Florida Society Ambulatory Surgery Center 2015 Conference

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1 Florida Society Ambulatory Surgery Center 2015 Conference Patricia Kaczmarek, BHSc., MSHL, RN Agency for Health Care Administration Registered Nurse Consultant Survey and Certification Support Branch Agency for Health Care Administration Ambulatory Surgery Center Regulation Update 1

2 Agency for Health Care Administration 3 ASC- Appendix M State of Florida Rule Revisions 4 2

3 Florida Rules 5 Florida Rules 6 3

4 Click on the 7 Impacts Florida Statute- Title XXIX Public Health Chapter Florida Administrative Code- 59A Appendix M State Licensure- Interpretation Appendix M Language/Citation Text 8 4

5 M Internal Risk Management Program Administrative Functions Establish a Program 9 M Categories of Adverse Incident Review Documentation and confirm Categories 10 5

6 M Provisions to Minimize Risk of the Adverse Incident Questions Who, How, When, What Demonstrate the mechanisms 11 M Two persons in recovery Exempt if in emergency, electronic observation Scheduling, Observe Recovery Room, Exemptions, P&P and Privacy issues 12 6

7 M Appropriate measures for Unlicensed personnel Scheduling, Assignments, Observe staffing/supervision, Review competency thresholds 13 M Systems to identify Patients, Procedures as planned, Correct site of planned procedure Review system, Review incidents, review risk reduction strategies, QAPI 14 7

8 M System to analyze Grievances Review Grievance System, Follow-up, Prevention, How analyzed? 15 M System to inform patient of Adverse Incident Notification-How soon after the event, Who notified patient 16 8

9 M System to report Incidents- Form or formatted Facility Method Reported 3 calendar days- RM or Designee 17 M System detailed Written Procedures, Communicated to staff Review System, Written Procedures, How communicated to staff, New staff -30 days Documentation 18 9

10 M System Report- Physician communication, All persons involved/witnesses, Staff writing the report Documentation, Physician notification, Witnesses contact information 19 M Governing Board has a responsibility RM Program Oversight Documentation, Job description, 20 10

11 M Risk Manager and access to records Free Access to medical records, Review P&P for free access 21 M Program and Incident Report records- Utilized to identify problem areas and adjust procedures for problem correction Review P&P for adjustments, review incidents/trends tracking 22 11

12 M TOO MANY TO FIT HERE TOO MANY TO FIT HERE 23 M Investigation of allegations of sexual misconduct made against a member of the facility staff Documentation of Sexual misconduct allegations/ Reports Review P&P Notification Family (if minor) DOH 24 12

13 M Notification of Police, RM & Administrator Understanding of the Definitions Sexual Abuse Review Sexual Abuse Reports Review P&P Notification Appropriate 25 M RM Summary Report to GB- Minimum Quarterly Review Summary Reports Interview RM 26 13

14 M Submit Annual Report- AHCA and DOH Name and Judgements Healthcare Practitioners Review Annual Report Documentation Interview RM- Report to AHCA & DOH 27 M Submit Annual Report- AHCA and DOH Name and Judgements Healthcare Practitioners Review Annual Report Documentation Interview RM- Report to AHCA & DOH 28 14

15 M Submit AHCA Annual Summary Report Review report Review outcomes, referrals to MQA 29 M AHCA Access to Facility Records Surveyor Access to record 30 15

16 M RM must have ability to execute reporting obligation Interview RM and staff for compliance 31 M Patient Safety Plan Adopted by Facility Interview RM and staff for compliance Review the Patient Safety Plan 32 16

17 M Patient Safety Officer- Appointed Patient Safety Committee- One nonemployee Member Review the Patient Safety Committee Documents-Promote health Identify Nonemployee Member

18 Any Questions? 35 18

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