Catalog Number : nad1667
Title : CMS ASC Curriculum: A $40 Million Grant to Ensure your Compliance with the Infection Control Standards in 2010
Speaker : Sue Dill

Webplay Recording Date : 10-7-2010
Webplay Price : $ 160 for two weeks viewing

Webinar Overview:

The Center for Medicare and Medicaid Services (CMS) issued new Conditions for Coverage that every freestanding ambulatory surgery center (ASC) must meet if the ambulatory surgery center wants paid for Medicare and Medicaid patients. The standards apply and must be followed for all patients treated in the ASC including worker comp and patients with commercial insurance. These standards became effective on May 18, 2009 and contained 167 pages and 267 tag numbers. The May manual also contained the 15 page infection control worksheet that must be filled out during every survey. CMS amended these on December 30, 2009.

The survey procedure or protocol covers the first 32 pages of the manual. It covers the tasks in the survey protocol. This includes off site preparation, entrance activities, gathering information and investigation, preliminary decision making and analysis of finding, exit conference, and post survey activities. This section will help ASCs prepare for the survey process by knowing what documents will be reviewed and what to expect during the survey process. It will help the ASC plan in advance as to what should be done when the surveyors show up.

Target Audience

• Anyone who is involved with the survey process if CMS shows up to do a complaint or validation survey under the CMS ambulatory surgery center conditions for coverage. This would include:
  • Board Members
  • Administrator
  • Chief Nursing Officer
  • Chief Medical Officer
  • Nurse Education
  • Department Directors
  • Compliance Officer
  • Risk Manager
  • Health Information Manager
  • Patient Safety Officer
  • Performance Improvement Coordinator
  • Infection Preventionist
  • others involved in the process

• Recall what documents will be requested during the document review session
• Discuss that the surveyor will complete the infection control worksheet during a validation survey
• Describe that compliance with the ASC CFC will be done by observations, interviews and through the document review session

• Compliance with the CFCs for payment
• Goal of the ASC survey
• Certification of compliance with standards
• Definition of an ASC
• Regulatory and policy references
• Access to the ASC by a CMS surveyor
• Off site preparation by surveyors
  • Types of surveys
  • Full or standard survey
  • Complaint survey
  • Survey team size and composition
  • Team coordinator
  • Assembling background information
• Entrance activities
  • General objectives
  • General procedures and arrival
  • Unannounced survey process
  • Entrance conference
  • Required material such as list of surgeries, locations etc.
  • Telephone, conference room, copy machine
  • Organizational chart, policies and procedures, personnel records, staff names
  • Infection control policy and program
  • List of contracted services
• Information gathering and Investigation
  • Compliance through observations, interviews and document review
  • Survey team daily meeting
  • Observations and tracers
  • ASC tour o Use of infection control tool
  • Document review session
  • Medical record review
  • Sampling for complaint survey
  • H&Ps, consents, pre-operative assessments, orders signed
  • Documentation of adverse drug reactions
  • Post op assessments documented
  • Reason for transfer to hospital
  • Discharge notes and documentation of needs
  • Interviews with staff and patients
• Preliminary decision making and analysis of findings
  • Objectives
  • Preparation
  • Discussion meetings
  • Standard or condition level citations
• Exit conference
  • Preparation for exit conference
  • Discontinuation of exit conference
  • Recording exit conference
  • General principles
  • Acceptable plan of correction
• Post Survey Activities
  • General procedures
  • Statement of deficiencies report
• Other survey package documentation

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.