Procedures permitted in an ASC (42 CFR 416.65) are those that generally do not require extended lengths of stay or extensive recovery or convalescent time. Such procedures require the use of a dedicated operating room (or suite), and a post-operative recovery room, or short term (not overnight) convalescent room.
Regulations do not allow for planned overnight recoveries in an ASC for approved procedures performed on Medicare patients and ASC rules do not permit the performance of surgical procedures on Medicare patients that would require transfer to a hospital.
–State Survey Agency Directors When it is determined in advance that a Medicare patient requires overnight recovery and care following a surgical procedure, the surgery should not be performed in an ASC even though the procedure may be on the list of Medicare-approved ASC procedures.
Overnight stays following surgery in an ASC should be infrequent and only occur in cases where an unanticipated medical condition requires medical observation or care within the capabilities of the ASC.
In all other situations involving Medicare patients, it is expected that an ASC would transfer the patient to an appropriate facility if an overnight stay is required. An ASC that routinely provides overnight recovery stays, regardless of the payment source, may no longer meet the regulatory definition of an ASC and will jeopardize its Medicare certification.
To evaluate compliance with these requirements, the surveyor should verify that:
1. The ASC has a written transfer agreement with a local hospital, or that all physicians performing surgery at the ASC have admitting privileges at a local hospital;
2. Medicare patients are scheduled only for procedures on the CMS approved list and that no Medicare patients are being scheduled for planned overnight stays;
3. Any overnight stay for a Medicare patient is the result of unanticipated conditions requiring continued observation or care within the capability of the ASC and is neither a planned nor routine occurrence.
4. With regard to non-Medicare patients, a Medicare-certified ASC may provide services to an individual who is expected to require an overnight stay if the ASC transfers the non-Medicare patients to overnight care facilities (such as skilled nursing facilities, recovery care centers, and other non-hospital, post-operative care facilities), on a routine or non-routine basis, without jeopardizing their Medicare certification.
5. However, an ASC that routinely provides overnight recovery stays in the ASC itself, regardless of the payment source, may no longer meet the definition of an ASC and will jeopardize its Medicare certification.
Now for an ASC that wants to be able to provide the 23-hour stay for those unusual occurrence that one would need to transfer the patient to this line of service, an ASC should consider these action items:
1. contact your local city office with zoning definitions and ensure that you are zoned to provide an overnight stay in your facility
2. contact your local landlord or property management company to ensure that they are aware of your desire to open a 23-hour stay facility
3. ensure that a new name is achieved in that you will discharge the patient from the surgery center, then readmit them into the 23-hour stay facility. this ensures no medicare action to deny or to deny recertification as a medicare provider
4. overnight stay facility must have a minimum of 2 staff persons on staff. (1) RN & (1) non-licensed staff like CNA/Front Office, type person - the reason for this is because of running a code. if a code were called, one person cannot provide total care and call EMT etc.
5. educate the doctors as to the need to discharge the patient from the surgery center and readmit them into the 23-hour hold/stay service line.
6. the creation of a new chart with appropriate paperwork like orders and progress notes
7. the orders for 23-hour stay should include often and frequent pain scales and assessment, with aggressive pain control measures, then reassessed.
8. an order for food and diet restrictions for the patient. you will need to have a means to obtain or provide the food and food services to the patient while they are in your facility
9. you will need a separate refrigerator with a monitoring device in it for monitoring the temperature, patient food must be labeled well with dates and expiration dates clearly marked
10. the ordering physician that ordered the patient to have 23-hour hold, should at minimum see the patient the next day face to face and then discharge. if this is not done, then there should be at least a well-documented nursing assessment of the patient condition one that would support the reason for the transfer to this service.
11. a conversation with the surgeon and the nurse, discussing the patient and condition should be well documented in order to obtain the order for discharge.
12. discharge should be a responsible adult, it does not require that they are monitored for 24 hours since they were monitored in your facility post surgery center procedure.
13. make sure the patient stays on all monitors for the duration of the 23-hour stay.
14. vital signs should be captured at the minimum:
-the first hour, q15 min (pain included)
-hour 2-3, q 30 min (pain included)
-hours 4, 5, 6, q 45 min (pain included)
-hours 7, 8, 9, 10, 11, 12 q one hour (pain included)
-hours 13-23, q 2 hours (pain included)
An RN assessment of the patient is done at the time of finalizing that round of vital signs with the focus on the pain control and the effectiveness of the pain remedy that was used. All signs should point to a resolution of pain and not an increase of it herein to justify the cost factor.
You then can bill for this service in the increments of the 15 min that the nurse did the continuous care and pain assessment with evaluation hereinto.
Before deciding to do a 23-hour hold facility, I would seriously give these items deep thought:
• Is there enough space on-site for a recovery center? If so, will space need to be reconfigured or built-out?
• Do you have enough nurses with recent recovery experience beyond a typical day surgery stay?
• How will meals be provided?
• During a renovation of existing space, where do you temporarily go with teammates and the workstations that are displaced, as well as store equipment, linen, etc.?
• Is there enough need in your market to warrant a recovery center?