THE WEEK OF OCTOBER 31, 2022

WELCOME TO THE PULSE!

We have developed The PULSE based on comments and suggestions from the membership and with your input in mind.

For it to reach its full potential, your contributions to content are needed.

Please send your questions and comments to the Editor, specific to these recurring columns: 

• SURVEY SNIPPETS
• WHAT’S ON YOUR MIND
• WE HEAR YOU

IT’S TIME TO RENEW YOUR NJAASC MEMBERSHIP!

Please be aware that 2023 NJAASC dues renewal letters have gone out to the membership.

NJAASC would like to thank all of you for your support this past year. We have even bigger plans for 2023, and we need your continued help to make it happen.

If you have any questions about your membership renewal or have not received a letter, please contact Kelly Biddle: kbiddle@njpsi.com

We also have a membership renewal giveaway!

One ASC and one Vendor member that renew prior to Thanksgiving will be randomly selected and treated to a lunch (up to $400) by NJAASC. In addition to lunch, a donation will be made in those member center and vendor names to the 30 Days of Giving charity drive that is underway.

PRESENTATIONS AND POWERPOINTS

ARE UP ON THE WEBSITE

Speaker presentations from the 10/19 Quarterly Membership Meeting are up on the website.

Q: I recently had an AAAHC inspection and Life Safety found us deficient for not having a WAGD loss policy in our Emergency Preparedness Plan. Are there any recommendations about the necessary information for this policy?

A: Below is the AAAHC standard and code section referenced in the standard. If the WAGD has its own system it must have an emergency plan to address the outage -- possibly through the Anesthesia machine? If it runs off the Vacuum the WAGD plan should address the outage of the vacuum system, as well. 

7.85. The facility has an emergency plan to address measures taken during a loss of WAGD, if applicable. NFPA 99: 5.2.3.7

5.2.3.7 Category 2 WAGD. Category 2 systems shall comply with 5.1.3.8, except as follows:

1. Medical WAGD pumps shall be permitted to be simplex.
2. The facility staff shall develop their emergency plan to deal with the loss of WAGD

James Masters

Ambulatory Healthcare Strategies

jmasters@ah-strategies.com

From a center:

Make sure you walk around the outside of your center and look at the landscaping, building and signage- are they well-groomed and informative? Life Safety looks at these types of things. I had a parking lot sign that was worn and not legible. Employee Badges- make sure you update your employee badges.

Among the most frequent statements I hear from clients about QAPI is: ‘We collected all this data, but we don’t know what to do with it.’

Data collection and analysis is one of the most essential aspects of QAPI studies. Why? Simply put, data doesn’t lie! If seeking to identify or validate an issue, your data will provide the proof. Determining what, where, when, who and how in data collection is the crucial step to study purpose and goals.

You have chosen your study topic, purpose and set the performance goals to be analyzed. Deciding WHAT data needs to be collected and developing a checklist is next. Data must be objective, measurable, meaningful to the study, and able to be statistically analyzed. Avoid data that asks more than one question for each indicator. HOW is the data to be obtained? Specify if it will be through direct observation, review of records, or electronically created reports. Engage staff to identify WHO is responsible for correctly obtaining the data. WHEN is how often the data will be collected. Studies are normally performed quarterly with data collected and analyzed throughout the study period.

Claire Cerame, MSN, RN

Positive Outcomes

ccerame@positiveoutcomesQI.com

During a Life Safety survey, a facility will be asked to confirm they have two copies of the generator operations manual. One copy is to be kept in a secure location near the equipment and the second, in an office area. It is recommended to put one copy of the manual in a dry bag and keep it inside the generator cabinet. I have found many centers do not have a copy of the manual for their generator. If there is no manual, it is not possible to know how to maintain your generator equipment per the manufacturer’s instructions (NFPA 110 Chapter 8 2010 edition).

Debbie Comerford, RN, CNOR, CASC, CLSS-HC

Life Safety Partners

debbie@ascqs.com

HAZARDOUS DRUG VS. HAZARDOUS WASTE

I receive a lot of questions on this topic and realized there is some confusion between determining which medications are categorized as hazardous drug or hazardous waste. Here are the main definitions, regulations, and

standards regarding hazardous drugs and hazardous waste and how you can determine if you have either. Feel free to have your pharmacist assist with any questions.

Remember, hazardous drugs pose an exposure risk to those handling them, while hazardous waste poses a risk to the environment if not disposed of correctly. And finally, not all hazardous drugs are considered hazardous waste.

Q: I received various questions about staff and patient testing/vaccination. I bundled them together and answered below.

A: Patients and their requirements are covered under ED 20-016 revised.

