Changes to the HFAP Ambulatory Surgical Center Chapter 5: The Physical Environment Brad Keyes, CHSP HFAP Engineering Advisor Jamie Crouch, BSBM, MHA Clinical Safety & Regulations Specialist, Spectrum Health

NOTE: The following changes are tentative, based on the changes to the 2017 HFAP manual submitted to CMS for approval. While CMS approval is expected, some minor changes may occur that are not accounted for in this presentation.

Objectives Upon completion of this program, the learner will: Understand what changes were made to the HFAP Ambulatory Surgical Center Chapter 5 on the Physical Environment mainly due to CMS adopting the 2012 Life Safety Code Realize when these changes will become effective

Why the Changes…? On May 4, 2016, CMS published their Final Rule to adopt the 2012 Life Safety Code, which became effective on July 5, 2016. However, in S&C Memo 16-29 issued June 20, 2016, CMS says they will not survey with the 2012 LSC until November 1, 2016, which allows 4 months of leniency to allow AOs and healthcare providers the opportunity to make necessary changes and get ready.

Why the Changes…? HFAP has submitted all the necessary changes to the Physical Environment chapter 5 for ASCs to CMS, and will be ready to evaluate the new requirements associated with the 2012 LSC on November 1, 2016. Until then, healthcare providers may take advantage of the changes that lessen their compliance that began on July 5, 2016.

Let’s Get Started… So… let’s begin by reviewing the changes made to the Physical Environment chapter of the 2017 HFAP manual for Ambulatory Surgical Centers….

05.00.03 Operating Room Design We added additional information in the Explanation column: Procedure rooms are better defined to include non-sterile rooms where procedures are performed ORs must be designed in accordance with industry standards regardless if the room is used for sterile and/or non-sterile procedures Existing ORs must meet the standards in force at the time they were constructed, while new ORs must meet current standards; However, procedure rooms do not have to meet the same design and equipment standards as traditional ORs.

05.00.03 Operating Room Design We added additional information in the Explanation column: Temperature, humidity and ventilation requirements must meet the requirements AHRAE standard 170 ASCs must ensure the OR humidity levels are appropriate for their surgical and anesthesia equipment and supplies

05.00.03 Operating Room Design We added additional information in the Observation column on what the surveyors will be looking for: Verify the ORs meet the applicable design standards Verify the ORs have the correct kind and quantity of equipment in the ORs for types and volumes of surgeries Verify logs exists that ASCs are inspecting, testing and maintaining electrical and mechanical equipment Verify who in ASC is responsible for equipment testing Review OR temp & humidity logs to ensure appropriate levels are maintained

05.00.05 Health Care Facilities Code This standard was previously not used. It is now used to comply with the CMS requirement for ASCs to comply with the NFPA 99 Health Care Facilities Code, 2012 edition. CMS adopted the entire 2012 edition of NFPA 99, with the exception of chapters 7, 8, 12 and 13.

05.00.05 Health Care Facilities Code CMS believes they have no jurisdiction over IT, plumbing, and security (chapters 7, 8 and 13), but they chose not to adopt chapter 12 on Emergency Management because they will publish their own Conditions for Coverage regarding Emergency Management that ASCs will have to comply with… sometime before the end of this year.

05.00.05 Health Care Facilities Code ASCs are required to evaluate their systems regulated by NFPA 99 (i.e. gas & vacuum systems; electrical systems; HVAC systems; electrical equipment; and gas equipment) to determine what level of risk category applies (i.e. Category 1 through Category 4). The systems must be tested, inspected and maintained to the appropriate risk category.

05.00.05 Health Care Facilities Code We added additional information in the Observation column on what the surveyors will be looking for: Verify the ASC has conducted the necessary risk assessments on the building systems Verify the ASC Safety Committee has reviewed and approved the risk categories designated for each building service

05.01.01 Safety from Fire We added additional information in the Standard column that states regardless the number of patients served, the ASC must comply with chapters 20 & 21 (Ambulatory Healthcare Occupancies), and the referenced Tentative Interim Amendments. The Explanation column reflects 2012 edition of the LSC is now being used and the effective date is July 5, 2016.

05.01.03 Sprinkler System Impairment This standard was previously not used. It is now used for sprinkler system impairments. Sprinkler systems that are out of service for 10 or more hours in a 24 hour period must either evacuate the ASC or conduct a fire watch. Previously, the standard required the sprinkler system to be impaired for 4 or more hours within a 24 hour period before evacuation or a fire watch is needed.

