The following article by Gayle R. Evans, RN, MBA, CNOR, CASC, president of Continuum Healthcare Consultants, first appeared in the August edition of the AmkaiSolutions electronic newsletter. To sign up to receive the newsletter, click here.
It has been one year and two months since the revised CMS Conditions for coverage were released. It has been nine months since surveyor training has occurred through CMS. There have been condition and standard level deficiencies, plans of correction, staff training just to mention a few of the outcomes of these surveys. Taking a step back from the anxiety of these unannounced surveys and the intensity of which they present the center should look at the practicality of the requirements associated with the expectation of the American consumer and implement according as required. The media has taken these deficiencies blown them out of proportion. It is the responsibility of the ASC to clarify the deficiencies and identify the competency of the center.
Governing body responsibilities
The update CMF CfC 416.41 identifies the governing body's responsibility in full legal responsibility for determining, implementing and monitoring policies governing the center's total operation. This includes oversight and accountability of the quality improvement program, facility policies and procedures administration for providing quality healthcare in a safe environment and developing and maintaining disaster preparedness plan.
Disaster preparedness plan
Many states especially along the gulf coast require disaster preparedness plans in their centers. These centers furthermore are required to coordinate these plans with the local community disaster programs. The programs require assessing the opportunities for given disasters in a community from flooding, threat of thunderstorm or tornado to terrorism disaster where there may be local military operations. As a small center one may not feel that this is critical for their center but … what would you do? What if that dam broke as it just happened in Iowa? What if it were tornado season in the Midwest and the community was devastated? What if a hurricane like Katrina and its uncertainty was bearing down on your community even though you were hundreds of miles inland? What if there was a major power failure on your block? How your small center would react and is the consideration on your radar. Implementing a disaster preparedness plan to include a risk assessment allows a center to identify which disasters may be likely and how the center will react both in the facility and in the community. Policies related to these disasters and staff implementation of reactive efforts must be rehearsed and revised as observed. Also if the center is affiliated with a physician practice then the practice should be involved in this process.
Infection control program
We have always provided cleaning or sterilization in a specific way and never had a problem. Sterilization practices are concepts that are often "passed down" in the center rather than conducting an annual retraining through video education, etc. Vendors who sell product for use in the sterilization process are excellent resources for staff education. There are online programs that will work well also. Training the staff related to hand washing, use of waterless supplies and use of cleaning agents is important. Reading labels of all chemicals used is important as all products are different even from the same manufacturer. Performing hand washing audits of the staff can also demonstrate how the center continually assesses its infection control program implementation. Resources that are nationally recognized should be readily available for use as part of the program.
Medical record documentation
Physician and anesthesia assessments and their respective documentation have been clarified in the current guidelines. There are patient assessments that must occur by the physician performing the procedure and anesthesia provider before and after the procedure. When these assessments occur or orders are written the physician must identify the time in which the assessment or order was initiated. Historically chart documentation has been performed at the convenience of the provider either before the procedure starts immediately after the procedure or at the end of the day.
Time outs are performed in different ways. Most recent observations have been the circulator only speaking with the surgeon or the time of "time out" not being documented. It is important according to standard that the entire team participate in time out and the time of the "time out" be documented. .
History and physicals and discharge assessments are performed in different sequences in each ASC. The important aspect of this is to identify that the physician has evaluated the patient prior to the procedure according to CMS CfC416,52(a)(2). Note that this includes the anesthesia assessment in addition to the practitioner who is credentialed to perform the history and physical. Both surgeon and anesthesia should make a note regarding assessment prior to surgery. Post operative evaluation for recovery from anesthesia must be performed by the anesthesia professional. This must be documented according to the time when the assessment was performed. On the other hand the standards identify that the physician performing the procedure signs a discharge order. The caveat is that the physician order must be signed within 15-30 minutes prior to the time the patient is discharged. (72 FR 50478)
Staffing
ASC staffing can present a number of models from hiring employees directly for the center to utilizing staff in some form of contract relationship with the physician office or an agency. The center is responsible for the orientation and ongoing training of the staff whether employed or contracted by the center. The center must likewise keep files that include:
- Application (can use one from contractor)
- License and form of identification
- Orientation and ongoing competency
- Health information
The ASC should have documentation of how the staffing mix is provided for safe patient care. This can be demonstrated through the use of a time schedule or other means as identified. The center should have this information readily available if requested by surveyors. Surveyors may review timecards to verify attendance of staff in drills or other training. I have actually see this requested. When staff sign in for education the center should also list those who were not in attendance. This also provides accountability to understand who needs further training or if there is mandatory attendance one can confirm the need.
Medication administration
Security of all medication regardless of if it is stored in the cabinet for general storage or in the operating room that can be unsupervised is a process that should be reviewed in the center. The center may be small and a few employees but the opportunity for unsecure medications to fall into the hands of unauthorized individuals always exist. Demonstration of medication security in whatever fashion appropriate to the center will be observed during the survey.
Medications that are labeled "single use only" should be used in that respect. Medications that are single use only do not have preservative thus the opportunity for contamination. If medications are pre drawn prior to their use the syringe should be labeled with the drug name, concentration, date of expiration, initials of person preparing medication. Constant control of scheduled drugs must be enforced thorough policy and will be followed by a surveyor. The records must be in order and all medications accounted for when monitored by surveyor.
All pharmaceutical services must be under the direction of an individual designated responsibility for oversight. This may be a physician or a registered pharmacists. Routine review of medication practices must be a part of this individuals responsibility.
Survey preparation
Survey preparation begins months before the pending Medicare survey. Many centers have not been surveyed by CMS in over three years. There are key processes that are beneficial in preparation.
- Perform a mock survey. Have someone perform an unannounced mock survey as soon as possible. They will need to go back 6-12 months to look at records. Findings of the survey can be part of the center's QI program in showing change and how the center is working toward meeting standards.
- Policy and procedure review. Policies and procedures are the backbone of all center activities. They must be reviewed annually and meet national standards.
- Involve all staff. The new survey process involves all staff and physicians. Preparation should do the same.
- Keep the governing body informed. The governing body should listen to the needs of the center and provide support to changes implemented to comply with standard requirements.
Considering the implementation of the steps listed and recognizing that these surveys are very intense compared to previous a center can learn and look forward to hopefully learning new ideas to improve the care rendered in their facility.
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