concerns infection control, for example, following a case will provide a good
opportunity to observe infection control practices throughout the ASC. On the other
hand, if the complaint concerns a failure to assess patients preoperatively for risk, it
would be more appropriate to look at a sample of closed records for the documentation of
the assessments, as well as to observe portions of several open cases, as the patients move
from registration into the OR or procedure room, to observe the pre-operative
assessments.
A revisit survey may or may not require review of open or closed cases, depending on the
specific standards and conditions being re-evaluated.
The surveyor must assign a unique identifier to each patient case observed/reviewed
during the survey. A key containing identifiable information for patients must be kept on
a separate identifier list. Do not use medical record numbers, Social Security numbers, or
billing record numbers to identify the patients or names or positions for staff.
Once the medical records are available, surveyors can begin reviewing each record for
evidence of compliance/noncompliance. The interpretive guidelines for the specific
regulatory standards can be used if that is their primary assignment.
In reviewing the record surveyors should confirm whether it contains items required by
various CfCs, including but not limited to:
• A comprehensive medical history and physical assessment completed not more
than 30 days before the date of the surgery;
• Pre-surgical assessments – update of the H&P upon admission, and assessment
for the risk of the procedure and anesthesia;
• Documentation of properly executed informed patient consent;
• Findings and techniques of the operation, including complications, allergies or
adverse drug reactions that occurred;
• Orders signed by the physician for all drugs and biologicals administered to the
patient;
• Documentation of adverse drug reactions, if any;
• Documentation of the post-surgical assessment of the patient, including for
recovery from anesthesia;
• Documentation of reason for transfer to a hospital, if applicable;
• Discharge notes, including documentation of post-surgical needs; and
• Discharge order, signed by the operating physician.
Interviews
Interviews provide another method to collect information, and to verify and validate
information obtained through observations, record review and review of other documents.
Informal interviews are conducted throughout the duration of the survey. The
information obtained from interviews may be used to determine what additional
observations, interviews, and record reviews are necessary. When conducting interviews:
• Prepare detailed notes of each interview conducted. Document the interview date,
time, and location, the full name and title of the person interviewed, and key
points made and topics discussed. To the extent possible, document quotes from
the interviewee.
• Interviews with facility staff should be brief and to the point.
• Interviews should be used to determine whether staff is aware of and understand
what they need to do for the ASC to comply with regulatory requirements, as well
as the ASC’s formal policies and procedures. It is not necessary for staff to be
able to cite specific Medicare regulations, but they should be able to describe
what they do in a way that allows surveyors to determine compliance with the
regulations.
• Be sure to interview staff having responsibilities related to each of the CfCs being
surveyed.
• Use open-ended questions whenever possible to elicit staff knowledge rather than
questions that lead the staff member to certain responses. For example, to
determine if a staff member is aware of building emergency procedures, and
his/her role in such events, simply ask, “If you smelled smoke, what would you
do?” Do not ask, “Does this ASC have policies and procedures to address
emergencies?” Likewise, ask, “Can you describe what typically happens in the
OR before surgery begins?” Do not ask, “Does this ASC employ a standard
‘time-out’ procedure before beginning surgery?”
• Surveyors must always introduce themselves and ask patients or their
representatives for permission to interview them. Surveyors must be sensitive
when selecting patients for interview; for example, if a patient in recovery appears
to still be feeling the effects of the anesthesia, an interview request should not be
made. The same holds if a patient appears to be experiencing significant pain or
anxiety. The privacy, dignity and well-being of the patient must always be
respected, along with the patient’s right to refuse to allow the surveyor to conduct
an interview.
• Patient interview questions should focus on factual matters about which the
patient is likely to have information. For example, ask “Did the doctor discuss
your surgery with you today? What information did the doctor discuss with you
about the surgery?” “Did you notice whether people washed their hands or used a
cleaning gel before providing care to you?”
• Problems or concerns identified during a patient or family interview must be
addressed in the staff interviews to validate the patient’s perception, or to gather
additional information.
• Validate as much of the information collected via interviews as possible by asking
the same question of several staff or patients, or by integrating interview
responses with related surveyor observations or record review findings.
• If necessary, telephone interviews may be conducted for closed cases; however,
in-person interviews are preferred.
Task 4 – Preliminary Decision Making and Analysis of Findings
General Objectives
The general objectives of this task are to integrate findings, review and analyze all
information collected from observations, interviews, and record reviews. The team’s or
surveyor’s preliminary decision-making and analysis of findings assist in preparing the
exit conference report.
Preparation
Prior to beginning this task, each surveyor must review his/her notes and completed
worksheets related to observations and interviews, as well as the documents he/she has
photocopied. The surveyor must be confident that he/she has everything needed to
support his/her presentation of findings to the team, and to the SA manager when
preparing a formal survey report.
Discussion Meeting
At this meeting, the surveyors share their findings, evaluate the evidence, and make team
decisions regarding compliance with each requirement. For initial, recertification, and
validation surveys, the Team should proceed sequentially through the regulatory
requirements for each CfC; for complaint surveys they should proceed to review each
CfC selected for investigation. The team must reach a consensus on all findings of
noncompliance. Decisions about deficiencies must be team decisions, with each member
having input. The team must document the evidence that supports each finding of
noncompliance. Any additional documentation or evidence needed to support identified
noncompliance must be gathered prior to exiting the facility.
All noted noncompliance must be cited as a deficiency, even when corrected onsite
during the survey.
When a noncompliant practice is determined to have taken place prior to the survey, this
would be considered evidence of current non-compliance, unless there is documentation
that the ASC identified the problem prior to the survey and implemented effective
corrective action. In evaluating whether the ASC is currently in compliance, the survey
team must consider:
• What corrective action the facility implemented;
• Whether the corrective action was sufficient to address the underlying, systemic
causes of the deficiency;
• Whether the corrective action was evaluated for its effectiveness to sustain long-
term compliance; and
• Whether there are any other findings from the survey indicating current non-
compliance.
If the deficient practice is identified and corrected by the ASC prior to the survey and
there is no other evidence of current non-compliance, do not cite noncompliance.
In the case of a revisit survey, the surveyor’s task is to determine current compliance with
the regulatory requirements that were cited during the previous survey and ensure that the
implementation of the written plan of correction submitted by the ASC and accepted by
the SA was effective in maintaining long term compliance. The surveyor should conduct
observations, document reviews and interviews to confirm current compliance with the
CfC(s) addressed by the plan of correction.
Integrating Findings
The survey team integrates the findings derived from document review, observations, and
interviews that pertain to each CfC surveyed, in order to make a determination of whether
there is evidence of compliance/non-compliance.
Determining the Citation Level of Deficiencies
Citing noncompliance at the appropriate level, i.e., standard- or condition-level, is critical
to the integrity of the survey process.
The regulations at 42 CFR 488.26 state, “The decision as to whether there is compliance
with a particular requirement, condition of participation, or condition for coverage
depends upon the manner and degree to which the provider or supplier satisfies the
various standards within each condition.” When noncompliance with a particular
standard within the Conditions for Coverage is noted, the determination of whether the
lack of compliance is at the Standard or Condition level depends upon the nature of the
noncompliance – i.e., how serious is the deficiency in terms of its potential or actual harm
to patients - and extent of noncompliance – i.e., is there noncompliance with the CfC
stem statement, or how many different regulatory requirements within a CfC are being
cited for noncompliance, or how frequent was a given noncompliant practice, etc. One
instance of noncompliance with a standard that poses a serious threat to patient health and
safety is sufficient to find condition-level noncompliance. Likewise, when an ASC has
multiple standard-level deficiencies in a CfC, this may add up to pervasive non-
compliance and could be sufficient to find condition-level noncompliance.
Determinations of citation level for complaint surveys follow the same process that is
applied to full surveys; the only difference is that the complaint survey itself is generally
limited to the CfCs implicated in the complaint.
Gathering Additional Information
If it is determined that the survey team needs additional information to determine facility
compliance or noncompliance, the Team Coordinator determines the best way to gather
such information.
Task 5 - Exit Conference
General Objective
The general objective of this task is to inform the ASC management of the team’s
preliminary findings.
Prior to the Exit Conference
• The Team Coordinator is responsible for organizing the exit conference, including
who will have a speaking role.
• The health and Life Safety Code (LSC) surveyors/survey teams must have one
joint exit conference if they are exiting at the same time; otherwise they may
conduct separate exit conferences.
• If the team feels it may encounter a problem during the exit conference, the Team
Coordinator should contact the SA manager in advance to discuss the potential
problems and appropriate methods to handle them.
Discontinuation of an Exit Conference
CMS’ general policy is to conduct an exit conference at the conclusion of all types of
surveys. However, there are some comparatively rare situations that justify refusal to
conduct or continue an exit conference. For example:
• If the ASC is represented by an attorney (all participants in the exit conference,
both surveyor team members and ASC staff, must identify themselves prior to
beginning the exit conference), surveyors may refuse to conduct the conference if
the attorney attempts to turn it into an evidentiary hearing; or
• If the ASC staff /administration create an environment that is hostile,
intimidating, or inconsistent with the informal and preliminary nature of an exit
conference, surveyors may refuse to conduct or continue the conference. Under
such circumstances, it is suggested that the Team Coordinator stop the exit
conference and call the SA for further direction.
Recording the Exit Conference
If the facility wishes to audio tape the conference, it must provide two tapes and tape
recorders, recording the meeting simultaneously. The Team Coordinator should select
one of the tapes at the conclusion of the exit conference to take back to the SA.
Videotaping is also permitted, if the survey team agrees to this, and a copy is provided at
the conclusion of the conference. The survey team is under no obligation to consent to
videotaping and is not required to offer a reason if it refuses to permit videotaping.
General Principles
The following general principles apply when conducting an exit conference:
• The ASC management determines which ASC staff will attend the exit
conference;
• The identity of individual patients or staff members must not be revealed by the
survey team when discussing the survey results. Identity includes not just the
name of an individual patient or staff member, but also includes any reference or
characterization by which identity may be deduced; and
• Because of the information gathering activities the survey team has already
engaged in, in most instances members of the ASC’s staff should generally be
aware prior to the exit conference of the areas, if any, where the survey team has
concerns. Accordingly, there should be few cases where the ASC has not already
had the opportunity prior to the exit conference to present additional information
that might be relevant to the survey team’s findings. The exit conference is not
the correct setting for further information-gathering activities.
Exit Conference Sequence of Events
Introductory Remarks:
• Thank everyone for their cooperation during the survey;
• Reintroduce all surveyors who participated in the survey, even if they are no
longer in the facility;
• Briefly reiterate what was the reason for the survey (i.e., initial, recertification,
validation, or complaint); and
• Explain how the team will conduct the exit conference and any ground rules:
• The exit conference is an informal meeting for surveyors to summarize their
preliminary findings;
• Brief comments on the findings may be made by the ASC, but will not be
debated; and
• Whether comments will be permitted in the middle of a surveyor’s
presentation or only after the presentation has concluded.
Presentation of Findings
• Do not refer to any specific ASPEN software data tag numbers when describing
deficiency findings. In the process of writing up the findings the SA will finalize
just which tags/regulatory text to cite for each finding, so it would be premature to
make such statements during the exit conference.
• Present the findings of noncompliance, explaining why the findings indicate
noncompliance with the regulatory requirement. If the ASC asks for the pertinent
regulatory reference, provide the citation for the applicable CfC.
• Do not make any general characterizations about the survey results (e.g., “Overall
the facility is very good.” or “In general the facility is in compliance with
Medicare requirements.”) Stick to presenting the specific factual findings.
• Do not make any statements about whether the findings represent condition-level
or standard-level deficiencies. Avoid statements such as, “the condition was not
met” or “the standard was not met.” It is better to state “the requirement related
to XXX is not met.”
• If an immediate jeopardy situation was identified during the team discussion that
the team had not previously discussed with the ASC’s management, explain the
significance and need for immediate correction. Follow instructions in Appendix
Q, Guidelines for Determining Immediate Jeopardy.
• Do not rank findings. Treat requirements as equal as possible.
• Be certain that all deficiency findings are discussed at the exit conference.
Closure
• Indicate the official survey findings are presented in writing to the ASC via the
Form CMS-2567, Statement of Deficiencies and Plan of Correction, which will be
prepared and mailed to the ASC within 10 working days. It documents either that
no deficiencies were found, or the specific deficiencies found, relating each to the
applicable regulatory requirement. There will also be a letter communicating
whether or not CMS will be taking enforcement action as a result of the survey’s
findings.
• The ASC’s plan of correction (POC) and time frames for implementation of
corrective actions are incorporated into the Form CMS-2567 and returned to the
SA. Explain that the Form CMS-2567 is the document disclosed to the public
about the facility’s deficiencies and what is being done to remedy those (Form
CMS-2567 with POC). The Form CMS-2567 is made public no later than 90
calendar days following completion of the survey.
• If any deficiencies have been identified, inform the ASC that a written plan of
correction must be submitted to the survey agency within 10 calendar days
following receipt of the written statement of deficiencies.
• Explain that, if a POC is required, the ASC will have the following three options:
• Accept the deficiencies stated on Form CMS-2567 and submit a PoC;
• Record objections to the cited deficiencies on Form CMS-2567 and submit a
PoC; or
• Record objections to cited deficiencies on Form CMS-2567, do not submit a
PoC, but submit written arguments and documented evidence that the
deficiencies are invalid.
• CMS will consider objections and accompanying documentation that
attempt to refute the factual accuracy of the survey findings, but will not
entertain objections to CMS’s judgment of the level, extent, scope or
severity of a deficiency. CMS reviews additional documentation
submitted by provider making an objection and, if the added evidence is
convincing, will remove the deficiency.
• If CMS disagrees with the ASC’s objections, the ASC must submit an
acceptable POC. Failure to submit an acceptable PoC or failure to correct
a deficiency may result in termination of the ASC’s supplier agreement in
accordance with 42 CFR 488.28(a), and 416.35(b).
Explain that an acceptable plan of correction must contain the following:
• Action that will be taken to correct each specific deficiency cited;
• Description of how the actions will improve the processes that led to the
deficiency cited;
• The procedure for implementing the corrective actions;
• A completion date for correction of each deficiency cited;
• Monitoring and tracking procedures to ensure the POC is effective in bringing the
ASC into compliance, and that the ASC remains in compliance with the
regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of
correction; and
• The administrator’s signature and the date signed on Page 1 of the Form CMS-
2567.
Indicate that the POC will be reviewed by the SA, or in some cases, the RO, to determine
whether it is acceptable. If a POC is determined not to be acceptable, it will be returned
to the ASC for revision.
State that in some cases, the SA will make an unannounced revisit survey to determine
whether the ASC has come into compliance.
If the exit conference was audio- or videotaped, obtain a copy of the tape before exiting
the facility.
All team members should leave the facility together immediately following the exit
conference. If the facility staff provides further information for review, the team
coordinator determines the best way to review the additional information. It is usually
prudent for at least two individuals to remain if all of the team members do not leave at
the same time.
Task 6 – Post Survey Activities
General Objective
The general objective of this task is to complete the survey and certification
requirements, in accordance with the regulations found at 42 CFR Part 488.
General Procedures
Each SA and RO must follow the instructions in the SOM including:
• Timelines for completing each step of the process;
• Responsibilities for completing the Form CMS 2567, “Statement of
Deficiencies,” following the “Principles of Documentation;”
• Notification to the ASC regarding survey results;
• Additional survey activities based on the survey results (e.g., revisit, forwarding
documents to the RO for further action/direction, such as concurrence with
findings for deemed ASCs, authorization of a full survey for deemed ASCs with
condition-level deficiencies); and
• Compilation of documents for the supplier’s file.
Survey Package
The Team Coordinator will assign responsibilities for completion of the various elements
of the survey package.
Statement of Deficiencies Report & Plan of Correction
The Statement of Deficiencies Report and Plan of Correction (Form CMS-2567) is the
official document that communicates the determination of compliance or noncompliance
with Federal requirements. Also, it is the form that the ASC will use to submit a plan to
achieve compliance. Form CMS-2567 is an official record and is available to the public
on request.
Indicate on Form CMS-2567 whether any deficiency constitutes immediate jeopardy to
the individual’s health and safety.
Write each deficiency statement in terms specific enough to allow a reasonably
knowledgeable person to understand what regulatory requirements were not met. The
consequence for incorrectly or unclearly documenting deficiencies can be the inability of
CMS to take needed enforcement action.
Refrain from making clinical judgments. Instead, focus on the ASC’s policies and
procedures, as well as how they were or were not implemented by the ASC’s medical and
other staff.
After you complete Form CMS-2567 in ASPEN, submit it to your supervisor for review.
If, after reviewing the form, your supervisor approves what you have documented, you
will begin working on the remainder of the survey package. If your supervisor does not
approve the form, then you will make any requested changes.
Other Survey Package Documentation
Complete the following documentation in hard copy. For complaint investigations,
attach these materials to the corresponding complaint in the Aspen Complaint Tracking
System:
• Description of sample selection;
• Summary listing of sample cases;
• Summary of interviews;
• Complaint investigation narrative;
• Form CMS-378E Ambulatory Surgical Center Crucial Data Extract
• For all surveys with a Life Safety Code component, Form CMS-2786U Fire
Safety Survey Report; and
• Form CMS-670, Survey Team Composition and Workload Report
Part II
General Provisions and Definitions;
General Conditions and Requirements
Interpretive Guidelines
Q-0001
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.25 Basic Requirements
Participation as an ASC is limited to facilities that –
(a) Meet the definition in §416.2; and
(b) Have in effect an agreement obtained in accordance with this Subpart.
Interpretive Guidelines: §416.25
An ASC must satisfy all the elements of the definition of an ASC and have in effect an
agreement to participate as an ASC in order to satisfy the basic Medicare ASC
requirements.
Q-0002
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.2 Definitions
As used in this part:
Ambulatory surgical center or ASC means any distinct entity that operates
exclusively for the purpose of providing surgical services to patients not requiring
hospitalization and in which the expected duration of services would not exceed 24
hours following an admission. The entity must have an agreement with CMS to
participate in Medicare as an ASC and must meet the conditions set forth in
Subpart B and C of this part.
Interpretive Guidelines: §416.2
According to the definition of an Ambulatory Surgical Center, or ASC, its key
characteristics are that it:
• Is a distinct entity;
• Operates exclusively for the provision of surgical services to patients not
requiring hospitalization, with the ASC’s services expected not to exceed 24
hours in duration following an admission;
• Has an agreement with Medicare to participate as an ASC; and
• Complies with the Conditions for Coverage (CfCs) in Subparts B and C, i.e., 42
CFR 416.25-52.
Distinct Entity
An ASC satisfies the criterion of being a “distinct” entity when it is wholly separate and
clearly distinguishable from any other healthcare facility or office-based physician
practice. The ASC is not required to be housed in a separate building from other
healthcare facilities or physician practices, but, in accordance with National Fire
Protection Association (NFPA) Life Safety Code requirements (incorporated by cross-
reference at §416.44(b)), it must be separated from other facilities or operations within
the same building by walls with at least a one-hour separation. If there are State licensure
requirements for more permanent separations, the ASC must comply with the more
stringent requirement.
An ASC does not have to be completely separate and distinct physically from another
entity, if, and only if, it is temporally distinct. In other words, the same physical premises
may be used by the ASC and other entities, so long as they are separated in their usage by
time. For example:
• Adjacent physician office: Some ASCs may be adjacent to the office(s) of the
physicians who practice in the ASC. Where permitted under State law, CMS
permits certain common, non-clinical spaces, such as a reception area, waiting
room, or restrooms to be shared between an ASC and another entity, as long as
they are never used by more than one of the entities at any given time, and as long
as this practice does not conflict with State licensure or other State law
requirements. In other words, if a physician owns an ASC that is located adjacent
to the physician’s office, the physician’s office may, for example, use the same
waiting area, as long as the physician’s office is closed while the ASC is open and
vice-versa. The common space may not be used during concurrent or
overlapping hours of operation of the ASC and the physician office.
Furthermore, care must be taken when such an arrangement is in use to ensure
that the ASC’s medical and administrative records are physically separate.
During the hours that the ASC is closed, its records must be secure and not
accessible by non-ASC personnel.
Permitting use of common, non-clinical space by distinct entities separated
temporally does not mean that the ASC is relieved of the obligation to comply
with the NFPA Life Safety Code standards for ASCs, in accordance with
§416.44(b), that require, among other things, a one-hour separation around all
physical space that is used by the ASC and fire alarms in the ASC.
It is not permissible for an ASC during its hours of operation to “rent out” or
otherwise make available an OR or procedure room, or other clinical space, to
another provider or supplier, including a physician with an adjacent office.
• Facilities with Diagnostic Imaging and Surgery Capability: Some facilities
are equipped to perform both ambulatory surgeries and diagnostic imaging.
However, Medicare regulations do not recognize a non-hospital institutional
healthcare entity that performs both types of services, and actually requires an
ASC to operate exclusively for the purpose of providing surgical services.
However, the Medicare Independent Diagnostic Testing Facility (IDTF) payment
regulations at 42 CFR 410.33(g) prohibit IDTFs that are not hospital-based or
mobile from sharing a practice location with another Medicare-enrolled individual
or organization. As a result, ASCs may not share space, even when temporally
separated, with a Medicare-participating IDTF.
NOTE: Certain radiology services integral to surgical procedures may be
provided when the facility is operating as an ASC.
• Separately Certified ASCs Sharing Space: Where permitted under State law,
several different ASCs, including ones that participate in Medicare and ones that
do not, may use the same physical space, including the same operating rooms, so
long as they are temporally distinct, i.e., they do not have concurrent or
overlapping hours of operation. However, an ASC and a hospital or CAH
outpatient surgery department, including a provider-based department that is
either on or off the hospital’s or CAH’s main campus, may not share the same
physical space, since the regulations at 42 CFR 413.65(d)(4) require that the
provider-based department be held out to the public as a part of the main hospital,
and that patients entering the provider-based facility are aware that they are
entering the hospital.
Each of the different ASCs that utilize the same space is separately and
individually responsible for compliance with all ASC Conditions for Coverage
(CfCs). So, for example, each ASC must have its own policies and procedures
and its own medical records. Likewise, although there is no prohibition against
each ASC using the same nursing and other staff under an arrangement with the
employer of the staff, each is nevertheless required to separately comply with all
requirements governing the utilization of staff in the ASC.
At the same time, each Medicare-certified ASC that shares the same space as
another Medicare-certified ASC should be aware, when entering into such an
arrangement, that identification of certain deficient practices may result in citation
of deficiencies for all ASCs occupying the same premises. For example, building
features that violate the Life Safety Code would not vary according to which ASC
happened to be operating on the premises at the time of a survey, and all ASCs at
that location would be cited for the deficiency.
If there are multiple ASCs utilizing the same space, but at different times, it may
be prudent to consider organizing recertification surveys in order to use the time
on-site to conduct multiple surveys allowing assessment of each ASC that utilizes
the space.
Exclusive Provision of Limited Surgical Services
The ASC must offer only surgical services. Separate ancillary services that are integral
to the surgical services, i.e., those furnished immediately before, during or immediately
after a surgical procedure, may be provided. The ASC may not, however, offer services
unrelated to the surgeries it performs.
What constitutes “surgery”?
For the purposes of determining compliance with the ASC definition, CMS relies, with
minor modification, upon the definition of surgery developed by the American College of
Surgeons (www.facs.org/fellows_info/statements/st-11.html.) Accordingly, the
following definition is used to determine whether or not a procedure constitutes surgery:
Surgery is performed for the purpose of structurally altering the human body by the
incision or destruction of tissues and is part of the practice of medicine. Surgery
also is the diagnostic or therapeutic treatment of conditions or disease processes by
any instruments causing localized alteration or transposition of live human tissue
which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles.
The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by
closed reductions for major dislocations or fractures, or otherwise altered by
mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of
diagnostic or therapeutic substances into body cavities, internal organs, joints,
sensory organs, and the central nervous system, is also considered to be surgery.
(This does not include the administration by nursing personnel of some injections,
subcutaneous, intramuscular, and intravenous, when ordered by a physician.) All of
these surgical procedures are invasive, including those that are performed with
lasers, and the risks of any surgical procedure are not eliminated by using a light
knife or laser in place of a metal knife, or scalpel.
An ASC is further limited to providing surgical services only to patients who do not
require hospitalization after the surgery. Further, the ASC’s surgical services must be
ones that ordinarily would not take more than 24 hours, including not just the time for the
surgical procedure but also pre-op preparation and recovery time, following the
admission of an ASC patient. These limitations apply to all of the ASC’s surgical
services, not just to surgeries on Medicare beneficiaries who use the ASC.
• The term “hospitalization” means that a patient needs a supervised recovery
period in a facility that provides hospital inpatient care. Whether a patient
“requires” hospitalization after a surgical procedure is a function both of the
characteristics of the patient and of the nature of the surgery. In other words, an
ASC might be an appropriate setting for a particular surgical procedure for
patients under the age of 65 without significant co-morbidities, but might be a
very risky, inappropriate setting for that same procedure when performed on a 75-
year old patient with significant co-morbidities. ASCs must consider patient-
specific characteristics that might make hospitalization more likely to be required
when determining their criteria for patient selection.
Any surgery for which a patient must be routinely transferred to a hospital after
the surgery is not appropriate for the ASC setting.
Some States permit the operation of “recovery centers” that are neither Medicare-
certified healthcare facilities nor licensed hospitals, but which provide post-
operative care to non-Medicare ASC patients. If such recovery centers would be
considered hospitals if they participated in the Medicare program, then it is
doubtful that an ASC that transfers patients to such centers meets the Medicare
definition of an ASC. However, surveyors are not expected to make
determinations about the nature of such recovery centers. If a SA is concerned
that a recovery center is providing hospital inpatient care, it should discuss this
matter further with the CMS Regional Office.
• Expected duration of services. ASCs may not provide services that, under
ordinary circumstances, would be expected to exceed 24 hours following an
admission. Patients admitted to an ASC will be permitted to stay 23 hours and 59
minutes, starting from the time of admission (see 73 FR at 68714 (November 18,
2008)). The time calculation begins with the admission and ends with the
discharge of the patient from the ASC after the surgical procedure. While the
time of admission normally would be the time of registration or check-in of the
patient at the ASC’s reception area, for the purposes of compliance with this
requirement ASCs may use the time when the patient moves from the
waiting/reception area into another part of the ASC. This time must be
documented in the patient’s medical record. The discharge occurs when the
physician has signed the discharge order and the patient has left the recovery
room. Other starting or end points, e.g., time of administration of anesthesia, or
time the patient leaves the OR, may not be used to calculate compliance with the
24-hour requirement.
This requirement applies to all ASC surgical services. For services to Medicare
beneficiaries there are additional payment regulations that further limit the surgical
services that Medicare will pay for. For example, payment regulations at
§416.166(b) state, among other criteria, that Medicare will generally pay for
surgical procedures for which standard medical practice dictates that the beneficiary
would not typically require active medical monitoring and care after midnight of the
day of the procedure. This more restrictive Medicare payment requirement is
enforced through the claims payment and audit processes. The SA surveyors may
not cite an ASC for failing to meet the definition of an ASC if instances of
Medicare beneficiaries who remain in the ASC are identified, so long as they meet
the 24-hour requirement.
Rare instances of patients whose length of stay in the ASC exceeds 24 hours do not
automatically mean that the ASC fails to meet the regulatory definition of an ASC
and must be cited as out of compliance with this requirement. The regulatory
language refers to surgical services whose “expected duration” does not exceed 24
hours. It is possible for an individual case to take longer than expected, due to
unforeseen complications or other unforeseen circumstances. In such rare cases the
ASC continues to be responsible for the care of the patient until the patient is stable
and able to be discharged in accordance with the regulatory requirements governing
discharge, as well as the ASC’s policy. However, if an ASC has cases exceeding
24 hours more than occasionally, this might suggest that the facility is not in
compliance with the definition of an ASC.
Cases that surveyors identify which exceed 24 hours must be reviewed further to
determine whether the expected duration of services for the procedure in question,
when performed on a patient with key clinical characteristics similar to those of the
patient in the case, would routinely exceed 24 hours. Key clinical characteristics
include, but are not limited to, age and co-morbidities. If the procedure is one that
Medicare pays for in an ASC setting, then it can be assumed that the expected
duration of services related to that procedure would not exceed 24 hours. If the
procedure is not one that Medicare pays for in an ASC, then the ASC must provide
evidence supporting its expectation that the services to the patient would not exceed
24 hours. Such evidence could include other cases in the ASC where similar
patients (in terms of condition prior to surgery) undergoing the same procedure
were discharged in 24 hours or less after admission.
In summary, exceeding the 24-hour time frame is expected to be a rare occurrence,
and each rare occurrence is expected to be demonstrated to have been something
which ordinarily could not have been foreseen. Not meeting this requirement
constitutes condition-level noncompliance with §416.25. In addition, review of the
cases that exceed the time frame may also reveal noncompliance with CfCs related
to surgical services, patient admission and assessment, and quality
assurance/performance improvement.
ASCs should be aware that, to the extent that patients remain within the ASC for 24
hours or longer, for purposes of Life Safety Code requirements the ASC would be
considered a “healthcare” rather than an “ambulatory” occupancy under the NFPA
Life Safety Code.
Has a Medicare Supplier Agreement
An entity cannot be an ASC, as that term is defined in Medicare’s regulations, if it does
not have an agreement to participate in Medicare as an ASC. Since ASCs are suppliers,
the ASC agreement is a supplier agreement. Thus, while Medicare regulations recognize,
for example, non-participating hospitals and will pay them for emergency services under
certain circumstances, in the case of an ASC, the term “ASC” has a meaning exclusive to
the entity’s participation in the Medicare program. Applicants to participate as an ASC
are not considered “ASCs” until they actually have a Medicare agreement in place.
In the case of a prospective ASC undergoing an initial survey to determine whether it
may be certified for Medicare participation, the SA may not conduct the survey until the
Medicare Administrative Contractor/legacy Carrier has reviewed the ASC’s Form 855B
enrollment application and made a recommendation for approval of the ASC’s
participation in Medicare.
Compliance with Subparts B and C
Finally, an ASC must comply with each of the requirements found in Subparts B and C,
i.e., the provisions found at 42 CFR 416.25 – 35 for Subpart B, and 42 CFR 416.40 – 52
for Subpart C.
Subpart B contains the supplier agreement requirements for an ASC. Enforcement of
these provisions generally follows the same process as that outlined in SOM §3030.
Although §3030 specifically addresses failures of providers to comply with the statutory
provider agreement requirements, noncompliance of an ASC supplier with the provisions
of Subpart B may be handled by CMS Regional Offices in the same way.
Subpart C contains the health and safety standards for ASCs, i.e., the Conditions for
Coverage. State Survey Agencies survey ASCs for their compliance with the ASC
definition and the CfCs. If an ASC has condition-level noncompliance with numerous
CfCs, then condition-level noncompliance with §416.25 may also be cited.
