Ambulatory Surgery Centers

Ambulatory Surgery Centers Patrick Waldron, M.Ed., LMSW February 2014

Health Facility Compliance Zone Map

A little explanation:Medicare Certified • 1864 agreement • Agreement between CMS and the State • DADS is the primary State agency • DSHS draws moneys from DADS

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 re-examine 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 • 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. • There were still 357 as of 2/21/14. • Texas has 7% of all ASCs in the nation and 63% of all ASCs in CMS Region 6!

And then the complaints are triaged to ensure that the allegations are regulatory in nature and a time frame for investigation is assigned. All complaints against Ambulatory Surgery Centers come to our implacable intake staff who does the first cursory glance

So far this calendar year There have been 4 complaints against individual ASCs in the state amounting to 21 different allegations, everything from nurse staffing and infection control to billing. 4/357= 1%

The top 10 deficiencies • 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)

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 • Must be physically separate OR • Must be temporally separate • 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… • 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: • A Hospital • A Critical Access Hospital • An Independent Diagnostic and Testing Facility

What is Surgery • 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 • 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 • 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 • 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 • 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 trend- may 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

Discharge-the final word • 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

HB 2- the Abortion bill • Enacted by the second Special called Session of the 83rd Legislature • Applies to: • 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.

Effective 10/29/2013 • 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

Abortions • Are outlawed post 20 week gestation • Determined by established medical practice and guidelines

In 2014 • 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)

I yield for anyquestions

Ambulatory Surgery Centers