THE WEEK OF OCTOBER 17, 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

AGAIN, NOTHING HAS CHANGED!

For ASCs, nothing has changed. You follow ED 20-016 revised. You do not follow the CDC guidelines that recently came out. Hopefully, the Department will revise ED-2016 to take those into consideration, but for now, use ED 20-016 revised.

You still mask, you still screen patients and staff, you still distance.

If you have patients that are not fully-vaccinated, they must still test and quarantine, per pages 6 &7 of ED 20-016.

For staff, you follow the various EO’s that require being ‘up to date,’ which is fully-vaccinated and only one booster. EO 294 clarifies up-to-date as one booster only. Staff that are not up-to-date require a religious or medical exemption, and they must test. The frequency is determined by the Community Levels (your county) located on the NJDOH website every week.

Do not follow the guidelines for Hospitals, Medical Practices (they have their own AO from DCA).

• From a Center: 

We recently had AAAHC in for our accreditation, and the first thing they asked for was our COVID binder. They would not even start the survey until it was provided, and they went over it with a fine-tooth comb. I have a binder for doctors, another for staff and another for vendors. They wanted to see how many exemptions and look at the percentages of my ‘up to date’ vs those with exemptions and testing. 

• Are you aware that AAAHC requires that the employer files contain evidence that personnel policies were made known to the employee at the time of employment (Personnel Records Worksheet 3.C.4). Surveyors are looking for an acknowledgement that the employee received a copy of the handbook and that they were given the opportunity to ask questions at the time of receipt. This is important as it could prevent miscommunication between management and the new employee. If the employee assumed that something was acceptable and then they are reprimanded for non- compliance, they could file a complaint with the Labor Relations Board. Whatever is in your manual must be followed exactly as written. It is a good idea to have your handbook developed and reviewed by a human resource expert; it is worth every penny! Develop an acknowledgement form and get it signed as soon as the employee starts work. If the manual is updated, all employees must receive the revised manual, and they should also sign a new acknowledgement form.

Ann Geier, MS, RN, CNOR(E), CASC

Ambulatory Healthcare Strategies

AGeier@AH-Strategies.com

Visit the Ambulatory Healthcare Strategies table at the 10/19 Membership Meeting

• Blue prints are a critical tool when a Life Safety Survey begins. All too often the lack of blue prints, also known as drawings, will cause a surveyor to make their own assumptions regarding construction type, building codes used at the time of construction, and square footage of the center. These factors determine the need for a sprinkler system, the number of exits, quantity and location of fire walls, plus a number of other life safety systems. Be sure to have an up-to-date set of Life Safety Drawings prior to your expected survey. If you don’t have them, talk to an architect to have a set drawn up; it can be well worth the cost.

Anthony Riehl, CFI, CESI

Healthcare Life Safety Consultants

anthony@hlsconsultantsllc.com

Third in a series of topics focusing on the accountability of 

Controlled Drug Substances

THE ANESTHESIA CHART AUDIT

How many different staff members provide care for your patients?

How many of them have access to controlled substances?

Those with access could divert.

Limiting access minimizes risk.

Hypothetically you should be able to trace the "life" of the controlled substance from receipt of orders to inventory in the narcotic cabinet, to sign-out, to administration, to wastage (if applicable). 

In essence, from “Cradle to Grave.”

Performing random chart audits comparing the administration of controlled substances in the patient chart to the narcotic count sheets is a recommended monthly audit. Audits of controlled substances by anesthesia providers and nursing staff should be considered. Click on the attached form which can be used to begin Anesthesia provider audits.

Discrepancies should be investigated and treated as an incident report. Trends should be investigated.

This is an excellent exercise to promote compliant documentation.

John Karwoski, RPh, MBA

President and Founder

www.jdjconsulting.net

Visit the JDJ Table at the 10/19 Membership Meeting

Q: When and where can the DON step up in the OR in case of a staff shortage?

A: NJDOH has opined about this on numerous occasions.

The DON is an administrative position and not meant to be someone who scrubs in daily. They can in an emergency, if, for instance, a nurse calls out.

They should not be part of the regular staffing plan.

Q: Please confirm is it OK for an ASC to have patients come for procedures with only 2 COVID vaccines without a booster dose, I cannot find anything; we only have requirements for healthcare workers.

Follow the guidelines of ED 20-016 revised for your patients. See page 6, b

Up-to-date which means fully-vaccinated for patients. Fully-vaccinated and one booster is only a requirement for healthcare workers.

Q: Is there such a thing as an inactive ASC license?

A: From NJDOH: Facilities that close temporarily may have an inactive license for a period of time. Facilities close for various reasons such as to conduct renovations or when there are changes with physician ownership.

Q: I see LeapFrog is speaking at the meeting. Are we required to take part in their survey? Does it affect our Medicare reimbursement?

A: It is not mandatory, and it does not affect reimbursement. You may be confusing it with ASC-20. 