Survey Procedures: §416.2
• Determine through interview and observation and consultation with the LSC
surveyor whether the ASC facility is physically separated by at least a 1 hour
separation from any other healthcare facility or physician office.
• Determine whether it is permissible under State licensure requirements for an
ASC to share its physical space with another entity from which it is temporally
separated. If sharing physical space that is temporally separate is not permitted
under State law, then it is also not permitted under Medicare.
• Where permitted under State law, if the ASC shares common administrative space
with an adjoining or contiguous physician’s office or clinic, ask the ASC for
evidence that use of this common space by the ASC and the other entity(ies) is
not concurrent or overlapping in time. Look for signs or schedules that would
confirm that the entities do not use the space at the same time.
• If an ASC complies with all other elements of the ASC definition but has
permitted concurrent use by an adjacent physician’s office or clinic of common
administrative space, this would constitute a standard-level violation. However,
co-mingling of services may also result in related deficiencies in the areas of
medical records, patients’ rights, medical staff, nursing staff, etc. that would be
cited under the applicable CfCs, and which together might result in a condition-
level violation of §416.25 and possibly the other CfCs.
• Where sharing of space by multiple healthcare entities is permitted under State
law, determine through interview, observation and review of facility documents
whether the ASC shares the same space, including clinical space, such as ORs,
procedure rooms, recovery rooms, etc., with another entity.
• If it does share space with other healthcare entities, ask the ASC for evidence
that the two entities never operate concurrently or have overlapping hours.
Look for signs or schedules that would confirm that the entities do not use the
same space at the same time.
• If there are multiple ASCs utilizing the same space and there are deficiencies
that are common to more than one ASC, citations must be issued to each ASC.
• If there is evidence that ASC and another entity that provides services other
than surgery share the same space, including clinical space, concurrently or
have overlapping hours of operation, this would constitute a condition-level
violation of §416.25 because the ASC would not be a distinct entity and it
would not be operating exclusively to provide surgical services. In addition,
co-mingling of services may also result in related deficiencies in the areas of
medical records, patients’ rights, medical staff, nursing staff, etc. that would
be cited under the applicable CfCs, and which together might result in
additional condition-level violations.
• If there is evidence that ASC and another entity that provides surgical services
share the same space, including clinical space, concurrently or have
overlapping hours of operation, this would constitute a standard-level
violation. However, this co-mingling of services may also result in related
deficiencies in the areas of medical records, patients’ rights, medical staff,
nursing staff, etc. that would be cited under the applicable CfCs, and which
together might result in condition-level violation of §416.25 and possibly the
other CfCs.
• Review all closed medical records in the survey sample to determine whether the
time elapsed between the patient’s admission or registration and discharge does
not exceed 23 hours and 59 minutes. The calculation of the timeframe begins with
the time documented in the medical record indicating when the patient moved
from the reception or waiting area into another part of the ASC, if the ASC
records this separate from the time of admission in the medical record.
• Determine whether the medical records note the patient’s admission and discharge
time.
• Observe whether the ASC correctly notes the time of admission for patients
checking in and being discharged.
• For cases reviewed that exceed the permitted expected time frame, ask the ASC to
provide documentation indicating why it was reasonable to have expected that the
time from admission to discharge would not exceed 24 hours. Acceptable
evidence could include, but is not limited to, documentation that the procedure is
one that Medicare has previously paid the ASC for, or other cases in the ASC
involving the same procedure on similar patients that did not exceed the
timeframe. ASCs may produce other evidence for surveyors to assess. Surveyors
are not expected to know all of the surgical procedures covered by Medicare in an
ASC, although they may obtain more information about this if they choose at
http://www.cms.hhs.gov/apps/ama/license.asp?file=/ascpayment/downloads/CMS
_1404_FC_ASC_AddAA_BB_DD1_DD2_EE.zip (This link requires a consent
to use policies and then leads to a series of spreadsheets; the pertinent one is the
ASC Addendum AA.) It is the responsibility of the ASC to demonstrate that the
procedure is covered by Medicare when performed in an ASC.
Q-0020
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.40 Condition for Coverage: Compliance With State Licensure
Law
The ASC must comply with State licensure requirements.
Interpretive Guidelines: §416.40
State licensure requirements generally exist for both healthcare facilities and healthcare
professionals. States vary considerably in their licensure requirements for entities that
meet the Medicare definition of an ASC. Some States may not require separate licensure
of these facilities, although all States require licensure of healthcare professionals
providing services within the ASC. Some States may require separate licensure for some,
but not all ASCs within their State; for example, in some States, ASCs that are operated
as part of a physician single or group private practice may not require separate licensure
as a healthcare facility. This condition requires that an ASC comply with whatever State
licensure requirements are applicable to it.
In States where a separate facility license is required for a facility providing ambulatory
surgical services, the ASC must have a current license that has not expired or been
suspended or revoked. The ASC must also be in compliance with the State licensure
requirements.
Failure of the ASC to meet State licensure law may be cited when the State has made a
determination of noncompliance and has also taken a final enforcement action as a result.
Citation of licensure deficiencies may represent an initial step rather than a final action or
determination by the State licensure authority. Additionally, the Federal survey of the
ASC focuses on current compliance or non-compliance, not past noncompliance. Thus,
for example, evidence that an ASC had been assessed a civil monetary penalty by the
State licensure authority in the previous year would not be grounds for citing the ASC for
noncompliance with State licensure law, unless the State licensure authority indicates the
ASC remains noncompliant.
If as a result of a State citation of an ASC for deficiencies in its compliance with
licensure requirements the ASC has ceased operations and no longer furnishes services, it
would be considered to have voluntarily terminated its Medicare supplier agreement as of
the last date on which it provided services to Medicare beneficiaries, in accordance
with§416.35(a)(3). The SA must advise the RO of the ASC’s cessation of business, and
the RO will process a voluntary termination.
If at the time of the survey the ASC’s State license has been revoked, suspended, or
otherwise formally limited (e.g., admissions have been curtailed by the State), then the
ASC is not in compliance with this condition and must be cited for a condition-level
deficiency. Furthermore, survey of the rest of the CfCs cannot be completed, since the
ASC is not providing surgical services to patients. The SA must advise the RO of such
formal licensure enforcement actions and the RO will proceed with action to terminate
the ASC supplier agreement, in accordance with standard termination procedures.
If the surveyor identifies a situation that suggests the ASC may not be in compliance with
State licensure law, the information may be referred to the State licensure authority for
follow-up.
While States vary as to the types of healthcare professionals that require licensure, all
ASCs have physicians and nursing staff that require State licensure. It is the ASC’s
responsibility to verify that all ASC personnel who require a State license have a current
license that has not expired or been suspended or revoked.
Survey Procedures: §416.40
• Determine prior to the survey whether a facility license is required for the ASC.
If there is access to State licensure files, review the ASC’s State licensure status.
Otherwise, ask to see the ASC’s license.
• Review the ASC’s documentation of all personnel required to be licensed under
State or local laws or regulations. Check that the ASC has evidence that all
personnel requiring licensure have current licenses in good standing.
Q-0040
§416.41 Condition for Coverage: Governing Body and Management
The ASC must have a governing body that assumes full legal responsibility for
determining, implementing, and monitoring policies governing the ASC’s total
operation. The governing body has oversight and accountability for the quality
assessment and performance improvement program, ensures that the facility
policies and programs are administered so as to provide quality healthcare in a safe
environment, and develops and maintains a disaster preparedness plan.
Interpretive Guidelines: §416.41
The ASC must have a designated governing body that exercises oversight for all ASC
activities. The governing body is responsible for establishing the ASC’s policies, making
sure that the policies are implemented, and monitoring internal compliance with the
ASC’s policies as well as assessing those policies periodically to determine whether they
need revision. The regulation particularly stresses the responsibility of the governing
body for:
• direct oversight of the ASC’s quality assessment and performance improvement
(QAPI) program (see 72 FR 50472, August 31, 2007) and 73 FR 68714,
November 18, 2008;
• the quality of the ASC’s healthcare services;
• the safety of the ASC’s environment; and
• development and maintenance of a disaster preparedness plan.
In the case of an ASC that has one owner, that individual constitutes the governing body.
Although the governing body may delegate day-to-day operational responsibilities to
administrative, medical, or other personnel, the ASC’s governing body retains the
ultimate responsibility for the overall operations of the ASC and quality of its services.
The regulation also emphasizes the governing body’s responsibilities in the areas of
QAPI and disaster preparedness. Delegations of governing body authority should be
documented in writing.
The governing body is responsible for creating a safe environment where ASC patients
can receive quality healthcare services. This means the governing body is not only
responsible for adopting formal policies and procedures that govern all operations within
the ASC, but also that it must take actions to ensure that these policies are implemented.
Through its direct oversight and accountability for the ASC’s QAPI program, it is
expected that the ASC is better able to improve care being furnished to its patients. (See
72 FR 51472, August 31, 2007.) When QAPI citations are made related to 42 CFR
416.43, particularly Standard (e), the citation at 42 CFR 416.41should also be considered.
If condition-level deficiencies are cited related to multiple other ASC CfCs, with the
result that the ASC does not provide quality healthcare or a safe environment, then it is
also likely that the ASC is not complying with the governing body CfC.
Survey Procedures: §416.41
• Ask the ASC for information about its governing body. If there are questions
about who constitutes the ASC’s governing body, it may help to review the
information the ASC reported in Section 6 of its CMS Form 855B application,
identifying those individuals with ownership interest or managing control of the
ASC.
• Ask the ASC how frequently the governing body meets and what are the typical
items on its meeting agendas.
• Has the governing body delegated operational responsibility to a manager?
• Ask for an organizational chart of the ASC management. Ask who performs the
following functions:
• Human Resources;
• Medical staff credentialing and granting of privileges;
• Management of surgical services;
• Management of nursing services;
• Management of pharmaceutical services;
• Management of laboratory (if applicable) and radiologic services;
• Management of the ASC’s physical plant;
• Medical records maintenance;
• Infection control;
• Quality Assurance and Performance Improvement.
• Ask to see meeting minutes or other evidence that the ASC’s policies and
procedures have been formally adopted by the governing body.
• Ask to see meeting minutes or other evidence of how the governing body assures
that its policies are implemented, and of how the governing body monitors
internal compliance with and reassesses the ASC’s policies. For example, is there
any evidence of data collected and submitted to the governing body related to
specific ASC policies?
• Ask to see meeting minutes or other evidence of how the governing body
exercises ongoing oversight of and accountability for the ASC’s QA/PI program.
See the discussion of §416.43 for more detail on the regulatory requirements
related to QA/PI.
Q-0041
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.41(a) Standard: Contract Services
When services are provided through a contract with an outside resource, the ASC
must assure that these services are provided in a safe and effective manner.
Interpretive Guidelines: §416.41(a)
The ASCs may contract with third parties for provision of the ASC’s services, including
the ASC’s environment. However, such a contract does not relieve the ASC’s governing
body from its responsibility to oversee the delivery of these ASC services. Given that
many ASCs operate closely with a physician practice or clinic, or that some ASCs share
space with other ASCs or other types of healthcare facilities operating at different times,
use of a wide range of contract services may be common in ASCs. The ASC must assure
that the contract services are provided safely and effectively. Contractor services must
be included in the ASC’s QAPI program.
For example:
• If the ASC contracts for cleaning of the ASC, including its ORs/procedures
rooms, the ASC’s governing body is still responsible for the sanitary condition of
the ASC and must exercise oversight over its contractor to assure that standard
sanitary practices are employed.
• If the ASC contracts for the provision of nursing services, the ASC remains
responsible for assuring that all contract nurses are properly licensed and trained
and oriented to perform their duties within the ASC. The ASC is responsible for
the direction of nursing staff, regardless of whether they are employees or
provided under contract.
• If the ASC contracts for provision of anesthesia services, the ASC remains
responsible for reviewing the credentials of all anesthesiologists and anesthetists
providing anesthesia services and granting them privileges to do so.
• If the ASC contracts (for example, with an associated adjacent physician practice)
for provision of receptionist services, the ASC is responsible for assuring that
such services are provided in a manner that complies with the patients’ rights CfC
requirements.
• If the ASC contracts for medical records services, it must ensure that the
contractor meets all requirements of the medical records CfC.
Survey Procedures: §416.41(a)
• Ask the ASC for a complete list of its currently contracted services.
• Review the personnel files of contract personnel to determine, as applicable, their
credentials, privileges, evidence of training, evidence of periodic evaluation, etc.
• If the ASC is one that shares space (temporally separated) with other entities, ask
the ASC whether it contracts or has some other formalized arrangement with any
of those other entities for services when the ASC is in operation. If employees of
an entity other than the ASC perform services while the ASC is in operation, and
the ASC has no contract or other formal documentation of an arrangement with
the other entity that governs the provision of such services, then the governing
body fails to exercise its responsibility for the administration of the ASC’s
programs.
• Ask the ASC how it assesses the safety and effectiveness of the services provided
by each contractor, including how contractor services are incorporated into its
QA/PI program. Select several contractors from the list and ask for
documentation of the most recent assessment of each by the ASC.
• Ask the ASC management what process it uses to correct deficiencies in
contracted services. Ask if there are any cases where it has identified deficiencies
and taken corrective action, and if so, ask to see documentation of these cases.
Q-0042
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.41(b) Standard: Hospitalization
(1) The ASC must have an effective procedure for the immediate
transfer, to a hospital, of patients requiring emergency medical care
beyond the capabilities of the ASC.
(2) This hospital must be a local, Medicare participating hospital or a
local, nonparticipating hospital that meets the requirements for
payment for emergency services under §482.2 of this chapter.
(3) The ASC must –
i. Have a written transfer agreement with a hospital that meets the
requirements of paragraph (b)(2) of this section; or
ii. Ensure that all physicians performing surgery in the ASC have
admitting privileges at a hospital that meets the requirements of
paragraph (b)(2) of this section.
Interpretive Guidelines: §416.41(b)
The ASC must be able to transfer a patient immediately to a local hospital when the
patient experiences a medical emergency that the ASC is not capable of handling, or
which requires emergency care extending well beyond the 24-hour time frame for ASC
cases. (See §§416.44(c) and (d) for a discussion of the emergency care capabilities each
ASC must have.)
(1) Immediate Transfer Procedure
An “effective procedure” for immediate emergency transfers includes:
• Written ASC policies and procedures that address the circumstances
warranting emergency transfer, including who makes the transfer decision;
the documentation that must accompany the transferred patient; and the
procedure for accomplishing the transfer safely and expeditiously,
including communicating with the receiving hospital. There must be
evidence that staff are aware of and can implement the ASC’s policy
immediately upon the development of a medical emergency.
• Provision of emergency care and initial stabilizing treatment within the
ASC’s capabilities until the patient is transferred. (See §§416.44(c) and
(d).)
• Arrangement for immediate emergency transport of the patient. (It is
acceptable if the ASC contacts the ambulance service via 911 to arrange
emergency transport, unless State licensure requires additional
arrangements, but the ASC is still responsible for communicating with the
receiving hospital to facilitate the transfer.)
(2) Transfer to a local hospital
The ASC is required to transfer patients who require emergency transfer to a local
Medicare-participating hospital, or to a local, non-Medicare-participating hospital that
meets the requirements for payment for emergency services by the Medicare program in
accordance with 42 CFR 482.2. (See the interpretive guidelines for §482.2 in Appendix
A of the State Operations Manual concerning non-participating emergency hospitals.)
A “local” hospital means the ASC is to consider the most appropriate facility to which
the ASC will transport its patients in the event of an emergency. If the closest hospital
could not accommodate the patient population or the predominant medical emergencies
associated with the type of surgeries performed by the ASC, another hospital that is able
to do so and which is closer than other comparable hospitals would meet the “local”
definition. For example, if there is a long term care hospital within five miles of the ASC,
and a short-term acute care hospital providing emergency services within fifteen miles of
the ASC, the ASC would be expected to transfer patients to the short-term acute care
hospital.
Patient-specific circumstances play a role in determining the appropriate local hospital
at the time of an emergency. For example, if the patient had a heart attack during
surgery at the ASC and needs an interventional cardiac catheterization, and the closest
hospital does not offer this service, it is expected that the ASC would transfer the patient
to a farther hospital with the cardiac catheterization capability.
If there are multiple hospitals with comparable capabilities that are roughly the same
distance from the ASC, i.e., there are only a few miles difference among them in their
distance from the ASC, then the ASC may make the transfer to any one of these hospitals.
For example, if there are three comparable, appropriate hospitals within a ten mile
radius of the ASC, transfer to any one would be acceptable. Likewise, for another
example, if the ASC is in a more rural area and there are two appropriate hospitals that
are each about 40 miles distant from the ASC, but in opposite directions, each of those
hospitals would be considered a “local” hospital for the ASC.
On the other hand, for example, if there is an appropriate hospital eight miles from the
ASC, and another hospital with similar capabilities twenty miles from the ASC, the
further hospital would not be considered a local hospital for ASC emergency transfer
purposes, unless the closer hospital lacks capacity at the time of the transfer.
A State-specific definition of what constitutes a “local” hospital for ASC transfer
purposes does not override the Medicare requirement to use the hospital nearest to the
ASC with the appropriate capabilities.
CMS expects that, absent the specific types of circumstances described above, emergency
transfers will ordinarily be made to a hospital with which the ASC has an arrangement(s)
to meet the requirements of §416.41(b)(2) and (3). Regardless of any business issues
that may arise between ASCs and their local hospital(s), the ASC is required to have an
effective procedure to immediately transfer its emergency cases to the nearest, most
appropriate local hospital, since a delay in transfer could affect the patient’s health. (See
72 FR 50472, August 31, 2007 and 73 FR 68714, November 18, 2008.)
(3) Transfer Agreement or Hospital Privileges
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).
A transfer agreement is a written agreement, signed by authorized representatives of the
ASC and the hospital, in which the hospital agrees to accept the transfer of the ASC’s
patients who need inpatient hospital care, including emergency care. Generally transfer
agreements establish the respective responsibilities of each party to the agreement, such
as the process for arranging a transfer, etc. A transfer agreement may have an expiration
date, or it may have terms stating that it remains in effect until and unless one of the
parties has terminated the transfer agreement. An ASC’s transfer agreement must be
reviewed to determine whether it is in force at the time of the survey.
If the ASC does not have a transfer agreement, then it must maintain documentation of
the current admitting privileges of all physicians who perform surgery at the ASC at local
hospitals that satisfy the regulatory requirements in §416.41(b)(2) . (Even if the ASC has
a transfer agreement, such documentation would be a good idea. However, it is required
under the regulations only if there is no transfer agreement.) If there is more than one
local hospital that meets the regulatory requirement for an appropriate local transfer
destination, the ASC may satisfy the requirement at §416.41(b)(3) when its operating
physicians each have admitting privileges at one of the eligible hospitals; it is not
necessary that they all have privileges in the same hospital. The physician who
performed the surgery on the patient requiring an emergency transfer is expected to
arrange the hospital admission of the patient, unless there is a compelling clinical reason
to transfer the patient to a different local hospital where the physician does not have
admitting privileges.
In some circumstances, a transfer agreement between the ASC and a local hospital or the
possession of hospital admitting privileges by the ASC’s operating physicians will not
guarantee that a hospital will accept a specific transfer, since the hospital may lack the
capacity to provide the required service at the time an emergency transfer request is
made. ASCs should have alternative plans to address such contingencies. While it is true
that the local hospital, if it is a Medicare-participating hospital that has an emergency
department, would be obligated under the Emergency Medical Treatment and Labor Act
(EMTALA), once the patient arrives on the hospital’s property, to provide a medical
screening examination, as well as stabilizing treatment to an individual with an
emergency medical condition, an ASC may not satisfy its transfer requirements by
simply relying upon an expectation that hospitals fulfill their EMTALA obligations. An
ASC may call 911 to arrange emergency transport, but it must also take steps to arrange
the transfer of the patient to a local hospital.
Survey Procedures: §416.41(b)
• Before going on the survey, determine which hospital(s) in the vicinity of the
ASC might meet the regulatory requirement of being a local hospital.
• Determine whether the ASC has a transfer agreement with an appropriate
local hospital that meets the regulatory requirements. If it does, ask to see the
transfer agreement. Look for an expiration date. If there is no expiration
date, ask the ASC whether the transfer agreement has been terminated by
either party. If there is doubt about the transfer agreement being in effect, a
surveyor may contact the hospital to ask it whether it has a current transfer
agreement with the ASC.
• If the ASC does not have a transfer agreement with an appropriate local
hospital, ask for documentation that each physician who has privileges to
perform surgery in the ASC has admitting privileges in an appropriate local
hospital. Ask the ASC how it ensures that its information is up-to-date.
• Ask to see the ASC’s policy and procedures for emergency transfer of patients.
Review the document to determine whether it addresses the essential elements.
• How is this protocol communicated to the clinical staff of the ASC?
• Ask the clinical staff how they would handle a medical emergency of an ASC
patient that could not be managed within the ASC. Do they know the ASC’s
policies and procedures for emergency transfer? Do they know how to arrange
emergency transport?
• Ask if the ASC has had any emergency transfers of patients in the previous 12
months. If it has, review the medical records of patients transferred to
hospitals to determine whether they were transferred to hospitals that meet the
regulatory requirements for a local hospital. If the ASC transfers emergency
cases to hospital(s) other than local one(s), ask for the rationale supporting
these alternative transfers.
• Determine whether the ASC had a transfer agreement, or a physician with
admitting privileges, at each hospital to which a patient was transferred.
• Does the medical record give any indication that the ASC took steps to arrange
the transfer, beyond calling 911?
Q-0043
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.41(c) Standard: Disaster Preparedness Plan
(1) The ASC must maintain a written disaster preparedness plan that
provides for the emergency care of patients, staff and others in the facility
in the event of fire, natural disaster, functional failure of equipment, or
other unexpected events or circumstances that are likely to threaten the
health and safety of those in the ASC.
(2) The ASC coordinates the plan with State and local authorities, as
appropriate.
(3) The ASC conducts drills, at least annually, to test the plan’s effectiveness.
The ASC must complete a written evaluation of each drill and promptly
implement any corrections to the plan.
Interpretive Guidelines: §416.41(c)
Disaster Preparedness Plan. The intent of this regulation is for an ASC to have in place
a disaster preparedness plan to care for patients, staff and other individuals who are on
the ASC’s premises when a major disruptive event occurs. The governing body of the
ASC is responsible for the development of this plan.
A wide range of events could occur, such as fire, flood, mass release of a biochemical
hazard, electrical failure, failure of the water supply, failure of key equipment needed to
sustain the operations of the ASC, etc. The ASC must take an all-hazards approach when
developing its plan, identifying hazards that are specific to the operating environment of
an ASC as well as hazards that may affect the community in which the ASC operates,
including the ASC.
Comprehensive emergency management includes the following phases, which should be
taken into account in the development of the ASC’s disaster preparedness plan:
Hazard Identification: ASCs should make every effort to include any potential hazards
that could affect the facility directly and indirectly for the particular area in which it is
located. Indirect hazards could affect the community but not the ASC, and as a result
interrupt necessary utilities, supplies, or staffing.
Hazard Mitigation: Hazard mitigation consists of those activities taken to eliminate or
reduce the probability of the event, or reduce the event’s severity or consequences, either
prior to or following a disaster or emergency.
The emergency plan should include mitigation processes for patients, staff and others
present in the facility at the time of the disaster or emergency. Mitigation details should
address provision of needed care for the ASC’s patients being prepared for procedures,
undergoing procedures, or recovering from procedures, as well as how the ASC will
educate staff in protecting themselves and others present in the ASC in the event of an
emergency. Comprehensive hazard mitigation efforts, including staff education, will aid
in reducing staffs' vulnerability to potential hazards. These activities precede any
imminent or post-impact timeframe, and are considered part of the response.
Preparedness: Preparedness includes developing a plan to address how the ASC will
meet the needs of patients, staff, and others present in the ASC if essential services break
down as a result of a disaster. It will be the product of a review of the basic facility
information, the hazard analysis, and an analysis of the ASC’s ability to continue
providing care and services during an emergency. It also includes training staff on their
role in the emergency plan, testing the plan, and revising the plan as needed.
Response: Activities taken immediately before (for an impending threat), during and
after a disaster/emergency event to address the immediate and short-term effects of the
emergency.
Recovery: Activities and programs that are implemented during and after the ASC’s
response that are designed to return the ASC to its usual state or a "new normal."
Resources for providers and suppliers on effective healthcare emergency preparedness may
be found on CMS’ Web site at
http://www.cms.hhs.gov/SurveyCertEmergPrep/03_HealthCareProviderGuidance.asp#Top
OfPage
Coordination of the Plan. The regulation requires that the ASC must coordinate its
disaster preparedness plan with State and local authorities that have responsibility for
emergency management within the State. Coordination should take place in addressing
threats that either extend beyond the premises of the ASC, e.g., floods, earthquakes, or
biochemical releases, etc., or threats within the ASC that require response from a
community agency, e.g., fire department.
Coordination assists in overall emergency management planning efforts within the area
where the ASC is located, for example by ensuring that the facility’s plans are consistent
with the larger community approach to similar hazards. It also makes known to both the
ASC and to the State and local authorities the assets and capabilities that each has
available during an emergency.
The regulation does not require that ASCs be integrated into State and local emergency
preparedness plans to address threats that extend beyond the premises of the ASC, since
it will ultimately be the decision of the State and local officials whether and how they
might utilize ASCs in a response to an emergency event. ASCs must, however,
document that they have made efforts to communicate with their State and local
emergency preparedness officials to inquire about potential coordination.
Testing, Evaluating, and Updating the Plan. At least once every year the ASC must
conduct a drill to test the plan’s effectiveness. A drill that is conducted in concert with
State or local authorities would qualify as an annual test. While the drill does not have to
test the response to every identified hazard, it is expected to test a significant portion of
the plan. For example, a fire drill does not qualify on its own as a sufficient annual drill
of the ASC’s plan.
The ASC must prepare a written evaluation of each annual drill, identifying problems that
arose as well as methods to address those problems. The disaster preparedness plan must
be promptly updated to reflect the lessons learned from the drill and the needed changes
identified in the evaluation.
Survey Procedures: §416.41(c)
• Ask the ASC’s leadership to show you the facility’s emergency preparedness
plan. Ask them to summarize the plan briefly for you, explaining how it
addresses protecting patients, staff, and others present in the ASC at the time of a
disaster or emergency.
• Ask the ASC’s leadership how staff are informed of the plan, including their roles
and responsibilities. Interview some ASC staff members, including physicians, to
determine whether they are aware of the plan and its contents.
• Ask for evidence of coordination with State or local emergency management
agencies. The degree to which State or local authorities engage in coordinated
planning with local healthcare facilities, especially ones that are not hospitals,
may vary among localities and States. At a minimum, the ASC must have
documentation that it has identified appropriate State and local agencies, and that
the ASC has made these agencies aware of the ASC’s interest in coordination.
• Ask for documentation of the annual drill (in the case of new ASCs undergoing an
initial survey, they must have evidence of having conducted at least one drill).
Ask the ASC’s leadership to describe how the drill was conducted, and what
features of the plan it is designed to test. Ask some ASC staff, including
physicians, if they have participated in a drill to test the emergency preparedness
plan.
• Ask to see the written evaluation of the drill. Determine whether the evaluation
reviews the drill in detail and makes assessments of whether the plan features that
were tested in the drill performed as expected. If problems during the drill were
noted, does the evaluation indicate what changes are needed to address those
problems? If the evaluation calls for changes, verify that the plan was revised
accordingly and that the changes were implemented.
Q-0060
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.42 Condition for Coverage: Surgical Services
Surgical procedures must be performed in a safe manner by qualified physicians who
have been granted clinical privileges by the governing body of the ASC in accordance
with approved policies and procedures of the ASC.
Interpretive Guidelines: §416.42
The standard level tag for §416.42 (Q-0064) provides more detailed guidance on the
requirements for performing surgical services in a safe manner, by qualified physicians.
It permits standard-level citations for identified deficiencies.
The manner and degree of noncompliance identified in relation to the standard level tags
for §416.42 may result in substantial noncompliance with this CoP, requiring citation at
the condition level.
Q-0061
(Rev.71, Issued: 05-13-11, Effective: 5-13-11-Implementation: 05-13-11)
§416.42(a) Standard: Anesthetic Risk and Evaluation
(1) A physician must examine the patient immediately before surgery to evaluate
the risk of anesthesia and of the procedure to be performed.
Interpretive Guidelines: §416.42(a)(1)
The purpose of the exam immediately before surgery is to evaluate, based on the patient’s
current condition, whether the risks associated with the anesthesia that will be
administered and with the surgical procedure that will be performed fall within an
acceptable range for a patient having that procedure in an ASC, given that the ASC does
not provide services to patients requiring hospitalization. The assessment must be
specific to each patient; it is not acceptable for an ASC to assume, for example, that
coverage of a specific procedure by Medicare or an insurance company in an ASC setting
is a sufficient basis to conclude that the risks of the anesthesia and surgery are acceptable
generically for every ASC patient. The requirement for a physician to examine the
patient immediately before surgery is not to be confused with the separate requirement at
42 CFR 416.52(a)(1) for a history and physical assessment performed by a physician,
although it is expected that the physician will review the materials from such pre-
admission examination as part of the evaluation. Nevertheless, this requirement does
constitute one component of the requirement at 42 CFR 416.52(a)(2) for a pre-surgical
assessment upon admission. In those cases, however, where the comprehensive history
and physical assessment is performed in the ASC on the same day as the surgical
procedure, the assessment of the patient’s procedure/anesthesia risk must be conducted
separately from the history and physical, including any update assessment incorporated
into that history and physical. See the interpretive guidelines for§§416.52(a)(1) & (2).
The ASC must have approved policies and procedures to assure that the assessment of
anesthesia-related and procedural risks is completed just prior to every surgical
procedure. (Ideally, the ASC would conduct such an assessment prior to the patient’s
admission as well as immediately prior to surgery, but this is not specifically required by
the regulations.)
The ASC’s policies must address the basis or criteria used within the ASC in conducting
these risk assessments, and must assure consistency among assessments.
The regulations do not specify the content or methodology to be employed in such
assessments. As an illustrative example, an ASC might choose to incorporate
consideration of a patient’s ASA Physical Classification into its criteria. Although the
American Society of Anesthesiologists did not create its ASA Physical Status
Classification System for the purpose of predicting operative risk, this system has
nevertheless been found to be useful in predicting morbidity and mortality in surgical
patients1 and has been used by surgical facilities as a standard tool. This system classifies
patients’ physical status in 6 levels:
ASA PS I – Normal healthy patient;
ASA PS II – Patient with mild systemic disease;
ASA PS III – Patient with severe systemic disease;
ASA PS IV – Patient with severe systemic disease that is a constant threat to life;
ASA PS V – Moribund patient who is not expected to survive without the
operation; and
ASA PS VI – Declared brain-dead patient whose organs are being removed for
donor purposes.