Staff and their requirements are covered under various EO’s from the Governor

Remember, hazardous drugs pose an exposure risk to those handling them, while hazardous waste poses a risk to the environment if not disposed of correctly. And finally, not all hazardous drugs are considered hazardous waste.

I have been told that the EOs requiring being up-to-date for workers will not be rescinded or modified.

Patients fully-vaccinated: There is not & never has been a requirement for a booster. They are not required to test (though, per your center policy, you can of still require it).

Patients not fully-vaccinated must test and quarantine.

Staff MUST BE up to date. This means fully-vaccinated and one booster.

You may NOT employ staff that are not up-to-date unless they have been granted a medical or religious exemption, in which case, they test weekly,and frequency is determined by community levels.

There is no provision for staff to be employed if they are not up-to-date and do not have an exemption, meaning there is no alternate test option for them.

Q: What are the NJDOH requirements for PACU?

1. Post anesthesia care units shall be adjacent to or within the operating suite.
2. The post anesthesia care unit shall be maintained as a closed unit. Access to the post anesthesia care unit shall be in accordance with facility policies and procedures.
3. All staff in the post anesthesia care unit shall be attired in scrub attire. Individuals who are permitted limited access shall be attired according to facility infection control policies.
4. Equipment and services available in the post anesthesia care unit shall include at least: a crash cart with defibrillator, drugs, pulse oximetry, electrocardiographic monitoring, body temperature monitoring, equipment necessary for intubation and various means of oxygen delivery. Constant and intermittent suction, blood pressure monitoring, adequate lighting, peripheral nerve stimulator, immediate access to a ventilator and end-tidal carbon dioxide monitoring in accordance with N.J.A.C. 8:43A 12/17( g) shall be made available. Provisions to ensure the patient’s privacy shall be maintained.
5. If neither general anesthesia nor regional anesthesia is administered in the facility, then the requirements for pulse oximetry, electrocardiographic monitoring, and a peripheral nerve stimulator found in (d) shall not apply to the post anesthesia care unit.
6. If the facility provides a second stage recovery area in addition to a post anesthesia care unit, the requirements above shall not apply to the second stage recovery area.  

Q: A patient tested positive last month. The parent says he is asymptomatic and has quarantined. Can we perform the case?

A: Yes, you can. See page 8, vii of ED-20-016 revised.  

Q: Is there such a thing as a ‘grab and go bag’? I never heard of it but another center I was speaking to mentioned it.

A: There is not. The regulations do not speak to nor require it. They are probably confusing it with the difficult airway cart. See 8:43 A-12.9 (Surgical service emergency equipment) and 8:43A-12.18 (Post anesthesia care units and equipment) for more clarification.

Ransomware is an ever-evolving form of malware designed to encrypt files on a device, rendering any files and the systems they rely on unusable. Malicious actors then demand ransom in exchange for decryption of the files.

 Stop Ransomware.gov was created to educate and offer resources to tackle ransomware more effectively.

The following resources were designed to help individuals and organizations prevent ransomware attacks that severely impact business processes and leave organizations without the data they need to operate and deliver mission-critical services. Some of the general information includes:

• Ransomware Guide
• CISA Insights: Ransomware Outbreak
• Ransomware: What It Is & What To Do About It
• Ransomware Protection and Response (NIST)
• Preparing for a Cyber Incident (FBI)

Dawn Meglino

HIPAA Compliance Specialist, CHPSE, CCSA, CCAP

DMeglino@ANATOMYIT.COM

There are several cybersecurity concerns and regulations affecting medical practices and ambulatory surgery centers.

Does your Practice:

• Follow the guidance of “IT-Staff,” assuming proper controls are in place?

• Believe that your risk is “transferred” to your EMR/EHR provider?
• Use an outside Managed-IT-Partner who you believe understands Cybersecurity Compliance/Regulations?
• Think “I’m too small – this will never happen to me”?
• Believe that hospitals are the focus of “Threat-Actors”?
• Assume that if something happens, your Cyber-Liability-Coverage will reimburse you?
• Understand the cost of a potential breach/incident – the Public Relations & Reputational damage?
• Have the required security controls in place to keep and maintain Cyber-Liability Insurance? 

Rachel Gisser

WITHUM

rgisser@withum.com

The key to filling out a staff at a surgical center without breaking the budget is to build in flexibility. Set up your staff and your hours so that you can always have just the right amount of people on hand. Not too many and not too few.

One way to help is by hiring full-time people wo are able to be cross-trained to do more than one thing. This gives management precious added flexibility with scheduling and gives you the opportunity to vary employees’ work weeks and keep them fresh.

