Friday, October 14, 2016

PHYSICIAN Owned Surgery centers are EXEMPT from OSHPD in CALIFORNIA

CODE SECTIONS Article 21, Chapter 7 California Administrative Code (CAC) Article 21 - Plan Review, Building Inspection and Certification of Surgical Clinics, Chronic Dialysis Clinics and Outpatient Services Clinics


 The determination of which clinics and outpatient facilities are subject to the OSHPD 3 requirements found in Title 24, California Building Standards Code is complex. This results in a lack of consistency in application of the model code and OSHPD 3 requirements to clinic facilities, and uncertainty regarding the roles of the local building jurisdiction and OSHPD in the plan review, certification and construction inspection processes.

Confusion exists, in part, because the use of the generic terms “clinics” and “outpatient facilities”. The OSHPD 3 requirements found in the code apply only to those clinics and outpatient facilities that are licensed pursuant to Health and Safety Code (H&SC) Section 1200 or 1250. There are variables in statute and regulations regarding the use and licensing of these clinic facilities, making consistent application of the regulations complex. Another source of confusion is that the applicability of certain requirements is determined by factors that are normally out of the scope of work of the building department and designer. For example, sources of financial reimbursement and the specific type of license a clinic owner desires to obtain determine what regulations apply and who has jurisdiction for the project.


 In order to determine the applicability of OSHPD 3 requirements, it is necessary to know if the clinic facility is licensed, and if so, how it is licensed. OSHPD 3 requirements for clinics only apply to clinics that are licensed pursuant to H&SC Section 1200 (which includes primary care clinics and specialty clinics) or H&SC Section 1250 (which includes outpatient clinical services of a licensed hospital). Where the term “clinic” or “outpatient facility” is used relative to OSHPD 3 requirements in the California codes, it shall mean a clinic or outpatient facility licensed pursuant to H&SC Section 1200 or 1250. The application of OSHPD 3 requirements is independent of the determination of occupancy classification. A Group B Occupancy doctor’s office is subject to OSHPD 3 requirements if the office is licensed as a clinic pursuant to H&SC Section 1200.

Conversely, a surgical clinic classified as a Group I-2.1 occupancy is not subject to OSHPD 3 requirements if it is not licensed pursuant to H&SC Section 1200 or 1250. It should be noted that other requirements, not enforced by OSHPD or the local building jurisdiction may apply, for example, the NFPA 101 Life Safety Code. The attached documents are intended to assist local building jurisdictions and designers in applying OSHPD 3 regulations, and determining which jurisdiction has authority over the plan review, certification and construction inspection of clinic facilities.

 California Medical Clinic Guidelines, Plan Review, Approval, Inspection and Certification Flowchart- Provides a process to follow in determining the appropriate authority having jurisdiction and applicable regulations for various clinic facilities.
        Flowchart Explanatory Notes. Provides additional information to use in applying the flowchart.
                  Appendix. Contains a glossary of terms, identities common acronyms and summary of roles of agencies involved in the plan review, certification and inspection of clinic facilities.

Monday, July 11, 2016

Template for a successful Surgery Center Accreditation

Starting a Surgery Center Accreditation Journey can be very time-consuming and exhausting, this template can help you obtain your basic survey readiness to determine where to begin your focus to get full compliance to the standards of the accrediting body.

This checklist or list of items to be very self-aware of is the first part of four major audits that should occur in your ASC.  The outline below of things to be aware of and to ensure you are on top of their resolution for your upcoming survey. Contact us here by leaving a message that you would like to have a copy of this amazing piece of time savings document.  Enjoy.

Wednesday, June 15, 2016

Great interactive cartoon characters in demonstrating total OSHA standards with PPE.

Get your free CE now with a one hour CE from the company

This free PPE training is exactly what your staff needs on a yearly basis.  Its a good refresher, and for a new beginner.  Check it out, they even mail you your certificate which you then will place in their files for your next up coming surveys.  Enjoy!

Tuesday, June 14, 2016

The following are some general tips from The Joint Commission Mock Tracer Made Simple on readiness regarding various aspects of a survey:

• Documents for review: The list of documents that must be available includes items that can be gathered in advance as well as items that will need to be pulled the morning of the survey. The documents list is located in The Joint Commission’s survey activity guide; review this list in advance. Many organizations keep a binder ready to go in the event of an unannounced survey. Conduct a practice run to ensure that documents that need to be located on the morning of the survey (e.g., lists of patients, procedures, surgeries, ambulatory/diagnostic testing appointments, etc.) can be retrieved quickly and efficiently. There is also a list of items that may be requested when the surveyor identifies an issue. Ensure that these items are current and accessible.
• Closed medical record review session: There is no scheduled closed medical record review; the focus will be on current, open records. If questions about compliance with documentation in the record arise, or if there are no patients of a certain type in the hospital at the time of the survey, the surveyors may ask for a sample of closed records to review. For example, if there are no patients in restraints at survey time, the surveyors will ask for a sample of closed records involving patients in restraints. Also, the medical record delinquency form must be completed and ready for the survey team. Don’t lose sight of your delinquency rate; it can affect your accreditation status if it exceeds twice the average monthly discharges.
• Competency assessment processes: The surveyors will identify times toward the end of the survey to review documentation of employees’ competency and the credentials of staff members with privileges. Expect names of staff members who interacted with surveyors during tracers to make up the bulk of this review. Also expect surveyors to request specific competency information during patient tracer activity.

• Visits to patient care settings and departments: This activity is incorporated into tracers. Note that any given area might be visited once, multiple times, or not at all. Therefore, the entire organization should
be survey-ready.
• Environment of care review: A formal session will be scheduled to review documents and to discuss issues related to environment of care. Currently, every hospital will have a Life Safety Code® specialist visit for at least two days during the survey.
• Emergency management: For hospital surveys, a formal session will be scheduled to review emergency management. Surveyors will evaluate the hazard vulnerability analysis, the emergency operations plan (EOP), the prior year’s EOP, and any emergency management drills and resulting actions taken.
• Daily briefing: This valuable meeting will occur from day two until the last day of the survey. Listen carefully to the issues that surveyors raise during the briefing to identify possible recommendations, and challenge any findings believed to be incorrect while the surveyors are still on-site. Use the issue resolution times to address any open items that need further clarification. Disputes with the survey team
should be channeled to the team leader.
• Off-shift survey visit: The Joint Commission no longer includes an off-shift visit during reaccreditation surveys, but it reserves the right to conduct such visits in “for cause” surveys.
• Exit conference: Organizations will receive their preliminary survey report at the exit conference. Remember, following the survey, you still have an opportunity to clarify (i.e., remove) disputed findings from this report. You should exercise this option when necessary and without reservation.
• Complex surveys: Organizations that have customarily had a “tailored survey” with ambulatory, long term care, homecare, or addictive disease surveyors added to the core team should expect to see a greater degree of integration, with only one leadership conference and members of the core team performing assessment of specialty areas whenever possible.
• Review of Measures of Success (MOS) from FSA: If you did not select Option 3 for your PPR, you may be asked to share the results of any required MOS.
• Compliance with the United States Pharmacopeia (USP)—National Formulary Chapter on Compounding, Sterile Precautions: Although The Joint Commission supports the goals of USP 797 requirements, the accreditor will not survey your compliance with these requirements.
• Compliance with CMS’ Conditions of Participation (CoP): Intense focus on standards derived from CMS’ CoP has become normal throughout a survey. For hospitals that use Joint Commission accreditation for deemed status, compliance is crucial. The electronic edition of the accreditation manual provides a crosswalk between the standards and CoPs.

About to enroll as a provider with CMS? Then read this...

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