ASC’s are now confronted with more frequent and more comprehensive surveys than ever before.  Understanding the Conditions for Coverage for an ASC as well as how they are interpreted by CMS is critical for ASC leaders.

As an ASC Leader, you must continuously make sure your ASC is ready for a Survey at any time.

Ambulatory Surgery Centers are subjected to a wide range of regulatory and accreditation requirements.  Keeping current with these requirements is not easy.  This is where Ambulatory Healthcare  Strategies can help!.

Unlike the “Management Company” approach – we provide oversight of your regulatory and accreditation compliance.  More importantly, we tailor our services to your needs – we don’t provide a “cookie cutter” approach to your services.  Representative services include:

STRATEGIC PLANNING/DEVELOPMENT

• • Work with the Administration to prepare annual goals and objectives for the organization (as required by CMS and by AAAHC Accreditation Standards) and assist in preparing a plan to carry out those goals and objectives.
  • Ongoing mentoring of the administrative staff of the ASC.

REGULATORY COMPLIANCE

• • Ongoing regulatory compliance assessments to discuss regulatory requirements and assess compliance with those requirements.
  • Annual comprehensive assessments (also known as a “Mock Survey”) of the operations for determining compliance with Accreditation Standards, regulations in the State of New York, and CMS Conditions for Coverage.
  • Periodic walkthroughs of the operation during each visit to identify progress on prior comments and emerging issues.
  • Based on the results of the assessments, AHS will work with the administration to prepare annual goals and objectives related to regulatory and accreditation compliance.
  • Organize and attend quarterly governing body meetings, monitor the duties and responsibilities of the governing body, the agenda, and the minutes to assist the organization in maintaining compliance with regulatory and accreditation requirements.
  • When available, be in attendance for all CMS, State, and Accreditation Surveys, assist in answering surveyor questions, review and prepare required action plans for survey findings and CMS citations, and work with administration to ensure action plans are carried out.
  • In cooperation with the Administration, prepare and maintain the Policy and Procedure Manual for the organization in compliance with applicable regulatory and accreditation requirements.

QUALITY IMPROVEMENT ACTIVITIES

• • Provide assistance to the QI Coordinator of the Quality Improvement Program.
  • Review Incidents, Adverse Events, and Transfers, review follow-up for compliance with loop closure requirements, and develop tracking and trending reports for the QI Committee.
  • Review infection control plan activities, assist in preparing quarterly reports to the QI Committee on activities.
  • Review Medical Record Consultant, Nursing, Physician, and Anesthesia Chart Audits, review follow-up for compliance with loop closure requirements, and develop tracking and trending reports for the QI Committee.
  • Review Environmental Scans and develop reports for QI on the status of outstanding and closed issues.
  • Review Pharmacy reports and develop reports for QI on the status of outstanding and closed issues.
  • Assist in developing QI Studies, review results of studies, and write QI Study reports.
  • Work with administration to prepare annual goals and objectives for the QI and Infection Control plans for approval by the Governing Body.
  • Prepare the QI Agenda, run Quarterly QI Meetings, assist in writing QI Minutes (or write them if necessary), and prepare summaries for the BOD and MEC.

EDUCATION

• • Develop Orientation and Annual Mandatory Education programs.

Call John Goehle today at 585-594-1167 for a no-risk, no pressure consultation.