Download 2012 AAAHC/CMS Crosswalk REVISED

2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.25
Condition:
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.
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 subparts B and C of this part.
The ASC must comply with State licensure requirements.
10.I.MS 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 42
CFR Part 416, Subpart B.
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 twenty four (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 42 CFR Part 416, Subparts B and C.
The ASC must comply with State licensure requirements.
416.2
Definitions:
416.40
Condition:
Compliance with
State licensure law
416.41
Condition:
Governing body
and management
416.41 (a)
Standard:
Contract services
10.I.MS ASC
Definition
2.I.A–MS
The ASC must have a governing body that assumes full legal
2.I.B-MS-1
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 facility policies
and programs are administered so as to provide quality health care
in a safe environment, and develops and maintains a disaster
preparedness plan.
When services are provided through a contract with an outside
2.I.B-11a, b, c, d,
resource, the ASC must assure that these services are provided in a and g
safe and effective manner.
The Accreditation Association for Ambulatory Health Care 2012
1
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 facility policies
and programs are administered so as to provide quality health care
in a safe environment, and develops and maintains a disaster
preparedness plan.
11. Approving and ensuring compliance of all major contracts or
arrangements affecting the medical and dental care provided under
its auspices and assuring services are provided in a safe and
effective manner, including, but not limited to, those concerning:
a. the employment or contracting of health care professionals
b. the provision of radiology services and pathology and medical
laboratory services
c. the use of external laboratories
d. the provision of care by other health care organizations, such as
hospitals
g. the Centers for Medicare & Medicaid Services (CMS)
requirements, if the organization participates in the
Medicare/Medicaid program
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
416.41 (b)(1)
Standard:
Hospitalization
416.41 (b)(2)
Standard:
Hospitalization
The ASC must have an effective procedure for the immediate
4.K-MS (1)
transfer, to a hospital, of patients requiring emergency medical care
beyond the capabilities of the ASC.
This hospital must be a local, Medicare-participating hospital or a 4.K-MS (2)
local, nonparticipating hospital that meets the requirements for
payment for emergency services under §482.2 of this chapter.
416.41 (b)(3)(i)
Standard:
Hospitalization
The ASC must—
416.41 (b)(3)(ii)
Standard:
Hospitalization
Have a written transfer agreement with a hospital that meets the
requirements of paragraph (b)(2) of this section; or
The ASC must—
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
416.41 (c)(1)
The ASC must maintain a written disaster preparedness plan that
Standard :
provides for the emergency care of patients, staff and others in the
Disaster
facility in the event of fire, natural disaster, functional failure of
preparedness plan equipment, or other unexpected events or circumstances that are
likely to threaten the health and safety of those in the ASC.
416.41 (c)(2)
The ASC coordinates the plan with State and local authorities, as
Standard :
appropriate.
Disaster
preparedness plan
The Accreditation Association for Ambulatory Health Care 2012
AAAHC chapter
& standard
identifier
AAAHC Standards
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.
This hospital must be a local, Medicare-participating hospital or a
local, nonparticipating hospital that meets the requirements for
payment for emergency services under Title 42 CFR 482.2.
4.K-MS (3)
The ASC must—
4.K-MS (4)
Have a written transfer agreement with a hospital that meets the
requirements of 4.K-MS-2; or
The ASC must—
7.II.F
Ensure that all physicians performing surgery in the ASC have
admitting privileges at a hospital that meets the requirements of
4 K-MS-2
The organization has a comprehensive written emergency and
disaster preparedness plan to address internal and external
emergencies, including participating in community health
emergency or disaster preparedness, when applicable. The written
plan must include a provision for the safe evacuation of individuals
during an emergency, especially individuals who are at greater risk.
7.II.F-MS (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.
7.II.F-MS (2)
The ASC coordinates its disaster preparedness plan with State and
local authorities, as appropriate.
2
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
416.41 (c)(3)
The ASC conducts drills, at least annually, to test the plan's
8.E
effectiveness. The ASC must complete a written evaluation of each
Standard :
Disaster
drill and promptly implement any corrections to the plan.
preparedness plan
416.42
Condition:
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.
416.42 (a)(1)
A physician must examine the patient immediately before surgery
Standard:
to evaluate the risk of anesthesia and of the procedure to be
Anesthetic risk and performed.
evaluation
416.42 (a)(2)
Before discharge from the ASC, each patient must be evaluated by a
Standard:
physician or by an anesthetist as defined at §410.69(b) of this
Anesthetic risk and chapter, in accordance with applicable State health and safety laws,
evaluation
standards of practice, and ASC policy, for proper anesthesia
recovery
416.42 (b)(1)
Anesthetics must be administered by only—
Standard:
A qualified anesthesiologist; or
Administration of
anesthesia
416.42 (b)(2)
A physician qualified to administer anesthesia, a certified registered
Standard:
nurse anesthetist (CRNA) or an anesthesiologist's assistant as
Administration of defined in §410.69(b) of this chapter, or a supervised trainee in an
anesthesia
approved educational program. In those cases in which a nonphysician administers the anesthesia, unless exempted in
accordance with paragraph (d)(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.
The Accreditation Association for Ambulatory Health Care 2012
10.I.C-MS
9.D-MS
9.M-MS
9.F-MS (1)
9.F-MS (2)
3
AAAHC Standards
The organization requires at least one (1) drill each calendar
quarter of the internal emergency and disaster preparedness plan.
One (1) of the annual drills must be a documented cardiopulmonary
resuscitation (CPR) technique drill, as appropriate to the
organization. The organization must complete a written evaluation
of each drill and promptly implement any corrections or
modifications to the plan
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.
A physician must examine the patient immediately before surgery
to evaluate the risk of anesthesia and of the procedure to be
performed.
