CHAPTER/STANDARD |
STANDARD DESCRIPTION |
1: Governing Body and Management 01.01.02 Contract services |
The ASC’s governing body is responsible for the safety and effectiveness of services provided by contracted employees and entities. |
2: Administration 02.01.04 Personnel records |
Basic information is obtained for employees and contracted staff at the time of hire including documentation of time-limited license, certification, or registration. |
3: Medical Staff 03.01.03 Surgical privileges roster |
A current roster identifying each surgical practitioner’s specific surgical privileges is available in the surgical suite and where scheduling takes place. The roster includes physicians and non-physician surgical assistants. |
4: Quality Assessment/ Performance Improvement 04.00.04 Quality Program data |
Quality metrics are identified for all patient care and contracted services provided. |
6: Medical Staff 06.00.02 Medical staff: Granting privileges |
The ASC’s medical staff makes recommendations to the governing body regarding initial, renewal, and revised privileges. Based on the information provided, the governing body may award, amend, withdraw or deny privileges to the applicant. |
6: Medical Staff 06.00.03 Medical staff: Credential files |
A credentialing file is maintained for each provider seeking privileges in the ASC. It includes evidence of professional qualifications and current competence that is updated as needed as well as evidence of review and action by the governing body following the request for privileges and recommendation of the medical staff. |
6: Medical Staff 06.00.04 Medical staff: Reappraisals |
The governing body has a formal, written process for periodic reappraisal and renewal of privileges. Reappraisal occurs at least every 36 months. The standard details specific requirements for those requesting new/additional privileges and for an ASC with a single physician owner. |
8: Medical Records 08.00.03 Form and content of the medical record |
Each patient of the ASC has a complete, accurate, and legible medical record that includes defined information, at minimum. |
14: Life Safety 14.05.04 Generator inspection |
Emergency power generators located within the building that houses the ASC are in a room with no other equipment and protected by a minimum 2-hour fire-rated barriers. Externally located generators are protected from rain and snow. Documented inspection occurs weekly. |
14: Life Safety 14.05.05 Generator monthly load test |
Emergency power generators must be tested 12 times annually for at least 30 minutes with tests occurring between 20 and 40 days apart. The standard provides specific parameters and expectations for testing. |
14: Life Safety 14.05.07 Automatic transfer switch test |
Automatic transfer switches (those that activate the emergency generator) must be tested monthly, operating the transfer switch from the standard position to the alternate position and then returning to the standard position. |
15: Emergency Management 15.01.07 Invoking the 1135 Waiver |
The ASC must develop and implement policies and procedures that describe its role in providing care during emergencies. This requirement encourages providers to collaborate with their local emergency officials in proactive planning to allow an organized and systematic response to assure continuity of care for their community. |