icaid Services (CMS) Conditions for Coverage changes. I found that I was way ahead of the game because I had already begun changing forms, etc., to comply, but if I had not been reading about the upcoming changes that CMS had passed, I would have been scrambling as the conference was just before the effective date of the changes.

Playing by the Rules

One-on-one with an ASC director INTERVIEWED BY SAHELY MUKERJI

gery in Charlotte, North Carolina, dis- cusses regulatory compliance and how her ASC consistently stays ahead of the curve. Carolina Center for Specialty Surgery performs minimally invasive spine procedures.


What are the biggest regulatory compliance challenges in your ASC? PAGE: I find that keeping up with the regulatory changes is the most difficult challenge and that the best way to keep in the know is to read. Recently, I dis- covered that North Carolina had insti- tuted a new HealthConnex data quality program. I advised some of my peers and they, too, were unaware. Frankly, it was not very well publicized, and once we looked into it we were unsure

renda Page, RN, director of Car- olina Center for Specialty Sur-

How do you maintain compliance in your facility? PAGE: We expect all employees to do what is right and follow all our poli- cies. The parent physician practice of the surgery center also requires annual competencies/testing in compliance. Additionally, an attorney from the prac- tice comes to our ASC to speak with us regarding compliance annually. She reviews HIPAA, fraudulent practices, etc. The practice has a hotline that can be called anonymously to report any fraudulent activity as well. At present, we have more than 200 policies in place. I write most of them with the assistance of the CRNAs, the post-anesthesia care unit (PACU) direc- tor and/or the medical director. We fre- quently review our policies to be sure they are in sync with our practices. We write an incident report for any untow- ard event or any event that is outside our normal scope of practice, i.e., when a female patient discovers she is pregnant and we cannot proceed with the surgery.

Brenda Page

if it pertained to surgery centers. But as I understand, it does.

Reading really has helped me. Sev- eral years ago, I attended an ASCA annual conference and attended a talk on the Centers for Medicare & Med-


How do you engage staff on maintaining regulatory compliance? PAGE: I just read something about The Joint Commission standards chang- ing for radiology and, while we are not accredited by The Joint Commission, the accreditation bodies are somewhat similar, so I forwarded it to my X-ray techs. They feel we may need a pol- icy on threshold dose/time for some of our cases that require more fluoroscopy. They will review with the surgeon who is the radiation safety officer. They felt that we comply with the other require-

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