As the ASA PS level of a patient increases, the range of acceptable risk associated with a
specific procedure or type of anesthesia in an ambulatory setting may narrow. An ASC
that employed this classification system in its assessment of its patients might then
consider, taking into account the nature of the procedures it performs and the anesthesia
used, whether it will accept for admission patients who would have a classification of
ASA PS IV or higher. For many patients classified as ASA PS level III, an ASC may
also not be an appropriate setting, depending upon the procedure and anesthesia.
If a State establishes licensure limitations on the types of procedures an ASC may
perform that are based on patient classifications and would permit ASCs to perform
fewer procedures than they would under the CfCs, then the ASC must conform to those
State requirements. However, State requirements that would expand the types of
procedures an ASC may offer beyond what is permitted under the CfCs are superseded
by the Federal CfC requirements.
Endnotes for Standard: Anesthetic Risk and Evaluation
1P. 636, Davenport et al., “National Surgical Quality Improvement Program Risk Factors
Can Be Used to Validate American Society of Anesthesiologists Physical Status
Classification Levels,” Annals of Surgery, Vol. 243, No. 5, May 2006
Survey Procedures: §416.42(a)(1)
• Verify that there is evidence for every medical record in the survey sample of an
assessment by a physician of the patient’s risk for the planned surgery and
anesthesia.
• Ask the ASC to provide you with its policies and procedures for assessment of
anesthesia and procedural risk. Check to determine that the policies include the
criteria the ASC’s physicians are to use in making the assessments.
• Ask the ASC’s leadership to demonstrate how they assure a consistent approach
in the assessment.
• Ask the ASC’s leadership whether they can point to any cases where an
assessment resulted in a decision not to proceed with the surgery. If there are no
such cases, ask the ASC to explain how its patient selection criteria assure that
there is an acceptable level of anesthesia and procedural risk for every patient
scheduled for surgery in the ASC – for example, do they use patient admission
criteria that exclude higher risk patients? If so, ask to see those criteria.
• The survey sample should include cases where a patient died or needed to be
transferred to a hospital; discuss the pre-surgical assessment of the patient in those
cases, preferably with the physician who conducted the assessments, to explore
the basis on which the patient was found to be suitable for the surgery and
anesthesia.
Q-0062
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.42(a) - Standard: Anesthetic Risk and Evaluation
(2) Before discharge from the ASC, each patient must be evaluated by a physician
or by an anesthetist as defined at §410.69(b) of this chapter, in accordance with
applicable State health and safety laws, standards of practice, and ASC policy, for
proper anesthesia recovery.
Interpretive Guidelines: §416.42(a)(2)
An evaluation of the patient’s recovery from anesthesia, to determine whether the patient
is recovering appropriately, must be completed and documented before the patient is
discharged from the ASC. The American Society of Anesthesiology (ASA) guidelines
do not define moderate or conscious sedation as anesthesia. While current practice
dictates that the patient receiving conscious sedation be monitored and evaluated before,
during, and after the procedure by trained practitioners, a postanesthesia evaluation is not
required.
The evaluation must be completed and documented by a physician or anesthetist, as
defined at 42 CFR 410.69(b), i.e., a certified registered nurse anesthetist (CRNA) or an
anesthesiologist’s assistant. See the discussion at §416.42(b) for more discussion of
CRNA and anesthesiologist’s assistant requirements.
ASCs would be well advised in developing their policies and procedures for
postanesthesia care to consult recognized guidelines. For example, Practice Guidelines
for Postanesthetic Care, Anesthesiology, Vol 96, No 3, March, 2002, provides the
recommendations of the American Society of Anesthesiologists for routine
postanesthesia assessment and monitoring, including monitoring/assessment of:
• Respiratory function, including respiratory rate, airway patency, and oxygen
saturation;
• Cardiovascular function, including pulse rate and blood pressure;
• Mental status;
• Temperature;
• Pain;
• Nausea and vomiting; and
• Postoperative hydration.
Depending on the specific surgery or procedure performed, additional types of
monitoring and assessment may be necessary.
Survey Procedures: §416.42(a)(2)
• Review the ASC’s policies and procedures regarding postanesthesia recovery and
evaluation to determine if they are consistent with the regulatory requirement.
Determine whether the ASC is following its own policy.
• Review a sample of medical records for patients who had surgery or a procedure
requiring anesthesia to determine whether a postanesthesia evaluation was
conducted for each patient.
• Determine whether the evaluation was conducted by a practitioner who is
qualified to administer anesthesia.
• Determine whether the evaluation was performed prior to the patient’s discharge.
Q-0063
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.42(b) - Standard: Administration of Anesthesia
Anesthetics must be administered by only-
(1) A qualified anesthesiologist, or
(2) A physician qualified to administer anesthesia, a certified registered nurse
anesthetist (CRNA) or an anesthesiologist’s assistant as defined in §410.69(b)
of this chapter, or a supervised trainee in an approved educational program.
In those cases in which a non-physician administers the anesthesia, unless
exempted in accordance with paragraph (c) of this section, the anesthetist
must be under the supervision of the operating physician, and in the case of
an anesthesiologist’s assistant, under the supervision of an anesthesiologist.
§416.42(c) - Standard: State Exemption
(1) An ASC may be exempted from the requirement for physician supervision of
CRNAs as described in paragraph (b)(2) of this section, if the State in which
the ASC is located submits a letter to CMS signed by the Governor, following
consultation with the State’s Boards of Medicine and Nursing, requesting
exemption from physician supervision of CRNAs. The letter from the
Governor must attest that he or she has consulted with State Boards of
Medicine and Nursing about issues related to access to and the quality of
anesthesia services in the State and has concluded that it is in the best
interests of the State’s citizens to opt-out of the current physician supervision
requirement, and that the opt-out is consistent with State law.
(2) The request for exemption and recognition of State laws, and the withdrawal
of the request may be submitted at any time, and is effective upon
submission.
Interpretive Guidelines: §416.42(b) & (c)
The ASC’s policies and procedures must include criteria, consistent with State law
governing scope of professional practice and other applicable State law, for determining
the anesthesia privileges to be granted by the governing body to an eligible individual
practitioner and a procedure for applying the criteria to individuals requesting privileges.
The ASC must specify the anesthesia privileges for each practitioner who administers
anesthesia, or who supervises the administration of anesthesia by another practitioner.
The privileges granted must be in accordance with State law and the ASC’s policy. The
type and complexity of procedures for which the practitioner may administer anesthesia,
or supervise another practitioner supervising anesthesia, must be specified in the
privileges granted to the individual practitioner.
When granting anesthesia privileges to a physician who is not an anesthesiologist, the
ASC’s governing body must consider the practitioner’s scope of practice, State law, the
individual competencies, education, and training of the practitioner and the practitioner’s
compliance with the ASC’s other criteria for granting physician privileges.
When an ASC permits operating physicians to supervise CRNAs administering
anesthesia, the governing body must adopt written policies that explicitly provide for this.
A CRNA is defined at §410.69(b) as a “…registered nurse who:
(1) is licensed as a registered professional nurse by the State in which the nurse
practices;
(2) meets any licensure requirements the State imposes with respect to non-
physician anesthetists;
(3) has graduated from a nurse anesthesia educational program that meets the
standards of the Council on Accreditation of Nurse Anesthesia Programs, or
such other accreditation organization as may be designated by the Secretary;
and
(4) meets the following criteria:
(i) has passed a certification examination of the Council on Certification of
Nurse Anesthetists, or any other certification organization that may be
designated by the Secretary; or
(ii) is a graduate of a program described in paragraph (3) of this definition and
within 24 months after that graduation meets the requirements of paragraph
(4)(i) of this definition.” A CRNA may administer anesthesia in an ASC
when under the supervision of the operating physician.
If the ASC is located in a State where the Governor has submitted a letter to CMS
attesting that he or she has consulted with State Boards of Medicine and Nursing about
issues related to access to and the quality of anesthesia services in the State, and has
concluded that it is in the best interests of the State’s citizens to opt-out of the current
physician supervision requirement, and that the opt-out is consistent with State law, then
a CRNA may administer anesthesia without physician supervision.
An anesthesiologist’s assistant is defined at §410.69(b) as a “…person who – (1) works
under the direction of an anesthesiologist; (2) is in compliance with all applicable
requirements of State law, including any licensure requirements the State imposes on
nonphysician anesthetists; and (3) is a graduate of a medical school-based
anesthesiologist’s assistant education program that – (A) is accredited by the Committee
on Allied Health Education and Accreditation; and (B) includes approximately two years
of specialized basic science and clinical education in anesthesia at a level that builds on a
premedical undergraduate science background.” An anesthesiologist’s assistant may
administer anesthesia when under the direct supervision of an anesthesiologist. The
anesthesiologist must be immediately available if needed, meaning the anesthesiologist
is:
• Physically present in the ASC; and
• Prepared to immediately conduct hands-on intervention if needed.
A trainee who is a physician in training to be an anesthesiologist in a recognized graduate
medical education program, or a student in a recognized nurse anesthesia or
anesthesiologist’s assistance educational program may administer anesthesia in an ASC
when supervised by the operating physician, in the case of a nurse anesthetist trainee, or
by an anesthesiologist, in the case of a physician trainee or an anesthesiologist’s assistant
trainee.
Survey Procedures: §§482.42(b) and (c)
• Prior to the survey, determine whether the State has exercised its CRNA
physician supervision opt-out option.
• Review the qualifications of individuals authorized to deliver anesthesia in the
ASC, to determine whether they are consistent with the regulatory requirements.
• Determine that there is documentation of current licensure or current certification
status for all persons administering anesthesia.
• If the ASC uses CRNAs, anesthesiologist’s assistants or trainees, interview the
ASC’s leadership to determine how they are supervised. Do the medical records
indicate that required physician supervision is provided?
• When observing a procedure, look for evidence of appropriately trained
practitioners with supervision as required by the regulations.
Q-0064
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
Standard level tag for
§416.42 Condition for Coverage: Surgical Services
Surgical procedures must be performed in a safe manner by qualified physicians who
have been granted clinical privileges by the governing body of the ASC in accordance
with approved policies and procedures of the ASC.
Interpretive Guidelines: §416.42
Qualified Physician: Surgery in an ASC may only be performed by a qualified
physician. With respect to ASCs, a physician is defined in accordance with §1861(r) of
the Social Security Act to include a doctor of medicine or osteopathy, a doctor of dental
surgery or dental medicine, and a doctor of podiatric medicine. In all cases, the physician
must be licensed in the State in which the ASC is located and practicing within the scope
of his/her license.
In addition, the regulation requires that each physician who performs surgery in the ASC
has been determined qualified and granted privileges for the specific surgical procedures
he/she performs in the ASC. The ASC’s governing body is responsible for reviewing the
qualifications of all physicians who have been recommended by qualified medical
personnel and granting surgical privileges as the governing body determines appropriate.
The ASC must have written policies and procedures that address the criteria for clinical
staff privileges in the ASC and the process that the governing body uses when reviewing
physician credentials and determining whether to grant privileges and the scope of the
privileges for each physician. See the interpretive guidelines for §416.45(a), Medical
Staff Membership and Clinical Privileges for further guidance.
Safe Manner: The surgical procedures that take place in the ASC must be performed in
a “safe manner.” “In a safe manner” means primarily that physicians and other clinical
staff follow acceptable surgical standards of practice in all phases of a surgical procedure,
beginning with the pre-operative preparation of the patient, through to the post-operative
recovery and discharge. Acceptable standards of practice include maintaining compliance
with applicable Federal and State laws, regulations and guidelines governing surgical
services, as well as, any standards and recommendations promoted by or established by
nationally recognized professional organizations (e.g., the American Medical Association,
American College of Surgeons, Association of Operating Room Nurses, Association for
Professionals in Infection Control and Epidemiology, etc.).
In addition, acceptable standards of practice include the use of standard procedures to
ensure proper identification of the patient and surgical site, in order to avoid wrong
site/wrong person/wrong procedure errors. Generally accepted procedures to avoid such
surgical errors require:
• A pre-procedure verification process to make sure all relevant documents
(including the patient’s signed informed consent) and related information
are available, correctly identified, match the patient, and are consistent with
the procedure the patient and the ASC’s clinical staff expect to be
performed;
• Marking of the intended procedure site by the physician who will perform
the procedure or another member of the surgical team so that it is
unambiguously clear; and
• A “time out” before starting the procedure to confirm that the correct
patient, site and procedure have been identified, and that all required
documents and equipment are available and ready for use.
Conducting surgery in a safe manner also requires appropriate use of liquid germicides in the
operating or procedure room. It is estimated that approximately 100 surgical fires occur
each year in the United States, resulting in roughly 20 serious patient injuries, including
one to two deaths annually. Fires occur when an ignition source, a fuel source, and an
oxidizer come together1. Heat-producing devices are potential ignition sources, while
alcohol-based skin preparations provide fuel. Procedures involving electro-surgery or the
use of cautery or lasers involve heat-producing devices. There is concern that an alcohol-
based skin preparation, combined with the oxygen-rich environment of an anesthetizing
location, could ignite when exposed to a heat-producing device in an operating room.
Specifically, if the alcohol-based skin preparation is improperly applied, the solution may
wick into the patient’s hair and linens or pool on the patient’s skin, resulting in prolonged
drying time. Then, if the patient is draped before the solution is completely dry, the
alcohol vapors can become trapped under the surgical drapes and channeled to the
surgical site.
On the other hand, surgical site infections (SSI) also pose significant risk to patients;
according to the Centers for Disease Control and Prevention (CDC)2, such infections are
the third most commonly reported healthcare associated infections. Although the CDC
has stated that there are no definitive studies comparing the effectiveness of the different
types of skin antiseptics in preventing SSI, it also states that “Alcohol is readily available,
inexpensive, and remains the most effective and rapid-acting skin antiseptic.”3 Hence, in
light of alcohol’s effectiveness as a skin antiseptic, there is a need to balance the risks of
fire related to use of alcohol-based skin preparations with the risk of surgical site
infection.
The use of an alcohol-based skin preparation in ASCs is not considered safe, unless
appropriate fire risk reduction measures are taken, preferably as part of a systematic
approach by the ASC to preventing surgery-related fires. A review of recommendations
produced by various expert organizations concerning use of alcohol-based skin
preparations in anesthetizing locations indicates there is general consensus that the
following fire risk reduction measures are appropriate:
• Using skin prep solutions that are: 1) packaged to ensure controlled
delivery to the patient in unit dose applicators, swabs, or other similar
applicators; and 2) provide clear and explicit manufacturer/supplier
instructions and warnings. These instructions for use should be carefully
followed;
• Ensuring that the alcohol-based skin prep solution does not soak into the
patient’s hair or linens. Sterile towels should be placed to absorb drips
and runs during application and should then be removed from the
anesthetizing location prior to draping the patient;
• Ensuring that the alcohol-based skin prep solution is completely dry prior
to draping. This may take a few minutes or more, depending on the
1 Tentative Interim Amendment (TIA 05-02) to (National Fire Protection Association) NFPA 99, 2005 edition,
13.4.1.2.2. Germicides and Antiseptics, issued July 29, 2005 and effective August 18, 2005. See also AORN Guidance
Statement: Fire Prevention in the Operating Room; and Patient Safety Advisory June 2005 (Vol. 2 No. 2) 14, Prepared
by ECRI for the Pennsylvania Patient Safety Reporting System.
2 CDC Hospital Infection Control Practices Advisory Committee, “Guideline for Prevention of Surgical
Site Infection, 1999,” Infection Control and Hospital Epidemiology April 1999 (Vol. 20 No. 4) 251.
3 Ibid, p. 257
amount and location of the solution. The prepped area should be
inspected to confirm it is dry prior to draping; and
• Verifying that all of the above has occurred prior to initiating the surgical
procedure. This can be done, for example, as part of a standardized pre-
operative “time out” used to verify other essential information to minimize
the risk of medical errors during the procedure.
ASCs that employ alcohol-based skin preparations in ORs or procedure rooms should
establish appropriate policies and procedures to reduce the associated risk of fire. They
should also document the implementation of these policies and procedures in the patient’s
medical record.
Failure by an ASC to develop and implement appropriate measures to reduce the risk of
fires associated with the use of alcohol-based skin preparations in ORs or procedure
rooms is cited as condition-level noncompliance with §416.44.
Requirements addressed in other ASC Conditions for Coverage are important components of
the provision of surgical services in a “safe manner,” and condition-level deficiencies in these
other areas may also constitute condition-level noncompliance with the Surgical Services
Condition. These other pertinent ASC regulatory requirements include:
• §416.44(a)(1), concerning operating room design and equipment – for example:
• The surgical equipment and supplies are sufficient so that the type of
surgery conducted can be performed in a manner that will not endanger
the health and safety of the patient;
• Surgical devices and equipment are monitored, inspected, tested, and
maintained by the ASC in accordance with Federal and State law,
regulations and guideline, and manufacturer’s recommendations; and that
• Access to the operative and recovery area is limited to authorized
personnel and that the traffic flow pattern adheres to accepted standards of
practice;
• §416.44(a)(2), concerning a separate recovery room;
• §416.44(a)(3) and §416.51, concerning infection control, for example:
• The conformance to aseptic and, when applicable, sterile technique by all
individuals in the surgical area;
• That there is appropriate cleaning between surgical cases and appropriate
terminal cleaning applied;
• That operating room attire is suitable for the kind of surgical case
performed;
• That equipment is available for rapid “emergency” high-level disinfection
or, as applicable, sterilization of operating room materials;
• That sterilized materials are packaged, handled, labeled, and stored in a
manner that ensures sterility e.g., in a moisture- and dust-controlled
environment, and policies and procedures for expiration dates have been
developed and are followed in accordance with accepted standards of
practice.
• That, as applicable, temperature and humidity are monitored and
maintained within accepted standards of practice; and
• §416.44(c) & (d), concerning emergency equipment and personnel – for
example:
• That surgical staff are trained in the use of emergency equipment.
Survey Procedures: §416.42
• Determine whether the ASC has policies and procedures that establish the
criteria and process the governing body uses when granting surgical
privileges to a physician. Ask for documentation that the governing body
approved these policies and procedures.
• Ask the ASC to identify each physician who currently has surgical
privileges or has had surgical privileges within the previous 6 months.
Ask the ASC for documentation of the governing body’s action to grant
privileges to each of these physicians. Conduct this review in conjunction
with the review of compliance with §§416.45(a)&(b).
• For each surgical case record that is reviewed as part of the survey team’s
medical record review, verify that the individual performing the surgery
was a physician who had been granted privileges by the ASC’s governing
body.
• Observe at least one surgical case from the pre-operative phase through to
the recovery room and discharge phase in order to determine whether
standard procedures are followed to avoid wrong site/procedure/patient
surgical errors, and that the requirements described above are met.
• Determine whether the ASC employs appropriate measures to reduce the
risk of surgical fires.
• Ask the ASC whether it has ever had a surgical fire, and if so, what
follow-up actions did it take to prevent the recurrence of surgical fires.
Q-0080
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.43 Condition for Coverage: Quality Assessment and Performance
Improvement
The ASC must develop, implement and maintain an ongoing, data-driven quality
assessment and performance improvement (QAPI) program.
Interpretive Guidelines: §416.43
The QAPI CfC requires an ASC to take a proactive, comprehensive and ongoing
approach to improving the quality and safety of the surgical services it delivers. The
QAPI CfC presumes that ASCs employ a systems approach to evaluating their systems
and processes, identifying problems that have occurred or that potentially might result
from the ASC’s practices and getting to root causes of problems rather than just
superficially addressing one problem at a time.
From a survey perspective, the focus of the QAPI condition is not on whether an ASC
has any deficient practices, but rather on whether it has an effective, ongoing system in
place for identifying problematic events, policies, or practices and taking actions to
remedy them, and then following up on these remedial actions to determine if they were
effective in improving performance and quality. QAPI programs work best in an
environment that fixes problems rather than assigning blame.
For surveyors this can sometimes pose difficult challenges, because it requires a
balancing act. ASCs are not relieved of their obligation to comply with all Medicare
CfCs, and surveyors are obligated when they find evidence of violations of a CfC to cite
accordingly. However, surveyors generally should avoid using the ASC’s own QAPI
program data and analyses as evidence of violations of other CfCs. For example, an ASC
that identifies problems with infection control through its QAPI program and takes
effective actions to reduce the potential for transmission of infection would be taking
actions consistent with the QAPI CfC. Absent evidence independently collected by the
surveyors of current noncompliance with the infection control CfC, it would not be
appropriate for surveyors to use the infection control information in the ASC’s QAPI
program as evidence of violations of the infection control CfC. There can be egregious
cases under investigation where it might be appropriate to use QAPI program information
as evidence of a deficiency, but these cases should be the exception rather than the rule.
CMS does not prescribe a particular QAPI program; it provides each ASC with the
flexibility to develop its own program. Each program must, however, satisfy the
regulatory criteria:
• Ongoing – i.e., the program is a continuing one, not just a one-time effort.
Evidence of this would include, but is not limited to, things like collection by the
ASC of quality data at regular intervals; analysis of the updated data at regular
intervals; and updated records of actions taken to address quality problems
identified in the analyses, as well as new data collection to determine if the
corrective actions were effective.
• Data-driven – i.e., the program must identify in a systematic manner what data it
will collect to measure various aspects of quality of care; the frequency of data
collection; how the data will be collected and analyzed; and evidence that the
program uses the data collected to assess quality and stimulate performance
improvement.
Survey Procedures: §416.43
When there is a team surveying the ASC, survey of the QAPI Condition should be
coordinated by one surveyor.
Q-0081
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.43(a) & §416.43(c)(1)
§416.43(a) Standard: Program Scope
(1) The program must include, but not be limited to, an ongoing program that
demonstrates measurable improvement in patient health outcomes, and
improves patient safety by using quality indicators or performance measures
associated with improved health outcomes and by the identification and
reduction of medical errors.
(2) The ASC must measure, analyze, and track quality indicators, adverse
patient events, infection control and other aspects of performance that
includes care and services furnished in the ASC.
§416.43(c) Standard: Program Activities
(1) The ASC must set priorities for its performance improvement activities that –
(i) Focus on high risk, high volume, and problem-prone areas.
(ii) Consider incidence, prevalence and severity of problems in those areas.
(iii) Affect health outcomes, patient safety and quality of care.
Interpretive Guidelines: §416.43(a) & §416.43(c)(1)
There are a variety of types of indicators that are currently in use for measuring and
improving quality of healthcare. This is also a rapidly changing field, as interest and
research in patient safety and healthcare quality measurement grows. As a result of a
recommendation of a 1998 Presidential Advisory Commission, the National Quality
Forum (NQF), a public-private not-for-profit membership organization, was created in
1999 to develop and implement a national strategy for healthcare quality measurement
and reporting. Since then NQF has developed detailed recommendations for ways to
promote and measure quality and patient safety, including in ASCs. The federal Agency
for Healthcare Quality and Research (AHRQ) supports research assessing the
effectiveness of care practices and procedures. A number of other organizations are also
active in the field of healthcare quality improvement and patient safety. As a result,
ASCs have many choices of indicators to use.
Indicators can be broken down into several types:
• Outcomes Indicators measure results of care; typical outcomes measures include
risk-adjusted mortality rates, complication rates, healthcare-associated infection rates,
length of stay, readmission rates, etc. In the ASC setting, outcomes measures might
focus on things like complication rates, healthcare-associated infection rates, cases
exceeding 24 hours, transfers to hospitals, wrong site surgeries, etc.
• Process of Care Indicators measure how often the standard of care was met for
patients with a diagnosis related to that standard. For example, in the ASC setting,
measures might focus on the administration and time of prophylactic antibiotics.
• Patient Perception Indicators measure a patient’s experience of the care he/she
received in the ASC. AHRQ sponsored development of one patient experience of
care instrument, H-CAHPS, that CMS now uses in reporting on hospital quality.
There may be similar patient survey instruments that could be used in the ASC
setting.
The regulation at §416.43(a) requires that an ASC’s QAPI program must improve both
patient health outcomes and patient safety in the ASC. In order to achieve these goals,
the ASC’s QAPI program must:
1. Be ongoing – i.e., the program is a continuing one, not just a one-time effort or
occasional effort. Evidence that the ASC’s program is ongoing would include, for
example, collection by the ASC of quality data at regular intervals; analysis of the
updated data at regular intervals; and updated records of actions taken to address
quality problems identified in the analyses, as well as new data collection to
determine if the corrective actions were effective.
2. Use quality indicators or performance measures associated with improved health
outcomes in a surgical setting. The quality and safety indicators available differ
in terms of the weight and type of evidence for their effectiveness in measuring
quality. For some indicators there is compelling peer-reviewed research of an
association with improved health outcomes. For others, typically process of care
indicators, consensus among experts in the field suggests a strong association with
improved quality of care. Indicators also differ in terms of how the data is
collected, and how frequently the data should be collected.
For example, measures of how quickly an ASC produces error-free billing claims,
while relevant to the ASC’s financial performance and of interest to ASC
governing bodies, have no direct relationship to the quality of care the ASC
provides. On the other hand, a measure of the frequency with which the ASC
administers antibiotic prophylaxis consistent with generally accepted standards of
care would be related to improved health outcomes, i.e., prevention of surgical
site infections. Likewise, an ASC could choose to collect data measuring its
compliance with applicable National Quality Forum Safe Practices, or with
applicable Centers for Disease Control and Prevention (CDC) infection control
guidelines, or with guidelines issued by national professional societies, such as
the American College of Surgeons, or with recommended practices developed by
national accreditation organizations or other organizations specializing in
healthcare quality improvement, such as the Institute for Healthcare
Improvement. CMS does not prescribe a certain set of indicators/measures for
ASCs to use, but ASCs must be able to demonstrate that the indicators they are
tracking will enable them to improve outcomes for ASC patients.
The regulations at §416.43(c)(1) also require the ASC to set priorities in choosing
its quality indicators/measures, because what is measured will determine where
the ASC focuses its efforts to make changes that improve performance. For
example, if the ASC does not track measures related to infection control, it will
not be in a position to determine whether or not its infection control program is
working well or poorly, and thus will not be in a position to improve it.
The ASC is required to focus on high risk, high volume, and problem-prone areas.
It is required to consider, when selecting the measures/indicators that will shape
its improvement activities in these areas, the following:
• The incidence, i.e., the rate or frequency at which problems occur in the ASC
related to area measured by the indicator. “Incidence” is a technical term used in
epidemiology, referring to the frequency with which something, such as a disease,
appears in a particular population or area. In disease epidemiology, the incidence
is the number of newly diagnosed cases during a specific time period. Applying
this concept in the ASC setting, as an example, the annual incidence of surgical
site infections in an ASC would be the rate that results when dividing the number
of such infections that occurred in a calendar year by the total number of surgical
cases in the ASC during that same year. Likewise, the annual incidence of
emergency transfers to a hospital would be the rate that results when dividing the
number of such transfers by the total number of surgical cases during the same
year;
• The prevalence, i.e., how widespread something is in an ASC at a given point in
time. “Prevalence” is also a technical term used in epidemiology, and is a
statistical concept referring to the number of cases of a disease that are present in
a particular population at a given time. In an ASC setting, for example, it would
make little sense to employ measures related to prevalence of pressure ulcers
among ASC patients, since the limited amount of time a patient typically spends
in an ASC makes it unlikely that the ASC’s care processes contributes to pressure
ulcers. On the other hand a more appropriate measure might be periodic
observation of the hand hygiene practices of all staff providing direct patient care,
in order to assess the prevalence of good versus deficient practices; and
• The severity of problems. For example, any single instance of a transfer of a
patient to a hospital represents a serious adverse, unplanned outcome of the
surgical procedure, and it would be appropriate for an ASC to track and evaluate
all such cases, due to their severity, even if they are low volume incidents.
Once having identified the quality indicators it will use, the ASC must collect and
analyze data on these indicators.
3. Identify and reduce medical errors/adverse patient events. Although there is no
single, standard definition of a medical error or adverse event, the Institute of
Medicine created a series of definitions related to patient safety that are helpful in
understanding the regulatory requirement:
“An error is defined as the failure of a planned action to be completed as
intended (i.e., error of execution) or the use of a wrong plan to achieve an aim
(i.e., error of planning).”
“An adverse event is an injury caused by medical management rather than the
underlying condition of the patient.”
“An adverse event attributable to error is a preventable adverse event.”1
Using these definitions, if an ASC performing orthopedic procedures operates on
the right shoulder of a patient with a left shoulder rotator cuff injury requiring
surgery, then the ASC has committed an error. The patient suffered an adverse
event – i.e., the harm to the patient of undergoing surgery on the wrong shoulder,
and presumably having to undergo yet another surgery on the correct shoulder.
Because the ASC’s error resulted in the adverse event, it is a preventable adverse
event that could and should have been avoided.
Not every adverse event is the result of an error. For example, the standard of
practice might call for use of a particular medication when certain indications are
present. A patient might have an allergy to that medication that is unknown to the
patient and the patient’s physicians. The patient develops an allergic reaction to
the medication, requiring further medical intervention to counteract the reaction.
Due to the unknown nature of the patient’s allergy, there was no error, even
though there was an injury resulting from medical management. On the other
hand, if the allergy had been documented in the patient’s medical record and the
medication had been administered anyway, this would constitute an error.
Not every error results in an adverse event; for example, an ASC with two
operating rooms might mix up the records of two ASC patients scheduled to have
the same orthopedic procedure, e.g., foot surgery, on the same date, but on the
opposite feet. This is an error. But the ASC employs a time-out procedure to
verify the identity of the patients and site of the surgery and recognizes the error
before surgery begins. The error did not result in an adverse event, but it was a
near miss.
ASCs must track all patient adverse events, in order to determine through
subsequent analysis whether they were the result of errors that should have been
preventable, to reduce the likelihood of such events in the future. ASCs are also
expected to identify errors that result in near misses, since such errors have the
potential to cause future adverse events.
ASCs seeking initial enrollment in the Medicare program are unlikely to have
collected extensive data for their QAPI program indicators, since they likely have
been in operation for a relatively brief period of time. Nevertheless, these initial
applicants must have a QAPI program in place, and must be able to describe how
the program functions, including which indicators/measures are being tracked, at
what intervals, and how the information will be used by the ASC to improve
quality and safety.
Examples of ASC Quality/Patient Safety Indicators
The following information is based on the National Quality Forum’s (NQF) consensus
standards for ASCs, and is provided only as an illustration of several types of measures
an ASC might choose to include in its QAPI program. An ASC is free to use different
measures, so long as the measures it chooses meets the regulatory criteria. ASCs are also
expected to develop additional measures related to infection control, for example to
enable it to comply with the requirement at §416.51(b)(2) for its infection control
program to be integrated into its QAPI program, and at §416.44(a)(3) to have a program
to identify healthcare associated infections and report diseases as required under State
law. Depending on the individual characteristics of the ASC, including problems it had
experienced in the past, it may be necessary to track other additional indicators as well.
