Skip Navigation LinksAFL-09-26

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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


AFL 09-26
August 12, 2009


TO:
Ambulatory Surgical Centers

SUBJECT:
Federal Fiscal Year 2010 Certification Surveys


Pursuant to Section 1864(a) of the United States Social Security Act, the California Department of Public Health (CDPH) is responsible for conducting certification surveys in California on behalf of the federal Centers for Medicare and Medicaid Services (CMS). These surveys are conducted to verify that health facilities receiving reimbursement under Medicare and Medicaid (referred to as Medi-Cal in California) are complying with all conditions for coverage (CfCs) and conditions of participation (CoP) for the respective facility type. All health facilities receiving reimbursement under Medicare and Medi-Cal are subject to certification surveys.

In an effort to combat deficient practices throughout the country regarding infection control, CMS has established a new survey protocol requiring the department to conduct onsite surveys of at least 33% of non-deemed Ambulatory Surgical Centers (ASCs) before the end of federal fiscal year 2010, in addition to the standard annual minimum of 5% of deemed ASCs. An ASC is considered "deemed" if it qualifies for CMS certification through accreditation by a private accrediting body, as specified in the federal regulations. In the coming months, the department will begin randomly selecting and surveying ASCs to ensure completion of the required surveys by the end of federal fiscal year 2010.

All certification surveys are unannounced. In most cases, the survey team will consist of two Health Facility Evaluators trained to conduct onsite certification surveys. The Nurses may examine the premises and physical environment for compliance with certification requirements, interview staff, review electronic and paper records, meet with facility administrators, observe a surgery from start to finish, and perform any other activities necessary to ensure compliance with the CfCs.

In preparation for the upcoming surveys, the department recommends that all facilities conduct self-assessments to determine compliance with certification regulations. These checks will help ASCs avoid deficiencies and may save time during the survey itself. As a reminder, all ASCs receiving reimbursement for Medicare or Medi-Cal are required to comply with the CfC for ASCs, contained in Title 42 of the Code of Federal Regulations, Sections 416.2 and 416.40-52. The text of the regulations and interpretive guidelines for surveyors are linked below. Failure to comply with the CfCs may result in issuance of a deficiency and/or termination from participation in Medicare.

If you have any questions, please contact your District Office Administrator/Manager.

Conditions for Coverage: Ambulatory Surgical Centers:

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=38af2161b33de70fc35286fdbee57ca6&rgn=div5&view=text&node=42:3.0.1.1.3&idno=42#PartTop

Guidance to Surveyors: Ambulatory Surgical Centers:

http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf 


Sincerely,

Original Signed by Pamela Dickfoss for Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director
Center for Health Care Quality

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