NJAASC, along with ASCA, is neutral as to participation; we are neither supporting nor opposing it. This is a decision for your center alone to make.

Q: Are criminal background checks required by the state for new hires in an ASC?

A: No, they are not. If you want it, you pay for it. It would be policy- driven. However, remember that LPNs/RNs are required to have background checks and fingerprinted as part of their license and renewal. 

Q: Is there a NJDOH mandate for flu vaccines for ASC employees?

A: No there is not. It is by center policy. 

Myth #1: Emailing patient data or Protected Health Information (PHI) is covered by the HIPAA Rule but text messaging is not.

Truth #1: This could not be further from the truth! Email and text messages are both considered forms of electronic communications (under HIPAA) and must comply with the HIPAA Privacy and Security Rules.

Myth #2: Healthcare Providers can share health information with employers.

Truth #2: Employers must have the ability to research health information about their employees; however, HIPAA prohibits healthcare providers from disclosing personal health information to employers without the patient’s consent.

Myth #3: HIPAA Privacy Rule applies only to electronic patient records.

Truth #3: HIPAA covers all patient records, regardless of whether they are in paper or electronic form. As long as the information can be stored, handled, transmitted, stolen or breached, the information needs to be protected per HIPAA regulations.

Myth #4: If contracts are in place for hardware, software vendors, billers, and third parties engaged with the healthcare company, it is not necessary to have HIPAA Business Associate Agreements in addition to the contracts.

Truth #4: Business Associate Agreements (BAAs) are a HIPAA requirement committing the Covered Entity’s Business Associate to abide by HIPAA rules and regulations as they apply to the Business Associate and their business operations. 

Myth #5: As a small healthcare practice it is not necessary to follow the HIPAA Rules because most of HIPAA applies to large organizations, healthcare clearinghouses and hospitals.

Truth #5: All Covered Entities and their Business Associates must follow the Privacy, Security, Breach Notification and Omnibus Rule under HIPAA.

First step – Risk Analysis!  

• In recent years ASCs have seen a decrease in reimbursement at the beginning of the year due to patients not returning the coordination of benefits form requested by their health insurance provider. It is a good practice to remind patients that their health insurance company may have asked them to return a COB form stating that they have only one health insurance plan.

If the patient does not return the form, the claim of an ASC may be denied. To avoid this denial, it is recommended that ASCs maintain a file of the most commonly requested COB forms and provide them to the patient during the initial eligibility and benefits call. The form should be completed by the patient and returned to the health insurance provider prior to surgery.

Jennienne Robertelli

CATALYSTRCM

jennienne@catalystrcm.com

Visit the CATALYSTRCM table at the 10/19 Membership Meeting

• The Top Procure-To-Pay Trends You Can't Ignore 

In the digital world, there is a need for new procurement-to-pay and new business opportunities. As a result, top procure-to-pay trends are highlighted, which brings professionalism to your business for the upcoming years. Here are some top procure-to-pay trends one must employ.

• Data and Analytics 
• Machine Learning and Artificial Intelligence 
• Risk Management 
• Leadership to Build Effective Talent Strategies 
• Transparency for Enhancing the Reputation 
• Global Regulations 

Jacque Grant

Hybrent 

jacqueg@hybrent.com 

• If your ASC is not already offering payment plan options, consider doing so. With patient responsibility increasing, this option can help reduce stress for those who may struggle to make a single, large payment by spreading their payments out over time. Explore the capabilities of technology including patient portals to assist this process.

Kathryn Boylan

SISFirst

kboylan@sisfirst.com

Visit the SISFIRST table at the 10/19 Membership Meeting

• Five Tips to Optimize Coding

1. Stay away from on-specific diagnosis codes. ICD 10 requirements for dx documentation are much more detailed than the previous ICD 9 ones were.

2. Incorrect modifier usage is the second most common reason for loss of potential reimbursement and claim denials.

3. Modifiers often depend on the requirement of payers. Incorporate payer specific guidelines in your coding to stay clear of denials and underpayments.

4. Stay away from upcoding. Never use a higher-level code or more expensive procedure as compared to the level of service. This will not only result in delays and denials, but it is also illegal.

5. Stay away from under-coding. Omitting or exchanging codes for a lower level of code or less expensive code is leaving money on the table. 

Nick Rodriguez

CONSENTUS

nrodriguez@consentus.com

Visit the CONSENTUS table at the 10/19 Membership Meeting

• According to ANSI/AAMI ST-79, ‘The temperature in the (steam) sterilizer access area should not exceed that specified in the sterilizer manufacturer’s written IFU.’ The sterilizer access room is the room behind your steam sterilizers where service is usually performed. However, this room needs to be maintained at the temperature recommended by the sterilizer manufacturer to ensure optimum operational performance of your sterilizer. You should contact your sterilizer manufacturer to provide this information to you in writing. This only applies to sterilizers with access rooms. 

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