the newest rules are critical for an effective emergency response.”

Get Your Paperwork in Order A large portion of the current rules concern an ASC’s documentation, says Jeanne Desautels, regional vice president for United Surgical Part- ners International, an owner, operator and developer of ASCs and short-stay surgical hospitals nationwide based in Addison, Texas. These documenta- tion requirements should not be taken lightly, she adds. “They serve multiple purposes,” says Desautels, who also serves as president of the Colorado Ambula- tory Surgery Center


Complying with Emergency Preparedness Requirements

Stay on top of your paperwork, perform drills and collaborate with your local authorities BY ROBERT KURTZ


o not think of complying with emergency preparedness require-

ments as a regulatory burden, says Kris Kilgore, RN, administrative director at Surgical Care Center of Michigan in Grand Rapids, Michigan. Rather, think of it as an opportunity. She says her ASC’s efforts to meet the latest requirements published by the Centers for Medicare & Medic- aid Services (CMS) in September 2016 (, with an implementation deadline of Novem- ber 15, 2017, have yielded significant benefits. “It has been a great learning experience and allowed us to change our processes to help ensure we are prepared for whatever happens.”

Anyone who wants to simultane- ously improve their emergency pre- paredness program and make sure they are compliant with the current regula- tions needs to maintain an attitude like that one, says Jan Allison, senior direc- tor regulatory, clinical services for ASC management company Amsurg, based in Nashville, Tennessee. “There seems to be a misconcep- tion among some ASCs about what is now required,” she says. “Just because you were compliant with previous rules does not ensure com- pliance with the newer requirements. Federal and accreditation surveyors are closely scrutinizing ASCs on their preparedness as the details added in


“For example, by completing a risk assessment, you should identify the hazards—for natural and man-made disasters—your ASC is most likely to encounter and how you would likely be affected by these incidents. You should put policies and procedures in place that explain how you will respond to those types of emergen- cies, including how you would evacu- ate or shelter in place and ensure staff and patients are accounted for.” Your ASC’s communications plan during an emergency should focus on a few areas, including how to effectively communicate with local authorities about what is happening during the emergency and how to share all the information needed to keep patients and staff safe, she adds. When reviewing your documen- tation, make sure it covers the new rules, Allison says. “I know of an ASC that was recently cited because it did not realize its emergency plan, which complied with its state rules, did not meet all federal requirements because it was missing a number of pieces specific to the CMS rules.” She also advises ASCs to avoid using a “generic” plan. “Do not sim- ply download a plan off the Inter- net, look it over, change anything

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