ADVOCACY   (updated 8-12-2017) TLF

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Important change to CMS Conditions of Participation


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ASHE is trying to assess the potential impact on a recent change to the Medicare and Medicaid Conditions of Participation that would require all hospital outpatient surgery departments to be classified as Ambulatory Surgical Occupancies under chapters 20 and 21 of the 2012 edition of NFPA 101: Life Safety Code®. This change, which the Centers for Medicare & Medicaid Services (CMS) released in June after the initial update to the Conditions of Participation, would apply to all existing and new business occupancies performing any type of surgery as defined by the American College of Surgeons.

ASHE believes this change will affect all facilities that are 1) performing services such as dental or oral surgery, plastic surgery, Mohs surgery, lithotripsy, endoscopy, hernia repair, knee arthroscopy, laser surgeries and other minimally invasive surgeries such as the Syme procedure for ingrown toenails and 2) billing either hospital or outpatient services under the hospital provider number.

To help ASHE assess the potential impact of this change, please complete this brief survey for each of the facilities you oversee that will be affected by the change.

Complete the brief survey

If you have a business occupancy, you may be affected by this change in the rule if your hospital is billing for any service that meets the definition of surgery below:

What constitutes "surgery"? (from CMS Interpretive Guidance)
For the purposes of determining compliance with the hospital surgical services CoP, CMS relies, with minor modification, upon the definition of surgery developed by the American College of Surgeons. Accordingly, the following definition is used to determine whether or not a procedure constitutes surgery and is subject to this CoP:

Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reductions for major dislocations or fractures, or otherwise altered by mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system also is considered to be surgery (this does not include the administration by nursing personnel of some injections, subcutaneous, intramuscular, and intravenous, when ordered by a physician). All of these surgical procedures are invasive, including those that are performed with lasers, and the risks of any surgical procedure are not eliminated by using a light knife or laser in place of a metal knife, or scalpel.



CMS Emergency Preparedness Rule Guidance

Health care providers will need to complete any changes necessary to meet the new emergency preparedness requirements by November as required by the Centers for Medicare & Medicaid Services (CMS) or risk citations for non-compliance.

CMS issued two Survey and Certification (S&C) memos recently stating that many organizations have asked whether the training exercises included in its 2016 emergency preparedness rule need to be completed by the November 15, 2017 rule implementation date. CMS said in an S&C memo that health care providers and suppliers affected by this rule must comply and implement all regulations by November 15, 2017 and that organizations who do not meet the requirements will be cited for non-compliance.

CMS said in the memo that health care providers should “seek out and to participate in a full-scale, community-based exercise with their local and/or state emergency agencies and health care coalitions and to have completed a tabletop exercise by the implementation date.”

CMS noted that not all agencies and coalitions may be able to work with all health care organizations in their area by the November deadline. When full-scale, community-based exercises are not possible, CMS said facilities should complete an individual facility-based exercise and document the reasons why a larger community exercise was not possible. Documentation should include the emergency agencies or health care coalitions contacted and specific reasons why the full-scale exercise was not possible, CMS said.

To help health care organizations meet the requirements of the emergency preparedness rule, CMS is also providing resources for health care providers. Online resources include state-by-state listings of health care coalitions, links to emergency preparedness agencies, and emergency preparedness checklists.

Also, CMS said in another S&C memo that it will be holding a conference call on April 27 from 2:30 p.m. to 3:30 p.m. Eastern Time to discuss the emergency planning rule and the training and testing requirements. Space on the call may be limited, so ASHE encourages members interested in this information to register as soon as possible.

ASHE resources related to the CMS emergency preparedness rule, including a webinar recording available only to ASHE members, are available on the ASHE website. ASHE will continue to keep members updated on the latest developments with the CMS emergency preparedness rule.

Updated 4/19/2017 TLF


CMS proposal would make survey reports public

Within the most current Hospital Inpatient Prospective Payment System proposed rule from the Centers for Medicare & Medicaid Services (CMS), CMS recommended that all accrediting organizations post provider/supplier survey reports and plans of corrections (PoCs) from CMS-approved accreditation programs on their website—a move that would make survey reports and PoCs publicly available. The American Hospital Association and the American Society for Healthcare Engineering (ASHE) are strong advocates for transparency and remain committed to sharing meaningful, accurate hospital quality information with patients and the public. ASHE believes that this information should be presented in an understandable manner.

There are several concerns that ASHE would like to see CMS address before moving forward with this proposal, including the need to make survey reporting information easy to understand by the general public. ASHE encourages its members to consider the effect that publicly available accrediting organization surveys could have on their health care organizations. ASHE encourages members to submit comments for the proposed rule. The proposed rule is available online, and the portion regarding public survey reports is located in the final paragraphs of the proposed rule. Public comments are due by 5 p.m. Eastern Time on June 13.

Read the Proposal or Submit Public Comments

Updated 6/1/2017 TLF 



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