05.01.03 Sprinkler System Impairment CMS describes a fire watch as consisting of dedicated staff with no other duties constantly circulating throughout the portion of the facility affected by the sprinkler system impairment looking for a fire, fire hazards, or hazardous conditions that may affect the fire safety of the facility. Surveyors will verify a compliant fire watch is conducted if the sprinkler system is impaired for more than 10 hours in a 24 hour period.

05.01.06 Alcohol Based Hand Rub Dispensers The 2012 Life Safety Code requires the ASC to adequately protect against inappropriate access to alcohol based hand-rub dispensers, such as pediatric and substance-abuse patients. Surveyors will interview staff to determine methods are employed to prevent patients from misusing the ABHR dispensers.

05.01.07 Emergency Equipment We added additional information in the Explanation column: Written polices are required identifying the specific types of emergency equipment available for use in ORs The ASC is required to conduct periodic assessments of their policies regarding emergency equipment- ‘Periodic’ is not defined, but is expected to be no less than once every 3 years The ASC must provide the appropriate emergency equipment, supplies and qualified individuals necessary to meet the emergency needs of the patient population

05.01.07 Emergency Equipment We added additional information in the Explanation column: Written policies must address whether the emergency equipment and supplies must be present in each OR, or in what quantity and locations they will be available The ASC must have qualified individuals capable of using all emergency equipment Whenever there is a patient in the OR there must always be staff present capable of using the emergency equipment

05.01.07 Emergency Equipment We added additional information in the Explanation column: Must ensure the mechanical and electrical equipment is regularly inspected, tested and maintained Must use qualified personnel to maintain emergency equipment, supplies and medications.

05.01.07 Emergency Equipment We added additional information in the Observation column on what the surveyors will be looking for: Will ask to see the policies on emergency equipment & supplies Will verify the ASC identified supplies & equipment needed in emergencies Will verify how the ASC determined the specific emergency equipment, supplies and medications will meet the emergency needs of the patients

05.01.07 Emergency Equipment We added additional information in the Observation column on what the surveyors will be looking for: Will determine if the policies clearly identify the quantity of equipment, supplies and medications required Will determine if the specified emergency equipment is immediately available to the ORs Will verify that there are sufficient clinical personnel qualified to use the emergency equipment & supplies

05.01.07 Emergency Equipment We added additional information in the Observation column on what the surveyors will be looking for: Will interview staff to determine how they will handle simultaneous emergencies Will determine if the electrical or mechanical equipment is regularly tested, inspected and maintained Will review emergency equipment and supplies to determine if they are expired

05.01.08 Emergency Personnel We added additional information in the Explanation column: The ASC must have staff present who are trained in CPR There must be sufficient trained individuals to deal with simultaneous emergencies

05.01.08 Emergency Personnel We added additional information in the Observation column on what the surveyors will be looking for: Will request documentation that confirms the ASC has adequate staff trained and competent in the use of emergency equipment & supplies, and CPR; and available whenever there is a patient in the ASC Will interview staff to determine if they are aware of their role in handling an emergency

05.02.01 Physical Environment We added additional information in the Observation column on what the surveyors will be looking for: Will verify the ASC design and construction meets or exceeds the 2012 Life Safety Code, the 2012 NFPA 99, and for new construction, the 2014 FGI Guidelines.

05.02.06 Hazardous Areas This standard was previously vacant. By July 5, 2017, all hazardous areas in ASC must have doors that are equipped with closers or automatic operators.

05.04.01 ASC in Compliance with Rehabilitation Act & ADA We added additional information in the Explanation column: Relocated the ‘Note’ from the end of the chapter regarding ADA compliance and inserted into the Explanation column

In Conclusion… Since CMS made the 2012 LSC official on July 5, 2016, that is when the clock begins ticking regarding new testing and inspection requirements This means by November 1, 2016, you need your first ‘Quarterly’ test/inspection completed. By January, 2017, you need to have your first semi-annual test/inspection completed. By July, 2017, you need to have your first annual test/inspection completed. By July, 2019, you need to have your first 3-year test/inspection completed. And so on….

Questions? Brad Keyes, CHSP bkeyes@hfap.org 815-629-2240

Certificate of Attendance ___________________________ Awarded 1.0 contact hours Changes to the HFAP Ambulatory Surgical Center Chapter 5: The Physical Environment A 60 minute audio-conference October 11, 2016 _________________ Brad Keyes, Presenter