More information on these and other NQF ASC measures is available at:
http://www.qualityforum.org/pdf/ambulatory/tbAMBALLMeasuresendorsed%201
2-10-07.pdf
• Patient Burn – Percentage of ASC admissions experiencing a burn prior to
discharge. Approximately 100 surgical fires occur each year nationally, in all
surgical settings, with about 20 resulting in serious injuries to patients.
• Prophylactic Intravenous Antibiotic Timing – Percentage of ASC patients who
received appropriate antibiotics ordered for surgical site infection prophylaxis on
time.
• Hospital Transfer/Admission – Percentage of ASC admissions requiring a
hospital transfer or hospital admission prior to being discharged from the ASC.
• Patient Fall – Percentage of ASC admissions experiencing a fall in the ASC.
• Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
- Percentage of ASC admissions experiencing a wrong site, wrong side, wrong
patient, wrong procedure, or wrong implant.
Survey Procedures: §416.43(a)
• Ask the ASC’s leadership to describe the QAPI program, including staff
responsibilities for QAPI and the quality/safety indicators being tracked.
• Ask what the rationale is for the particular indicators that the ASC has chosen to
track. Are they based on nationally-recognized recommendations? If not, what
evidence does the ASC have that the indicators it has chosen are associated with
improvement in patient health outcomes and safety?
• At a minimum, do the indicators include cases of patients transferred from the
ASC to a hospital?
• At a minimum, do the indicators include measures appropriate for surgery and
infection control measures?
• At a minimum, does the ASC have a system for tracking adverse patient
events?
• Ask the staff responsible for QAPI what the method and frequency is for data
collection for each QAPI program indicator.
1P. 28, ToErr is Human, Institute of Medicine, November, 1999.
Q-0082
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.43(b) and §416.43(c)(2) & (3)
§416.43(b) Standard: Program Data
(1) The program must incorporate quality indicator data, including patient care
and other relevant data regarding services furnished in the ASC.
(2) The ASC must use the data collected to –
(i) Monitor the effectiveness and safety of its services, and quality of its care.
(ii) Identify opportunities that could lead to improvements and changes in its
patient care.
§416.43(c) Standard: Program Activities
(2) Performance improvement activities must track adverse patient events,
examine their causes, implement improvements, and ensure that
improvements are sustained over time.
(3) The ASC must implement preventive strategies throughout the facility
targeting adverse patient events and ensure that all staff are familiar with
these strategies.
Interpretive Guidelines: §416.43(b)& §416.43(c)(2) & (3)
Active Data Collection
The ASC must not only have identified a number of indicators or measures of quality and
patient safety, but it must actively collect data related to those measures at the intervals
called for by its QAPI program. Staff responsible for collection of the data should be
trained in appropriate techniques to collect and maintain the data.
Data Analysis
Once having collected the data, the ASC must analyze it to monitor ASC performance,
i.e., to determine what the data suggests about the ASC’s quality of care and the
effectiveness and safety of its services. Analysis must take place at regular intervals, in
order to avoid too much time elapsing before the ASC is able to detect problem areas. In
the case of data related to adverse events, the ASC must use the data to analyze the
cause(s) of the adverse events. Data collection and analysis must be conducted by
personnel with appropriate qualifications to collect and interpret quantitative data. CMS
does not expect ASCs to engage in sophisticated statistical modeling of data, but
calculation of incidence rates should be within the skill set of individual(s) conducting
the analysis. On the other hand, CMS does expect ASCs to conduct thorough analyses
that focus on systemic issues. For example, if the ASC’s adverse event tracking system
identifies a medication error that resulted in serious injury to a patient, the ASC would
not be taking the type of systems approach mandated under the QAPI regulations if it
states that the event was caused by the staff member who administered the medication
incorrectly, and that its method for improving performance was to fire that staff member.
An acceptable analysis would look at the root causes that facilitated the error by the staff
member: Were medications stored in a manner that increased the possibility of error?
Were the physician’s orders clearly written? Was the staff member appropriately
trained? Is there any evidence of similar errors made by other staff members, including
errors that did not result in adverse events? There are probably additional issues that
should be investigated in order to fully understand the causes of the adverse event. Once
there is a thorough analysis of these causes, the ASC would then be in a better position to
identify improvement strategies that are appropriately designed to address the underlying
causes.
The ASC may choose to use contractors for technical aspects of the QAPI program,
including analysis of data, but the ASC is also expected to actively involve ASC staff in
the program and the ASC’s leadership retains the responsibility for the ongoing
management of the program, even when a contractor is used.
Analysis of the monitoring data must be used to identify areas where there is room for
improvement in the ASC’s performance, as well as follow-up actions taken to improve
performance. A good monitoring system, even in a good ASC surgical program, is likely
to always find some areas of performance that are weaker than others. These identified
areas of weakness present opportunities for the ASC to make changes in its systems,
policies or procedures that result in improved patient care.
Implement Improvements/Preventive Strategies
Once the ASC’s analysis of its data has identified opportunities for improvement, the
ASC must develop specific changes in its policies, procedures, equipment, etc., as
applicable, to accomplish improvements in the identified areas of weakness. In
particular, an ASC must implement preventive strategies designed to reduce the
likelihood of adverse events throughout the ASC. For example, if an ASC has three
operating or procedure rooms, and it has an adverse event in a case in one of these rooms
that is attributable in part to a confusing storage of emergency medications, the ASC
should review the set up in each of the rooms to ensure that the same problem does not
occur elsewhere.
Sustaining Improvements
The ASC must also have a method to ensure that the improvements it makes are
sustained over time. For example, if an ASC’s QAPI program identifies problems with
hand hygiene in ASC staff providing care to patients, the ASC must be able to
demonstrate that whatever solution it adopted to address this problem continues to work
over time. Generally this means that the ASC must collect data on indicators that
measure staff hand hygiene on an ongoing basis.
Staff Training
The ASC is required to make all staff aware of the strategies it has adopted for prevention
of adverse events. For example, all staff who are involved in the preparation of a patient
for the surgical procedure, as well as in the conduct of the surgical procedure, must be
familiar with the ASC’s strategies for avoiding wrong patient, wrong site, wrong side,
wrong procedure, wrong implant, and adverse surgical events. All staff involved in the
preparation and administration of injectable medications should be aware of standard safe
injection practices designed to avoid the transmission of infectious disease. Staff should
be encouraged to ask questions when they observe a practice, or receive an order, etc. that
they believe might compromise patient safety or quality of care in the ASC.
Prospective ASC’s Applying for Initial Certification in Medicare
A facility seeking initial certification as an ASC may not have been in operation long
enough to demonstrate extensive data collection or the identification of opportunities for
improvement based on the monitoring data. However, it must be able to show that it has
an active data collection and analysis infrastructure in place as well as to indicate when it
expects to have sufficient data to begin analysis and what procedures it has put in place to
consider the results of QAPI program analyses.
Survey Procedures: §416.43(b)
• Ask the ASC to show you examples of quality and adverse event data it is
collecting. Is the ASC collecting data on all of the indicators/measures it
identified for its QAPI program? Is it collecting the data at the frequency
specified in its QAPI program?
• Ask the ASC who is responsible for the data collection and analysis, and what
their qualifications are? In particular, ask the ASC how it determines the causes
of adverse events – does the ASC stop with the immediate cause (staff error,
equipment failure, etc.) or does it probe to discover the underlying root causes of
the adverse events?
• If ASC staff handle these duties, do they have education or training that equips
them to conduct analyses of the data?
• Ask the ASC to provide examples of instances where it used QAPI data to
identify opportunities for improving processes for providing care. Ask how it
evaluated whether the improvements were effective and sustained.
• Ask the ASC how it trains staff on ways to prevent adverse events from
occurring.
• Ask ASC staff what they know about the ASC’s QAPI program, focusing in
particular on staff awareness of policies and procedures for preventing adverse
events.
Q-0083
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.43(d) Standard: Performance Improvement Projects.
(1) The number and scope of distinct improvement projects conducted annually
must reflect the scope and complexity of the ASC’s services and operations.
(2) The ASC must document the projects that are being conducted. The
documentation, at a minimum, must include the reason(s) for implementing
the project, and a description of the project’s results.
Interpretive Guidelines: §416.43(d)
Every ASC must undertake one or more specific quality improvement projects each year.
Larger ASCs with multiple ORs or procedure rooms, multiple types of surgical
procedures offered, or high volume of cases are expected to undertake more or more
complex projects. Furthermore, a highly complex improvement project might be of such
scope that it could reasonably be the only project an ASC undertakes in a given year.
CMS does not specify particular projects that each ASC must undertake, but instead
expects the projects to be based on the types of services the ASC furnishes, as well as
other aspects of the ASC’s operations. The requirement for annual projects does not
mean that an ASC may not undertake a complex project that is expected to require more
than 1 year in order to be completed.
The ASC must keep records on its performance improvement projects. Each project
must, at a minimum, include an explanation of why the project was undertaken. The
explanation must indicate what data collected in the ASC or based on recommendations
of nationally recognized organizations leads the ASC to believe that the project’s
activities will actually result in improvements in patient health outcomes and safety in the
ASC. For projects that are still underway, the ASC must be able to explain what
activities the project entails, and how the impact of the project is being monitored.
Unless the project has just begun, the ASC must be able to provide evidence that it is
collecting data that will enable it to assess the project’s effectiveness. For projects that
are completed, the ASC must be able to show documentation that explains what the
results of the project were, and what actions, if any, the ASC took in response to those
results.
Survey Procedures: §416.43(d)
• Ask the ASC to show you documentation for performance improvement projects
currently underway, as well as those completed in the prior year.
• If a large, complex, or high volume ASC has only one project underway, is the
scope of that project such that it is likely to have a significant impact on the
ASC’s quality of care or patient safety?
• Does the ASC’s documentation indicate the rationale for undertaking each
project? Does the ASC have data indicating it had a problem in the area targeted
for improvement, or could the ASC point to recommendations from a nationally
recognized expert organization suggesting the activities?
• Does the documentation for the completed project(s) include the project’s results?
If a project was unsuccessful, ask the ASC what actions it took as a result of that
information. If the project was successful, ask the ASC how it is sustaining the
improvement.
Q-0084
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.43(e) Governing body responsibilities.
The governing body must ensure that the QAPI program –
(1) Is defined, implemented, and maintained by the ASC.
(2) Addresses the ASC’s priorities and that all improvements are evaluated for
effectiveness.
(3) Specifies data collection methods, frequency, and details.
(4) Clearly establishes its expectations for safety.
(5) Adequately allocates sufficient staff, time, information systems and training to
implement the QAPI program.
Interpretive Guidelines: §416.43(e)
An ongoing, successful QAPI program requires the support and direction of the ASC’s
leadership. This regulation makes clear CMS’ expectations that the ASC’s governing
body must assume responsibility for all aspects of the design and and implementation of
every phase of the QAPI program. The governing body must assure that the ASC’s
QAPI program:
• Is defined, in writing, for example in the minutes of a meeting where the
governing body established the program;
• Is actually implemented, with written evidence of this implementation, as well as
evidence of knowledge of the program by the ASC’s staff;
• Is implemented on an ongoing basis;
• Employs quality and patient safety indicators that reflect appropriate
prioritization, as required by §416.43(c);
• Describes in detail the indicator data to be collected, how it will be collected, how
frequently it will be collected;
• Uses the data collected and analyzed to improve the ASC’s performance;
• Evaluates changes designed to improve the ASC’s performance to determine
whether they are effective, and takes appropriate actions to make further changes
as needed;
• Is designed to establish clearly the governing body’s expectations that patient
safety is a priority, not only by the tracking of all adverse events, but also by the
program’s processes for analyzing and making changes in ASC operations to
prevent future such events; and
• Has sufficient resources, i.e., the ASC’s governing body must allocate sufficient
and qualified staff (including consultants), staff time, information systems and
training to support the program. Given the great variety in size and complexity
among ASCs, the extent of resources required will vary as well. However, the
resources dedicated to the QAPI program must be commensurate with the ASC’s
overall scope and complexity. The ASC must also be able to identify in detail
the resources that it dedicates to the QAPI program.
Survey Procedures: §416.43(e)
• Does the ASC’s QAPI program include all of the essential elements described
above?
• Ask the ASC’s leadership to explain how the governing body is involved in the
QAPI program. Does the ASC’s leadership display ready knowledge of the
program’s structure and activities. If a contractor is used for some portions of the
program, does the ASC’s leadership monitor closely the contractor’s activities?
• Is there evidence of a governing body review of all elements of the QAPI
program, e.g., meeting minutes?
• Ask the ASC’s leadership how it uses the program to improve performance. Ask
for evidence of changes made as a result of QAPI program activities.
• Ask the ASC’s leadership for documentation of the details of the resources that
are dedicated to the QAPI program. Is there evidence that these resources were
actually made available as planned? For example, interview staff identified as
having a role in the QAPI program to determine whether they actually perform
QAPI functions, and for what percentage of their time. Is there evidence that
planned data collections and analyses actually took place?
Q-0100
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.44 Condition for Coverage: Environment
The ASC must have a safe and sanitary environment, properly constructed,
equipped, and maintained to protect the health and safety of patients.
Interpretive Guidelines: §416.44
The ASC must comply with requirements governing the construction and maintenance of
a safe and sanitary physical plant, safety from fire, emergency equipment and emergency
personnel.
Survey Procedures: §416.44
A surveyor trained in surveying for the applicable Life Safety Code standards must
survey for compliance with the Safety from Fire Standard; the rest of the standards under
this Condition are surveyed by Health surveyors.
Q-0101
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.44(a) Standard: Physical Environment
The ASC must provide a functional and sanitary environment for the provision of
surgical services.
(1) Each operating room must be designed and equipped so that the types of
surgery conducted can be performed in a manner that protects the lives
and assures the physical safety of all individuals in the area.
Interpretive Guidelines: §416.44(a)(1)
State Agencies may wish to assign surveyors who are trained in evaluating healthcare
facility design and construction assist in evaluating compliance with this standard.
“Operating room” (OR) in an ASC includes not only traditional ORs, but also procedure
rooms, including those where surgical procedures that do not require a sterile
environment are performed.
ORs must be designed in accordance with industry standards for the types of surgical
procedures performed in the room, including whether the OR is used for sterile and/or
non-sterile procedures. Existing ORs must meet the standards in force at the time they
were constructed, while new or reconstructed ORs must meet current standards.
Although the term “OR” includes both traditional ORs and procedure rooms, this does
not mean that procedure rooms must meet the same design and equipment standards as
traditional operating rooms. In all cases, the OR design and equipment must be
appropriate to the types of surgical procedures performed in it.
National organizations, such as the Facilities Guidelines Institute, may be used as a
source of guidance to evaluate OR design and construction in an ASC. If a State’s
licensure requirements include specifications for OR design and construction, the ASC
must, in accordance with §416.40, comply with those State requirements.
The location of the OR within the ASC and the access to it must conform to accepted
standards of practice, particularly for infection control, with respect to the movement of
people, equipment and supplies in and out of the OR. The movement of staff and patients
on stretchers must proceed safely, uninhibited by obstructions.
The OR must also be appropriately equipped for the types of surgery performed in the
ASC. Equipment includes both facility equipment (e.g., lighting, generators or other
back-up power, air handlers, medical gas systems, air compressors, vacuum systems,
etc.) and medical equipment (e.g., biomedical equipment, radiological equipment if
applicable, OR tables, stretchers, IV infusion equipment, ventilators, etc.). Medical
equipment for the OR includes the appropriate type and volume of surgical and
anesthesia equipment, including surgical instruments. Surgical instruments must be
available in a quantity that is commensurate with the ASC
’
s expected daily procedure
volume, taking into consideration the time required for appropriate cleaning and, if
applicable, sterilization. In addition, emergency equipment determined to be necessary
in accordance with §416.44(c) must be either in or immediately available to the OR.
The OR equipment must be inspected, tested and maintained appropriately by the ASC,
in accordance with Federal and State law (including regulations) and manufacturers’
recommendations.
Temperature, humidity and airflow in ORs must be maintained within acceptable
standards to inhibit microbial growth, reduce risk of infection, control odor, and promote
patient comfort. ASCs must maintain records that demonstrate they have maintained
acceptable standards.
An example of an acceptable humidity standard for ORs is the American Society for
Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170,
Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires
RH in ORs to be maintained between 20 - 60 percent. In addition, this ASHRAE
standard has been incorporated into the Facility Guidelines Institute (FGI) 2010
Guidelines for Design and Construction of Health Care Facilities, and has been approved
by the American Society for Healthcare Engineering of the American Hospital
Association and the American National Standards Institute. ASCs must also ensure,
however, that the OR humidity level is appropriate for all of their surgical and anesthesia
equipment, and that supplies which require a different level of humidity than that in the
OR are appropriately stored until used.
Each operating room should have separate temperature control. Acceptable standards for
OR temperature, such as those recommended by the Association of Operating Room
Nurses (AORN) or the FGI, should be incorporated into the ASC’s policy.
Equipment for rapid emergency sterilization of OR equipment/materials whose sterility
has been compromised must be available on-site. However, an ASC that routinely uses
sterilization procedures intended for emergency use only as its standard method of
sterilization between cases, in order to reuse surgical instruments, must be cited for
violating §§416.44(a)(1) & (3) and the Infection Control Condition at §416.51.
It is not necessary for the ASC to have equipment for routine sterilization of equipment
and supplies on-site, so long as this service is provided to the ASC under arrangement.
Survey Procedures: §416.44(a)
• 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.
Q-0102
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.44(a) Standard: Physical Environment
[The ASC must provide a functional and sanitary environment for the
provision of surgical services.]
(2) The ASC must have a separate recovery room and waiting area.
Interpretive Guidelines: §416.44(a)(2)
The ASC is required to have both a waiting area and a recovery room, which must be
separate from each other as well as other parts of the ASC. They may not be shared with
another healthcare facility or physician office. (See the interpretive guidelines for §416.2
concerning sharing of physical space by an ASC and another entity.)
There must be a room within the ASC where patients recover immediately after surgery.
A “room” consists of an area with at least semi-permanent walls from floor to ceiling
separating it from other areas of the ASC. The recovery room must be equipped to allow
appropriate monitoring of the patient’s recovery. The type of equipment required
depends on the type(s) of surgery performed in the ASC. The size of the recovery room
must be commensurate with the number of ORs in the ASC and the expected volume of
patients who will be in recovery simultaneously.
The recovery room may also be used for preoperative preparation of patients as well as
for post-operative recovery, consistent with accepted standards of practice. Under no
circumstances, however, may the recovery room also be used as a general waiting area
for patients awaiting preoperative preparation or for people who accompany patients.
Likewise, patients recovering from surgery may not be placed in a waiting room or area,
unless they have already been discharged from the ASC and are, for example, waiting
briefly while the adult who accompanied them brings a car to the ASC’s entrance.
Consistent with accepted standards of practice, including infection control standards, and
protection of patients’ rights to privacy and confidentiality of their clinical information
the ASC may permit individuals who accompany patients to be present in the recovery
room during the patient’s recovery from surgery.
Survey Procedures: §416.44(a)(2)
• Observe whether there is a separate room in which patients recover from their
surgery, and whether it is appropriately equipped.
• Observe whether there is a separate waiting area for visitors and patients who
have not yet begun preoperative preparation.
Q-0104
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.44(b) Standard: Safety From Fire
(1) Except as otherwise provided in this section, the ASC must meet the provisions
applicable to Ambulatory Healthcare Centers of the 2000 edition of the Life
Safety Code of the National Fire Protection Association, regardless of the number
of patients served. The Director of the Office of the Federal Register has
approved the NFPA 101 2000 edition of the Life Safety Code, issued January
14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1
CFR part 51. A copy of the Code is available for inspection at the CMS
Information Resource Center, 7500 Security Boulevard, Baltimore, MD and at the
National Archives and Records Administration (NARA). For information on the
availability of this material at NARA, call 202-741-6030, or go to
http://www.archives.gov/federal
register/code_of_federal_regulations/ibr_locations.html. Copies may be obtained
from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA
02269. If any changes in this edition of the Code are incorporated by reference,
CMS will publish notice in the Federal Register to announce the changes.
(2) In consideration of a recommendation by the State survey agency, CMS may
waive, for periods deemed appropriate, specific provisions of the Life Safety
Code which, if rigidly applied, would result in unreasonable hardship upon an
ASC, but only if the waiver will not adversely affect the health and safety of the
patients.
(3) The provisions of the Life Safety Code do not apply in a State if CMS finds that a
fire and safety code imposed by State law adequately protects patients in an ASC.
(4) An ASC must be in compliance with Chapter 21.2.9.1, Emergency Lighting,
beginning on March 13, 2006.
(5) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the
contrary, an ASC may place alcohol-based hand rub dispensers in its facility if-
(i) Use of alcohol-based hand rub dispensers does not conflict with any State or
local codes that prohibit or otherwise restrict the placement of alcohol-
based hand rub dispensers in healthcare facilities;
(ii) The dispensers are installed in a manner that minimizes leaks and spills that
could lead to falls;
(iii) The dispensers are installed in a manner that adequately protects against
inappropriate access; and
(iv) The dispensers are installed in accordance with the following provisions:
(A) Where dispensers are installed in a corridor, the corridor shall have a
minimum width of 6 ft (1.8m);
(B) The maximum individual dispenser fluid capacity shall be:
(1) 0.3 gallons (1.2 liters) for dispensers in rooms, corridors, and areas
open to corridors.
(2) 0.5 gallons (2.0 liters) for dispensers in suites of rooms;
(C) The dispensers shall have a minimum horizontal spacing of 4 feet (1.2m)
from each other;
(D) Not more than an aggregate of 10 gallons (37.8 liters) of ABHR solution
shall be in use in a single smoke compartment outside of a storage cabinet;
(E) Storage of quantities greater than 5 gallons (18.9 liters) in a single smoke
compartment shall meet the requirements of NFPA 30, Flammable and
Combustible Liquids Code;
(F) The dispensers shall not be installed over or directly adjacent to an ignition
source;
(G) In locations with carpeted floor coverings, dispensers installed directly
over carpeted surfaces shall be permitted only in sprinklered smoke
compartments; and
(v) The dispensers are maintained in accordance with dispenser manufacturer
guidelines.
Interpretive Guidelines: §416.44(b)
Because ASCs are not permitted to provide care to patients exceeding 24 hours, they are,
for purposes of compliance with National Fire Protection Association (NFPA) Life
Safety Code (LSC) requirements, subject to a combination of healthcare and business
occupancy requirements. They are, therefore, unlike hospitals and other facilities that
keep patients more than 24 hours, which are considered healthcare occupancies.
Compliance with LSC requirements for an ASC is assessed by a surveyor trained in the
application of NFPA LSC standards.
The provisions of the NFPA LSC (2000 edition), Chapter 20, New Ambulatory Health
Care Occupancies, apply as of January 10, 2003, the date when CMS adopted the NFPA
2000 edition for ASCs, to any new buildings used for an ASC, alterations to existing
ASCs, and alterations to existing buildings for new occupation by an ASC. The chapter
includes: general requirements regarding structure and applicability; means of egress
requirements; requirements related to protection from hazards, alarms and other
emergency requirements, and subdivision of space; building services; and operating
features. For older ASCs that have not undergone renovations, the provisions of chapter
21, Existing Ambulatory Health Care Occupancies apply.
Emergency Power
The NFPA 2000 LSC requires that when general anesthesia or life support equipment is
used, the ambulatory health care facility (ambulatory surgical center) shall be provided
with an essential electrical system in accordance with NFPA 99, Health Care Facilities,
1999 edition. For ASCs newly constructed or renovated after January 10, 2003, a Type 1
essential electrical system shall be installed which may include a generator as the source
of back-up electrical power. Existing ASCs may continue to use a Type 3 electrical
system and may continue to use batteries as the source of back-up electrical power.
Existing ASCs that change procedures that include the use of general anesthesia or life
support equipment not previously required will be required to upgrade their existing
electrical system to a Type 1 system including a generator back-up electrical source of
power. In all cases, ASCs are expected to have a reliable source of back-up power that
enables them to protect patients and staff when power is lost, including proceeding with
the surgical procedure until such point as it is safe to either terminate or complete it.
Use of Alcohol-based Skin Preparations
See the interpretive guidelines for §416.42 related to use of alcohol-based skin preparations
in anesthetizing locations. In light of alcohol’s effectiveness as a skin antiseptic, there is a
need to balance the risks of fire related to use of alcohol-based skin preparations with the risk
of surgical site infection by:
• Using skin prep solutions that are: 1) packaged to ensure controlled delivery to
the patient in unit dose applicators, swabs, or other similar applicators; and 2)
provide clear and explicit manufacturer/supplier instructions and warnings;
• Ensuring that the alcohol-based skin prep solutions do not soak into the patient’s
hair or linens. Sterile towels should be placed to absorb drips and runs during
application and should then be removed from the anesthetizing location;
• Ensuring that the alcohol-based skin prep solution is completely dry prior to
draping. This may take a few minutes or more, depending on the amount and
location of the solution. The prepped area should be inspected to confirm it is dry
prior to draping;
• Verifying that all of the above has occurred prior to initiating the surgical
procedure. This can be done, for example, as part of a standardized preoperative
“time out” to minimize the risk of medical errors during the procedure such as
verifying that the patient is receiving the correct surgery.
Failure to take these measures to reduce the risk of surgical fire when an alcohol-based
skin preparation is used must be cited as a condition-level violation of §416.44.
State Code in Lieu of LSC
The process by which CMS reviews a State’s request to use of its State Code in lieu of
the NFPA LSC is addressed in Survey and Certification policy memorandum S&C-08-
34, September 5, 2008. CMS will advise any SA when and if it approves a State
application to use the State Code in lieu of the LSC.
Survey Procedures: §416.44(b)
• States vary as to the type of personnel who conduct surveys for compliance with
LSC requirements. Some States use fire authority personnel, while others use
architects, engineers, or healthcare professionals with LSC training. In all cases,
however, the surveyors must have training in the application of the NFPA’s LSC
Standards to ASCs and must follow the guidance in Appendix I.
• Health surveyors observing ASC surgical case(s) should determine whether the
ASC employs appropriate measures to reduce the risk of surgical fire when
alcohol-based skin preparations are used.
Q-0105
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.44(c) Standard: Emergency Equipment
The ASC medical staff and governing body of the ASC coordinates, develops, and
revises ASC policies and procedures to specify the types of emergency equipment
required for use in the ASC’s operating room. The equipment must meet the
following requirements:
(1) Be immediately available for use during emergency situations.
(2) Be appropriate for the facility’s patient population.
(3) Be maintained by appropriate personnel.
Interpretive Guidelines §416.44(c)
The ASC’s medical staff and governing body must adopt written policies and procedures
that address the specific types of emergency equipment that must be available for use in
the ASC’s operating room. No specific list of emergency equipment is specified in the
rule, but the ASC is expected to maintain a comprehensive, current and appropriate set of
emergency equipment, supplies and medications that meet current standards of practice
and are necessary to respond to a patient emergency in the ASC.
The ASC must conduct periodic assessments of its policies and procedures in order to
anticipate the emergency equipment, supplies and medications that may be needed to
address any likely emergencies, taking into consideration the types of patients the ASC
serves and the types of procedures performed in the ASC.
The ASC must provide the appropriate emergency equipment and supplies and qualified
personnel necessary to meet the emergency needs of the ASC’s entire patient population
in accordance with acceptable standards of practice in the ASC industry. Acceptable
standards of practice include adhering to State laws as well as standards or guidelines
issued by nationally recognized professional organizations, etc. The ASC’s policies and
procedures must be written and ensure the emergency equipment is immediately
available for use during emergency situations; be appropriate for the facility’s patient
population; and be maintained by appropriate personnel.
Immediately available for use
The ASC must have an adequate supply of emergency equipment and supplies
immediately available to the operating room(s) (OR). The equipment and supplies must
be in working condition. The ASC’s policies must address whether the equipment and
supplies must be present in each OR, or in what quantity and locations they will be
available to all ORs as needed.
In the case of an ASC with more than one OR, the medical staff should adopt a policy, in
writing, that addresses:
• The type and quantity of emergency equipment and supplies that must be present
in each OR; and
• For equipment not present in each OR, how many items must be available and in
which locations so that the equipment is immediately available when needed in
each OR.
The ASC must have qualified personnel capable of using all emergency equipment as
necessary. Personnel must be able to utilize the emergency equipment in accordance
with their scope of practice. There is no requirement for all ASC clinical personnel to be
able to use all emergency equipment; however, whenever there is a patient in the OR,
there must always be staff present capable of using the emergency equipment.
Although the regulation addresses availability of emergency equipment to the OR
specifically, a prudent ASC should also make emergency equipment, supplies and
medications available for patients in the recovery room.
Appropriate for the ASC’s patient population
The policies and procedures must incorporate the emergency equipment, supplies, and
medications that are most suitable for the potential emergencies associated with the
procedures performed in the ASC and the population the ASC serves. The ASC’s
policies must take into account the ASC’s patient population, particularly, any risks or
co-morbidities prevalent among that patient population. The ASC must consider the
types of procedures performed as well as the risks and types of emergencies that the ASC
may face based on those types of procedures. For example, if an ASC routinely provides
care to pediatric patients, it must ensure that it has equipment and supplies that are the
appropriate size for pediatric patients.
The ASC would also need to take into account the types of anesthesia used for the
procedures performed. It would be expected that an ASC using general anesthesia is
doing more complicated procedures that may have a higher risk of emergent
complications, in addition to the risks associated with the use of general anesthesia. The
ASC would be expected to have a more extensive supply of emergency equipment,
supplies and medications than an ASC which only uses local anesthesia to perform low-
risk procedures. For example, if an ASC uses anesthetics that carry a risk for malignant
hyperthermia, then the ASC is expected to have supplies of medications required to treat
this emergency condition. The amount of medication that must be immediately available
is to be based on available information on the frequency with which malignant
hyperthermia may occur, as well as ASC patient characteristics, since the dosage for the
emergency medication is weight-based. An ASC that performs bariatric procedures on
obese patients would need to have more emergency medications available than would an
ASC that specializes in pediatric procedures.
Maintained by appropriate personnel
The ASC must ensure that mechanical and electrical equipment must be regularly
inspected, tested, and maintained to assure their availability when needed. Emergency
supplies and medications must be regularly monitored and replaced when they are
removed for use or expire. The ASC must use qualified personnel to maintain emergency
equipment, supplies and medications. The ASC may use contracted personnel to perform
these functions.
Survey Procedures: §416.44(c)
• Ask to see the ASC’s policies and procedures on emergency equipment and
supplies. Has the ASC identified supplies and equipment that are likely to be
needed in emergency situations?
