COVER STORY
Accreditation Developments and Notes AAAASF set to begin assessing compliance with new emergency preparedness standards BY THOMAS S. TERRANOVA
The ASC community is among several provider- types about to experience a major change in the Medi- care Conditions for Cover-
age (CfC). Beginning November 15, 2017, all accreditation surveyors, in- cluding those with the American Asso- ciation for Accreditation of Ambulatory Surgery Facilities (AAAASF), will be- gin to evaluate whether the ASCs they survey are in compliance with Medi- care’s current emergency preparedness regulations. This is true for all ASCs that are certified by the Centers for Medicare & Medicaid Services (CMS). The new emergency preparedness
standards became effective on Novem- ber 16, 2016, and CMS gave facilities a year to be in compliance. ASCs must complete several required activities before accreditation surveys begin- ning November 15 of this year. These are not requirements with which pro- viders can comply merely by having a plan to conduct the required activities when the survey takes place. Instead, failure to perform the activities prior to the survey will result in deficiency citations as required by Medicare. That means that ASCs that have not started their emergency preparedness activi- ties should get started immediately. The new emergency preparedness standards require ASCs to establish and maintain a comprehensive emer- gency plan that the ASC updates at least annually. The plan should be devel- oped using an all-hazards approach to assess risk based on the specific facil- ity and the community in which it is located. This means that the assess- ment should consider natural disasters common to the area as well as man-
cise. Additional requirements apply to ASCs that are part of an integrated health system. All accreditation and state surveys beginning November 15, 2017, will assess whether the ASC has already developed its plan, conducted training and held exercises. For people who are not emergency management professionals, these tasks can seem daunting and even knowing where to begin can be difficult. Several resources are available to help ASCs get started. Remember, emergency preparedness is a community effort and ASCs are not in this alone. The Department of Health & has
Human Services created the
Office of the Assistant Secretary for Preparedness and Response (ASPR) as a resource to help providers through the
emergency planning process.
made risks. Emergency preparedness plans must also consider the ASC’s patient population and the process for cooperation with emergency respond- ers from various agencies. Generally, the plan should result in emergency policies that also are updated annually. Requirements for the plan are detailed in the regulations and recent CMS interpretive guidance. ASCs should consult these materials or accreditation agency standards directly for details. In addition to a fully developed pro- gram and written plan, the ASC must institute an emergency preparedness training and testing program that also is reviewed and updated annually. ASCs must conduct at least annual exercises and analyze the results to consider possible revisions to their plans. This annual exercise must include at least two tests; one community- or facility- based and the other a tabletop exer-
10 ASC FOCUS SEPTEMBER 2017 |
www.ascfocus.org
ASPR provides guidance and sup- port through its Technical Resources, Assistance Center and Information Exchange (TRACIE). For assistance, go to
https://asprtracie.hhs.gov/. ASPR-TRACIE can provide com- munity resource information and help ASCs develop emergency plans and training programs. Also, ASCs can use local resources, such as first responders, to get a better idea of how to navigate this process and how to participate in community exercises. Finally, ASCs can work with their accreditation organization. AAAASF is ready to provide resources wher- ever possible. Please visit our web site,
www.aaaasf.org, or call our office at 888.545.5222 for assistance.
Life Safety Code Interpretation Another common area of concern for ASCs is compliance with the new Life Safety Code standards. The Life Safety Code requirements changed near the end of 2016, thus there is an acute focus on these standards. Last year, the Medicare ASC program adopted the 2012 edition of the Life Safety Code, an update from the pre- vious 2000 edition. When changes
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30
