Transcript Ambulatory Surgery Centers - Texas Ambulatory Surgery Center

A LITTLE EXPLANATION:
MEDICARE CERTIFIED
1864 agreement
Agreement between CMS and the State
DADS is the primary State agency
DSHS draws moneys from DADS
BY THE 1864 AGREEMENT
The federal government (HCFA/CMS)
was told that they would HAVE to
work with the States.
OF THE TOTAL MEDICARE BUDGET
Survey and Certification gets
1/100th of one cent of every dollar!
FEDERAL MANDATES
NURSING HOMES!!!!
 Why DADS gets the money first
Validation surveys
When an ambulatory surgery center
has “deemed” status, the State Agency,
at the request of CMS, goes behind
the accrediting body to make sure
that they found everything
they were supposed to.
ALL OTHER ACTIVITY
Spelled out in the annual
Mission and Priority
Document
MISSION AND PRIORITY
Every year about this time, we (the State) receive
a draft of the M & P Document- about 75
pages long. In the M & P, we get our “marching
orders” for the coming year.
WE ALSO GET OUR INSTRUCTIONS:
State Operations Manual- Chapter two (for
certification)
RS&C Letters
S&C Letters
Admin Info
E-mails
Verbal
CMS region 6
Etc….
THE M & P ESTABLISHED THE
TIER SYSTEM
ALL BASED ON FUNDING
CMS tells us how much money we’re going
to get; we tell them how much work
we’re going to do.
CMS tells us there’s work we HAVE to do
(the upper tiers), what they would like us
to do (Tier III), and what we can put off
(Tier IV).
CHANGES IN SURVEY PROCESS
In 2008, there were some infection control issues
identified in one of the Western States, that put
patients’ lives at risk. This prompted CMS to reexamine their policies towards the inspections of ASCs
as well as other facility types.
Plus the growth of the industry
• 2002- 3478 Certified ASCs in the nation
• 2012- 5359 Certified ASCs in the nation
•
a 54.1 % increase
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This doesn’t include those ASCs that are not certified or are
licensed only
• Accreditation- giving deemed status, has also grown dramatically
• 2008- 893 accredited ASCs having deemed status
• 2012- 1368 accredited ASCs having deemed status- that’s a 53.2 %
increase
In Texas
• On October 1, 2012, there were 352 certified
ASCs, by September 30, 2013 there were 357.
• Texas has 7% of all ASCs in the nation and
63% of all ASCs in CMS Region 6!
Ambulatory Surgical Center is:
A Distinct entity
Operates EXCLUSIVELY to provide surgical
services
-to patients not requiring hospitalization
- expected stay not more than 24 hours
If receiving Medicare reimbursement:
Has an ASC provider agreement
Complies with the CMS ASC Conditions for Coverage
(CfCs)
Distinct Entity
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Must be physically separate OR
Must be temporally separate
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Same physical space but not opened at the
same time.
Two (or more) ASCs may share the same
physical space as long as they are not
open at the same time.
If two or more share the same
space…
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No overlapping hours
Records kept separate
Different governing bodies
Different CCN (if they all participate in
Medicare)
If one of these has a condition out-like
environment- they may all have that
condition out
An ASC may NOT share space
with:
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A Hospital
A Critical Access Hospital
An Independent Diagnostic and Testing
Facility
What is Surgery
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An invasive procedure performed to
structurally alter the body by incision or
destruction of tissues
OR
Diagnostic or therapeutic treatment by
any instruments causing localized
alteration/transposition of live tissue
Tissue
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Can be~
Burned, vaporized, frozen, sutured,
probed, manipulated by closed
reductions for major dislocations or
fractures, or otherwise altered by
mechanical, thermal, light-based,
electromagnetic, or chemical means
and
includes
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The injection of diagnostic or
therapeutic substances into body
cavities, internal organs, joints, sensory
organs, and the central nervous system.
Doesn’t include nurses administering
IVs, IMs, or Sub-q injections.
not more than 24 hours
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A patient stay in the ASC should not
usually be more than 23 hours, 59
minutes. Clock starts when the patient
moves from the waiting room into a
clinical part of the ASC (pre-op) and
stops at discharge, leaving the ASC
about 15-30 minutes after discharge
from the recovery room.
If more than 24 hours
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Then it may have been an inappropriate
patient for an ASC (more on that under
assessment). If just one patient or
occasional, may not be an issue.
However, if frequent or shows a trendmay be a citation waiting to be written.
• So, beginning in 2008, ASCs became a “Special
focus” on CMS.