Before discharge from the ASC, each patient must be evaluated by a
physician or by an anesthetist as defined at Title 42 CFR 410.69
(b), in accordance with applicable State health and safety laws,
standards of practice, and ASC policy, for proper anesthesia
recovery
Anesthetics must be administered by only—
A qualified anesthesiologist; or
A physician qualified to administer anesthesia, a certified registered
nurse anesthetist (CRNA) or an anesthesiologist's assistant as
defined in Title 42 CFR §410.69(b), or a supervised trainee in an
approved educational program. In those cases in which a nonphysician administers the anesthesia, unless exempted in
accordance with Title 42 CFR §416.42 (d)(c) , 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.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
416.42 (c)(1)
Standard:
State exemption
9.B-MS (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.
An ASC may be exempted from the requirement for physician
supervision of CRNAs as described in Title 42 CFR 416.42(b)(2), 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.
416.42 (c)(2)
Standard:
State exemption
416.43
Condition:
Quality assessment
and performance
improvement
The request for exemption and recognition of State laws, and the
withdrawal of the request may be submitted at any time, and are
effective upon submission.
The ASC must develop, implement and maintain an ongoing, datadriven quality assessment and performance improvement (QAPI)
program.
The request for exemption and recognition of State laws, and the
withdrawal of the request may be submitted at any time, and are
effective upon submission.
In striving to improve the quality of care and to promote more
effective and efficient utilization of facilities and services, an
accreditable organization maintains an active, integrated,
organized, ongoing, data-driven, peer-based program of quality
management and improvement that links peer review, quality
improvement activities and risk management in an organized,
systematic way.
416.43 (a)(1)
Standard :
Program scope
The program must include, but not be limited to, an ongoing
5.II.A-MS (1)
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
The ASC must measure, analyze, and track quality indicators,
5.III.C-MS (1)
adverse patient events, infection control and other aspects of
performance that includes care and services furnished in the ASC.
416.43 (a)(2)
Standard :
Program scope
The Accreditation Association for Ambulatory Health Care 2012
AAAHC chapter
& standard
identifier
9.B-MS (2)
5, Quality
Mangement and
Improvement
4
AAAHC Standards
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
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.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
416.43 (b)(1)
Standard :
Program data
The program must incorporate quality indicator data, including
5.II.A-5-6
patient care and other relevant data regarding services furnished in
the ASC.
The Accreditation Association for Ambulatory Health Care 2012
AAAHC chapter
& standard
identifier
AAAHC Standards
The organization develops and implements a quality improvement
program that is broad in scope to address clinical, administrative
and cost-of-care performance issues, as well as actual patient
outcomes, i.e., results of care, including safety of patients.
Characteristics of the written program must include, but are not
limited to:
5. Development of processes to identify important problems or
concerns that are appropriate to address for improving the quality
of services provided by the organization
6. Identification of quality improvement activities such as studies,
including methods for performing internal and external
benchmarking1 to support the goals of the program
5.II.B-2, 5
The organization conducts specific quality improvement activities
that support the goals of the written QI program. Written reports of
QI activities must demonstrate that each activity includes at least
the following elements:
2. Identification of the performance goal against which the
organization will compare its current performance in the area of
study
5. Data analysis that describes findings about the frequency,
severity and source(s) of the problem(s).
5.II.C-2
The organization's written quality improvement program must
include participation in external performance benchmarking
activities that allow for the comparison of key perfromance
measures with other similar organizations or with recognized best
practices of national or professional targets or goals.
2. Results of benchmarking activities must be incorporated into
other quality improvement activities of the organization
5
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.43 (b)(2)
Standard :
Program data
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.
5.II.A-5-6
The organization develops and implements a quality improvement
program that is broad in scope to address clinical, administrative
and cost-of-care performance issues, as well as actual patient
outcomes, i.e., results of care, including safety of patients.
Characteristics of the written program must include, but are not
limited to:
5. Development of processes to identify important problems or
concerns that are appropriate to address for improving the quality
of services provided by the organization
6. Identification of quality improvement activities such as studies,
including methods for performing internal and external
benchmarking1 to support the goals of the program
5.II.B-5-9
The organization conducts specific quality improvement activities
that support the goals of the written QI program. Written reports of
QI activities must demonstrate that each activity includes at least
the following elements:
5. Data analysis that describes findings about the frequency,
severity and source(s) of the problem(s)
6. A comparison of the organization’s current performance in the
area of study against the previously identified performance goal
7. Implementation of corrective action(s) to resolve identified
problem(s)
8. Re-measurement (a second round of data collection and analysis
as described in Standard 5.II.B-4-6) to objectively determine
whether the corrective actions have achieved and sustained
demonstrable improvement
9. If the initial corrective action(s) did not achieve and/or sustain
the desired improved performance, implementation of additional
corrective action(s) and continued remeasurement until the
problem is resolved or is no longer relevant
The organization’s benchmarking activities may include, but are
not limited to:
a. The use of selected performance measures that are appropriate
for improving the processes or outcomes of care relevant to the
patients served
5.II.C-1a
The Accreditation Association for Ambulatory Health Care 2012
6
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
416.43 (c)(1)
The ASC must set priorities for its performance improvement
5.II.A-MS (2)
Standard :
activities that—
Program activities (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
416.43 (c)(2)
Performance improvement activities must track adverse patient
5.II.A-MS (3)
Standard :
events, examine their causes, implement improvements, and ensure
Program activities that improvements are sustained over time.
416.43 (c)(3)
The ASC must implement preventive strategies throughout the
2.I.B-21
Standard :
facility targeting adverse patient events and ensure that all staff are
Program activities familiar with these strategies.
The Accreditation Association for Ambulatory Health Care 2012
7
AAAHC Standards
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
Performance improvement activities must track adverse patient
events, examine their causes, implement improvements, and ensure
that improvements are sustained over time.
