Checklist for the Changes in the ASC Medicare Conditions For Coverage

The following checklist was prepared by the ASC Association of Illinois for the changes in the ASC Medicare Conditions for Coverage (effective May 18).

GOVERNING BODY - Policies & Procedures (written):

• Specify all details of QUALITY ASSESSMENT and PERFORMANCE IMPROVEMENT PROGRAM (QAPI) and allocate sufficient resources and EVALUATE for EFFECTIVENESS
• Approve DISASTER PREPAREDNESS PLAN and review reports
• Designate Grievance Officer
• Designate QUALIFIED INFECTION CONTROL OFFICER

MANAGEMENT & OPERATIONS - Policies & Procedures (written):

• Policy & Process for PROMPT RETURN OF ANY MONEY INCORRECTLY COLLECTED
• Written TRANSFER AGREEMENT WITH A NEARBY HOSPITAL (update if necessary)
• Develop a DISASTER PREPAREDNESS PLAN and Plan MUST BE COORDINATED WITH STATE & LOCAL AUTHORITIES
• Expand Policy & Procedures on PATIENT RIGHTS
• Must INFORM PATIENTS with VERBAL & WRITTEN NOTICE on PATIENT RIGHTS – FIND WAY TO DO IN ADVANCE OF DOS
• POST expanded NOTICE ON PATIENT RIGHTS in Lobby/Reception
• Disclose to Patients PHYSICIANS’ FINANCIAL INTEREST IN ASC – FIND WAY TO DO IN ADVANCE OF DOS
• Establish a FORMAL GRIEVANCE PROCEDURE (process, deadlines and reporting)
• Inform Patient of POLICIES ON ADVANCED DIRECTIVES – FIND WAY TO DO IN ADVANCE OF DOS
• Improve PRIVACY & SECURITY OF CLINICAL RECORDS

CLINICAL - Policies & Procedures (written):

• Patient has a RESPONSIBLE ADULT to whom Patient will be discharged or (written) WAIVER from Surgeon
• Develop SELF-ASSESSMENT and feed DATA into QAPI with MEASURABLE IMPROVEMENTS
• Develop PROACTIVE QAPI Program & Document Improvements
• Conduct PERFORMANCE IMPROVEMENT ACTIVITIES (projects) each year
• Formal Medicare-approved RADIOLOGY SERVICE
• Maintain an INFECTION CONTROL PROGRAM and PLAN OF ACTION
• H&P + Physician Assessment < or = 30 days before DOS
• H&P on Chart PRIOR to Starting Surgical Procedure
• Document Pre-Surgical Assessment prior to Procedure and
• NOTE ANY CHANGES IN PATIENT’s CONDITION SINCE H&P
• Document Pre-Surgical ANESTHESIA RISK ASSESSMENT
• Document Post-Surgical Patient Assessment
• Provide Written Discharge Instructions
• Provide Patient with OVERNIGHT SUPPLIES
• Make Follow-up Appointment with Surgeon as appropriate
• Discharge Order signed by Surgeon or other procedure
• Discharge Patient to a RESPONSIBLE ADULT except IF EXEMPTED BY THE ATTENDING PHYSICIAN
• NEVER EVENT REPORTING

This checklist is intended as a summary and guide regarding several key changes in the
Medicare Conditions for Coverage for ASCs. These changes become effective as of May 18, 2009.

The checklist is not intended as a substitute for actual Medicare standards, conditions, rules or interpretive guidelines.

This checklist was prepared by the ASC Association of Illinois, Mark Mayo, Executive Director.

For further information please contact Mark Mayo, executive director of the ASC Association of Illinois, at mayconsultant@msn.com.