• In Federal fiscal year 2010, the States were
told to survey 33% of all ASCs.
• In Federal fiscal year 2011, it became standard
policy that the States would survey 25% of all
ASCs.
– For those ASCs with “deemed status”, the States
would conduct “validation” surveys at the
direction of CMS- 5 to 10%
There were also other CMS mandated
changes
• Hightened awareness of infection control
processes.
– Use of the Infection Control Surveyor Worksheet
• Tracer patient
– One surveyor MUST BE an RN
The top 10 deficiencies
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Sanitary Environment
Administration of Drugs
Infection Control Program
Form and Content of Record
Infection Control Program- Direction
Physical Environment
Disaster Preparedness Plan
Organization and Staffing
Infection Control
Notice- Posting (ownership)
Infection Control
Includes completing the required worksheet
Infection Control and ASCs (416.51)
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The ASC must maintain an infection control
program that seeks to minimize infections and
communicable diseases
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Presents remarkable challenges:
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Patients are in common areas
Rapid turnarounds in ORs, PACUs
Patients bringing in communicable diseases that may or may not
have been identified (especially if the H & P is nearing 30 days)
Patients go home quickly- uncertainty of appropriate postsurgical care
Surgical site infections common
416.51 (a)
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The ASC must provide a functional and
sanitary environment for the provision of
surgical services by adhering to professionally
acceptable standards of practice.
416.51(b)
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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. The program is…..
416.51 (b) continued
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(1) Under the direction of a designated and qualified
professional who has training in infection control;
(2) An integral part of the ASC’s QAPI program,
and
(3) Responsible for providing a plan of action for
preventing, identifying and managing infections and
communicable diseases and for immediately
implementing measures that result in improvement.
The ASC must have
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One staff member has to be designated as the
infection control person with responsibility for the
program. Can have other duties, even be a contract
employee. Certification is desirable, but not
required. Ongoing training in infection control is
required.
If the ASC is part of a national chain, the corporate
infection control officer is OK but not sufficient;
have to have somebody on-site- but no designation
as to how long or how often they have to be on site.
416.44(a)(3)
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The ASC must establish a program for
identifying and preventing infections,
maintaining a sanitary environment, and
reporting the results to the appropriate
authorities.
Some components of an infection
control program
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All staff must be trained (includes MDs)
Based on a recognized program
Establish policies and procedures regarding
infection control
Hand hygiene
Safe practices for injecting meds, saline, and
other infusions
Hand hygiene
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Extremely important
Healthcare provides should wear gloves for
procedures that might involve contact with blood or
body fluids
When handling potentially contaminated patient
equipment
After doing a gloved task, remove gloves, wash
hands, glove and go to next task.
Injection safety
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Needles are used for only ONE patient
Syringes are used for only ONE patient
Medication vials are always entered with a
new needle and a new syringe (multidose for
more than one patient)
Pre-drawing medications
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Labeled with
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Date and time the meds were drawn
Initials of the person drawing the meds
Name of the medication
Strength
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If the above items aren’t present, don’t use.
Multidose vials
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Ideally, used for only one patient; however, if
used for more than one patient…
Rubber septum disinfected with alcohol
PRIOR to each entry
Vials dated when opened- discarded by day
28 (unless manufacturer says earlier)
Not stored where direct patient contact can
occur (like the bedside)
Sharps disposal
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Disposed in a puncture resistant “sharps
container”
Container discarded when the line is reached.
No matter what you drop in there, its just not
worth trying to fish it out. Your husband can
always buy you another diamond; but he can’t
get another you.
Sterilization/equipment reprocessing
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“Spaulding Classification”
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Critical devices-items that enter normally sterile
tissue or the vascular system (surgical
instruments)
Semicritical devices: items that come in contact
with non-intact skin or mucous membranes
(endoscopes, laryngoscope blades)
Noncritical devices: items that come in contact
with intact skin but not mucous membranes
(blood pressure cuffs, pulse oximeters)
Critical devices
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Need to be cleaned prior to sterilization
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As soon as possible after use
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With detergent and water or enzyme cleaner and water
(get the chunks off first), then
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Sterilize:
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Steam autoclave
Peracetic acid
Ethylene oxide
Hydrogen peroxide gas plasma
Flash sterilization- should be the exception rather than the rule
Semi-critical devices
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High-level disinfected (at a minimum)
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Manual
Automated (stericycle)
Following manufacturer’s instructions
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Disinfected for the appropriate length of time
Disinfected at the appropriate temperature
Allowed to dry before use
Stored in a clean place
Noncritical devices
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Cleaned as needed
Environmental cleaning
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Operating rooms- cleaned and disinfected after each
surgical or invasive procedure
“terminal clean” at end of day after last procedure.