Governing body responsibilities include, but are not limited to:
21. Establishing processes for the identification, reporting, analysis,
and prevention of adverse incidents and ensuring consistent and
effective implementation by developing a system that includes:
a. Definition of an adverse incident that, at a minimum,
includes:
i. An unexpected occurrence during a health care encounter
involving patient death or serious physical or psychological injury
or illness, including loss of limb or function, not related to the
natural course of the patient’s illness or underlying condition
ii. Any process variation for which a recurrence carries a
significant chance of a serious adverse outcome
iii. Events such as actual breaches in medical care,
administrative procedures or other events resulting in an outcome
that is not associated with the standard of care or acceptable risks
associated with the provision of care and service for a patient
iv. Circumstances or events that could have resulted in an
adverse event
b. Review of frequency of occurrences, severity of outcomes and
reportable events
c. A process for conducting a thorough analysis when an adverse
incident occurs in order to identify the basic or causal factors that
underlie variation in performance, including the occurrence or
possible occurrence of an adverse incident. The analysis identifies
potential improvements in processes or systems that would tend to
decrease the likelihood of such incidents in the future, or
d
i
f
l i h
hi
ii
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
416.43 (c)(3)
The ASC must implement preventive strategies throughout the
Standard :
facility targeting adverse patient events and ensure that all staff are
Program activities familiar with these strategies.
d. A process for reporting adverse incidents through established
channels within the organization and, as appropriate, to external
agencies in accordance with law and regulation.
e. An action plan that identifies the strategies that the
organization intends to implement to reduce the risk of similar
incidents occurring in the future. The plan should address
responsibility for implementation, oversight, pilot testing as
appropriate, time lines, and strategies for measuring the
effectiveness of the actions
3.B-7
4.E-1
5.III.C-MS (2)
5.III.G
416.43 (d)(1)
Standard :
Performance
improvement
projects
416.43 (d)(2)
Standard :
Performance
improvement
projects
416.43 (e)(1)
Standard :
Governing body
responsibilities
The number and scope of distinct improvement projects conducted
annually must reflect the scope and complexity of the ASC's
services and operations.
AAAHC Standards
5.II.A-MS (4)
Specify privileges and responsibilities of employment, including
compliance with an adverse incident reporting system, as described
in Standard 2.I.B-21.
The organization facilitates the provision of high-quality health
care as demonstrated by the following:
1. Health care provided is consistent with current professional
knowledge
The ASC must implement preventive strategies throughout the
facility targeting adverse patient events and ensure that all staff are
familiar with these strategies.
Education in risk management activities, including infection
control and safety policies and processes, is provided to all staff
within thirty (30) days of commencement of employment, annually
thereafter, and when there is an identified need.
The number and scope of distinct improvement projects conducted
annually must reflect the scope and complexity of the ASC's
services and operations.
The ASC must document the projects that are being conducted. The 5.II.A-MS (5)
documentation, at a minimum, must include the reason(s) for
implementing the project, and a description of the project's results.
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.
The governing body must ensure that the QAPI program—
Is defined, implemented, and maintained by the ASC.
The governing body must ensure that the QAPI program—
Is defined, implemented, and maintained by the ASC.
The Accreditation Association for Ambulatory Health Care 2012
5.II.A-MS (6)
8
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.43 (e)(2)
Standard :
Governing body
responsibilities
416.43 (e)(3)
Standard :
Governing body
responsibilities
416.43 (e)(4)
Standard :
Governing body
responsibilities
416.43 (e)(5)
Standard :
Governing body
responsibilities
416.44
Condition:
Environment
416.44 (a)
Standard:
Physical
Environment
416.44 (a)(1)
Standard:
Physical
Environment
416.44 (a)(2)
Standard:
Physical
environment
416.44 (a)(3)
Standard:
Physical
environment
The governing body must ensure that the QAPI program—
Addresses the ASC's priorities and that all improvements are
evaluated for effectiveness.
5.II.A‐MS(7)
The governing body must ensure that the QAPI program—
Addresses the ASC's priorities and that all improvements are
evaluated for effectiveness.
The governing body must ensure that the QAPI program—
Specifies data collection methods, frequency, and details.
5.II.A-MS (8)
The governing body must ensure that the QAPI program—
Specifies data collection methods, frequency, and details.
The governing body must ensure that the QAPI program—
Clearly establishes its expectations for safety.
5.II.A-MS (9)
The governing body must ensure that the QAPI program—
Clearly establishes its expectations for safety.
The governing body must ensure that the QAPI program—
5.II.A-MS (10)
Adequately allocates sufficient staff, time, information systems and
training to implement the QAPI program.
The governing body must ensure that the QAPI program—
Adequately allocates sufficient staff, time, information systems and
training to implement the QAPI program.
The ASC must have a safe and sanitary environment, properly
constructed, equipped, and maintained to protect the health and
safety of patients.
The ASC must provide a functional and sanitary environment for
the provision of surgical services.
8.MS
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.
The ASC must have a separate recovery room and waiting area.
10.I.I-MS.
The ASC must have a safe and sanitary environment, properly
constructed, equipped, and maintained to protect the health and
safety of patients.
Surgical procedures must be performed in a functional and sanitary
environment and are limited to those procedures that are approved
by the governing body upon the recommendation of qualified
medical staff.
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.
The ASC must have a separate recovery room and waiting area.
The ASC must establish a program for identifying and preventing
infections, maintaining a sanitary environment, and reporting the
results to appropriate authorities.
4.F-5
10.I.A
8.N-MS
7.I.A
The Accreditation Association for Ambulatory Health Care 2012
9
The organization provides for accessible and available health
services and ensures patient safety by at least the following:
5. A mechanism to notify public health authorities of reportable
conditions
The organization must establish a program for identifying and
preventing infections, maintaining a sanitary environment, and
reporting the results to appropriate authorities.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.44 (a)(3)
Standard:
Physical
environment
The ASC must establish a program for identifying and preventing
infections, maintaining a sanitary environment, and reporting the
results to appropriate authorities.