• Ask the ASC how it determined that the specified emergency equipment, supplies
and medications meet the emergency needs of the ASC’s patients, taking into
account the patient population and types of procedures performed and anesthesia
used.
• For ASCs with multiple ORs, does the policy clearly identify the quantity of
equipment, supplies and medications required and their location?
• Determine whether the designated emergency equipment is immediately available
to the OR(s) if needed.
• Interview ASC clinical staff to determine if they know where the emergency
equipment is located.
• Verify that there are sufficient clinical personnel qualified to utilize the
emergency equipment, medications and supplies.
• Ask the ASC how it would handle simultaneous emergencies, e.g., an emergency
in more than one OR, or an emergency in the OR and another one in the recovery
room.
• Is there evidence that mechanical or electrical equipment is regularly inspected,
tested, and maintained by qualified personnel?
• Are emergency supplies and medications current or expired?
Q-0106
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.44(d) Standard: Emergency Personnel
Personnel trained in the use of emergency equipment and in cardiopulmonary
resuscitation must be available whenever there is a patient in the ASC.
Interpretive Guidelines: §416.44(d)
Whenever there is a patient who has been registered in the reception area and not yet
discharged from the ASC, including patients in the waiting area, in pre-operative
preparation, in surgery, or in the recovery room, the ASC must also have clinical
personnel present who have appropriate training and competence in the use of the
requirement emergency equipment and supplies. It is not necessary for the ASC to have
one person who knows how to use all the equipment/supplies, so long as for each type of
equipment/supply there is always some staff member present who is competent to use it.
For example, performing a tracheostomy is outside the scope of practice of a registered
nurse and must be performed by a physician. On the other hand, use of an ambu-bag is
within the RN’s scope of practice.
There must also be staff present in the ASC who are trained in cardiopulmonary
resuscitation (CPR) techniques. Although the regulation does not require that staff must
be trained in advanced cardiac life support (ACLS) techniques, an ASC would be well-
advised to consider having staff trained in ACLS, depending on the types of surgery
performed and the characteristics of the ASC’s patient population.
For ASCs that perform multiple procedures simultaneously, or have multiple persons in
the recovery room simultaneously, there must be sufficient trained personnel to deal with
multiple simultaneous emergencies.
Survey Procedures: §416.44(d)
• Request documentation that confirms the ASC has staff with the requisite training
and competence to use all required emergency equipment and supplies, and in
cardiopulmonary resuscitation.
• Ask for evidence that someone trained in the use of the emergency
equipment/supplies is available whenever there is a patient in the ASC.
• Interview staff identified as having emergency responsibilities to determine if
they are aware of their role in handling an emergency. Do they know where the
emergency equipment/suppliers are kept?
• Ask staff with emergency responsibilities what the ASC’s procedures are when a
staff member designated to handle emergencies is participating in a procedure on
another patient? What type of back-up system is available?
Q-0120
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.45 Condition for Coverage: Medical Staff
The medical staff of the ASC must be accountable to the governing body.
Interpretive Guidelines §416.45
The organization of the medical staff is left to the discretion of the governing body, but
however the staff is organized, the ASC must have an explicit, written policy that
indicates how the medical staff is held accountable by the governing body. The policy
must address all requirements in this condition. Medical staff privileges may be granted
both to physician and non-physician practitioners, consistent with their permitted scope
of practice in the State, as well as their training and clinical experience.
It is possible for an ASC to be owned and operated by one physician, who could be both
the sole member of the governing body and also the sole member of the ASC’s medical
staff. In such cases the physician owner must nevertheless implement a formal process
for complying with all medical staff regulatory requirements.
Survey Procedures §416.45
Ask the ASC’s leadership for its policy detailing how the governing body holds the
medical staff accountable.
Q-0121
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.45(a) Standard: Membership and Clinical Privileges
Members of the medical staff must be legally and professionally qualified for the
positions to which they are appointed and for the performance of privileges granted.
The ASC grants privileges in accordance with recommendations from qualified
medical personnel.
Interpretive Guidelines §416.45(a)
All members of the ASC’s medical staff and all clinicians granted medical staff
privileges must be appointed to their position within the ASC by the ASC’s governing
body. They must be granted privileges by the governing body, in writing, that specify in
detail the types of procedures they may perform within the ASC. It is not sufficient for
the governing body to grant privileges to “perform surgery” or even to perform
“orthopedic surgery.” For example, an ASC that specializes in orthopedic surgery of
various types must specify which types of procedures each surgeon is privileged to
perform.
The ASC’s governing body must assure that medical staff privileges are granted only to
legally and professionally qualified practitioners.
“Legally qualified” means the practitioner has a current license to practice within the
State where the ASC is located, and that the privileges to be granted fall within that
State’s permitted scope of practice. The ASC must verify that each practitioner has a
current professional license and document the license in the practitioner’s file.
“Professionally qualified” means that the practitioner has demonstrated competence in
the area for which privileges are sought. Competence is demonstrated through evidence
of specialized training and experience, e.g., certification by a nationally recognized
professional board.
The governing body is also required to solicit the opinion of qualified medical personnel
on the competence of applicants for privileges. The recommendation provided must be in
writing, and should include a supporting rationale. The qualified medical personnel may
be current members of the ASC’s medical staff, but may also be physicians not practicing
in the ASC. ASCs should consider seeking the recommendations of qualified outside
physicians when they do not have appropriate expertise in-house to evaluate the
competency of an applicant for privileges. This is particularly advisable when the ASC’s
governing body consists of one physician owner who is also the sole member of the
medical staff. The ASC’s governing body is not required to accept the recommendation
provided by the qualified medical personnel to grant, deny, or restrict privileges to a
practitioner. However, when the ASC’s governing body makes a decision contrary to the
recommendation, it is expected to document its rationale for doing so.
The ASC should document the process by which the governing body grants medical staff
privileges, including the documentation, or credentials, it reviews for each candidate, the
criteria it uses in evaluating the candidate, how it selects the qualified medical personnel
who make recommendations on the practitioner’s qualifications, and whether and under
what circumstances the governing body may make a privileging decision contrary to the
recommendation of the qualified medical staff.
Survey Procedures: §416.45(a)
Ask the ASC’s leadership to explain its process for granting clinical privileges.
Review the personnel records for all medical staff that have been granted clinical
privileges.
There must at a minimum be documentation of:
• State licensure, registration, or state certification, as applicable;
• Certification by a specialty organization, as appropriate;
• Other training or pertinent experience;
• Evidence of a recommendation by qualified medical personnel concerning the
practitioner’s competence;
• The scope of the privileges granted to the practitioner; and
• If the governing body granted privileges against the recommendation of the
qualified medical personnel, its rationale for doing so.
Does the review of each practitioner’s record provide evidence that they are legally and
professionally qualified to exercise the privileges granted them by the ASC?
Q-0122
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.45(b) Standard: Reappraisals
Medical staff privileges must be periodically reappraised by the ASC. The scope of
procedures performed in the ASC must be periodically reviewed and amended as
appropriate.
Interpretive Guidelines: §416.45(b)
The ASC’s governing body must have a process reappraising the medical staff privileges
granted to each practitioner. CMS recommends a reappraisal at least every 24 months.
The reappraisal must include:
• Review of the practitioner’s current credentials; and
• The practitioner’s ASC-specific case record, including measures employed
in the ASC’s quality assurance/performance improvement program, such
as emergency transfers to hospitals, post-surgical infection rates, other
surgical complications, etc.
The ASC’s governing body should use a similar process, including the recommendation
of qualified medical personnel, for the periodic reappraisal as it used when initially
granting privileges.
Based on the evidence, the ASC’s governing body must decide whether to continue the
practitioner’s current privileges without change, or to amend those privileges by
contracting or expanding them, or by withdrawal of the practitioner’s privileges entirely.
The ASC must also reappraise a practitioner any time the practitioner seeks to perform
procedures outside the scope of previously granted procedures.
The ASC should also develop triggers for reappraisal of privileges outside the periodic
reappraisal schedule.
In the case of an ASC whose sole member of the governing body is also a member of the
ASC’s medical staff, it would be advisable to seek the recommendation of outside
qualified medical personnel who review not only the physician’s credentials, but also
evidence of the physician’s performance in the ASC.
Survey Procedures: §416.45(b)
• Does the ASC periodically reappraise all practitioners granted clinical
privileges?
• Ask the ASC’s leadership how it re-evaluates the professional
qualifications of practitioners with privileges to practice in the ASC?
• Review the personnel records for all practitioners with privileges to
practice in the ASC to determine whether they have been reappraised
within the timeframe specific in the medical staff policy.
• Do the reappraisals include evidence that data on the practitioner’s
practice within the ASC is considered along with the practitioner’s
credentials?
Q-0123
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.45(c) Standard: Other Practitioners
If the ASC assigns patient care responsibilities to practitioners other than
physicians, it must have established policies and procedures, approved by the
governing body, for overseeing and evaluating their clinical activities.
Interpretive Guidelines: §416.45(c)
Patient care responsibilities (which may or may not include formal medical staff
privileges, but excluding nursing care services) may be assigned to licensed practitioners
not meeting the definition of physician in §1861(r) of the Act. “Physician” is defined in
§1861(r) of the Social Security Act as:
• Doctor of medicine or osteopathy;
• Doctor of dental surgery or of dental medicine;
• Doctor of podiatric medicine;
• Doctor of optometry with respect to services legally authorized to be performed in
the State; and
• Chiropractor with respect to treatment by manual manipulation of the spine (to
correct subluxation diagnosed by x-ray).
When an ASC uses licensed practitioners to provide patient care, other than nursing care,
the ASC’s governing body must approve written policies and procedures that establish a
system for overseeing and evaluating the quality of the clinical services provided by other
practitioners. The policies must address:
• The specific types of clinical activities that each class of practitioner, e.g., Nurse
Practitioner, Physician’s Assistant, CRNA, will be eligible to perform. The ASC
may not permit performance of any activities that are outside the licensed
practitioner’s permitted scope of practice under applicable State law;
• The process by which the ASC exercises oversight over each class of practitioner.
Depending on the practitioner’s scope of practice, physician supervision of the
practitioner may be required; in other cases oversight through collaborative
practice with a physician or some other means may suffice;
• The process and criteria for reviewing the qualifications of each individual
practitioner before he/she is permitted to provide patient care; and
• The process, criteria and frequency for evaluating the performance in providing
clinical services by practitioners other than physicians. Evaluations must take
place at regular intervals specified in the ASC’s policy.
Survey Procedures: §416.45(c)
• Determine whether the ASC uses licensed practitioners other than physicians to
provide care, other than nursing care, within the ASC. If it does:
• Ask to see the ASC’s policy governing the oversight and evaluation of
practitioners other than physicians. Does the policy address all required
issues?
• Review the personnel files for each licensed practitioner who is not a
physician providing patient care in the ASC. Does each file contain evidence
of the practitioner’s qualifications, consistent with the ASC’s policy? Does
each file contain evidence of periodic evaluation of the practitioner’s
performance?
Q-0140
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.46 Condition for Coverage: Nursing Service
The nursing services of the ASC must be directed and staffed to assure that the
nursing needs of all patients are met.
Interpretive Guidelines: §416.46
The ASC must ensure that the nursing service is directed under the leadership of an RN.
The ASC must have documentation that it has designated an RN to direct nursing
services.
There must be sufficient nursing staff with the appropriate qualifications to assure the
nursing needs of all ASC patients are met. This implies that there is ongoing assessment
of patients’ needs for nursing care, and that identified needs are addressed. The number
and types of nursing staff needed will depend on the volume and types of surgery the
ASC performs.
Survey Procedures: §416.46
• Ask the ASC’s leadership to identify the person responsible for the direction of
nursing services within the ASC. Is that person an RN?
• Review the staffing available for patients undergoing surgery during the survey; is
there sufficient staff to address each patient’s nursing needs?
Do nursing staff have the appropriate qualifications for the tasks they are asked to
perform?
Q-0141
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.46(a) Standard: Organization and Staffing
Patient care responsibilities must be delineated for all nursing service personnel.
Nursing services must be provided in accordance with recognized standards of
practice. There must be a registered nurse available for emergency treatment
whenever there is a patient in the ASC.
Interpretive Guidelines: §416.46(a)
Every nurse in the ASC must have clearly delineated assigned responsibilities for
providing nursing care to patients. These assignments must be in writing; job
descriptions would suffice for a general articulation of the responsibilities for each nurse.
Individual patient assignments on a given day must be documented clearly in the
assignment sheet.
The ASC’s nursing services must be consistent with recognized standards of practice.
“Recognized standards of practice” means that the services provided are consistent with
State laws governing nursing scope of practice, as well as with nationally recognized
standards or guidelines for nursing care issued by organizations such as the American
Nurses Association, the Association of Operating Room Nurses, etc.
An RN with specialized training or experience in emergency care must be available to
provide emergency treatment whenever there is a patient in the ASC. “Available” means
on the premises and sufficiently free from other duties that the nurse is able to respond
rapidly to emergency situations. In accordance with the requirements at §416.44(d), the
ASC must have personnel present who are trained in the use of the required emergency
equipment specified at §416.44(c) and in cardiopulmonary resuscitation whenever there
is a patient in the ASC. The RN(s) designated to provide emergency treatment must be
able to use any of the required equipment, so long as such use falls within an RN’s scope
of practice. ASC’s would be well advised to assure that the RN(s) designated to provide
emergency treatment have training in advanced cardiac life support interventions.
Survey Procedures: §416.46(a)
• Are the general responsibilities for each ASC nurse for providing patient care
clearly documented?
• Ask the nursing staff to explain what their duties for the day of the survey are; can
they articulate clearly what their patient care responsibilities are?
• Ask the ASC to explain how it evaluates the nursing care provided in the ASC for
conformance to acceptable standards of practice.
• Ask the ASC to identify the RN(s) who are available for emergency treatment. Is
there documentation of their qualifications to provide emergency treatment? Do
staff in the ASC know which RN(s) (as well as medical staff) to call when a
patient develops an emergency?
• Ask the ASC for evidence that one or more RN(s) are readily available to provide
emergency treatment. How do they assure that an RN can leave their current task
to respond to the emergency without putting another patient at risk of harm?
Q-0160
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.47 Condition for Coverage: Medical Records
The ASC must maintain complete, comprehensive, and accurate medical records to
ensure adequate patient care.
Interpretive Guidelines: §416.47
The ASC must have a complete, comprehensive and accurate medical record for each
patient. Material required under other Conditions, such as the history and physical
examination or documentation of allergies to drugs and biologicals required under
§416.52, must be incorporated into the medical record in a timely fashion. The ASC
must use the information contained in each medical record in order to assure that
adequate care is delivered to each ASC patient. In accordance with the provisions of the
Patients’ Rights Condition at §416.50(g), the ASC must ensure the confidentiality of each
patient’s medical record.
Survey Procedures: §416.47
Review a sample of active and closed medical records for completeness and accuracy in
accordance with Federal and State laws and regulations and ASC policy. If patient
records are not collected in a systematic manner for easy access, annotate this on the
survey report form.
Q-0161
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.47(a) Standard: Organization. The ASC must develop and maintain a system
for the proper collection, storage, and use of patient records.
Interpretive Guidelines: §416.47(a)
The ASC must have a documented system that enables it to systematically develop a
unique medical record for each patient, permit timely access to the medical record to
support the delivery of care, and to store records. Records may exist in hard copy,
electronic format, or a combination of the two media.
The regulation does not prescribe how long a closed record is to be maintained by the
ASC, but many States have laws governing retention of medical records.
Survey Procedures: §416.47(a)
• Review the ASC’s medical record policy and interview the person responsible for
the medical records to ascertain that the system is structured appropriately.
• If the ASC employs a fully or partially electronic medical record system, ask
clinical personnel to demonstrate how they use the system in order to determine
whether they are able to make entries and access needed information in order to
support the provision of care.
• Determine that closed records are retained in accordance with applicable State
law.
• Review a sample of active and closed medical records for completeness and
accuracy in accordance with Federal and State laws and regulations and ASC
policy. If patient records are not collected in a systematic manner for easy access,
annotate this on the survey report form.
Q-0162
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.47(b) Standard: Form and Content of Record
The ASC must maintain a medical record for each patient. Every record must be
accurate, legible, and promptly completed. Medical records must include at least
the following:
(1) Patient identification;
(2) Significant medical history and results of physical examination;
(3) Pre-operative diagnostic studies (entered before surgery), if performed;
(4) Findings and techniques of the operation including a pathologist’s report on all
tissues removed during surgery, except those exempted by the governing body;
(5) Any allergies and abnormal drug reactions;
(6) Entries related to anesthesia administration;
(7) Documentation of properly executed informed patient consent; and
(8) Discharge diagnosis.
Interpretive Guidelines: §416.47(b)
The medical record must contain all of the required elements listed in the regulation.
Specifically:
• The identity of the patient must be clear through use of identifiers such as name,
date of birth, social security number, etc.
• A comprehensive medical history and physical assessment (H&P), completed and
entered into the medical record in accordance with the requirements at §416.52, as
well as the results of the pre-surgical assessments specified at §416.42 and
§416.52.
• If pre-operative diagnostic studies were performed, they must be included in the
medical record prior to the start of surgery.
• An operative report that describes the surgical techniques and findings. A
pathologist’s report on all tissues removed during surgery must also be included,
unless the governing body has adopted a written policy exempting certain types of
removed tissue from this requirement. Depending on the type of surgery
performed in the ASC, tissue may or may not routinely be removed during
surgery; no pathologist’s report is required when no tissue has been removed.
The governing body’s policy on exemption should provide the clinical rationale
supporting the exemption decision. For example, an ASC that performs cataract
removal and implantation of an artificial lens might exempt from the pathologist’s
report requirement the ocular lens removed in routine procedures where there is
no indication suggesting the presence of other disease for which a pathology
analysis should be required. On the other hand, it generally would not be
reasonable to exempt intestinal polyps removed during a colonoscopy, since a
pathologist’s analysis of the tissue would be required to confirm whether or not
the polyp(s) were malignant growths.
• The patient’s history of allergies or abnormal drug reactions prior to the surgery,
as well as any allergies or abnormal drug reactions that occurred during or after
the surgery prior to discharge.
• Information related to the administration of anesthesia during the procedure and
the patient’s recovery from anesthesia after the procedure.
• Documentation of a properly executed informed patient consent. A well-designed
informed consent process would most likely include a discussion of the following
elements:
• A description of the proposed surgery, including the anesthesia to be used;
• The indications for the proposed surgery;
• Material risks and benefits for the patient related to the surgery and
anesthesia, including the likelihood of each, based on the available clinical
evidence, as informed by the responsible practitioner’s clinical judgment.
Material risks could include risks with a high degree of likelihood, but a low
degree of severity, as well as those with a very low degree of likelihood, but a
high degree of severity;
• Treatment alternatives, including the attendant material risks and benefits;
• Who will conduct the surgical intervention and administer the anesthesia;
• Whether physicians other than the operating practitioner will be performing
important tasks related to the surgery. Important surgical tasks include:
opening and closing, dissecting tissue, removing tissue, harvesting grafts,
transplanting tissue, administering anesthesia, implanting devices and placing
invasive lines; and
• Whether, as permitted by State law, qualified medical practitioners who are
not physicians will perform important parts of the surgery or administer the
anesthesia, and if so, the types of tasks each type of practitioner will carry out;
and that such practitioners will be performing only tasks within their scope of
practice for which they have been granted privileges by the ASC.
• Documentation of the patient’s discharge diagnosis. The record should also
include the patient’s disposition, i.e., whether the patient was discharged to home
(including to a nursing home for patients already resident in a nursing home at the
time of surgery), or transfer to another healthcare facility, including emergent
transfers to a hospital.
Survey Procedures: §416.47(b)
• Evaluate the sample of open and closed records selected for review to determine
whether they contain all of the required elements. For open records of patients
whose surgery has not yet begun, focus on the elements that must be present
before surgery, e.g., H&P, immediate pre-surgical assessment, informed consent,
etc. The absence of any required element must be cited as standard-level
noncompliance. The absence of a number of elements from a number of medical
records might warrant citation of condition-level noncompliance. Likewise the
absence of one element from a number of medical records – e.g., lack of informed
consent to surgery – should warrant citation of condition-level noncompliance.
• Ask the ASC’s leadership if the ASC removes tissue during surgery and, if so,
does it exempt any or all classes of tissue removed from the requirement for
analysis by a pathologist? If yes, ask to see the policy and its rationale, to
determine whether it was adopted by the governing body and whether the clinical
rationale for the exemption is reasonable.
Q-0180
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.48 Condition for Coverage: Pharmaceutical Services
The ASC must provide drugs and biologicals in a safe and effective manner, in
accordance with accepted professional practice, and under the direction of an
individual designated responsible for pharmaceutical services.
Interpretive Guidelines: §416.48
Drugs and biologicals used within the ASC must be provided safely and in an effective
manner, consistent with generally accepted professional standards of pharmaceutical
practice and with the requirements specified in the Standards within this Condition.
The ASC must designate a specific licensed healthcare professional to provide direction
to the ASC’s pharmaceutical service. That individual must be routinely present when the
ASC is open for business, but continuous presence is not required, particularly when the
ASC is open for longer periods of time to accommodate the recovery of patients for up to
24 hours. Ideally the ASC should have available a pharmacist who provides oversight or
consultation on the ASC’s pharmaceutical services, but this is not required by the
regulation, unless the ASC is performing activities which under State law may only be
performed by a licensed pharmacist.
Survey Procedures: §416.48
• Ask the ASC’s leadership for evidence that a qualified individual has been
designated to direct pharmaceutical services in the ASC.
• Ask how often and for how long this individual is on-site at the ASC. Determine
whether there is any documentation indicating that the individual is providing
active direction and oversight to the program.
Q-0181
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.48(a) Standard: Administration of Drugs
Drugs must be prepared and administered according to established policies and
acceptable standards of practice
Interpretive Guidelines: §416.48(a)
Drugs and biologicals used within the ASC must be administered to patients in
accordance with formal policies the ASC has adopted, and those policies and the ASC’s
actual practices must conform to acceptable standards of practice for medication
administration.
“Accepted professional practice” and “acceptable standards of practice” mean that
drugs and biologicals are handled and provided in the ASC in accordance with applicable
State and Federal laws as well as with standards established by organizations with
nationally recognized expertise in the clinical use of drugs and biologicals. This would
include organizations such as the National Association of Boards of Pharmacy, the
Institute for Safe Medication Practices, the American Society of Health-System
Pharmacists, etc.
The ASC must have policies and procedures designed to promote medication
administration consistent with acceptable standards of practice. The policies and
procedures should address issues including, but not limited to:
• A physician or other qualified member of the medical staff acting within their
scope of practice must issue an order for all drugs or biologicals administered
in the ASC. The administration of the drugs or biologicals must be by, or
under the supervision of, nursing or other personnel in accordance with
applicable laws, standards of practice and the ASC’s policies.
• Following the manufacturer’s label, including storing drugs and biologicals as
directed; disposing of expired medications in a timely manner; using single-
dose vials of medication for one ASC patient only; etc.
• Avoiding preparation of medications too far in advance of their use. For
example, while it may appear efficient to pre-draw the evening before all
medications that will be used for surgeries scheduled the following day, this
practice may, depending on the particular drug or biological, promote loss of
integrity, stability or security of the medication.
• Any pre-filled syringes must be initialed by the person who draws it, dated
and timed to indicate when they were drawn, and labeled as to both content
and expiration date.
• Employing standard infection control practices when using injectable
medications.
There must be records of receipt and disposition of all drugs listed in Schedules II, III,
IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970, if the
ASC uses any such scheduled drugs. The ASC’s policies and procedures should also
address the following:
• Accountability procedures to ensure control of the distribution, use, and
disposition of all scheduled drugs.
• Records of the receipt and disposition of all scheduled drugs must be current and
must be accurate.
• Records to trace the movement of scheduled drugs throughout the ASC.
• The licensed health care professional who has been designated responsible for the
ASC’s pharmaceutical services is responsible for determining that all drug records
are in order and that an account of all scheduled drugs is maintained and
reconciled.
• The record system, delineated in policies and procedures, tracks movement of all
scheduled drugs from the point of entry into the ASC to the point of departure,
either through administration to the patient, destruction, or return to the
manufacturer. This system provides documentation on scheduled drugs in a
readily retrievable manner to facilitate reconciliation of the receipt and disposition
of all scheduled drugs.
• All drug records are in order and an account of all scheduled drugs is maintained
and any discrepancies in count are reconciled promptly.
• The ASC’s system is capable of readily identifying loss or diversion of all
controlled substances in such a manner as to minimize the time frame between the
actual loss or diversion to the time of detection and determination of the extent of
loss or diversion?
Survey Procedures: §416.48(a)
• Is there evidence in the medical records reviewed that there is an order, signed by
a physician or other qualified practitioner, for every drug or biological
administered to the patient?
• Are drugs or biologicals administered only by nurses or other qualified
individuals, or under the supervision of nurses or other qualified individuals, as
permitted under Federal or State law and the ASC’s policy?
• Determine whether medications are properly labeled, stored, and have not
expired.
• Using the infection control survey tool, determine whether the ASC employs safe
injection practices.
• If the ASC uses scheduled drugs:
• Determine if there is a record system in place that provides information on
controlled substances in a readily retrievable manner.
• Review the records to determine that they trace the movement of scheduled
drugs throughout the ASC.
• Determine if there is a system, delineated in policies and procedures, that
tracks movement of all scheduled drugs from the point of entry into the ASC
to the point of departure, either through administration to the patient,
destruction or return to the manufacturer. Determine if this system provides
documentation on scheduled drugs in a readily retrievable manner to facilitate
reconciliation of the receipt and disposition of all scheduled drugs.
• Determine if the licensed health care professional who is in charge of the
ASC’s pharmaceutical services is responsible for determining that all drug
records are in order and that an account of all scheduled drugs is maintained
and periodically reconciled.
• Is the ASC’s system capable of readily identifying loss or diversion of all
controlled substances in such a manner as to minimize the time between the
actual losses or diversion to the time of detection and determination of the
extent of loss or diversion?
• Determine if facility policy and procedures minimize scheduled drug
diversion.
Q-0182
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.48(a) Standard: Administration of Drugs
(1) Adverse reactions must be reported to the physician responsible for the patient
and must be documented in the record.
Interpretive Guidelines: §416.48(a)(1)
Every adverse reaction to a drug or biological that a patient experiences while in the ASC
must be reported promptly to the physician on the ASC’s medical staff who is responsible
for that patient. This permits that physician to assess the patient in a timely manner and
determine whether additional treatment is required in order to counteract the adverse
reaction.
All adverse drug reactions experienced by patients while in the ASC must be documented
in the patient’s medical record.
The ASC’s policies and procedures must incorporate these requirements and ASC staff
must be aware of and comply with them.
Survey Procedures: §416.48(a)(1)
• Interview clinical staff to ask them what steps they would take if a patient
experiences an adverse reaction to a drug? Are staff aware of the requirement to
promptly report this information to the physician on the ASC’s medical staff who
is responsible for the patient?
• Look for documentation of adverse drug reactions in the sample of records
selected for review. If no adverse drug reactions are noted, ask ASC staff whether
they recall any patients having adverse drug reactions, and if so, whether they
could pull a medical record containing documentation of an adverse drug reaction.
• Determine whether the ASC’s policies and procedures address adverse drug
reactions and are consistent with the regulatory requirements.
Q-0183
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.48(a) Standard: Administration of Drugs
(2) Blood and blood products must be administered only by physicians or
registered nurses.
Interpretive Guidelines: §416.48(a)(2)
If the ASC ever administers blood or blood products to patients, it may permit only a
physician on the ASC’s medical staff or an RN working in the ASC to administer blood
and blood products. The ASC’s policies and procedures must specifically address this
requirement, unless the ASC does not keep blood or blood products on hand and never
administers such products to ASC patients.
Survey Procedures: §416.48(a)(2)
• Determine whether the ASC administers blood or blood products to patients. If yes,
• Determine from the record review whether anyone other than a physician on the
ASC’s medical staff or an ASC RN administered the blood or blood product.
• Determine whether the ASC’s policies specifically restrict administration of blood
and blood products to a physician or RN.
Q-0184
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.48(a) Standard: Administration of Drugs
(3) Orders given orally for drugs and biologicals must be followed by a written
order and signed by the prescribing physician.
Interpretive Guidelines: §416.48(a)(3)
Orders for drugs and biologicals that are transmitted as oral, spoken communications
between the prescribing physician and the ASC’s nursing staff, delivered either face-to-
face or via telephone, commonly called “verbal orders,” must be followed by a written
order that is signed by the prescribing physician.
CMS expects ASC policies and procedures for verbal orders to include a read-back and
verification process whereby the nurse receiving the order repeats it back to the
prescribing physician, who verifies that it is correct. When administering a drug or
biological per a verbal order, the nurse should include in the medical record entry
covering the administration of the drug or biological a note that it was prescribed orally,
indicating the name of the prescribing physician.
The prescribing physician must sign, date, and time the written order in the patient’s
medical record confirming the verbal order. This should be done as soon as possible after
the verbal order is issued.
In the ASC setting medications prescribed for patients in recovery present a particular
area of vulnerability in terms of the potential failure to follow-up a verbal order with a
written order signed by the prescribing physician. Careful attention must be given to
compliance with the regulatory requirement for medications administered during
recovery room.
Survey Procedures: §416.48(a)(3)
• Does the ASC have policies and procedures addressing verbal orders? Does it
require the prescribing practitioner to sign, date, and time a written order as soon
as possible after issuing the verbal order?
• Do the ASC's policies and procedures for verbal orders include a "read back and
verify" process where the nurse who receives the order repeats it back to the
prescribing physician to verify that the order was understood accurately?
• Ask ASC nursing staff how they handle verbal orders. Does their practice
conform to the regulatory requirements? Do they use a read-back and verify
process?
• Is there evidence in the medical records reviewed that each verbal order was
followed by a written order signed by the prescribing physician?
Q-0200
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.49 Condition for Coverage: Laboratory and Radiologic Services
Interpretive Guidelines: §416.49(a)
Lack of substantial compliance with either the laboratory or the radiologic standard
within this condition could provide a basis for citing a condition-level deficiency.
Q-0201
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.49(a) Standard: Laboratory Services
If the ASC performs laboratory services, it must meet the requirements of part 493
of this chapter. If the ASC does not provide its own laboratory services, it must
have procedures for obtaining routine and emergency laboratory services from a
certified laboratory in accordance with Part 493 of this chapter. The referral
laboratory must be certified in the appropriate specialties and subspecialties of
service to perform the referred tests in accordance with the requirements of Part
493 of this chapter.
Interpretive Guidelines: §416.49(a)
ASC policies and procedures should list the kinds of laboratory services that are provided
directly by the facility, and services that are provided through a contractual agreement.
