In the final part of this compliance series, learn what has changed and how you can be ready for your next CMS survey

If you haven’t had a CMS survey in a year or so, you will want to start preparing for the changes you’ll see in your next survey. On July 5, 2016, CMS mandated that ASCs meet requirements of the 2012 editions of the National Fire Prevention Association (NFPA) manuals, NFPA 101: Life Safety Code and NFPA 99: Health Care Facilities Code. The NFPA is a global non-profit organization that promotes safety standards, education, training, and advocacy on fire and electrical hazards. CMS-certified ASCs must meet these standards or jeopardize their certification.

CMS didn’t only update its requirement to the newest editions of these standards. They also changed their survey protocol completely. Historically, except for initial certification, CMS only sent the clinical team to survey your center (RN, MD, and so on). Now, you can expect a second team of engineer(s) at your surveys, focused solely on life safety compliance.

Most centers are not prepared for the scrutiny of these surveys. In this final part of my compliance series, I focus on the biggest changes your clinical director will be required to meet. Based on my experience, those areas are life safety utility maintenance, NFPA wet location assessment, and American Society for Health Care Engineering of the American Hospital Association (ASHE) risk assessment of each area of your center.

Survey Challenge: Life Safety Maintenance

In my experience, the most common instances of noncompliance during these surveys seem to be with life safety code maintenance requirements. ASCs typically have a qualified vendor maintain life safety equipment, such as fire extinguishers, generators, and exit lights, but maintenance can slide between those vendor visits. The clinical director typically maintains maintenance logs for these assets. With the new survey process, those logs are just a small fraction of what the surveyors will expect to see.

To prepare for this survey, it is important that you obtain all NFPA standards related to your building (Figure 1). Even with all of the NFPA standards in hand, however, it’s not always easy to find the required maintenance of each system. The NFPA 99 and 101 requirements aren’t all inclusive, but they will refer you to the NFPA standards on each specific system (Figure 2).

Survey Challenge: ASHE Risk Assessment

In addition to life safety utility maintenance (Figure 3), CMS also requires ASCs to utilize the ASHE Life Safety Risk Assessment Tool, which must be purchased from ASHE (ashe.org ).

The ASHE tool defines each chapter of NFPA 99: Health Care Facilities Code and recommends specific risk assessments for each area of your surgery center to ensure you meet those codes. The areas must have an initial assessment with the tool, with annual follow-up assessments.

Survey Challenge: Wet Location Assessment

According to the 2012 edition of NFPA 99: Health Care Facilities Code, operating rooms are considered a wet procedure location unless a risk assessment conducted by the health care governing body determines otherwise. The NFPA lays out how you can assess which way your operating rooms will be categorized (community.nfpa.org/docs/DOC-1241 ).

Another tool you can use is CMS form 2786u, which is available on the CMS website (cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS009395.html ). This form, geared specifically to the ASC, is the one the CMS engineer will use to assess your life safety compliance.

Ready for Your Next Survey

Because surgery centers have so many life safety requirements, we can’t list them all in this article. I hope this guidance helps you find the requirements that apply to your ASC, so you can put the systems in place to meet them. Like any new rules, once these updated standards become part of the fabric of your ASC, following them becomes routine, and, thus, you are prepared for any survey. ■