7.I.C
The infection control and prevention program reduces the risk of
healthcare associated infection as evidenced by education and active
surveillance, consistent with:
1. WHO, CDC or other nationally-recognized guidelines for hand
hygiene
2. CDC or other nationally-recognized guidelines for safe injection
practices
3. Precautions to minimize communicable disease exposure to
patients healthcare staff and others
Procedures are available to minimize the sources and transmission
of infections, including adequate surveillance techniques.
7.I.G
416.44 (a)(3)
Standard:
Physical
environment
416.44 (b)(1)
Standard:
Safety from fire
416.44 (b)(2)
Standard:
Safety from fire
416.44 (b)(3)
Standard:
Safety from fire
416.44 (b)(4)
Standard:
Safety from fire
The ASC must establish a program for identifying and preventing
infections, maintaining a sanitary environment, and reporting the
results to appropriate authorities.
8.M
A system exists for the proper identification, management,
handling, transport, treatment, and disposal of hazardous materials
and wastes, whether solid, liquid, or gas.
1. The system includes, but is not limited to, infectious,
radioactive, chemical, and physical hazards.
2. The system provides for the protection of patients, staff, and the
environment
Except as otherwise provided in this section, the ASC must meet
Physical
AAAHC Physical Environment Checklist for Ambulatory Surgery
the provisions applicable to Ambulatory Health Care Centers of the Environment
Centers based on the 2000 LSC [The checklist is contained in a
2000 edition of the Life Safety Code of the National Fire Protection Checklist (PEC) for separate document.]
Association, regardless of the number of patients served.
Ambulatory
Surgical Centers
NOTE: In consideration of a recommendation by the State survey
In consideration of a recommendation by the State survey agency, Physical
agency, CMS may waive, for periods deemed appropriate, specific
Environment
CMS may waive, for periods deemed appropriate, specific
provisions of the Life Safety Code which, if rigidly applied, would Checklist (PEC) for provisions of the Life Safety Code which, if rigidly applied, would
result in unreasonable hardship upon an ASC, but only if the
Ambulatory
result in unreasonable hardship upon an ASC, but only if the
waiver will not adversely affect the health and safety of the patients.
waiver will not adversely affect the health and safety of the patients. Surgical Centers
The provisions of the Life Safety Code do not apply in a State if
Will only be applied
CMS finds that a fire and safety code imposed by State law
on a case-by-case
adequately protects patients in an ASC.
basis
An ASC must be in compliance with Chapter 21.2.9.1, Emergency Physical Environment
Checklist (PEC) for
Lighting, beginning on March 13, 2006.
The Accreditation Association for Ambulatory Health Care 2012
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.
See requirements for 3. Exiting, 3.15
ASCs
10
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
416.44 (b)(5)
Standard:
Safety from fire
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 health care
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;
(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 ft
(1.2m) from each other;
(D) Not more than an aggregate 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
(5) (v) The dispensers are maintained in accordance with dispenser
manufacturer guidelines.
Physical
See requirements for 6.2 ABHR dispensers
Environment
Checklist (PEC) for
Ambulatory
Surgical Centers
The Accreditation Association for Ambulatory Health Care 2012
11
AAAHC Standards
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
416.44 (c)
Standard:
Emergency
equipment
Emergency equipment available to the operating rooms must
8.O-MS
include at least. 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:
8.O-MS (1)
Emergency call system.Be immediately available for use during
emergency situations.
Emergency equipment available to the operating rooms must
include at least. 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:
Emergency call system.Be immediately available for use during
emergency situations.
Oxygen. Be appropriate for the facility’s patient population.
Oxygen. Be appropriate for the facility’s patient population.
416.44 (c)(1)
Standard:
Emergency
equipment
416.44 (c)(2)
Standard:
Emergency
equipment
416.44 (c)(3)
Standard:
Emergency
equipment
416.44 (c)(4)
Standard:
Emergency
equipment
416.44 (c)(5)
Standard:
Emergency
equipment
416.44 (c)(6)
Standard:
Emergency
equipment
416.44 (c)(7)
Standard:
Emergency
equipment
416.44 (c)(8)
Standard:
Emergency
equipment
AAAHC chapter
& standard
identifier
8.O-MS (2)
AAAHC Standards
8.O-MS (3)
Mechanical ventilatory assistance equipment including airways,
manual breathing bag, and ventilator. Be maintained by appropriate
personnel.
Mechanical ventilatory assistance equipment including airways,
manual breathing bag, and ventilator. Be maintained by appropriate
personnel.
Cardiac defibrillator.
8.O-MS (4)
(4) Cardiac defibrillator.
Cardiac monitoring equipment.
8.O-MS (5)
(5) Cardiac monitoring equipment.
Tracheostomy set.
8.O-MS (6)
(6) Tracheostomy set.
Laryngoscopes and endo-tracheal tubes.
8.O-MS (7)
(7) Laryngoscopes and endo-tracheal tubes.
Suction equipment.
8.O-MS (8)
(8) Suction equipment.
The Accreditation Association for Ambulatory Health Care 2012
12
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.44 (c)(9)
Standard:
Emergency
equipment
416.44 (d)
Standard :
Emergency
personnel
Emergency medical equipment and supplies specified by the
medical staff.
8.O-MS (9)
(9) Emergency medical equipment and supplies specified by the
medical staff.
Personnel trained in the use of emergency equipment and in
cardiopulmonary resuscitation must be available whenever there is
a patient in the ASC.
10.I.K
416.45
Condition:
Medical staff
The medical staff of the ASC must be accountable to the governing 2.II.A
body.
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.
Health care professionals trained in the use of emergency
equipment and BLS must be available whenever there is a patient in
the facility. At least one (1) physician or dentist is present or
immediately available by telephone whenever patients are
physically present in the facility
The medical staff must be accountable to the governing body. The
governing body establishes and is responsible for a credentialing
and reappointment process, applying criteria in a uniform manner
to appoint individuals to provide patient care for the organization.
