Massachusetts Deadline for Licensure of Clinics- December 12, 2009

In late June, the Massachusetts Department of Health began sending letters to ambulatory surgery centers across the state notifying them of the changes to licensure requirements for clinics under the new Chapter 305 regulations. According to the new regulations, ambulatory surgery centers are no longer exempt from licensure requirements. All ambulatory surgery centers will be required to seek licensure status by December 12, 2009.
For facilities that are Medicare certified or accredited, there is a deemed-by-accreditation licensure option. This option is available to Medicare certified and accredited ambulatory surgery centers that were in operation on August 10, 2008, or an ASC that was under construction on August 10, 2008 and that is in operation on December 12, 2009.

Furthermore, the Department expects that those ASCs planning to take advantage of the grandfathering provisions in chapter 305 will be applying for licensure as substantially the same entity that was in operation in August of 2008. The grandfathering provision does not apply to, for exmaple, a surgery center with one physician and one OR that in the interim has added two more physicians or another operating room. The Department would find that the newly-configured ASC was not in operation on August 10, 2008 and the ASC would be required to obtain a Determination of Need (DoN) prior to licensure. Similarly, if an ASC that operated as a single-specialty practice on August 10, 2008 seeks clinic licensure as a multi-specialty practice, the Department would find that the multi-specialty practice was not in operation on August 10 and therefore would need DoN approval prior to licensure. You can seek an advisory opinion from DoN if you have specific questions regarding changes in your facilities operation.

If you need more information, here is a copy of the updated regulations 105 CMR 140.000: Licensure of Clinics. Copies of the circular letters and required forms can be found at the DOH ASC Licensure website.

If you are an ambulatory surgery center in the state of Massachusetts and your facility needs assistance becoming compliant with the new regulations, contact Ortmann Healthcare Consultants. We have worked in Massachusetts, are familiar with the changes, and can assist your facility in completing the required paperwork for licensure. And as always, the sooner you complete this paperwork, the better!

Submitted by Jessica Miller, Director of Regulatory Affairs

Surviving Your Fire Safety Survey

Surgery centers undergo a number of inspections for everything from the certificate of occupancy, medicare certification and accreditation. The fire safety survey, also known as the NFPA 101 Life Safety Code, is an important survey that you will have to complete as part of medicare certification. Typically the State Agency for certification assists in setting up the fire safety survey, but due to budget cuts, they often defer to the accrediting agency. It is preferable that if your state will still provide the fire safety survey that you go with them because otherwise the accrediting agency will charge an additional fee for this survey.

Each state survey process varies but to prepare for this survey there are a few things you should have on hand. Ortmann Healthcare Consultants likes to prepare and organize our facilities paperwork into a binder system. Two binders are specifically helpful for the fire safety survey: construction documents, and ancillary agreements. In these binders you should have records regarding the fire alarm system, sprinkler system, and generators if applicable. The inspector will also ask to see fire drill records, depending on how long the facility has been open, and will review the policy and procedure for staff training.

It is also helpful to have handy a set of plans showing fire rated doors and walls. The inspector may want to use a ladder to physically inspect these partitions. Also make sure your medical gas, electrical, and mechanical rooms are free of any clutter. These spaces cannot be used for storage and nothing should be on the floor or around the major equipment.

There is a template available for the fire safety survey and we ask our architects to assist in completing the form so the surveyor may use it as a guide. If your facility is expecting a fire safety inspection, contact Ortmann Healthcare Consultants today to see how we can help!

News of the Wierd- Fake Nurse

A news story recently ran on MSN.com that is further proof of how important proper credentialing procedures are for physicians, nurses and other providers. According to the report, Betty Lichtenstien, 56, has been charged with pretending to be a nurse at a doctors office. Lichtenstien also held a dinner party in her own honor for being named ‘Nurse of the Year’ by a nursing association authorities say does not exist. Authorities began investigating Lichtenstien after a patient complaint.

There are several safe guards in place that, when done properly during the credentialing process, can prevent the hiring of unqualified, illegal, or troubled personnel. Some tools available to employers are state registries of licensed nurses and practitioners. With the appropriate information you can verify a license online. You can also do this for professional associations the provider might belong to. Many states also have requirements for background checks of all health care providers in a facility. Employing these tools can protect you and your patients.

If your ambulatory surgery center needs assistance with credentialing or selecting individuals for employment, Ortmann Healthcare Consultants can help. Contact us at (803) 252-7979 to learn about our credentialing, and center director and staff training services.

Federal Funds Released to 12 States to Survey Ambulatory Surgery Centers

American Recovery and Reinvestment Act of 2009 (Recovery Act) Ambulatory Surgical Center Healthcare-Associated Infection (ASC-HAI) Prevention Initiative

Federal funds have recently become available for 12 states to survey ambulatory surgery centers. Kathleen Sebelius, Secretary for HHS, announced on July 31st that funding would be available for 12 states to survey more than 125 ambulatory surgery centers. The funding comes from the American Recovery and Reinvestment Act of 2009 (ARRA) and will be administered by CMS in the amount of $9.95 million.

The first 12 states to volunteer, and the amounts they were awarded are listed below:

• Arkansas- $14,000
• Florida- $16,250
• Indiana- $62,500
• Kansas- $53,500
• Maine- $13,500
• Maryland- $73,000
• Michigan- $53,000
• New Jersey- $125,000
• North Carolina- $34,000
• Oregon- $53,500
• Utah- $62,500
• Wyoming- $11,500
• Total for States & DC- $572,250

CMS believes the additional funding will assist in reducing the number of health care associated infections (HAI). The surveys will also ensure that facilities are following Medicare’s guidelines for infection control. The initiative includes the use of a new survey process and tool developed with the CDC. The tool is the infection control survey that is available at the end of the new Interpretive Guidelines issued by CMS.

The surveys should be completed by September 30, 2009. An additional $9 million in funding will be available in October for the remaining states to survey their ambulatory surgery centers. The CDC has also promised to make available an additional $40 million for states to create or expand their HAI prevention and surveillance efforts.
Additional information can be found at the following links:
Medicare Press Release
HHS’ 2009 Action Plan to Prevent Health care-Associated Infections

If you operate an ambulatory surgery center in one of the first 12 volunteer states and want to make sure your facility is prepared for a survey, contact Ortmann Healthcare Consultants at (803) 252-7979. We have the tools to help you prepare and a record of “No Deficiencies” for every licensure, accreditation, and certification survey we have participated in.