Review the contractual agreements and determine if the referral laboratory is a CLIA-
approved laboratory. The ASC procedures must include the following:
• A well-defined arrangement (need not be contractual) with outside services;
• Laboratory services that are provided by the ASC;
• Routine procedures for requesting lab tests; and
• Language that requires the incorporation of lab/radiological reports into patient
records.
When laboratory tests are performed prior to admission, the results should be readily
available to the attending physician in the ASC.
Q-0202
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.49(b) Standard: Radiologic Services.
(1) Radiologic services may only be provided when integral to procedures
offered by the ASC …
Interpretive Guidelines: §416.49(b)(1)
An ASC may only provide radiological services as an integral part of the surgical
procedures it performs. Radiological services integral to the procedure itself are those
imaging services performed immediately before, during or after the procedure that are
medically necessary to the completion of the procedure.
If the ASC does not provide these radiological services directly, i.e., utilizing its own
staff, then it must obtain them via a contract or other formal arrangement.
Survey Procedures: §416.49(b)(1)
• Does the ASC provide, either directly or under arrangement, radiologic
services? If yes, verify that it performs only those radiologic services that
are integral to its surgical services?
Q-0203
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.49(b)(1) [Radiologic services…]
. . . must meet the requirements specified in § 482.26(b), (c)(2), and (d)(2) of this
chapter.
Interpretive Guidelines §416.49(b)(1)
The scope and complexity of radiological services provided within the ASC, either
directly or under arrangement, as an integral part of the ASC’s surgical services must be
specified in writing and approved by the governing body. The ASC must also ensure that
the provision of radiological services in the ASC complies with the hospital radiologic
services requirements at § 482.26(b), (c)(2), and (d)(2), regardless of whether the service
is provided directly by the ASC or under arrangement.
The interpretive guidelines for § 482.26(b), (c)(2), and (d)(2) in Appendix A, Survey
Protocol, Regulations and Interpretive Guidelines for Hospitals of the State Operations
Manual, provide the following guidance in determining compliance:
§482.26(b) Standard: Safety for Patients and Personnel
The radiologic services, particularly ionizing radiology procedures, must be free from
hazards for patients and personnel.
Interpretive Guidelines §482.26(b)
The hospital must adopt and implement policies and procedures that provide safety for
patients and personnel.
Survey Procedures §482.26(b)
Observe locations where radiological services are provided. Are they safe for patients
and personnel? Are any hazards to patients or personnel observed?
§482.26(b)(1) Proper safety precautions must be maintained against radiation
hazards. This includes adequate shielding for patients, personnel, and facilities, as
well as appropriate storage, use and disposal of radioactive materials.
Interpretive Guidelines §482.26(b)(1)
The hospital policies must contain safety standards for at least:
• Adequate shielding for patients, personnel and facilities;
• Labeling of radioactive materials, waste, and hazardous areas;
• Transportation of radioactive materials between locations within the
hospital;
• Security of radioactive materials, including determining who may have
access to radioactive materials and controlling access to radioactive
materials;
• Testing of equipment for radiation hazards;
• Maintenance of personal radiation monitoring devices;
• Proper storage of radiation monitoring badges when not in use;
• Storage of radio nuclides and radio pharmaceuticals as well as radioactive
waste; and
• Disposal of radio nuclides, unused radio pharmaceuticals, and radioactive
waste.
• Methods of identifying pregnant patients.
The hospital must implement and ensure compliance with its established safety standards.
Survey Procedures §482.26(b)(1)
• Verify that patient shielding (aprons, etc.) are properly maintained and
routinely inspected by the hospital.
• Verify that hazardous materials are stored properly in a safe manner.
• Observe areas where testing is done for violations in safety precautions.
§482.26(b)(2) Periodic inspection of equipment must be made and hazards identified
must be properly corrected.
Interpretive Guidelines §482.26(b)(2)
The hospital must have policies and procedures in place to ensure that periodic
inspections of radiology equipment are conducted, current and that problems identified
are corrected in a timely manner. The hospital must ensure that equipment is inspected in
accordance with manufacturer’s instructions, Federal and State laws, regulations, and
guidelines, and hospital policy. The hospital must have a system in place, qualified
employees or contracts, to correct hazards. The hospital must be able to demonstrate
current inspection and proper correction of all hazards.
Survey Procedures §482.26(b)(2)
• Review the inspection records (logs) to verify that periodic inspections are
conducted in accordance with manufacturer’s instructions, Federal and
State laws, regulations, and guidelines and hospital policy.
• Determine that any problems identified are properly corrected in a timely
manner.
§482.26(b)(3) Radiation workers must be checked periodically, by the use of
exposure meters or badge tests, for amount of radiation exposure.
Interpretive Guidelines §482.26(b)(3)
The requirement that “radiation workers must be checked periodically, by use of
exposure meters or badge tests, for amount of radiation exposure” would include
radiological services personnel, as well as, other hospital employees who may be
regularly exposed to radiation due to working near radiation sources. This could include
personnel such as certain nursing and maintenance staff.
Survey Procedures §482.26(b)(3)
• Verify that the hospital requires periodic checks on all radiology personnel
and any other hospital staff exposed to radiation and that the personnel are
knowledgeable about radiation exposure for month, year, and
cumulative/entire working life.
• Observe that appropriate staff have a radiation-detecting device and that
they appropriately wear their radiation detecting device.
• Review records to verify that periodic tests of radiology personnel by
exposure meters or test badges are performed.
§482.26(b)(4) Radiologic services must be provided only on the order of
practitioners with clinical privileges or, consistent with State law, of other
practitioners authorized by the medical staff and the governing body to order the
services.
Survey Procedures §482.26(b)(4)
Review medical records to determine that radiological services are provided only on the
orders of practitioners with clinical privileges and to practitioners outside the hospital
who have been authorized by the medical staff and the governing body to order
radiological services, consistent with State law.
§482.26(c)(2) Only personnel designated as qualified by the medical staff may use
the radiologic equipment and administer procedures.
Interpretive Guidelines §482.26(c)(2)
There should be written policies, developed and approved by the medical staff, consistent
with State law, to designate which personnel are qualified to use the radiological
equipment and administer procedures.
Survey Procedures §482.26(c)(2)
Determine which staff are using differing pieces of radiological equipment and/or
administering patient procedures. Review their personnel folders to determine they meet
the qualifications established by the medical staff for the tasks they perform.
§482.26(d)(2) The hospital must maintain the following for at least 5 years:
(i) Copies of reports and printouts
(ii) Films, scans, and other image records, as appropriate.
Interpretive Guidelines §482.26(d)(2)
Patient radiology records are a type of patient medical record. The hospital must
maintain radiology records in compliance with the medical records CoP and this CoP.
Medical records, including radiology records, must be maintained for 5 years.
Survey Procedures §482.26(d)(2)
• Verify that the hospital maintains records for at least 5 years.
• Verify that radiology records are maintained in the manner required by the
Medical Records….” [CfC].
Survey Procedures: §416.49(b)(1)
• If the ASC provides radiologic services as an integral part of surgical
procedures, does it comply with the requirements of §482.26(b), (c)(2),
and (d)(2) in its provision of those services, using the hospital radiologic
services interpretive guidelines cited above?
• Interview the individual designated responsible for assuring compliance
with this CfC and review related documentation to assess how these
responsibilities have been implemented in the ASC. For example, is there
evidence that this individual monitors and/or oversees the monitoring of
compliance with all of the requirements in §482.26(b), (c)(2), and (d)(2)?
What steps are available to this individual to remedy the situation if there
is evidence of noncompliance with any of the requirements?
Q-0204
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§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.
Interpretive Guidelines: §416.49(b)(2)
If the ASC provides radiologic services, the ASC’s governing body must appoint an
individual who has appropriate qualifications, in accordance with State law and Federal
regulations, to provide oversight of these services. The appointed individual is
responsible for assuring the ASC’s compliance with §§482.26(b), (c)(2), and (d)(2). In
order to assure compliance with these requirements the individual is expected to be
qualified, through training and/or experience, to oversee areas including, but not limited
to: use of safety precautions (shielding, and appropriate storage, use and disposal of
radioactive materials) against radiation hazards; regular equipment inspection and
hazard correction; regular review of radiation worker radiation exposure; assuring use
of radiologic equipment only by qualified personnel; and maintenance of imaging results
or records. The person appointed to oversee radiologic services could be someone
already working in the ASC who is qualified in accordance with State law and Federal
regulations. Under the medical staff credentialing and privileging requirements at
§416.45, the ASC’s governing body will continue to be required to ensure that the
operating surgeon is competent both to perform the surgical procedures for which
privileges have been issued by the ASC and to appropriately and safely use the imaging
modalit(ies) that are integral to the procedures s/he performs.
Survey Procedures: §416.49(b)(2)
• Can the ASC demonstrate that the individual responsible for assuring all
radiologic services are provided in accordance with the requirements of
this section:
o Is qualified for this role in accordance with State and/or Federal
law and regulations and ASC policies?
o Was appointed by the ASC’s governing body?
Q-0219
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50 Condition for Coverage - Patient Rights
The ASC must inform the patient or the patient’s representative or surrogate of the
patient’s rights and must protect and promote the exercise of these rights, as set
forth in this section. The ASC must also post the written notice of patient rights in a
place or places within the ASC likely to be noticed by patients waiting for treatment
or by the patient’s representative or surrogate, if applicable.
Interpretive Guidelines: §416.50
The ASC must inform each of its patients, or the patient’s representative or surrogate in
the case of minor patients or other situations where there is a designated representative
for the patient, of their rights as an ASC patient. Further, all of the ASC’s policies,
procedures and actions must be consistent with the protection of the patients’ rights
articulated in this Condition. Further, the ASC must actively promote the patient’s
exercise of their rights.
In addition, the ASC must ensure that the written notice of patient rights is posted in one
or more places where it is likely to be seen by patients waiting for treatment, or the
patient’s representative or surrogate, if applicable. Such areas include, but are not limited
to, waiting rooms or pre-operative preparation areas where patients are awaiting care.
Notices must be posted in at least one area. Whether the ASC must post more than one
notice depends on the size and physical layout of the areas where notices are posted. The
determining factor is whether the notice(s) are posted in a manner that all patients (or
their representatives or surrogates, as applicable) are likely to see the notice.
The patient’s representative or surrogate is an individual designated by the patient, in
accordance with applicable State law, to make health care decisions on behalf of the
individual or to otherwise assist the patient during his/her stay in the ASC. Designation
may be in writing, as in an advance directive or medical power of attorney, or may be
oral (verbal). Written designation may occur before the patient presents to the ASC, or
during the ASC registration process. Oral designation may take place at any time during
the patient’s visit in the ASC. The patient’s representative or surrogate includes, but is
not limited to, an individual who could be a family member or friend who accompanies
the patient. Depending on the designation the patient has made, the patient’s
representative or surrogate may make all health care decisions for the patient during
his/her ASC visit, or may act in a more limited role, for example, as a liaison between the
patient and the ASC to help the patient communicate, understand, remember, and cope
with the interactions that take place during the visit, and explain any instructions to the
patient that are delivered by the ASC staff. If a patient is unable to fully communicate
directly with the ASC staff, then the ASC may give patient rights information to the
patient’s representative or surrogate.
Survey Procedures: §416.50
When there is a team surveying the ASC, survey of the Patients’ Rights Condition should
be coordinated by one surveyor. However, each surveyor, as he or she conducts his/her
survey assignments, should assess the ASC’s compliance with the Patient’s Rights
regulatory requirements. It is particularly important for the surveyor who will be
following one or more patients from the start of their case to discharge to be observing
how the ASC’s actions protect and promote those patients’ exercise of their rights.
• Determine whether the ASC provides patients (or their representatives or
surrogates, as applicable), with notice of their rights, consistent with the standards
under this condition.
• Determine whether the ASC promotes the patients’ exercise of their rights (or
their representatives or surrogates, as applicable), consistent with the standards
under this condition.
Review posted notices to determine if they contain the same information as the individual
written notice provided to patients or their representatives/surrogates, as required under
§416.50(a). Deficiencies related to posting of the notice are to be cited using tag -Q0219.
Q-0220
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50…. The ASC must also post the written notice of patient rights in a place or
places within the ASC likely to be noticed by patients waiting for treatment or by
the patient’s representative or surrogate, if applicable.
Interpretive Guidelines: §416.50 (standard-level citation only)
Since the condition concerning posting the written notice does not have a counterpart in a
standard within the patient rights condition, a second tag is provided for this portion of
the condition for citations at the standard level. Deficiencies related solely to posting of
the notice must be cited at the standard level, using tag Q-0220. The condition-level tag,
Q-0219, must be cited whenever the manner and degree of noncompliance on the part of
an ASC represents substantial noncompliance.
Survey Procedures: §416.50(standard-level citation only)
Observe waiting rooms and pre-operative areas where patients await care to see if notice
of patient rights is posted in a manner where all patients awaiting care are likely to see a
notice. Ensure that the notices are posted in conspicuous locations in the waiting rooms,
pre-operative preparation areas, recovery rooms, or other common areas. If only one
notice is posted, verify that it is conspicuously located in an area use by every ASC
patient. Deficiencies related to posting of the notice are to be cited using tag -Q0219.
Q-0221
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.50(a) Standard: Notice of Rights
An ASC must, prior to the start of the surgical procedure, provide the patient, or
the patient’s representative, or the patient’s surrogate with verbal and written
notice of the patient’s rights in a language and manner that ensures the patient, the
representative, or the surrogate understand all of the patient’s rights as set forth in
this section. The ASC’s notice of rights must include the address and telephone
number of the State agency to which patients may report complaints, as well as the
Web site for the Office of the Medicare Beneficiary Ombudsman.
Interpretive Guidelines: §416.50(a)
The ASC must inform each patient, or the patient’s representative or surrogate of the
patient’s rights. This notice must be provided both verbally and in writing prior to the
start of the surgical procedure, i.e., prior to the patient’s movement out of the pre-
operative area, and, if applicable, before the patient is medicated with a drug(s) that
suppresses the patient’s consciousness. It is not acceptable for the ASC to provide the
notice when the patient has already been moved into the operating room (including
procedure room) or has been medicated in such a manner that he or she is not able to
follow or remember the provision of notice.
This regulation does not require that in every instance notice be delivered just prior to the
start of the surgical procedure. Instead, the regulation indicates the latest acceptable time
for delivery of the notice. It would be acceptable for the ASC to mail or e-mail the notice
of patient rights in advance of the date of the scheduled procedure, or at the time the
patient appears in the registration area on the date of the procedure. CMS recommends
that ASCs provide patients notice of their rights as soon as possible after the procedure is
scheduled, but so long as notice is provided prior to the start of the surgical procedure,
the ASC is in compliance with the regulation.
Notice must be provided regardless of the type of procedure scheduled to be performed.
The regulation does not require a specific form or wording for the written notice, so it is
acceptable for the ASC to develop a generic, pre-printed notice for use with all of its
patients, as long as the notice includes all of the patient rights established under the
regulation.
The notice must include the address and telephone number of the appropriate State
agency to which patients may report complaints about the ASC. If available, an e-mail or
web address for submission of complaints to the State agency should also be provided.
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:
http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html
Patients who are Medicare beneficiaries, or their representative or surrogates, should be
informed that the role of the Medicare Beneficiary Ombudsman is to ensure that
Medicare beneficiaries receive the information and help they need to understand their
Medicare options and to apply their Medicare rights and protections. These Medicare
rights are in addition to the rights available to all ASC patients under this CfC.
The notice must:
• Address all of the patient’s rights under this Condition.
• Be provided and explained in a language and manner that the patient or the
patient’s representative or surrogate understands, including patients who do
not speak English or with limited communication skills. The patient has the
choice of using an interpreter of his or her own, or one supplied by the ASC.
A professional interpreter is not considered to be a patient’s representative or
surrogate. Rather, it is the professional interpreter’s role to pass information
from the ASC to the patient. In following translation practices, CMS
recommends, but does not require, that a written translation be provided in
languages that non-English speaking patients can read, particularly for
languages that are most commonly used by non-English-speaking patients of
the ASC. We note that there are many hundreds of languages (not all written)
that are used by one or more residents of the United State, but that in most
geographic areas the most common non-English language generally is
Spanish. We note there are other applicable legal requirements, most notably,
those under title VI of the Civil Rights Act of 1964. The Department of
Health and Human Services’ (HHS) guidance related to Title VI of the Civil
Rights Act of 1964, ‘‘Guidance to Federal Financial Assistance Recipients
Regarding Title VI Prohibition Against National Origin Discrimination
Affecting Limited English Proficient Persons’’ (68 FR 47311, Aug. 8, 2003)
applies to those entities that receive federal financial assistance from HHS,
including ASCs. This guidance may assist ASCs in ensuring that patient rights
information is provided in a language and manner the patient understands. The
regulation at §416.50(a) is compatible with guidance on Title VI.
Survey Procedures: §416.50(a)
• Determine what the ASC’s policy and procedures are for providing all
patients and/or their representatives or surrogates notice of their rights prior to
the start of the surgical procedure. Are the policies and procedures consistent
with the regulatory requirements?
• Determine whether the information provided in the written notice to the
patients and/or their representatives or surrogates by the ASC is complete and
accurate:
o Does the notice address all of the patients’ rights listed in this Condition?
o Does the notice provide the required information about where to file
complaints or how to contact the Medicare Ombudsman?
• Is the staff who are responsible for advising patients of their rights aware of
the ASC’s policies and procedures for providing such notice, including to
those patients with special communication needs?
• Review records, interview staff, and observe staff/patient interaction to
examine how the ASC communicates information about patient rights to
diverse patients, including patients who need assistive devices or translation
services.
• Does the ASC provide all patients with verbal and written notice of their
rights prior to the start of the surgical procedure?
• Does the ASC have a significant number of patients with limited English
proficiency? If so, are there written notice materials available for patients
who have a primary language other than English? If not, does the ASC
have translators available to provide verbal notice of their rights to ASC
patients?
• Ask patients to tell you how, when and what the ASC has told them about
their rights.
Q-0222
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.50(a) Standard: Notice of rights
(1)[…] In addition, the ASC must –
(i) Post written notice of patient rights in a place or places within the ASC likely
to be noticed by patients (or their representatives, if applicable) waiting for
treatment. The ASC’s notice of rights must include the name, address, and
telephone number of a representative in the State agency to whom patients can
report complaints, as well as the Web site for the Office of the Medicare Beneficiary
Ombudsman.
Interpretive Guidelines: §416.50(a)(1)(i)
The ASC must ensure that a written notice of patient rights is posted in one or more
places where they are likely to be noticed. This would include waiting rooms, recovery
rooms, or any other areas where patients and/or their representatives are likely to be.
Notices must be posted in at least one area. Posting in more than one area increases the
likelihood that patients will see the notice, but an ASC may post only one notice and
comply with the requirement, so long as the notice is posted in an area used by every
ASC patient and where it is likely to be noticed.
The notice 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. Because there can be staff turnover in the State survey agency, creating a
burden for both States and ASCs to keep current the names of State staff, it is sufficient if
the notice provides the title of the individual in the State survey agency to whom
complaints may be reported, as well as the address and telephone number.
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:
http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html
Patients who are Medicare beneficiaries, or their representative, should be informed that
the role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries
receive the information and help they need to understand their Medicare options and to
apply their Medicare rights and protections. These Medicare rights are in addition to the
rights available to all ASC patients under this CfC.
Survey Procedures: §416.50(a)(1)(i)
• Observe waiting rooms, recovery rooms, and other common areas used by
patients to see if one or more notices of patient rights are posted. Ensure
that the notices are posted in conspicuous locations in the waiting rooms,
recovery rooms, or other common areas. If only one notice is posted,
verify that it is conspicuously located in an area used by every ASC
patient.
• Observe notices to see that each notice contains all required information.
Q-0223
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(b) Standard: Disclosure of physician financial interest or
ownership
The ASC must disclose, in accordance with Part 420 of this subchapter, and where
applicable, provide a list of physicians who have financial interest or ownership in
the ASC facility. Disclosure of information must be in writing.
Interpretive Guidelines: §416.50(b)
An ASC that has physician owners or investors must provide written notice to the patient,
the patient’s representative or surrogate, prior to the start of the surgical procedure, that
the ASC has physician-owners or physicians with a financial interest in the ASC. CMS
considers the disclosure of physician financial interest or ownership to be part of the
overall “patient rights information” that is now required to be given prior to the start of
the procedure. 42 CFR Part 420 provides definitions and requirements concerning
ownership and control of Medicare-participating providers and suppliers. Surveyors are
not expected to have expert knowledge of what constitutes ownership and control, but
ASCs are required to comply with the provisions of Part 420. ASCs that meet the
physician ownership and control threshold specified in 42 CFR Part 420 must disclose
their physician ownership to patients and provide them with a list of physicians who have
a financial interest or ownership in the ASC. The intent of this disclosure requirement is
to assist the patient in making an informed decision about his or her care by making the
patient, or the patient’s representative or surrogate, aware when physicians who refer
their patients to the ASC for procedures, or physicians who perform procedures in an
ASC also have an ownership or financial interest in the ASC.
The written notice must disclose, in a manner designed to be understood by all patients,
that physicians have an ownership or financial interest in the ASC. Information should
be provided in a manner that is not only technically correct, but also easily understood by
persons not familiar with financial statements, legal documents or technical language.
The ASC should also be aware of the age and the cognitive abilities of its patients in
developing its written notice. (72 FR 50475, August 31, 2007)
Survey Procedures: §416.50(b)
• Ask the ASC whether it is has reported in accordance with 42 CFR Part 420 to the
Medicare program whether the ASC has any physicians with ownership/financial
interests. (Surveyors are not required to make an independent determination
regarding whether an ASC has physicians with ownership or financial interests.) If
the answer is yes, then the ASC is required to comply with the requirement for
disclosure to patients. If the ASC’s response is no, then the ASC has no disclosure
requirement and the surveyor does not have to investigate further.
• If the ASC indicates it has physicians with ownership/financial interests in the ASC:
• Does the ASC have policies and procedures in place to make the required
disclosures to patients? Are the policies and procedures consistent with the
regulatory requirements?
• Does the ASC provide a written notice of disclosure to all patients prior to the
start of the surgical procedure, including a list of physicians with financial
interests or ownership in the ASC?
• Interview ASC staff to assess their knowledge and understanding of the physician
ownership notice requirements, including the ASC’s process for delivering the notice.
• Interview patients to ask them whether they were aware that the ASC has physician
owners/investors. Ask them if they recall getting a written notice about this prior to
the start of their surgical procedure.
Q-0224
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(c) Standard: Advance Directives
The ASC must comply with the following requirements:
(1) Provide the patient or, as appropriate, the patient’s representative with written
information concerning its policies on advance directives, including a description of
applicable State health and safety laws and, if requested, official State advance directive
forms.
(2) Inform the patient or, as appropriate, the patient’s representative of the patient’s
rights to make informed decisions regarding the patient’s care.
(3) Document in a prominent part of the patient’s current medical record, whether or
not the individual has executed an advance directive.
Interpretive Guidelines: §416.50(c)
Information on Advance Directives
An advance directive is a written instruction, such as a living will or durable power of
attorney for healthcare, recognized under State law (whether statutory or as recognized
by the courts of the State), relating to the provision of healthcare when the individual who
has issued the directive is incapacitated. (See 42 CFR 489.100.)
Each ASC patient has the right to formulate an advance directive consistent with
applicable State law and to have ASC staff implement and comply with the advance
directive, subject to the ASC’s limitations on the basis of conscience. To the degree
permitted by State law, and to the maximum extent practicable, the ASC must respect the
patient’s wishes and follow that process.
The facility must provide the patient or the patient’s representative, as appropriate, the
following information in writing, prior to the start of the surgical procedure:
• Information on the ASC’s policies on advance directives;
• A description of the applicable State health and safety laws. (Note that CMS does
not determine whether this description is accurate. State Survey Agencies are
responsible for making this accuracy determination.); and
• If requested, official State advance directive forms, if such exist.
The ASC must include in the information concerning its advance directive policies a
clear and precise statement of limitation if the ASC cannot implement an advance
directive on the basis of conscience or any other specific reason that is permitted under
State law. A blanket statement of refusal by the ASC to comply with any patient advance
directives is not permissible. However, if and to the extent permitted under State law, the
ASC may decline to implement elements of an advance directive on the basis of
conscience or any other reason permitted under State law if it includes in the information
concerning its advance directive policies a clear and precise statement of limitation. A
statement of limitation must:
• Clarify any differences between ASC-wide conscience objections and those that
may be raised by individual ASC staff;
• Identify the state legal authority permitting such objection; and
• Describe the range of medical conditions and procedures affected by the objection
For example, the ASC’s notice of limitation could, if permitted by State law, indicate that
it would always attempt to resuscitate a patient and transfer that patient to a hospital in
the event of deterioration.
The patient may wish to delegate his/her right to make informed decisions to another
person, even though the patient is not incapacitated. To the extent permitted by State
law, the ASC must respect such delegation. In some cases, the patient may be
unconscious or otherwise incapacitated. If the patient is unable to make a decision, the
ASC must consult the patient’s advance directives, medical power of attorney, or patient
representative or surrogate, if any of these are available. In the advance directive or the
medical power of attorney, the patient may provide guidance as to his or her wishes in
certain situations, or may delegate decision-making to another individual as permitted by
State law. If such an individual has been selected by the patient, or if a person willing
and able under applicable State law is available to make treatment decisions, relevant
information should be provided to the representative or surrogate, so that informed
healthcare decisions can be made for the patient. However, as soon as the patient is able
to be informed of his or her rights, the ASC should also provide that information to the
patient.
The right to make informed decisions presumes that the patient, or the patient’s
representative or surrogate, has been provided information about the patient’s health
status, diagnosis and prognosis. It includes providing consent to the surgical procedure(s)
to be performed in the ASC. The patient, or the patient’s representative or surrogate,
must receive adequate information, provided in a manner that the patient or the patient’s
representative or surrogate can understand, to assure that the patient can effectively
exercise the right to make informed decisions about care in the ASC. In many cases, the
informed consent may take place in a physician office outside the ASC and prior to the
patient’s visit to the ASC. Nevertheless, the ASC is responsible for ensuring an informed
process is in place for each patient. (See discussion of fully informing the patient under
§416.50(e)(iii).)
Documentation of Advance Directives
The ASC must document in the patient’s current medical record, i.e., the record for the
current ASC visit, whether or not the patient has executed an advance directive. This
documentation must be placed in a prominent part of the medical record where it will be
readily noticeable by any ASC staff providing clinical services to the patient. The
documentation requirement applies, even if the ASC is unable to comply with the
patient’s advance directive on the basis of conscience or a State law limitation.
If the patient with an advance directive is transferred from the ASC to another healthcare
facility, e.g., if there is an emergency transfer to a hospital, the ASC must ensure that a
copy of the patient’s advance directive is provided with the medical record when the
patient is transferred.
The ASC should provide education to its staff concerning the facility’s policies and
procedures on advance directives.
Survey Procedures: §416.50(c)
• Review the ASC’s policies and procedures related to the advance directive
requirements. Do they conform to the regulatory requirements?
• Ask to see a copy of the written notice of the ASC’s advance directive policies
and applicable State law. Does it contain all required information? If there is a
statement of limitations based on conscience or State law, does it include all
required information?
• If the State has an official advance directive form, ask the ASC to demonstrate
how it provides these forms upon request to patients.
• Ask the ASC how it documents that required advance directive information is
provided to the patient prior to the start of the surgical procedure. Review each
record in the survey sample to determine if there is evidence that the information
was provided to the patient or the patient’s representative prior to the start of the
surgical procedure.
• Review each record in the survey sample to determine if advance directive
information was provided prior to the start of the surgical procedure.
• Does the ASC advise patients, or the patient’s representative or surrogate, of their
right to make informed decisions about their care in the ASC?
• Review each record in the survey sample to determine if information is
prominently displayed as to whether or not there is an advance directive in effect
for the patient. Is the information displayed in a manner such that patients with
advance directives can be readily distinguished from patients without an advance
directive?
• Determine to what extent the ASC educates its staff regarding advance directives
and promoting informed decisions. Does the ASC have a training class or any
educational materials available for the staff regarding advance directives and
informed patient decision-making? Interview staff to determine their knowledge
of the advance directives of the patients in their care.
Q-0225
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(d) Standard: Submission and investigation of grievances
The ASC must establish a grievance procedure for documenting the existence,
submission, investigation, and disposition of a patient’s written or verbal grievance to the
ASC. The following criteria must be met:
***
(4) The grievance process must specify timeframes for review of the grievance and
the provisions of a response.
(5) The ASC, in responding to the grievance, must investigate all grievances made by
a patient, the patient’s representative, or the patient’s surrogate regarding treatment or
care that is (or fails to be) furnished.
(6) The ASC must document how the grievance was addressed, as well as provide the
patient, the patient’s representative, or the patient’s surrogate with written notice of its
decision. The decision must contain the name of an ASC contact person, the steps taken
to investigate the grievance, the result of the grievance process and the date the grievance
process was completed.
Interpretive Guidelines: §§416.50(d)(4), (5), & (6)
What is a Grievance?
A “patient grievance” is a formal or informal written or verbal complaint that is made to
the ASC by a patient or a patient’s representative or surrogate, regarding a patient’s care
(when such complaint is not resolved at the time of the complaint by the staff present),
abuse, neglect, or ASC compliance issues.
• A complaint from someone other than a patient or a patient’s representative or
surrogate is not a grievance.
• A complaint that is presented to the ASC’s staff and resolved at that time is not
considered a grievance; the grievance process requirements do not apply to such
complaints. For example, a complaint that discharge instructions are unclear may
be resolved relatively quickly before the patient is discharged, and would not
usually be considered a “grievance.”
If a patient care complaint cannot be resolved at the time of the complaint by the staff
present, is postponed for later resolution, is referred to other staff for later resolution,
requires an investigation, and/or requires additional actions for resolution, the complaint
is then considered a grievance for purposes of these requirements.
Billing issues are not usually considered grievances for the purposes of this grievance
requirement.
Although complaints may be both written and verbal, a written complaint is always
considered a grievance. This includes written complaints from a current patient, a
released/discharged patient, or a patient’s representative or surrogate regarding the
patient care provided, abuse or neglect, or the ASC’s compliance with the CfCs. For the
purposes of this requirement, an email or fax is considered written.
Information obtained from patient satisfaction surveys conducted by the ASC usually is
not considered a grievance. However, if an identified patient writes or attaches a written
complaint on the survey and requests resolution, the complaint must be treated as a
grievance. If an identified patient writes or attaches a complaint to the survey, but does
not request resolution, the ASC should treat this as a grievance if the ASC would usually
treat such a complaint as a grievance.
Patient complaints that are considered grievances also include situations where a patient
or a patient’s representative or surrogate telephones the ASC with a complaint regarding
the patient’s care or with an allegation of abuse or neglect, or a failure of the ASC to
comply with one or more of the CfCs.