The governing body approves mechanisms for credentialing,
reappointment and the granting of privileges, and suspending or
terminating clinical privileges, including provisions for appeal of
such decisions
Privileges to carry out specified procedures are granted by the
organization to the health care professiona to practice for a
specified period of time. The health care professional must be
legally and professionally qualified for the privileges granted.
These privileges are granted based on an applicant’s qualifications
within the services provided by the organization and
recommendations from qualified medical personnel
Surgical procedures must be performed in a safe manner only by
qualified providers who:
1. Are licensed to perform such procedures within the state in
which the organization is located
2. Have been granted clinical privileges to perform those procedures
by the governing body, in accordance with Chapter 2.II
2.II.D
10.I.C
10.II.B-1
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.
The Accreditation Association for Ambulatory Health Care 2012
2.II.C-MS
13
The organization ensures that its facility provides a safe
environment, including:
1. Granting privileges for each specific device
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.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
416.45 (c)
If the ASC assigns patient care responsibilities to practitioners
Standard:
other than physicians, it must have established policies and
Other practitioners procedures, approved by the governing body, for overseeing and
evaluating their clinical activities.
416.46
The nursing services of the ASC must be directed and staffed to
Condition:
assure that the nursing needs of all patients are met.
Nursing services
416.46 (a)
Patient care responsibilities must be delineated for all nursing
Standard:
service personnel. Nursing services must be provided in accordance
Organization and with recognized standards of practice. There must be a registered
staffing
nurse available for emergency treatment whenever there is a patient
in the ASC
416.47
The ASC must maintain complete, comprehensive, and accurate
Condition:
medical records to ensure adequate patient care.
Medical records
416.47 (a)
Standard:
Organization
416.47 (b)
Standard:
Form and content
of record
The ASC must develop and maintain a system for the proper
collection, storage, and use of patient records.
AAAHC chapter
& standard
identifier
AAAHC Standards
2.II.G-MS
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.
The nursing services of the ASC must be directed and staffed to
assure that the nursing needs of all patients are met.
10.I.H-MS (1)
10.I.H-MS (2)
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
6, Clinical Records An accreditable organization maintains electronic and/or paper
and Health
clinical records and a health information system from which
Information
information can be retrieved promptly. Clinical records are
complete, comprehensive, legible, documented accurately in a
timely manner, and readily accessible to health care professionals.
6.A
The organization develops and maintains a system for the proper
collection, processing, maintenance, storage, retrieval, and
distribution of patient records.
6.A-MS
The ASC must develop and maintain a system for the proper
collection, storage, and use of patient records.
Clinical record entries are legible and easily accessible within the record
by the organization’s personnel.
6.D
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:
6.D-MS
The Accreditation Association for Ambulatory Health Care 2012
14
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:
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
416.47 (b)
Standard:
Form and content
of record
6.F
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:
There is a designated person in charge of clinical records whose
responsibilities include, but are not limited to:
1. The confidentiality, security and physical safety of records
2. The timely retrieval of individual records upon request
3. The unique identification of each patient’s record
4. The supervision of the collection, processing, maintenance, storage,
and appropriate access to and usage of records
5. The maintenance of a predetermined, organized and secured record
format
416.47 (b)(1)
Standard:
Form and content
of record
Patient identification
An individual clinical record is established for each person
receiving care. Each record includes, but is not limited to:
1. Name
2. Identification number (if applicable)
3. Date of birth
4. Gender
5 Responsible party if applicable
Unique patient identifiers are consistently used throughout care.
6.B
7.II.D
416.47 (b)(2)
Standard:
Form and content
of record
Significant medical history and results of physical examination
4.E-3
6.I
6.L-3,4
10.I.D
The Accreditation Association for Ambulatory Health Care 2012
15
AAAHC Standards
The organization facilitates the provision of high-quality health
care as demonstrated by the following:
3. Appropriate and timely diagnosis based on findings of the
current history and physical examination
Reports, histories and physicals, progress notes, and other patient
information (such as laboratory reports, x-ray readings, operative
reports, and consultations) are reviewed and incorporated into the
record in a timely manner.
Entries in a patient's clinical record for each visit include, but are
not limited to:
3. Clinical findings
4. Discharge diagnosis or impression
An appropriate and current health history must be completed, with
a list of current prescription and non-prescription medications and
dosages, when available, physical examination, and pertinent preoperative diagnostic studies incorporated into the patient’s clinical
record within thirty (30) days prior to the scheduled
surgery/procedure
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.47 (b)(3)
Standard:
Form and content
of record
Pre-operative diagnostic studies (entered before surgery), if
performed
4.E-9
The organization facilitates the provision of high-quality health
care as demonstrated by the following:
9. Appropriate and timely follow-up of findings and tests
Reports, histories and physicals, progress notes, and other patient
information (such as laboratory reports, x-ray readings, operative
reports, and consultations) are reviewed and incorporated into the
record in a timely manner.
Entries in a patient's clinical record for each visit include, but are
not limited to:
5. Studies ordered, such as laboratory or x-ray studies
6.I
6.L-5
10.I.D
416.47 (b)(4)
Standard:
Form and content
of record
416.47 (b)(4)
Standard:
Form and content
of record
Findings and techniques of the operation, including a pathologist's 10.I.L
report on all tissues removed during surgery, except those exempted
by the governing body.
416.47 (b)(5)
Standard:
Form and content
of record
Any allergies and abnormal drug reactions
6.K
416.47 (b)(6)
Standard:
Form and content
of record
Entries related to anesthesia administration
9.I
Findings and techniques of the operation, including a pathologist's 10.I.M
report on all tissues removed during surgery, except those exempted
by the governing body.
