Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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