1. 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

2. 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.

3. 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

4. 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, However, in S&C Memo 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.

5. 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, Until then, healthcare providers may take advantage of the changes that lessen their compliance that began on July 5, 2016.

6. 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….

7. 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.

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. 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.

28. 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

29. 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….

30. Questions?
Brad Keyes, CHSP

31. Certificate of Attendance
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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
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Brad Keyes, Presenter