The Accreditation Association for Ambulatory Health Care 2012
16
An appropriate and current health history must be completed, with
a list of current prescription and non-prescription medications and
dosages, when available, physical examination, and pertinent preoperative diagnostic studies incorporated into the patient’s clinical
record within thirty (30) days prior to the scheduled
surgery/procedure
With the exception of those tissues exempted by the governing body
after medical review, tissues removed during surgery are examined
by the pathologist, whose signed report of the examination is made
a part of the patient’s record.
The findings and techniques of a procedure are accurately and
completely documented immediately after the procedure by the
health care professional who performed the procedure. This
description is immediately available for patient care and becomes a
part of the patient’s record
The presence or absence of allergies and untoward reactions to
drugs and materials is recorded in a prominent and consistent
location in all clinical records. This is verified at each patient
encounter and updated whenever new allergies or sensitivities are
identified
Clinical records include entries related to anesthesia administration.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.47 (b)(7)
Standard:
Form and content
of record
Documentation of properly executed informed patient consent
6.P
Discussions with the patient concerning the necessity,
appropriateness and risks of proposed care, surgery or procedure, as
well as discussions of treatment alternatives and advance directives,
as applicable, are incorporated into the patient’s medical record.
9.E
The informed consent of the patient, or if applicable, of the patient
representative, is obtained before the procedure is performed. One
consent form may be used to satisfy the requirements of this
standard and Standard 10.I.T
The informed consent of the patient, or if applicable, of the
patient’s representative, is obtained before an operation is
performed.
Entries in a patient's clinical record for each visit include, but are
not limited to:
4. Discharge diagnosis or impression
10.I.T
416.47 (b)(8)
Standard:
Form and content
of record
416.48
Condition:
Pharmaceutical
services
Discharge diagnosis.
6.L-4
The ASC must provide drugs and biologicals in a safe and effective 11.A
manner, in accordance with accepted professional practice, and
under the direction of an individual designated responsible for
pharmaceutical services.
416.48 (a)
Drugs must be prepared and administered according to established 11.B
Standard:
policies and acceptable standards of practice.
11.C
Administration of
drugs
11.D
416.48 (a)
Drugs must be prepared and administered according to established 11.E
Standard:
policies and acceptable standards of practice.
Administration of
11.F
drugs
The Accreditation Association for Ambulatory Health Care 2012
17
Pharmaceutical services are provided or made available in a safe
and effective manner, in accordance with accepted professional
practice, and under the direction of an individual designated
responsible for pharmaceutical services in accordance with
Standard 11.J.
Pharmaceutical services are provided in accordance with ethical
and professional practice and applicable federal and state laws.
Staff demonstrates knowledge of applicable state and federal
pharmaceutical laws.
Records and security are maintained to ensure the control and safe
dispensing of drugs, including samples, in compliance with federal
and state laws.
Staff informs patients concerning safe and effective use of
medications consistent with legal requirements and patient needs.
Measures have been implemented to ensure that prescription pads
are controlled and secured from unauthorized patient access, and
pre-signed and/or postdated prescriptions pads are prohibited.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
Drugs must be prepared and administered according to established 11.G
416.48 (a)
policies and acceptable standards of practice.
Standard:
Administration of
drugs
11.H
11.I
All medications, including vaccines and samples, are checked for
expiration dates on a regular basis; expired items are disposed of in
a manner that prevents unauthorized access, protects safety, and
meets state and federal requirements.
All injectable medications drawn into syringes or oral medications
removed from the packaging identified by the original manufacturer
must be appropriately labeled if not administered immediately.
Adverse reactions must be reported to the physician responsible for 6.K-MS
the patient and must be documented in the record.
The organization must have policies in place for safe use of
injectables and single-use syringes and needles that at minimum
include the CDC or comparable guidelines for safe injection
practices.
Providers or other health care professionals who prescribe,
dispense, administer and provide patient education on medications
have easy access to current drug information and other decision
support resources.
If such medications are present, the organization identifies and
maintains a current list of look-alike and sound-alike medications,
and actions to prevent errors are evident.
Procedures are established by the organization for maintenance,
cleaning, distribution and use of devices such as nebulizer units,
intravenous infusion pumps or any other mechanical device used in
the medication delivery process.
Adverse reactions must be reported to the physician responsible for
the patient and must be documented in the record.
Blood and blood products must be administered by only physicians 11.B-MS (1)
or registered nurses.
Blood and blood products must be administered by only physicians
or registered nurses.
Orders given orally for drugs and biologicals must be followed by a 11.B-MS (2)
written order, signed by the prescribing physician.
Orders given orally for drugs and biologicals must be followed by a
written order, signed by the prescribing physician.
11.K
11.L
11.M
416.48 (a)(1)
Standard:
Administration of
drugs
416.48 (a)(2)
Standard:
Administration of
drugs
416.48 (a)(3)
Standard:
Administration of
drugs
AAAHC Standards
The Accreditation Association for Ambulatory Health Care 2012
18
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
416.49
Condition:
Laboratory and
Radiologic
Services
416.49 (a)
If the ASC performs laboratory services, it must meet the
Standard:
requirements of Part 493 Title 42 of the Code of Federal
Laboratory services Regulations. 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 Title 42 of the Code of Federal
Regulations. 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
Title 42 of the Code of Federal Regulations
416.49 (b)(1)
The ASC must have procedures for obtaining radiological services
Standard :
from a Medicare approved facility to meet the needs of patients.
Radiologic services
Radiologic services must meet the hospital conditions of
416.49(b)(2)
Standard :
participation for radiologic services specified in §482.26 of this
Radiologic services chapter.
416.50
Condition:
Patient Rights
416.50 (a)
Standard :
Notice of rights
AAAHC chapter
& standard
identifier
AAAHC Standards
12.II.A
An accreditable organization providing laboratory services meets
the requirements of CLIA (part 493 of Title 42 of the Code of
Federal Regulations) and has obtained a CLIA certificate.
12.I.A-2
An accreditable organization:
2. Has procedures for obtaining routine and emergency laboratory
services from a certified laboratory in accordance with CLIA if it
does not perform its own laboratory services.