Whenever the patient or the patient’s representative or surrogate requests that his or her
complaint be handled as a formal complaint or grievance, or when the patient requests a
response from the ASC, the complaint is considered a grievance and all the grievance
requirements apply.
Grievance Process
The ASC must have an established procedure in place for documenting the existence,
submission, investigation, and disposition of a grievance.
As part of its obligation to notify patients of their rights, the ASC must inform the patient
and/or the patient’s representative or surrogate of the ASC’s grievance process, including
how to file a grievance.
All grievances submitted to any ASC staff member, whether verbally or in writing, must
be reported by the staff to an ASC official who has authority to address grievances. The
ASC’s grievance policies and procedures must identify the person(s) in the ASC who
have the authority to respond to grievances. The ASC is expected to educate staff on
their obligation to report all grievances, including whom they should report the grievance
to.
All grievances must be investigated, but the regulation stresses this in particular for
grievances related to treatment or care that the ASC provided or allegedly failed to
provide. In its investigation the ASC should not only respond to the substance of the
grievance, but should also use the grievance to determine if there are systemic problems
indicated by the grievance that require resolution. An ASC would be well-advised to
integrate its grievance process into its overall quality assessment and performance
improvement program.
The ASC’s grievance process must include a timeframe for the completion of the ASC’s
review of the grievance allegations, as well as for the ASC to provide a response to the
person filing the grievance. The timeframe must be reasonable, i.e., allowing the ASC
sufficient but not excessive time to conduct its review and issue its response. CMS does
not mandate a particular timeframe. The application of the ASC’s timeframe begins with
the date of the receipt of the grievance by the ASC.
The ASC must document for each grievance how it was addressed. The ASC must also
notify the patient or the patient’s representative or surrogate, in writing, of the ASC’s
decision regarding each grievance.
The ASC may use additional methods to resolve a grievance, such as meeting with the
patient’s family. There are no restrictions on the ASC’s use of additional effective
methods to handle a patient’s grievance. However, in all cases, the ASC must provide a
written notice of its decision on each patient’s grievance. The written notice must
include the name of an ASC contact person, the steps the ASC took to investigate the
grievance, the results of the grievance process, and the date the process was completed.
When a patient communicates a grievance to the ASC via email, the ASC may respond to
the patient via email, pursuant to the ASC’s policy. (Some ASC may have policies
prohibiting communication to patients via email.) If the patient requests a response via
email, the ASC may respond via email. If the email response contains the name of an
ASC contact person, the steps taken to investigate the grievance, the results of the
grievance process, and the date the process was completed, the email meets the
requirements for a written response.
In its written response to any grievance, the ASC is not required to include statements
that could be used in a legal action against the ASC, but the ASC should provide
adequate information to address the specific grievance. A form letter with generic
statements about grievance process steps and results is not acceptable.
Survey Procedures: §§416.50(d)(4)(5), & (6):
• Determine whether the ASC has a written policy addressing the grievance
process. Does the process specifically address how grievances are documented,
how they are to be submitted, how they are to be investigated, and how the
findings are to be used to dispose of the grievance? Does the policy comply with
the regulatory requirements concerning reporting of grievances,, timeframe, and
notice of disposition?
• Ask the ASC how many grievances it received during the past year. Ask how it
documents the existence of grievances. Ask what the disposition was of
grievances processed during that period. Ask to see a sample of grievance files.
If this is a complaint survey concerning a grievance, ask to see grievances
submitted at the time of the grievance that triggered the complaint survey.
• Review a sample of grievance files to determine if grievances are properly
documented and handled in accordance with the ASC’s policy and the regulatory
requirements.
• Interview staff to see if staff is aware of the ASC’s grievance policies. Do staff
know the difference between a complaint handled on the spot and a grievance?
• Interview patients and/or representatives or surrogates to determine if they know
how to file a grievance and who to contact if they have a complaint/grievance.
• Interview staff and patients to see how staff and patients are educated regarding to
whom grievances and allegations should be reported.
Q-0226
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(d) Standard: Submission and investigation of grievances
…. The following criteria must be met:
(1) All alleged violations/grievances relating, but not limited to, mistreatment,
neglect, verbal, mental, sexual, or physical abuse, must be fully documented.
(2) All allegations must be immediately reported to a person in authority in the ASC.
(3) Only substantiated allegations must be reported to the State authority or the local
authority, or both.
Interpretive Guidelines: §§416.50(d)(1), (2), & (3)
Grievances making allegations related to mistreatment; neglect; verbal, mental, sexual or
physical abuse; or other serious allegations of harm must be fully documented. This
means that all pertinent details of the allegation must be recorded and retained in the
ASC’s files. Documentation of the allegation should include, at a minimum, the date and
time of the alleged occurrence, the location, the names of all individuals involved, and a
description of the behavior that is alleged to have occurred within the ASC and to have
constituted mistreatment, neglect or abuse or other serious harm.
The ASC regulation does define the terms “mistreatment,” “neglect,” or “abuse.”
However, the following definitions from long term care regulations may be helpful in
making common sense judgments about whether an allegation fits into one of these
categories:
• Neglect - Failure to provide goods and services necessary to avoid physical harm,
mental anguish, or mental illness (42 CFR 488.301).
• Abuse - The willful infliction of injury, unreasonable confinement, intimidation,
or punishment with resulting physical harm, pain or mental anguish (42 CFR
488.301).
In addition, according to the Merriam Webster dictionary, “mistreatment” means to treat
badly. It is also a synonym for abuse.
Finally, if there is applicable State law defining mistreatment, neglect or abuse in a
healthcare facility, including ASCs, those definitions will apply.
All grievances alleging mistreatment, neglect or abuse that are submitted to any ASC
staff member, whether verbally or in writing, must be reported immediately, i.e., as soon
as possible, and at least on the same day, by the staff member to an ASC official who has
authority to address grievances. The ASC’s grievance policies and procedures must
identify the person(s) in the ASC who have the authority to respond to grievances. The
ASC is expected to educate staff on their obligation to immediately report all grievances
alleging mistreatment, neglect or abuse, including whom they should report the grievance
to.
Grievances alleging mistreatment, neglect, abuse or other behavior that endangers a
patient should be investigated as soon as possible, given the seriousness of the allegations
and the potential for harm to patients. The ASC must conduct a careful investigation,
balancing the need for speedy resolution with the need to ascertain all pertinent facts.
If the ASC confirms that the alleged mistreatment, abuse, neglect or other serious harm
took place, then the ASC is obligated to report the event to the appropriate local or State
authority, or even both. Depending on the specifics of the case and State or local law, the
appropriate authority(ies) might include the local police, a State healthcare professional
licensing board, a State agency that licenses the ASC, a State ombudsman, etc. The ASC
should contact the appropriate authority promptly after it concludes its investigation of
the grievance.
Survey Procedures: §§416.50(d)(1)(2), & (3)
• Do the ASC’s grievance policies and procedures separately address the process
for investigating grievances alleging mistreatment, abuse, neglect or other serious
harm? Do the policies and procedures conform to the regulatory requirement?
• Interview staff to determine how they would handle a grievance alleging
mistreatment, abuse, neglect or other serious harm? Do they know who to report
the grievance to? Do they know that it should be reported immediately?
• Ask the ASC who is the person authorized to handle such grievances. Interview
that person to determine if he/she understands the requirements to fully document
the allegation, conduct a prompt investigation, and to report substantiated
grievances to the proper authority.
• Ask the person authorized to handle such grievances if the ASC has had any
grievances alleging mistreatment, neglect, abuse or other serious harm? If the
answer is yes, ask to review the files for one or more such grievances. If such
grievances were substantiated, verify whether there is documentation that the
findings were reported to the appropriate authority.
Q-0227
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(e) Standard: Exercise of rights and respect for property and
person.
(1) The patient has the right to the following:
(i) Be free from any act of discrimination or reprisal.
Interpretive Guidelines: §416.50(e)(1)(i)
The ASC may not take punitive action as a reprisal or discriminate against a patient. This
includes reprisals or discrimination against a patient merely because he or she has
exercised her rights. The ASC’s patients’ rights policies and procedures must indicate
that the ASC does not engage in reprisals or discriminatory behavior.
Survey Procedures: §416.50(e)(1)(i)
• Interview staff to determine whether they are aware that the ASC may not
discriminate against patients, or take punitive actions against any patient as a
reprisal for some act on the patient’s part.
• Review the ASC’s policies and procedures to determine whether it is clear that
patients, or their representatives, or surrogates may exercise their rights without
fear of reprisal.
• Interview staff about how a patient who has filed a grievance or otherwise
exercises his/her rights is treated. Is staff aware that they should not treat patients
differently if the patient files a grievance?
Q-0228
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(e) Standard: Exercise of rights and respect for property and
person.
[(1) The patient has the right to the following: ]
(ii) Voice grievances regarding treatment or care that is (or fails to be) provided.
Interpretive Guidelines: §416.50(e) (1)(ii)
This requirement complements the requirement for the ASC to have a grievance system.
Patients have the right to express a grievance regarding the treatment or care they receive
in the ASC.
The patient, or the patient’s representative or surrogate, as appropriate, may file a
grievance, verbally or in writing, before the date of the scheduled procedure, on the date
of the procedure, or after the date of the procedure. The regulation does not prescribe any
limitation as to when a patient may submit a grievance. However, it is understood that, if
a substantial amount of time has passed since the care episode addressed in the grievance,
e.g., several years, that it may, depending on the nature of the grievance, be harder for the
ASC to investigate the grievance and ascertain the pertinent facts.
Survey Procedures: §416.50(e) (1)(ii)
• Interview ASC staff to determine if they are aware of the patient’s right to file a
grievance.
• If the survey is related to a complaint alleging that an ASC ignored a patient’s
grievance, include that medical record in the sample and review it to determine if
there is any evidence of a grievance as well as of action to respond to the
grievance.
Q-0229
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.50(e) Standard: Exercise of rights and respect for property and
person.
[(1) The patient has the right to the following:]
(iii) Be fully informed about a treatment or procedure and the expected outcome before it
is performed.
Interpretive Guidelines: §416.50(e)(1)(iii)
As in the case of advance directives, the patient has the right to make an informed
decision regarding his/her care in the ASC. The right to make informed decisions means
that the patient or patient’s representative or surrogate is given the information needed in
order to make "informed" decisions regarding his/her care. The right to make informed
decisions regarding care presumes that the patient has been provided information about
his/her health status, diagnosis, and prognosis. Furthermore, it includes the patient's
participation in the development of their plan of care, including providing consent to, or
refusal of, medical or surgical interventions, and in planning for care after discharge from
the ASC. The patient or the patient's representative or surrogate should receive adequate
information, provided in a manner that the patient or the patient's representative or
surrogate can understand, to assure that the patient can effectively exercise the right to
make informed decisions.
ASCs must utilize an informed consent process that assures patients or their
representatives or surrogates are given the information and disclosures needed to make an
informed decision about whether to consent to a surgical procedure in the ASC. The
primary purpose of the informed consent process in the ASC is to ensure that the patient,
or the patient’s representative or surrogate, is provided information necessary to enable
him/her to evaluate a proposed surgery before agreeing to the surgery. Typically, this
information would include potential short- and longer-term risks and benefits to the
patient of the proposed intervention, including the likelihood of each, based on the
available clinical evidence, as informed by the responsible physician’s professional
judgment. Informed consent must be obtained and the informed consent form must be
signed by the patient, or as appropriate, the patient’s representative, and placed in the
patient’s medical record, prior to surgery. It would be acceptable if the ASC required the
physician(s) who perform procedures in the ASC to obtain the patient’s informed consent
outside of the ASC, prior to the date of the surgery, since this might allow more time for
discussion between the patient and physician than would be feasible on the date of the
surgery. In such cases, the physician must follow the ASC’s informed consent process.
In all cases, the ASC must ensure that the patient’s informed consent is secured prior to
the start of the surgical procedure, and that this consent is documented in the patient’s
medical record. (See the interpretive guidelines for §416.47(b)(7) concerning
documentation in the medical record of informed consent.)
Given that ASC surgical procedures generally entail use of some form of anesthesia, and
that there are risks as well as benefits associated with the use of anesthesia, ASCs should
assure that their informed consent process provides the patient with information on
anesthesia risks and benefits as well as the risks and benefits of the surgical procedure.
The ASC’s surgical informed consent policy should describe the following:
• Who may obtain the patient’s informed consent;
• The circumstances when a patient’s representative, rather than the patient,
may give informed consent for a surgery (see guidance for §416.50(e)(2)
& (3);
• The content of the informed consent form and instructions for completing
it;
• The process used to obtain informed consent, including how informed
consent is to be documented in the medical record;
• Mechanisms that ensure that the informed consent form is properly
executed and is in the patient’s medical record prior to the surgery; and
• If the informed consent process and informed consent form are obtained
outside the ASC, how the properly executed informed consent form is
incorporated into the patient’s medical record prior to the surgery.
If there are additional requirements under State law for informed consent, the ASC must
comply with those requirements.
Example of a Well-Designed Informed Consent Process
A well-designed informed consent process would include discussion of the following
elements:
• A description of the proposed surgery, including the anesthesia to be used;
• The indications for the proposed surgery;
• Material risks and benefits for the patient related to the surgery and
anesthesia, including the likelihood of each, based on the available clinical
evidence, as informed by the responsible practitioner’s clinical judgment.
Material risks could include risks with a high degree of likelihood but a
low degree of severity, as well as those with a very low degree of
likelihood but high degree of severity;
• Treatment alternatives, including the attendant material risks and benefits;
• The probable consequences of declining recommended or alternative
therapies;
• Who will conduct the surgical intervention and administer the anesthesia;
• Whether physicians other than the operating practitioner will be
performing important tasks related to the surgery, in accordance with the
ASC’s policies. Important surgical tasks include: opening and closing,
dissecting tissue, removing tissue, harvesting grafts, transplanting tissue,
administering anesthesia, implanting devices and placing invasive lines;
• Whether, as permitted by State law, qualified medical practitioners who
are not physicians will perform important parts of the surgery or
administer the anesthesia, and if so, the types of tasks each type of
practitioner will carry out; and that such practitioners will be performing
only tasks within their scope of practice for which they have been granted
privileges by the ASC.
Survey Procedures: §416.50(e)(1)(iii)
• Determine whether the ASC has an informed consent policy that meets the
regulatory requirements.
• Verify in the survey sample of medical records that there is documentation
that informed consent was given prior to the surgical procedure. Was the
consent signed by the patient or as appropriate, the patient’s
representative?
• As part of the process of following one or more cases from start to finish,
determine whether there is an informed consent that was executed prior to
the surgery date on file, and if not, observe whether the ASC obtains
informed consent.
• Check the records of patients who are in recovery on the date(s) of the
survey to verify that there is documentation of informed consent.
• Interview patients to determine whether they recall being asked to consent
to the procedure, and whether the risks and benefits were discussed with
them at that time.
Q-0230
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(e) Standard: Exercise of rights and respect for property and person.
(2) If a patient is adjudged incompetent under applicable State laws by a court of proper
jurisdiction, the rights of the patient are exercised by the person appointed under
State law to act on the patient’s behalf.
(3) If a State court has not adjudged a patient incompetent, any legal representative or
surrogate designated by the patient in accordance with State law may exercise the
patient’s rights to the extent allowed by State law.
Interpretive Guidelines: §§416.50(e)(2 )& (3)
A patient who has been determined to be incompetent under a State legal process is not
capable of exercising his or her rights independently. For such patients, the person
appointed under State law to act on the patient’s behalf may exercise any and all of the
rights afforded to any ASC patient.
In addition, a competent patient may wish to delegate his/her right to make informed
decisions to another person. To the degree permitted by State law, and to the maximum
extent practicable, the ASC must respect the patient’s wishes and follow that process. In
some cases, the patient may be unconscious or otherwise incapacitated, for example, if a
complication requiring a treatment decision arises during a procedure. If the patient is
unable to make a decision, the ASC must consult the patient’s advance directives,
medical power of attorney or patient representative or surrogate, if any of these are
available. In the advance directive or the medical power of attorney, the patient may
provide guidance as to his/her wishes in certain situations, or may delegate decision-
making to another individual as permitted by State law. If such an individual has been
selected by the patient, or if a person willing and able under applicable State law is
available to make treatment decisions, relevant information should be provided to the
representative or surrogate so that informed healthcare decisions can be made for the
patient.
Survey Procedures: §§416.50(e)(2) &(3)
• Verify that there is a policy addressing the exercise of rights on behalf of a patient
judged legally incompetent.
• Verify that there is a policy addressing the delegation by a patient of the exercise
of rights to a representative.
Q-0231
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(f) Standard: Privacy and Safety.
The patient has the right to –
(1) Personal privacy.
Interpretive Guidelines: §416.50(f)(1)
The underlying principle of this requirement is the patient’s basic right to respect,
dignity, and comfort. “The right to personal privacy” includes at a minimum, that
patients have privacy during personal hygiene activities (e.g., toileting, dressing), during
medical/surgical treatments, and when requested as appropriate.
People not involved in the care of the patient should not be present without the patient’s
consent while the patient is being examined or treated. Video or other electronic
monitoring or recording methods should not be used when the patient is being examined
without the patient’s consent. If a patient requires assistance during toileting and other
personal hygiene activities, staff should assist, giving the utmost attention to the patient’s
need for privacy. Privacy should also be afforded when staff visits the patient to discuss
clinical care issues or conduct any examination.
A patient’s right to privacy may be limited in situations where a person must be
continuously observed, such as when there is an emergency and transfer to a hospital is
pending.
In most situations, security cameras in non-patient care areas such as stairwells, public
waiting areas, outdoor areas, entrances, etc. are not generally affected by this
requirement.
Survey Procedures: §416.50(f)(1)
• Observe whether patients are provided privacy during examinations, activities
concerning personal hygiene, and discussions regarding the patient’s health status
or healthcare, and any other appropriate situations.
Q-0232
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(f) Standard: Privacy and Safety.
The patient has the right to –
(2) Receive care in a safe setting.
Interpretive Guidelines: §416.50(f)(2)
Each patient should receive care in an environment that a reasonable person would
consider to be safe. The ASC staff should follow current standards of practice for patient
environmental safety, infection control, and security. The ASC staff should also provide
protection for the patient’s emotional health and safety as well as the patient’s physical
safety. Respect, dignity, and comfort would be components of an emotionally safe
environment.
Survey Procedures: §416.50(f)(2)
• Review and analyze patient and staff incident and accident reports to identify any
incidents or patterns of incidents concerning a safe environment. Expand your
review if you suspect a problem with safe environment in the ASC.
• Review safety, infection control and security documentation to determine if the
ASC is identifying problems, evaluating those problems, and taking steps to
ensure a safe patient environment.
• Observe the environment where care and treatment are provided.
• Review policy and procedures to see what steps the facility takes to curtail
unwanted visitors and/or contaminated materials.
• Interview staff and patients to see if either have any concerns about the safety of
the setting.
Q-0233
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(f) Standard: Privacy and Safety.
The patient has the right to –
(3) Be free from all forms of abuse or harassment.
Interpretive Guidelines: §416.50(f)(3)
An ASC must prohibit all forms of abuse, neglect (as a form of abuse), and harassment
from staff, other patients, or visitors. The ASC must have mechanisms/methods in place
ensure that patients are free from all forms of abuse, neglect, or harassment.
As discussed in the guidance for §416.50(d), abuse is the willful infliction of injury,
unreasonable confinement, intimidation, or punishment with resulting physical harm,
pain or mental anguish or mental illness and neglect is the failure to provide goods and
services necessary to avoid physical harm, mental anguish, or mental illness. The
Merriam Webster Dictionary defines “harassment” as creating an unpleasant or hostile
situation, especially by uninvited and unwelcome verbal or physical conduct.
The following components are suggested as necessary for effective protection from
abuse, neglect or harassment:
Prevent - Persons with a record of abuse or neglect should not be hired or retained as
employees. It is recommended that the ASC have a process in place to screen all
applicants for employment or privileges to practice in the ASC.
Identify - The ASC should create and maintain a proactive approach to identify events
and occurrences that may constitute or contribute to abuse and neglect.
Train - The ASC, during its orientation program, and through an on-going training
program, should provide all employees with information regarding patient abuse and
neglect, including who in the ASC is authorized to receive and handle allegations of
abuse and neglect.
Investigate - The ASC ensures, in a timely and thorough manner, an objective
investigation of all allegations of abuse, neglect, or mistreatment. This includes
investigation not only of grievances from patients or their representatives, for which the
grievance process prescribed in §416.50(d) must be used, but also allegations from any
other source.
Respond - The ASC should assure that any and all incidents of abuse, neglect, or
harassment are reported and analyzed, and the appropriate corrective, remedial or
disciplinary action occurs, in accordance with the applicable local, State, or Federal law.
Survey Procedures: §416.50(f)(3)
Examine the extent to which the ASC has a system in place to protect patients from
abuse, neglect, and harassment of all forms, whether from staff, other patients, visitors, or
other persons. In particular, determine the extent to which the ASC addresses the
following issues:
• Does the ASC have policies and procedures for investigating allegations of abuse
and neglect in addition to the required grievance process that applies to
allegations from patients or their representatives?
• Does the ASC use the same process as for grievances alleging abuse and neglect?
If not, what is the ASC’s policy and process, including the process for training
staff?
• Interview staff to determine if staff members know what to do if they witness
abuse and neglect.
• Ask the ASC if it has had any allegations of patient abuse or neglect from any
source during the past year? If it has, ask the ASC to provide the files and to
describe how the matter was handled.
• Review the records to see if the appropriate agencies were notified in accordance
with State and Federal laws regarding incidents of substantiated abuse and
neglect?
Q-0234
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.50(g) Standard: Confidentiality of Clinical Records
The ASC must comply with the Department’s rules for the privacy and security of
individually identifiable health information, as specified at 45 CFR Parts 160 and
164.
Interpretive Guidelines: §416.50(g)
Section 45 CFR Parts 160 and 164, generally known as the Health Insurance Portability
and Accountability Act (HIPAA) Privacy and Security rules, establish standards for
health care providers and suppliers that conduct covered electronic transactions, such as
ASCs, among others, for the privacy of protected health information (phi), as well as for
the security of electronic phi (ephi).
45 CFR 160.103 defines “Protected health information” as “individually
identifiable health information” with specified exceptions and limitations.
45 CFR 160.103 defines “Individually identifiable health information” as
“information that is a subset of health information, including demographic
information collected from an individual, and:
(1) Is created or received by a healthcare provider, health plan, employer,
or healthcare clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or
condition of an individual; the provision of healthcare to an
individual; or the past, present, or future payment for the provision of
healthcare to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the
information can be used to identify the individual.”
Privacy Rule
Individually identifiable health information that is held by HIPAA Covered Entities is
protected under the Privacy Rule. Such information held by the "business associates" of
Covered Entities is protected through contractual requirements in their contracts with the
Covered Entities.
The Privacy Rule requires ASCs that are HIPAA Covered Entities to engage in activities
such as:
• Notifying patients about their privacy rights and how their information can be
used;
• Adopting and implementing privacy procedures for the ASC;
• Training employees so that they understand the privacy procedures;
• Designating an individual to be responsible for seeing that the privacy procedures
are adopted and followed within the ASC; and
• Securing patient records containing individually identifiable health information so
that they are not readily available to those who do not need them.
To ease the burden of complying with these requirements, the Privacy Rule gives needed
flexibility for ASCs to create their own privacy procedures, tailored to fit their size and
needs. This scalability provides a more efficient and appropriate means of safeguarding
protected health information than would any single standard. For example:
• The privacy official at a small ASC may be the office manager, who will have
other non-privacy related duties; the privacy official at a very large, high volume
ASC may be a full-time position.
• The training requirement may be satisfied by a small ASC’s providing each new
member of the workforce with a copy of its privacy policies and documenting that
new members have reviewed the policies; whereas a very large ASC may provide
training through live instruction, video presentations, or interactive software
programs.
• The policies and procedures of small ASCs may be more limited under the Rule
than those of a very large ASC, based on the volume of health information
maintained and the number of interactions with those within and outside of the
healthcare system.
The Department of Health and Human Services Office of Civil Rights, which is charged
with responsibility for enforcing the Privacy Rule, provides more detailed information at
the following website: http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html
A summary of the Privacy Rule’s requirements may be found at:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
Security Rule
The Department of Health and Human Services (HHS), Office of Civil Rights, also
established standards, as required under HIPAA, for the security of health information.
The Security Rule specifies a series of administrative, technical, and physical security
standards with which covered entities must comply to ensure the confidentiality,
integrity, and availability of all ephi that the covered entity creates, receives, maintains,
or transmits. The standards include required and addressable implementation
specifications. Unlike the Privacy Rule, which applies to protected health information in
both electronic and non-electronic forms, the Security Rule only applies to phi in
electronic form. More information on the Security Rule may be found at the following
Web site:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/securityruleguidance.ht
ml
Expectations for Surveyors
Surveyors are not expected to have detailed knowledge of the requirements of the Privacy
and Security Rules, but instead are to focus on the steps the ASC takes to protect the
confidentiality of clinical records, as well as to assure a patient’s access to his/her own
clinical record. If broader violations of the Privacy Rule are suspected, the case may be
referred to the Regional Office, which may in turn forward the information to the Office
of Civil Rights.
The ASC must have sufficient safeguards to ensure that access to all clinical records is
limited to those individuals designated by law, regulation, and policy, or duly authorized
by the patient to have access. No unauthorized access or dissemination of clinical
records is permitted. Clinical records must be kept secure and only viewed when
necessary by those persons participating in some aspect in the patient’s care.
The right to the confidentiality of clinical records means safeguarding the content of
information, including patient paper records, video, audio, and/or computer-stored
information from unauthorized disclosure without the specific informed consent of the
patient or patient’s representative.
Confidentiality applies to both central storage of the closed clinical records and to open
clinical records in use throughout the ASC.
Survey Procedures: §416.50(g)
• What policies and procedures does the ASC have in place to prevent the release or
disclosure of individually identifiable patient information?
• Observe whether patient information is visible in areas where it can be viewed by
visitors or other patients? How likely is it that an unauthorized individual could
read and/or remove a patient’s medical record?
• What security measures are in place to protect the patient’s medical records?
Q-0240
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.51 Condition for Coverage – Infection control
The ASC must maintain an infection control program that seeks to minimize
infections and communicable diseases.
Interpretive Guidelines: §416.51
This regulation requires the ASC to maintain an active program for the minimization of
infections and communicable diseases. The National Institute of Allergy and Infectious
Diseases (NIAID) defines an infectious disease as a change from a state of health to a
state in which part or all of a host’s body cannot function normally because of the
presence of an infectious agent or its product. An infectious agent is defined by the
NIAID as a living or quasi-living organism or particle that causes an infectious disease,
and includes bacteria, viruses, fungi, protozoa, helminthes, and prions. NIAID defines a
communicable disease as a disease associated with an agent that can be transmitted from
one host to another. (See NIAID website glossary)
The ASC’s infection control program must:
• Provide a functional and sanitary environment for surgical services, to avoid
sources and transmission of infections and communicable diseases;
• Be based on nationally recognized infection control guidelines;
• Be directed by a designated health care professional with training in infection
control;
• Be integrated into the ASC’s QAPI program;
• Be ongoing;
• Include actions to prevent, identify and manage infections and communicable
diseases; and
• Include a mechanism to immediately implement corrective actions and preventive
measures that improve the control of infection within the ASC.
The ambulatory care setting, such as an ASC, presents unique challenges for infection
control, because: patients remain in common areas, often for prolonged periods of time;
surgical prep, recovery rooms and ORs are turned around quickly; patients with
infections/communicable diseases may not be identified; and there is a risk of infection at
the surgical site. Furthermore, due to the short period of time patients are in an ASC, the
follow-up process to identify infections associated with the ASC requires gathering
information after the patient’s discharge rather than directly. It is essential that ASCs
have a comprehensive and effective infection control program, because the consequences
of poor infection control can be very serious. In recent years, for example, poor infection
control practices related to injections of medications, saline or other infusates in some
ASCs have resulted in the transmission of communicable diseases, such as hepatitis C,
from one patient infected with the disease prior to his/her ASC visit to other ASC
patients, and a requirement to notify thousands of other ASC patients of their potential
exposure.
Survey Procedures: §416.51
One surveyor is responsible for completion of the Infection Control Surveyor Worksheet,
Exhibit 351, which is used to facilitate assessment of compliance with this Condition.
However, each member of the survey team, as he or she conducts his/her survey
assignments, should assess the ASC’s compliance with the Infection Control regulatory
requirements.
Q-0241
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.51(a) Standard: Sanitary Environment
The ASC must provide a functional and sanitary environment for the provision of
surgical services by adhering to professionally acceptable standards of practice.
Interpretive Guidelines: §416.51(a)
The ASC must provide and maintain a functional and sanitary environment for surgical
services, to avoid sources and transmission of infections and communicable diseases. All
areas of the ASC must be clean and sanitary. This includes the waiting area(s), the pre-
surgical prep area(s), the recovery room(s), and the operating or procedure rooms. The
ASC must appropriately monitor housekeeping, maintenance (including repair,
renovation, and construction activities), and other activities to ensure a functional and
sanitary environment. Policies and procedures for a sanitary and functional environment
should address the following:
• Ventilation and water quality control issues, including measures taken to maintain
a safe environment during internal or external construction/renovation;
• Maintaining safe air handling systems in areas of special ventilation, such as
operating rooms;
• Techniques for food sanitation if employee food storage and eating areas are
provided;
• Techniques for cleaning and disinfecting environmental surfaces, carpeting, and
furniture;
• Techniques for disposal of regulated and non-regulated waste; and
• Techniques for pest control.
These activities must be conducted in accordance with professionally recognized
standards of infection control practice. Examples of national organizations that
promulgate nationally recognized infection and communicable disease control guidelines,
and/or recommendations include: the Centers for Disease Control and Prevention (CDC),
the Association for Professionals in Infection Control and Epidemiology (APIC), the
Society for Healthcare Epidemiology of America (SHEA), and the Association of
periOperative Registered Nurses (AORN).
Survey Procedures: §416.51(a)
Using the specific questions on the infection control survey worksheet related to
environmental infection control to guide you:
• Observe throughout the ASC the cleanliness of the waiting area(s), the recovery
room(s), the OR/procedure rooms, floors, horizontal surfaces, patient equipment,
air inlets, mechanical rooms, supply, storage areas, etc.
• Interview staff to determine whether cleaning/disinfection takes place at the
appropriate frequencies, using suitable EPA-registered agents. Ask for supporting
documentation to confirm what staff say in interviews.
• Determine whether the ASC has a procedure for decontamination after gross
spills of blood or other bodily fluids.
• Determine whether used sharps are disposed of properly.
• Determine whether the ASC re-uses devices marketed for single use, and if so,
does it send them to an FDA-approved vendor for reprocessing?
