AS I SEE IT
The Devil That We Know . . . With or without new Life Safety Code standards, ASCs
can prepare for successful facility surveys. BY TOM SCHEIDEL
Since the release of the 2012 edition of NFPA 101: Life Safety Code, the National Fire Protec- tion Association (NFPA)
has been working with the Centers for Medicare & Medicaid Services (CMS) toward adoption of the new standards. NFPA is projecting an adoption date of 2013 or early 2014. While the health care community awaits CMS’ decision, ASCs can take steps now to ensure that they comply with the current standards and are prepared for any changes the fu- ture might bring. After 18 years as a CMS surveyor focused primarily on health require- ments and the Life Safety Code, I have developed a few suggestions for help- ing facilities comply. In general, sur- veyors do not want to cite deficiencies. Instead, they prefer proof of compliance and will sometimes dig deep to find it. However, the time each surveyor can devote to conducting a survey, writing deficiencies and initiating the related enforcement process is limited. To help ASCs comply and success-
fully prepare for a survey, I offer two sug- gestions. First, know the CMS require- ments for Life Safety Code compliance as well as you know CMS’ requirements related to the clinical care you provide. There are many educational resources available, including the surveyors who come into your ASC, this magazine, ASCA’s meetings and webinars and the accreditation agencies such as The Joint Commission and the Accreditation As- sociation for Ambulatory Health Care. Your contractors’ representatives who inspect and service systems such as your ASC’s generator and your sprinkler, oxygen and piped gas systems can also
provide you with valuable information. These contractors are the technical ex- perts, and often you just need to ask to learn more from them. Second, try to manage the survey process and help the surveyor. Know what information is going to be re- quired in the first 60 to 90 minutes of the survey, and make certain that you
have most of that information immedi- ately available at all times so that you do not have to spend hours collecting the information you need when an inspec- tor arrives at your ASC. The develop- ers of the survey process and surveyors generally agree that the information requested is a good indicator of quality and safety. It sets the tone of the sur- vey. If you collect and evaluate these data reports monthly or quarterly, your ASC will likely avoid virtually all of the
Resources to Help You Prepare for a Survey
The process that the surveyor will use is contained in the State Operations Manual and certain CMS forms. Some materials that can help you prepare for a survey include:
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The Appendix “L” to the State Operations Manual that deals with the overall survey of ASCs, primarily the health requirements:
www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf
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The Appendix “I” to the State Operations Manual that deals with the life safety code survey for many types of health care facilities including ASCs:
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ som107ap_i_lsc.pdf
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The survey form used for life safety code surveys for ASCs (and end stage renal disease facilities):
www.cms.gov/Medicare/CMS-Forms/CMS-Forms/ Downloads/CMS2786U.pdf
Many surveyors and their agencies have taken the information out of these sources and reduced it down to a checklist or entrance form. If asked, they will often share a copy. That form, and the order in which it appears, can become the “table of contents” in a binder that contains all of this information. A binder like that can help both the surveyor and the ASC’s managers during a survey. The binder contents can be adapted and improved based on the feedback your ASC receives from each surveyor who comes into your facility.
If your facility is changing a major life-safety or environmental system, I encourage you to keep one final cost-saving idea in mind. Although it is not yet required, the 2012 Life Safety Code (NFPA 101) and its mandatory references, including the Health Care Facilities Code (NFPA 99, 2012 Edition), should be brought to the table by your architect, engineer and installer.
ASCA will alert you if CMS adopts the new life safety code, when you would need to be in compliance with the new code and when surveyors will start using it. These would probably be three separate dates a couple of months apart from each other. The information contained in this article can help you meet the existing regulatory requirements and any new regulations that are applied.
The advice and opinions expressed in this article are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion. 10 ASC FOCUS MARCH 2013
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