13.A-MS (1)
The ASC must have procedures for obtaining radiology service,
from a Medicare approved facility to meet the needs of patients.
13.A-MS (2)
Radiologic services must meet the hospital conditions of
participation for radiologic services specified in Title 42 CFR
482.26.
The ASC must inform the patient or the patient’s representative or
1.F-MS
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.
An ASC must, prior to the start of the surgical procedure, provide the
1.F-MS (1)
patient, 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, or the patient’s representative, or the surrogate
understands 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
Website for the Office of the Medicare Beneficiary Ombudsman.
The Accreditation Association for Ambulatory Health Care 2012
19
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 Title 42 CFR 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.
An ASC must, prior to the start of the surgical procedure, provide the
patient, 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, or the patient’s representative, or the surrogate
understands all of the patient’s rights as set forth in Title 42 CFR 416.50
(a).
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
Website for the Office of the Medicare Beneficiary Ombudsman.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.50 (b)
Standard :
Disclosure of
physician financial
interest or
ownership
416.50 (c)(1)
Standard :
Advance directives
The ASC must disclose, in accordance with Part 420 of this subchapter,
and where applicable, provide a list of physicians who have financial
interests or ownership in the ASC facility. Disclosure of information must
be in writing.
2.I.A-1-MS
The ASC must disclose, in accordance with Title 42 CFR Part 420, and
where applicable, provide a list of physicians who have financial interests
or ownership in the ASC facility. Disclosure of information must be in
writing.
The ASC must comply with the following requirements:
1.F-8-MS (1)
The ASC must 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.
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.
416.50 (c)(2)
Inform the patient or, as appropriate, the patient's representative of 1.D-MS
Standard :
the patient's right to make informed decisions regarding the
Advance directives patient's care.
Inform the patient or, as appropriate, the patient's representative of
the patient's right to make informed decisions regarding the
patient's care.
416.50 (c)(3)
Document in a prominent part of the patient's current medical
Standard :
record, whether or not the individual has executed an advance
Advance directives directive.
Document in a prominent part of the patient's current medical
record, whether or not the individual has executed an advance
directive.
416.50 (d)
Standard :
Submission and
investigation of
grievances
416.50 (d)(1)
Standard :
Submission and
investigation of
grievances
416.50 (d)(2)
Standard :
Submission and
investigation of
grievances
1.F-8-MS (2)
The ASC must establish a grievance procedure for documenting the 2.I.B-20-MS
existence, submission, investigation, and disposition of a patient's
written or verbal grievance to the ASC. The following criteria must
be met:
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:
All alleged violations/grievances relating, but not limited to,
mistreatment, neglect, verbal, mental, sexual, or physical abuse,
must be fully documented.
2.I.B-20-MS (1)
All alleged violations/grievances relating, but not limited to,
mistreatment, neglect, verbal, mental, sexual, or physical abuse,
must be fully documented.
All allegations must be immediately reported to a person in
authority in the ASC.
2.I.B-20-MS (2)
All allegations must be immediately reported to a person in
authority in the ASC.
The Accreditation Association for Ambulatory Health Care 2012
20
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.50 (d)(3)
Standard :
Submission and
investigation of
grievances
416.50(d)(4)
Standard :
Submission and
investigation of
grievances
416.50 (d)(5)
Standard :
Submission and
investigation of
grievances
416.50 (d)(6)
Standard :
Submission and
investigation of
grievances
Only substantiated allegations must be reported to the State
authority or the local authority, or both.
2.I.B-20-MS (3)
Only substantiated allegations must be reported to the State
authority or the local authority, or both.
The grievance process must specify timeframes for review of the
grievance and the provisions of a response.
2.I.B-20-MS (4)
The grievance process must specify timeframes for review of the
grievance and the provisions of a response.
416.50 (e)(1)(i)
Standard :
Exercise of rights
and respect for
property and
person
416.50 (e)(1)(ii)
Standard :
Exercise of rights
and respect for
property and
person
The ASC, in responding to the grievance, must investigate all
2.I.B-20-MS (5)
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.
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.
The ASC must document how the grievance was addressed, as well 2.I.B-20-MS (6)
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 results of the grievance process, and
the date the grievance process was completed.
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 results of the grievance process, and
the date the grievance process was completed.
The patient has the right to the following—
The patient has the right to the following—
1.L-MS (1)
Be free from any act of discrimination or reprisal.
Be free from any act of discrimination or reprisal.
Voice grievances regarding treatment or care that is (or fails to be) 1.E
furnished.
Patients are given the opportunity to participate in decisions
involving their health care, except when such participation is
contraindicated for medical reasons.
Patients are informed about procedures for expressing suggestions,
complaints and grievances, including those required by state and
federal regulations.
Voice grievances regarding treatment or care that is (or fails to be)
furnished.
The Accreditation Association for Ambulatory Health Care 2012
1.L
1.L-MS (2)
21
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.50 (e)(1)(iii)
Standard :
Exercise of rights
and respect for
property and
person
416.50 (e)(2)
Standard :
Exercise of rights
and respect for
property and
person
416.50 (e)(3)
Standard :
Exercise of rights
and respect for
property and
person
416.50 (f)
Standard :
Privacy and safety
Be fully informed about a treatment or procedure and the expected
outcome before it is performed.
1.D-MS (1)
The patient has the right to be fully informed about a treatment or
procedure and the expected outcome before it is performed.
If a patient is adjudged incompetent under applicable State laws by 1.D-MS (2)
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.
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.
If a State court has not adjudged a patient incompetent, any legal
representative designated by the patient in accordance with State
law may exercise the patient's rights to the extent allowed by State
law.
1.D-MS (3)
If a State court has not adjudged a patient incompetent, any legal
representative designated by the patient in accordance with State
law may exercise the patient's rights to the extent allowed by State
law.
416.50 (f)(1)
Personal privacy.