Q-0242
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.51(b) Standard: Infection control program.
The ASC must maintain an ongoing program designed to prevent, control, and
investigate infections and communicable diseases. In addition, the infection control
and prevention program must include documentation that the ASC has considered,
selected, and implemented nationally recognized infection control guidelines. [ …]
Interpretive Guidelines: §416.51(b)
The ASC must maintain an ongoing program to prevent, control, and investigate
infections and communicable diseases. As part of this ongoing program, the ASC must
have an active surveillance component that covers both ASC patients and personnel
working in the facility. Surveillance includes infection detection through ongoing data
collection and analysis.
The ongoing program must be based on nationally recognized infection control
guidelines that the ASC has selected, after a deliberative process. Examples of national
organizations that promulgate nationally recognized infection and communicable disease
control guidelines, and/or recommendations include: the Centers for Disease Control and
Prevention (CDC), the Association for Professionals in Infection Control and
Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), and
the Association of periOperative Registered Nurses (AORN).
The ASC should select one or more sets of guidelines that enable it to address the
following key functions of an effective infection control program:
• Maintenance of a sanitary ASC environment (see requirements of §416.51(a));
• Development and implementation of infection control activities related to ASC
personnel, which, for infection control purposes, includes all ASC medical staff,
employees, and on-site contract workers (e.g., nursing staff employed by
associated physician practice who also work in the ASC, housekeeping staff, etc);
• Mitigation of risks associated healthcare-associated infections:
• Identifying infections;
• Monitoring compliance with all policies, procedures, protocols and other infection
control program requirements;
• Program evaluation and revision of the program, when indicated;
The following provides a more detailed overview of the types of activities related to these
key functions.
ASC staff-related activities:
• Evaluating ASC staff immunization status for designated infectious diseases, for
example, as recommended by the CDC and its Advisory Committee on
Immunization Practices (ACIP);
• Policies articulating the authority and circumstances under which the ASC screens
its staff for infections likely to cause significant infectious disease or other risk to
the exposed individual, and for reportable diseases, as required under local, state,
or federal public health authority;
• Policies articulating when infected ASC staff are restricted from providing direct
patient care or required to remain away from the facility entirely;
• New employee and regular update training in preventing and controlling
healthcare-associated infections and methods to prevent exposure to and
transmission of infections and communicable diseases; and
• Methods to evaluate staff exposed to patients with infections and communicable
diseases.
Mitigation of risks contributing to healthcare-associated infections (HAI):
For the purposes of its surveillance activities in an acute care setting, the CDC defines an
HAI as a localized or systemic condition resulting from an adverse reaction to the
presence of an infectious agent(s) or its toxin(s). There must be no evidence that the
infection was present or incubating at the time of admission to the ASC.
HAIs may be caused by infectious agents from endogenous or exogenous sources.
Endogenous sources are body sites, such as the skin, nose, mouth, gastrointestinal (GI)
tract, or vagina that are normally inhabited by microorganisms. Exogenous sources are
those external to the patient, such as patient care personnel, visitors, patient care
equipment, medical devices, or the health care environment.
HAI risk mitigation measures include:
Surgery-related infection risk mitigation measures:
• Implementing appropriate prophylaxis to prevent surgical site infection (SSI),
such as protocol to assure that antibiotic prophylaxis to prevent SSI for
appropriate procedures is administered at the appropriate time, done with an
appropriate antibiotic, and discontinued appropriately after surgery; and
• Addressing aseptic technique practices used in surgery, including sterilization or
high-level disinfection of instruments, as appropriate.
• Other ASC healthcare-associated infection risk mitigation measures:
• Promotion of hand hygiene among staff and employees, including utilization of
alcohol-based hand sanitizers;
• Measures specific to the prevention of infections caused by organisms that are
antibiotic-resistant;
• Measures specific to safe practices for injecting medications and saline or other
infusates;
• Requiring disinfectants and germicides to be used in accordance with the
manufacturers’ instructions;
• Appropriate use of facility and medical equipment, including air filtration
equipment, UV lights, and other equipment used to control the spread of
infectious agents;
• Educating patients, visitors, and staff, as appropriate, about infections and
communicable diseases and methods to reduce transmission in the ASC and in the
community.
Identifying Infections
The ASC must conduct monitoring activities throughout the entire facility in order to
identify infection risks or communicable disease problems. The ASC should document
its monitoring/tracking activities, including the measures selected for monitoring, and
collection and analysis methods. Activities should be conducted in accordance with
recognized infection control surveillance practices, such as, for example, those utilized by
the CDC’s National Healthcare Safety Net (NHSN). Monitoring includes follow-up of
patients after discharge, in order to gather evidence of whether they have developed an
infection associated with their stay in the ASC. See discussion of §416.44(a)(3).
The ASC must develop and implement appropriate infection control interventions to
address issues identified through its detection activities, and then monitor the
effectiveness of interventions through further data collection and analysis.
Monitoring Compliance
It is not sufficient for the ASC to have detailed policies and procedures governing
infection control; it must also take steps to determine whether the staff of the ASC adhere
to these policies and procedures in practice. Are staff washing their hands prior to
providing care to patients? Do personnel who prepare injections comply with all pertinent
protocols? Is equipment properly sterilized or disinfected? Is the facility clean? The
ASC must demonstrate that it has a process in place for regularly assessing infection
control compliance.
Program Evaluation
See the guidance for §416.51(b)(2), which requires that the infection control program
must be an integral part of the ASC's quality assessment and performance improvement
program.
An ASC presents different challenges for infection control as patients at varying levels of
wellness are gathered in waiting or recovery areas, including the elderly, immuno-
compromised patients, pre- and post-operative patients, and individuals with active or
incubating infectious and communicable diseases. The length of stay for such individuals
can range from brief to all day. Additionally, as ASCs are performing more invasive
procedures, the level of risk for developing and transmitting infections and
communicable diseases for patients and heath care workers increases. The ASC should
design its infection control program with these challenges in mind. For instance, the
ASC should take appropriate control measures for those individuals who may present risk
for the transmission of infectious agents by the airborne or droplet route. When such
individuals are identified, the ASC could, for example, implement such prevention
measures that would include prompt physical separation, implementation of respiratory
hygiene/cough etiquette protocols, and appropriate isolation precautions based on the
routes of transmission of the suspected infection.
Survey Procedures: §416.51(b)
• Use the infection control tool to assist in assessing compliance with this standard.
• Determine that there is an ongoing program for the prevention, control, and
investigation of infections and communicable diseases among patients and ASC
personnel, including contract workers and volunteers.
• Determine whether the policies and procedures of the program of the infection
control program are implemented correctly. Specifically, surveyors should
determine whether the ASC:
• Mitigates risks contributing to healthcare-associated infections (for example,
observe whether staff exhibit good hand hygiene);
• Performs monitoring/tracking activities to identify infections; and
• Monitors compliance with all infection control program requirements.
• Review the parameters of the program to determine whether it is consistent with
nationally recognized infection control guidelines. Is there documentation that
the ASC has developed the procedures and policies of the program based on
nationally recognized infection control guidelines?
Q-0243
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.51(b) Standard: Infection control program.
[…] The program is –
(1) Under the direction of a designated and qualified professional who has training
in infection control;
Interpretive Guidelines: §416.51(b) (1)
The ASC must designate in writing, a qualified licensed health care professional who will
lead the facility’s infection control program. The ASC must determine that the individual
has had training in the principles and methods of infection control. Note that
certification in infection control, such as that offered by the Certification Board of
Infection Control and Epidemiology Inc. (CIBC), while highly desirable, is not required,
so long as there is documentation that the individual has training that qualifies the
individual to lead an infection control program. The individual selected to lead the
ASC’s infection control program must maintain his/her qualifications through ongoing
education and training, which can be demonstrated by participation in infection control
courses, or in local and national meetings organized by recognized professional societies,
such as APIC and SHEA.
Although CMS does not specify the number of hours that the qualified individual must
devote to the infection control program, resources must be adequate to accomplish the
tasks required for the infection control program. The ASC should consider the type of
surgical services offered at the facility as well as the patient population in determining the
size and scope of the resources it commits to infection control. The CDC’s HICPAC as
well as professional infection control organizations, such as the APIC and the SHEA,
publish studies and recommendations on resource allocation that ASCs may find useful.
Survey Procedures: §416.51(b) (1)
• Determine whether a qualified individual has been designated with the
responsibility for leading the infection control program.
• Review the personnel file of the infection control individual to determine whether
he/she is qualified through ongoing education, training, or certification to oversee
the infection control program.
Q-0244
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.51(b) Standard: Infection Control Program.
[…The program is –]
(2) An integral part of the ASC’s quality assessment and performance improvement
program; and
Interpretive Guidelines: §416.51(b)(2)
To reflect the importance of infection control the regulations specifically require that the
ASC’s infection control program must be integrated into its QAPI program. Among
other things this means that infection control data and program activities are an ongoing
component of the QAPI program, and that actions are taken in response to data analyses
to improve the ASC’s infection control performance. See the discussion related to
§416.43, which articulates the ASC QAPI requirements.
Survey Procedures: §416.51(b)(2)
• Determine whether the ASC’s quality assessment and performance program
includes measures/indicators and activities related to infection control on an
ongoing basis.
• Determine whether there is evidence that the QAPI infection control activities
result in specific actions designed to improve infection control within the ASC.
Q-0245
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
§416.51(b) Standard: Infection control program.
The program is –]
(3) Responsible for providing a plan of action for preventing, identifying, and
managing infections and communicable diseases and for immediately
implementing corrective and preventive measures that result in improvement.
Interpretive Guidelines: §416.51(b)(3)
The ASC’s infection control professional must develop and implement a comprehensive
plan that includes actions to prevent, identify and manage infections and communicable
diseases within the ASC. The plan of action must include mechanisms that result in
immediate action to take preventive or corrective measures that improve the ASC’s
infection control outcomes. The plan should be specific to each particular area of the
ASC, including, but not limited to, the waiting room(s), the recovery room(s), and the
surgical areas. The designated infection control professional must assure that the
program’s plan of action addresses the activities discussed in the interpretive guidelines
for §416.51(b), i.e.,
• Maintenance of a sanitary environment; (See discussion of §416.51(a))
• Development and implementation of infection control measures related to ASC
personnel;
• Mitigation of risks associated with patient infections present upon admission;
• Mitigation of risks contributing to healthcare-associated infections;
• Active surveillance;
• Monitoring compliance with all policies, procedures, protocols, and other
infection control program requirements;
• Plan evaluation and revision of the plan, when indicated;
• Coordination as required by law with federal, state, and local emergency
preparedness and health authorities to address communicable and infectious
disease threats and outbreaks; and
• Compliance with reportable disease requirements of the local health authority.
(See discussion of §416.44(a)(3))
ASCs are required to have a process to follow up on each patient after discharge, in order
to identify and track infections associated with the patient’s stay in the ASC. An ASCs is
not expected to establish routine post-surgical laboratory testing for infectious diseases,
but if it learns of an infection in the post-discharge period from the patient or patient’s
physician, the ASC might consider inquiring whether there is a lab confirmation of an
infectious disease, and, if there are indications that the infection was associated with the
patient’s stay in the ASC. If the ASC learns of a disease that is reportable under State
law (including regulations), they must report it to the appropriate State authorities.
ASCs may delegate portions of this follow-up responsibility to the physicians on the
ASC’s staff who will see the patients in their office post-discharge only if the ASC’s
process includes a mechanism for ensuring that the results of the follow-up are reported
back to the ASC and documented in the patient’s medical record.
Survey Procedures: §416.51(b)(3)
• Ask the infection control professional to describe actual examples of how, as a
result of the action plan, infection control issues were identified and corrective or
preventive actions were taken.
• Ask for documentation of how those actions were evaluated to assure that they
resulted in improvement.
• Ask the infection control professional to review the ASC’s infection control plan
of action with you, explaining how it addresses the fundamental elements of an
infection control program.
• Does the plan address all the basic elements of infection control?
• Ask the ASC’s leadership how it tracks infections among patients and staff.
• Ask for documentation of this tracking – is there tracking of all patients?
• Ask the ASC’s leadership what diseases are reportable to the State to verify the
ASC’s awareness of applicable reporting requirements.
• Ask the ASC if it has ever reported a reportable disease to the State. If yes,
review the ASC’s documentation of the case.
Q-0260
(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.52 Condition for coverage – Patient Admission, Assessment and
Discharge
The ASC must ensure each patient has the appropriate pre-surgical and post-
surgical assessments completed and that all elements of the discharge requirements
are completed.
Interpretive Guidelines §416.52
The core objectives of this condition are to ensure that:
• The patient can tolerate a surgical experience;
• The patient’s anesthesia risk and recovery are properly evaluated
• The patient’s post-operative recovery is adequately evaluated;
• The patient received effective discharge planning; and
• The patient is successfully discharged from the ASC
(See 72 FR 50477, August 31, 2007.)
All elements of the specific requirements of this condition concerning pre- and post-
surgical assessments, together with the patient assessment requirements in the surgical
services CfC at§416.42(a) , must be met. Deficiencies related to §416.42(a), concerning
the need for a physician to evaluate the patient for anesthesia risk and surgical procedure
risk prior immediately before surgery, and for anesthesia recovery prior to discharge are
to be considered when determining whether the requirements of this Condition have been
met.
Q-0261
(Rev. 71, Issued: 05-13-11, Effective: 5-13-11-Implementation: 05-13-11)
§416.52(a) Standard: Admission and Pre-surgical Assessment
(1) Not more than 30 days before the date of the scheduled surgery, each patient
must have a comprehensive medical history and physical assessment completed by a
physician (as defined in section 1861(r) of the Act) or other qualified practitioner in
accordance with applicable State health and safety laws, standards of practice, and
ASC policy.
Interpretive Guidelines §416.52(a)(1)
The purpose of a comprehensive medical history and physical assessment (H&P) is to
determine whether there is anything in the patient's overall condition that would affect the
planned surgery, such as a medication allergy, or a new or existing co-morbid condition
that requires additional interventions to reduce risk to the patient, or which may even
indicate that an ASC setting might not be the appropriate setting for the patient’s surgery.
The H&P must be comprehensive in order to allow assessment of the patient’s readiness
for surgery and is required regardless of the type of surgical procedure. The H&P should
specifically indicate that the patient is cleared for surgery in an ambulatory setting.
The H&P must be completed and documented for each ASC patient no more than 30
calendar days prior to date the patient is scheduled for surgery in the ASC.
• In cases where the patient is scheduled for two surgeries in the ASC within a short
period of time, the same H&P may be used so long is it is completed no more than 30
calendar days before each surgery. For example, if a patient has two surgeries for
cataracts scheduled, one eye on May 3rd, and the other eye on May 18th, and H&P
performed on April 20th could be used for both surgeries.
• The H&P is still required in those cases where the patient is referred to the ASC for
surgery on the same day as the referral and the referring physician has indicated it is
medically necessary for the patient to have the surgery on the same date. The H&P may
be performed by the referring physician, if the ASC’s policies permit this, or qualified
personnel in the ASC. If there are elements of the H&P that are essential to the
performance of the physician assessment required under §416.42(a) or under this
requirement at §416.52(a)(1), based on the type of procedure to be performed as well as
applicable State health and safety laws, standards of practice, or ASC policy, and those
elements cannot be completed prior to the scheduled time of the surgical procedure, then
it is questionable whether the case is suitable for that ASC.
• The H&P may be performed on the same day as the surgical procedure, and may be
performed in the ASC, as long as it is conducted by qualified personnel, is
comprehensive, and the results of the H&P are placed in the patient’s medical record
prior to the surgical procedure (see §416.52(a)(3). It is not acceptable to conduct the
H&P after the patient has been prepped and brought into the operating or procedure
room, since the purpose of the H&P is to determine before the surgery whether there is
anything in the patient’s overall condition that would affect the conduct of the planned
procedure, or which may even require cancellation of the procedure.
The medical history and physical examination must be completed and documented by a
physician (as defined in Section 1861(r) of the Act) or other qualified licensed individual
practitioner in accordance with State law, generally accepted standards of practice, and
ASC policy.
Section 1861(r) defines a physician as a:
• doctor of medicine or osteopathy;
• doctor of dental surgery or of dental medicine;
• doctor of podiatric medicine;
• doctor of optometry; or a
• chiropractor.
In all cases the practitioners included in the definition of a physician must be legally
authorized to practice within the State where the ASC is located and providing services
within their authorized scope of practice.
Other qualified licensed individuals are those licensed practitioners who are authorized in
accordance with their State scope of practice laws or regulations to perform an H&P and
who are also formally authorized by the ASC to conduct an H&P. Other qualified
licensed practitioners could include nurse practitioners and physician assistants.
More than one qualified practitioner can participate in performing, documenting, and
authenticating an H&P for a single patient. When performance, documentation, and
authentication are split among qualified practitioners, the practitioner who authenticates
the H&P will be held responsible for its contents.
In the case of an ASC the H&P is typically completed by the patient’s primary care
practitioner rather than a member of the ASC’s medical staff. The ASC’s policy on
H&Ps should address submission of an H&P prior to the patient’s scheduled surgery date
by a physician who is not a member of the ASC’s medical staff and should indicate
whether it will accept H&Ps performed by a qualified licensed individual who does not
practice at the ASC but is acting within his/her scope of practice under State law or
regulations.
Survey Procedures: §416.52(a)(1)
• Determine whether the ASC has a policy requiring that an H&P be performed for
each patient no more than 30 days before each patient’s scheduled surgery by a physician
(as defined in Section 1861(r) of the Act), or other qualified licensed individual in
accordance with State law and hospital policy.
• Does the ASC’s policy address who may perform the H&P? If it permits acceptance
of H&Ps by qualified licensed individuals who are not physicians, is it consistent with the
State’s scope of practice law or regulations?
• Review a sample of open and closed medical records to verify that:
• There is an H&P that was completed no more than 30 days before the patient’s
surgery date;
• For H&Ps performed in the ASC on the day of the surgery, that the H&P is
comprehensive and performed prior to the patient’s being moved into the OR or
procedure room; and
• The H&P was performed by a physician, or other qualified licensed individual
authorized in accordance with State law, standards of practice, and ASC policy.
Q-0262
(Rev. 71, Issued: 05-13-11, Effective: 5-13-11-Implementation: 05-13-11)
§416.52(a) Standard: Admission and Pre-surgical Assessment
(2) Upon admission, each patient must have a pre-surgical assessment completed by
a physician or other qualified practitioner in accordance with applicable State
health and safety laws, standards of practice, and ASC policy that includes, at a
minimum, an updated medical record entry documenting an examination for any
changes in the patient’s condition since completion of the most recently documented
medical history and physical assessment, including documentation of any allergies
to drugs and biologicals.
Interpretive Guidelines: §416.52(a)(2)
Each ASC patient upon admission to the ASC must have a pre-surgical assessment. The
requirement at §416.42(a)(1) for a physician to examine the patient immediately before
surgery to evaluate the risk of the anesthesia and of the procedure for that patient is one
component of the requirement at 42 CFR 416.52(a)(2). This component must be
conducted by a physician, immediately prior to surgery, and must be performed in a
manner consistent with the requirements at §416.42(a)(1). (See the interpretive
guidelines for §416.42(a)(1). Other elements of the assessment may be conducted by a
licensed practitioner who is credentialed and privileged by the ASC to perform an H&P.
In all cases, the update must take place prior to the surgery.
If the H&P required under §416.52(a)(1)is performed on the day of the surgical
procedure in the ASC, some, but not all, elements of the pre-surgical assessment may be
incorporated into the H&P. However, the assessment of the patient’s risk for the
procedure and anesthesia required under §416.42(a)(1) must still be conducted separately,
by a physician and immediately prior to surgery.
The patient must be assessed for any changes in his/her condition since the patient's H&P
was performed that might be significant for the planned surgery. Patients may have had a
change in health status after the H&P, but may not recognize the significance for their
planned surgery. Any changes in health and medication can have an impact on the
patient’s ability to tolerate the surgery or anesthesia, and the post-admission pre-surgical
assessment is designed to identify these changes and take appropriate action, up to and
including postponing or cancellation of the surgery. In addition, the pre-surgical
assessment must identify and document any allergies the patient may have to drugs and
biologicals, or indicate that the patient has no known allergies to drugs and biologicals.
Further, if the practitioner finds that the H&P done before admission is incomplete,
inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P, examining the
patient, and completing the update may disregard the existing H&P, and conduct and
document in the medical record a new H&P prior to the surgery.
The patient’s medical record must include documentation that the patient was examined
prior to the commencement of surgery for changes since the H&P. The physician or
qualified licensed individual uses his/her clinical judgment, based upon his/her
assessment of the patient’s condition and co-morbidities, if any, in relation to the
patient’s planned surgery to decide the extent of the update assessment needed as well as
the information to be included in the update note in the patient’s medical record.
If, upon examination, the licensed practitioner finds no change in the patient's condition
since the H&P was completed, he/she may indicate in the patient's medical record that the
H&P was reviewed, the patient was examined, and that "no change" has occurred in the
patient's condition since the H&P was completed. Likewise, any changes in the patient’s
condition must be documented by the practitioner in the update note prior to the start of
surgery.
Survey Procedures: §416.52(a)(2)
• Determine whether the ASC’s policies require a pre-surgical assessment for all
patients to update the findings of the H&P performed prior to the date of surgery.
• In the sample of medical records selected for review, verify that an updated medical
record entry documenting an examination for any changes in the patient's condition was
completed prior to the surgery.
• Verify that a physician performs those components of the pre-surgical assessment
related to evaluation of anesthetic risk and procedural risk, as required by §416.42(a)(1).
a. Verify that the pre-surgical assessment includes documentation in the medical record
of the patient’s allergies or lack of known allergies to drugs and biologicals.
Q-0263
(Rev.5 6, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.52(a) Standard: Admission and Pre-surgical Assessment
(3) The patient’s medical history and physical assessment must be placed in the
patient’s
medical record prior to the surgical procedure.
Interpretive Guidelines: §416.52(a)(3)
Ideally, the comprehensive H&P must be submitted to the ASC prior to the patient’s
scheduled surgery date, in order to allow sufficient time for review of the H&P by the
ASC’s medical staff and adjustments if necessary, including postponement or
cancellation of the surgery. At a minimum, the H&P must be placed in the patient’s
medical record prior to the pre-surgical assessment required under §416.52(a)(2), since
that assessment must first consider the findings of the H&P before examining the patient
for changes. Both the H&P and the pre-surgical assessment must be placed in the
patient’s medical record before the surgery.
Survey Procedures: §416.52(a)(3)
In the sample of medical records selected for review, verify that each record contains
both the H&P and the updated pre-surgical assessment. Focus in particular on open
records of patients scheduled for surgery during the on-site survey, to determine whether
these documents are in the patients’ records before the start of their surgical procedures.
Q-0264
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.52(b) Standard: Post-surgical Assessment.
(1) The patient’s post-surgical condition must be assessed and documented in the
medical
record by a physician, other qualified practitioner, or a registered nurse with, at a
minimum, post-operative care experience in accordance with applicable State health
and safety laws, standards of practice, and ASC policy.
(2) Post-surgical needs must be addressed and included in the discharge notes.
Interpretive Guidelines: §416.52(b)
Each patient must be assessed after the surgery is completed. In accordance with the
requirements of §416.42(a)(2), a physician or anesthetist must assess each patient for
recovery from anesthesia after the surgery. See the interpretive guidelines for
§416.42(a)(2) for a discussion of the requirements for a post-anesthesia assessment.
In addition, each post-surgical patient’s overall condition must be assessed and
documented in the medical record, in order to determine how the patient’s recovery is
proceeding, what needs to be done to facilitate the patient’s recovery, and whether the
patient is ready for discharge or in need of further treatment or monitoring.
Except for the assessment of the patient’s recovery from anesthesia, the assessment may
be performed by a physician, another qualified practitioner, or a registered nurse with
post-operative care experience who is permitted, under applicable State laws as well as
general standards of practice and the ASC’s clinical policy, to assess patients’ post-
operatively.
If the assessment identifies post-surgical patient needs that must be addressed in order for
the patient to be safely discharged, or, in the case of patients who develop needs that
exceed the capabilities of the ASC, appropriately and timely transferred to a hospital for
further care, the ASC must address those patient needs. This must be documented in the
discharge notes in the patient’s medical record.
Survey Procedures: §416.52(b)
• Verify through observation of post-surgical patient care and through record review
whether the ASC evaluates each patient after surgery, both for recovery from anesthesia,
as required under §416.42(a)(2), and for his/her overall recovery from the surgery and
suitability for discharge.
• Are the post-surgical assessments performed by qualified personnel, i.e., a physician
or anesthetist assesses the recovery from anesthesia, while the overall assessment is
performed by a physician, other licensed practitioner or RN with appropriate experience
in post-operative care? Where an RN performs an assessment, is there documentation of
the RN’s qualifications to do so?
• Does the ASC identify patient needs related to safe discharge, or, as applicable, does
it identify patients who require transfer to a hospital for further treatment that exceeds the
ASC’s capabilities? Do the records reflect actions by the ASC to address the needs it has
identified?
• Do the medical records reflect the post-surgical assessment, needs identified, and
actions taken by the ASC to address those needs in the medical record’s discharge notes?
Q-0265
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.52(c) Standard: Discharge. The ASC must -
(1) Provide each patient with written discharge instructions and overnight
supplies. When
appropriate, make a follow-up appointment with the physician, and ensure that all
patients are informed, either in advance of their surgical procedure or prior to
leaving the ASC, of their prescriptions, post-operative instructions and physician
contact information for follow-up care.
Interpretive Guidelines: §416.52(c)(1)
Each patient, or the adult who accompanies the patient upon discharge, must be provided
with written discharge instructions.
Either before the surgery or before discharge each patient must be provided with:
• Prescriptions they will need to fill associated with their recovery from surgery;
• Written instructions that specify actions the individual should take in the immediate
post-operative, post-discharge period to promote their recovery from the surgery;
warning signs of complications to be alert for, etc.
• How to contact the physician who will provide follow-up care to the patient. When
appropriate, the ASC must make an appointment with the physician for follow-up care.
The ASC must also provide supplies, such as gauze, bandages, etc., sufficient for the
patient’s needs through the first night after the surgery.
Survey Procedures: §416.52(c)(1)
• Determine whether there is a copy of the discharge instructions provided to the
patient in the patient’s medical record.
• Look at the discharge instructions in the sample of records under review, as well as
for patients being discharged while the ASC is being surveyed. Do the discharge
instructions include post-operative care instructions for the patient? Do they indicate if
the patient was provided prescriptions, if applicable? Do they provide physician contact
information?
• Ask the ASC when and how it schedules follow-up appointments with the physician
for patients.
• Ask the ASC what types of supplies it typically provides to patients upon discharge.
Observe whether patients being discharged during the survey are provided any supplies to
cover their overnight needs.
Q-0266
(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)
§416.52(c) Standard: Discharge.
The ASC must -
(2) 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.
Interpretive Guidelines: §416.52(c)(2)
No patient may be discharged from the ASC unless the physician who performed the
surgery or procedure signs a discharge order. The ASC must ensure that physicians
follow applicable State laws as well as generally accepted standards of practice and ASC
policy when determining that a patient has recovered sufficiently from surgery and may
be discharged from the ASC, or, as applicable, that the patient must be transferred to
another healthcare facility that can provide the ongoing treatment that the patient requires
and that the ASC is unable to provide. It is permissible for the operating physician to
write a discharge order indicating “the patient may be discharged when stable.” (73 FR
68721). In such cases there must be documentation of when patient was stable. It is
expected that a patient will actually leave the ASC within 15 – 30 minutes of the time
when the physician signs the discharge order or when he or she was found to be stable,
whichever happens later.
Survey Procedures: §416.52(c)(2)
• Determine whether there is a discharge order, signed by the physician who
performed the surgery/procedure, in the sample of medical records being
reviewed.
• Determine whether there is a discharge order signed by the physician for
patients being discharged while the survey takes place.
Q-0267
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.52(c) Standard: Discharge.
The ASC must -
(3) Ensure all patients are discharged in the company of a responsible adult,
except those patients exempted by the attending physician.
Interpretive Guidelines: §416.52(c)(3)
Unless the physician who is responsible for the patient’s care in the ASC has exempted
the patient, the ASC may not discharge any patient who is not accompanied by a
responsible adult who will go with the patient after discharge. ASCs would be well-
advised to develop policies that address what criteria a physician should consider when
deciding a patient does not need to be discharged in the company of a responsible adult.
Exemptions must be specific to individual patients, not blanket exemptions to a whole
class of patients.
Survey Procedures: §416.52(c)(3)
• Do the medical records being review identify for each patient the responsible adult
who will accompany the patient after discharge or, alternatively, a specific exemption or
this patient from this requirement by the physician?
• Observe whether the ASC ensures an adult accompanies patients discharged while the
survey is taking place, unless the patient has been specifically exempted from this
requirement.
Transmittals Issued for this Appendix
Rev #
Issue Date
Subject
Impl Date
CR#
R137SOM
04/01/2015
Revisions to State Operations Manual (SOM)
Appendices A, G, L and T related to
Hospitals, Rural Health Clinics, Ambulatory
Surgical Centers and Swing Beds
03/27/2015
N/A
R99SOM
01/31/2014
Revised State Operations Manual (SOM)
Appendices A, I, L, and W
01/31/2014
N/A
R95SOM
12/12/2013
Revised Appendix A, Interpretive Guidelines
for Hospitals, Appendix L, Interpretive
Guidelines for Ambulatory Surgical Centers
and Appendix W, Interpretive Guidelines for
Critical Access Hospitals
06/07/2013
N/A
R89SOM
08/30/2013
Revised State Operations Manual (SOM)
Appendices A, I, L, and W – Rescinded and
replaced by Transmittal 99
08/30/2013
N/A
R84SOM
06/07/2013
Revised Appendix A, Interpretive Guidelines
for Hospitals, Appendix L, Interpretive
Guidelines for Ambulatory Surgical Centers
and Appendix W, Interpretive Guidelines for
Critical Access Hospitals – Rescinded and
replaced by Transmittal 95
06/07/2013
N/A
R76SOM
12/22/2011
Clarifications to Appendix L, Ambulatory
Surgical Center Interpretive Guidelines –
Obtaining Consent Before Observing Surgical
Procedures
12/22/2011
N/A
R71SOM
05/13/2011
Clarifications to Appendix L, Ambulatory
Surgical Center Interpretive Guidelines –
Comprehensive Medical History and Physical
(H&P) Assessment and Anesthetic Risk and
Evaluation
05/13/2011
N/A
R56SOM
12/30/2009
Revised Appendix L, “Interpretive Guidelines
for Ambulatory Surgical Centers”
12/30/2009
N/A
R01SOM
05/24/2004
Initial Release of Pub 100-07
N/A
N/A

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