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Cleaning of all surfaces, including floors
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High touch surfaces in rest of facility cleaned and
disinfected as needed
Facility has a procedure for cleaning up gross blood spills
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Point of Care testing
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Glucose testing
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A new single-use auto-disabling lancet is used for
each patient
If allowed by manufacturer to be used on
numerous patients, blood glucose monitor is
cleaned and disinfected after every use
Infection Control Worksheet
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All 16 pages must be completed- facility can
assist with some, if not most, of the
completion of the forms.
If more than one surveyor, each completes
one of the forms and team lead collates the
info.
Faxed to CMS data people at end of survey
Patient Assessment and
Discharge
Tracer Patient
Two types of assessments:
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Before Surgery
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History and Physical
Pre-surgical assessment
Anesthesia/procedure
risk
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H & P no more than 30
days old
Presurgical done at the
time of admit
Anesthesia risk
assessment done
immediately before
surgery
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After Surgery
Anesthesia recovery
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Performed by MD, other
qualified practitioner
Availability of a
responsible adult to
whom the patient can be
discharged
History and Physical
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Comprehensive, performed by a MD, DO,
DDS, podiatrist (within the scope of their
practice), required prior to surgery.
No more than 30 days before-can be
immediately prior to admit to ASC in the case
of a same day surgery
Can be used for more than one surgery if
multiple surgeries are done within 30 days; but
not more than 30 days.
Presurgical assessment
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Done at the time of admission of the
patient to the ASC- ascertains any
changes since H & P done-update must
be in medical record prior to surgery.
May be combined with
anesthesia/procedure assessment, done
by physician immediately before surgery
to evaluate risks
Post-op assessments (416.52(b)
and 416.42(a)(2))
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Performed by MD/other qualified practitioner
Assess patient’s overall condition after
anesthesia:
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Respiratory function/airway patency
O2 Saturation
Cardiovascular functioning (pulse/ blood pressure)
Mental status
Pain
Nausea/vomiting
Discharge (416.52(c))
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Discharge order-signed by the physician
who did the surgery
Discharge instructions
Any necessary supplies to last through
the night
Follow-up appointments
Adult accompaniment, unless the MD
expressly in writing exempts the patient
Discharge
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continued
416.52(c)(1):
Discharge instructions include any
prescriptions to be filled, how to contact
the MD or the ASC staff in case of an
emergency
Order reading “discharge when stable” is
okay.
Discharge-the final word
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Patient should be ready to leave the
facility within 15 to 30 minutes after the
discharge order is written, therefore, very
important that the physician dates and
TIMES his order.
• Enacted by the 82nd legislature
• Applies to:
• General Hospitals
• Ambulatory Surgical Centers
• Abortion facilities
HB 15– the SONOGRAM bill
• A woman seeking an abortion
• Will have a sonogram performed at least 24 hours before
the scheduled procedure
• Fetal development and gestational age will be described to
the woman
• Heart sounds will be made available for the woman to hear
• Woman’s Right to Know booklet made available
HB 15- Mandates
• Document
• Document
• Document
• Did I say Document?
HB 15
 Enacted
by the second Special called Session
of the 83rd Legislature
 Applies to:
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Abortion Facilities
Ambulatory Surgery Centers
General Hospitals
Physicians’ offices (to a limited extent)

Parts of the law took effect 10/29/2013, the
remainder will take effect September of 2014.
 Physicians
who perform abortions must have
admitting privileges at a hospital within 30
miles of the facility in which the abortion is
performed
 The
medical abortion “pill” must be
administered by a physician and there must
be two follow-up visits by the patient
following the appointment in which the
“pill” is administered
 Are
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outlawed post 20 week gestation
Determined by established medical practice and
guidelines
 Any
facility that offers abortion services
must meet the physical plant guidelines of an
Ambulatory Surgical Center at a minimum.
 As
you are aware, federal judge in Austin
“enjoined” (stopped) the Department from
enforcing the rules that took effect
10/29/13, Federal 5th Circuit overruled him.
 On

its way to the Supreme Court
Planned Parenthood has petitioned the U.S. Supreme Court to
reverse the 5th Circuit and reinstate the injunction. Justice Scalia
has given the state until Nov. 12 to respond to the request. He will
likely forward to the full court for decision. (11/4/13)
The END!