A second key is to build a part-time - what we call a ‘PRN’ staff - for heavier days. It broadens your talent pool since some nurses want to work but don’t want to work full-time. It also offers cost savings over hiring full-time staff.

Employ creative scheduling to maximize the use of your staff. 

Finding good full-time staff in today’s market for nurses takes some creativity. Job Fairs, Staffing Companies, Advertisements and Networking. Community relationships are another good source for candidates. RN students on rotation from the local community college are a good investment in candidates for future staff. 

Nancy Goldstein MA, RNC

HORIZON HEALTHCARE STAFFING

nancy@hhstaff.com

Vendor Management is defined as the process that businesses and organizations use to maintain their suppliers (vendors). The vendor management process includes controlling costs, finding vendors, decreasing vendor-related risks, guaranteeing service delivery, and negotiating contracts. Vendor management is crucial because it plays an important role in choosing vendors to streamline business activities. Collaborating with the appropriate vendor can accomplish strategic goals, including:

1. Increase profits
2. Reduce expenses
3. Maximize employee time
4. Leverage spend volume
5. Expedite the vendor onboarding process

Jillian Dickerson

HYBRENT

hello@hybrent.com

One of the biggest challenges for ASCs is when a carrier requires an implant invoice to process and reimburse the claim. Typically, device vendors submit their invoices 2-to-4 weeks following the service date. Claim submission should not be delayed until the invoice is received. Instead, the implant cost can be calculated using the purchase order and the claim submitted for processing. This process will reduce the likelihood of timely filing denials, as well.

Karena McKenzie

SURGICAL NOTES

Karena.mckenzie@surgicalnotes.com

Patient collections is not just an area of concern for an ASC’s AR staff. Everyone working in the ASC, as well as the staff of an ASC’s affiliated physician practices, should understand the financial and compliance importance of point-of-service collections. In addition, team members should know where to direct patients when they have questions, concerns or complaints about their financial responsibility. If staff provide incorrect information to patients, it could make collection more difficult and harm patient and provider satisfaction.

Kathryn Boylan

SISFIRST

kboylan@sisfirst.com

Properly maintain your facility thru terminal cleaning. At the end of each day you should have in place a well designed terminal cleaning program. A properly cleaned facility has a positive impact on the safety and well being of your patients and staff. Your cleaning staff should be properly trained on how to perform a terminal cleaning and their training should be documented and kept on site for

regulatory agencies to review. This training should take place upon their hire, and then follow-up training sessions should be conducted and documented. Terminal cleaning should not be confused with the cleaning that is performed between cases. With terminal cleaning, you have to follow a certain pattern such as starting from the top/your ceilings and work your way down to the floors. It is important to have all equipment moved away from the walls, those areas cleaned, and then the equipment moved back in place. The surgical table also has to be moved due to spills and debris falling and ending underneath the table. It is crucial that the cleaning procedure is performed in a uniform fashion daily to ensure the quality of the cleaning. Your staff needs to be very familiar with the disinfectant they are using, especially the dwell time for the specific disinfectant, to ensure all surfaces stay wet for the manufacturers recommended time. Upon completion of cleaning one room, all cleaning materials such as mops and cloths must be disposed of and not used in another room. There are no short cuts with terminal cleaning, and the proper cleaning of your rooms should be viewed as an investment in the safety of all who enter the room

Peter Garbera

PREMIER BUILDING SERVICES

ptgarb@aol.com

Infection Prevention is a Shared Responsibility between Infection Control and the Sterile Processing Department (SPD). They need to work together to understand each other's responsibilities and roles in their healthcare facilities. This is vital for patient safety and quality outcomes.

Infection control needs to have an overall knowledge of why SPD does what they do, as well as how they do it. SPD needs to have the knowledge, skills and abilities (KSA’s) to perform their everyday responsibilities and to maintain that through certification, continuing education and training. SPD staff must have annual competencies performed by a Subject Matter Expert (SME). However, do not mistaken an annual evaluation as a competency. Competency is the ability of an individual to do a task. An Evaluation focuses on the work performance of an individual.

According to the NJDOHSS Licensure Standards for Ambulatory Care, section 8:43.1, Administrator’s responsibilities: (a) The administrator, or designee, shall ensure the development and implementation of an infection prevention and control program. (b) The administrator shall designate an infection control professional who shall be responsible for the direction, provision, and quality of infection prevention and control services.

Who is responsible for your Sterile Processing Department?

Al Spath, SP Management Consulting LLC & Sterile Processing Learning Center LLC

414 River View Plaza Trenton, N.J. 08611 •  (609) 503-7696  • info@njaasc.org

njaasc.org