Standard :
Privacy and safety
1.B-MS
The patient has the right to personal privacy.
Receive care in a safe setting.
416.50 (f)(2)
Standard :
Privacy and safety
8.B-MS
The patient has the right to receive care in a safe setting
416.50 (f)(3)
Be free from all forms of abuse or harassment.
Standard :
Privacy and safety
1.A-MS
The patient has the right to be free from all forms of abuse or
harassment.
416.50 (g)
Standard :
Confidentiality of
clinical records
1.C-MS
The ASC must comply with the Department's rules for the privacy
and security of individually identifiable health information, as
specified at Title 45 CFR parts 160 and 164.
The patient has the right to—
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.
The Accreditation Association for Ambulatory Health Care 2012
22
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
416.51
Condition :
Infection Control
The ASC must maintain an infection control program that seeks to 7.I
minimize infections and communicable diseases.
Subchapter I — Infection Prevention and Control: An accreditable
organization maintains an active and ongoing infection control and
prevention program as evidenced by the following characteristics:
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.
7.I.D
The organization provides a functional and sanitary environment
for the provision of services. The organization adheres to
professionally accepted standards of practice, manufacturer’s
recommendations, and state and federal guidelines, including but
not limited to the cleaning, disinfection and sterilization of
instruments, equipment, supplies, and implants
7.I.F
A safe environment for treating patients, including adequate
safeguards to protect the patient from cross-infection, is assured
through the provision of adequate space, equipment, supplies and
personnel.
Surgical procedures must be performed in a functional and sanitary
environment and are limited to those procedures that are approved
by the governing body upon the recommendation of qualified
medical staff.
The infection control and prevention program includes
documentation that the organization has considered, selected, and
implemented nationally-recognized infection control guidelines.
The program is:
1. Approved by the governing body
2. An integral part of the organization’s quality improvement
program
3. Under the direction of a designated and qualified health care
professional who has training and current competence in infection
control
4. Implemented with a plan of action to:
a. Prevent, identify, minimize and manage infections and
communicable diseases
b. Immediately implement corrective and preventive measures
10.I.A
416.51 (b)
Standard :
Infection control
program
The ASC must maintain an ongoing program designed to prevent, 7.I.B
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)(1)
Standard :
Infection control
program
Under the direction of a designated and qualified professional who 7.I.B-3
has training in infection control;
The Accreditation Association for Ambulatory Health Care 2012
23
AAAHC Standards
The infection control and prevention program is under the direction
of a designated and qualified professional who has training in
infection control.
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.51 (b)(2)
Standard :
Infection control
program
416.51 (b)(3)
Standard :
Infection control
program
An integral part of the ASC's quality assessment and performance
improvement program; and
7.I.B-2
The infection control program is an integral part of the ASC's
quality assessment and performance improvement program; and
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.
7.I.B-5
The infection control program is 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.
7.I.G
Procedures must be available to minimize the sources and
transmission of infections, including adequate surveillance
techniques.
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.
416.52
Condition:
Patient admission,
assessment and
discharge
416.52 (a)(1)
Standard:
Patient admission,
assessment and
discharge
The ASC must ensure each patient has the appropriate pre-surgical 10.I.D-MS
and post-surgical assessments completed and that all elements of
the discharge requirements are completed.
Not more than 30 days before the date of the scheduled surgery,
10.I.D-MS (1)
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
Upon admission, each patient must have a pre-surgical assessment 10.I.D-MS (2)
416.52 (a)(2)
completed by a physician or other qualified practitioner in
Standard:
Patient admission, accordance with applicable State health and safety laws, standards
of practice, and ASC policy that includes, at a minimum, an
assessment and
updated medical record entry documenting an examination for any
discharge
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.
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 Social Security Act) or other qualified practitioner in
accordance with applicable State health and safety laws, standards
of practice and ASC policy
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
The patient's medical history and physical assessment must be
416.52 (a)(3)
placed in the patient's medical record prior to the surgical
Standard:
Patient admission, procedure.
assessment and
discharge
An appropriate and current health history must be completed, with
a list of current prescription and non-prescription medications and
dosages, when available, physical examination, and pertinent preoperative diagnostic studies incorporated into the patient’s clinical
record within thirty (30) days prior to the scheduled
surgery/procedure
The Accreditation Association for Ambulatory Health Care 2012
10.I.D
24
Effective July 16, 2012
2012 AAAHC/CMS Crosswalk REVISED
CFC #
CMS Requirements
AAAHC chapter
& standard
identifier
AAAHC Standards
416.52 (b)(1)
Standard :
Post-surgical
assessment
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, postoperative care experience in accordance with applicable State
health and safety laws, standards of practice, and ASC policy.
10.I.X-MS (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, postoperative care experience in accordance with applicable State
health and safety laws, standards of practice, and ASC policy.
416.52 (b)(2)
Standard :
Post-surgical
assessment
416.52 (c)
Standard :
Discharge
416.52 (c)(1)
Standard :
Discharge
Post-surgical needs must be addressed and included in the
discharge notes.
10.I.X-MS (2)
Post-surgical needs must be addressed and included in the
discharge notes.
The ASC must—
10.I.Y-MS (1)
The ASC must—
Provide each patient with written discharge instructions and
overnight supplies. When appropriate, make a followup
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 followup care.
10.I.Y-MS (1)
The ASC must—
416.52 (c)(2)
Standard :
Discharge
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.
10.I.Y-MS (2)
The ASC must—
416.52 (c)(3)
Standard :
Discharge
Ensure all patients are discharged in the company of a responsible
adult, except those patients exempted by the attending physician.
9.O-MS
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
The ASC must—
The Accreditation Association for Ambulatory Health Care 2012
Provide each patient with written discharge instructions and
overnight supplies. When appropriate, make a followup
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 followup care.
Ensure all patients are discharged in the company of a responsible
adult, except those patients exempted by the attending physician.
25
Effective July 16, 2012