Ambulatory Surgical Centers

An Ambulatory Surgical Center is any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization in which the expected duration of services would not exceed 24 hours following an admission.

In the State of New Hampshire, Ambulatory Surgical Centers are also required to follow HE-P 812 Administrative Rules.

Emergency Operations Plan

Every facility's Emergency Operations Plan (EOP) must be based on a documented facility-specific risk assessment, use an all-hazards approach, and must be updated at least annually.

The EOP must include strategies for addressing emergency events that are described in the risk assessment.

Ambulatory Surgical Center EOPs must also address the patient population, the type of services the facility has the ability to provide in an emergency, and the facility's Continuity of Operations Plan (including delegations of authority and succession plans.)

There must also be a documented process for cooperation and collaboration with local, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This process should also include documentation of the efforts of the ASC to contact these officials and its participation in collaborative and cooperative planning efforts.

Policies and Procedures

Policies and procedures must be based on the emergency plan, risk assessment, and the communication plan for the Ambulatory Surgical Center, and they must be reviewed and updated annually.

Policies and procedures are required to address the following:

• A system to track the location of on-duty staff and sheltered patients in the ASC's care during an emergency. If on-duty staff or sheltered patients are relocated during the emergency, the ASC must document the specific name and location of the receiving facility or other location.
• Safe evacuation from the ASC, which includes consideration of care and treatment needs of evacuees, staff responsibilities, transportation, the identification of evacuation location(s), and primary and alternate means of communication with external sources of assistance.
• A means to shelter in place for patients, staff, and volunteers who remain in the ASC.
• A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.
• The use of volunteers in an emergency or other staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
• The role of the ASC under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Communications Planning

ASCs are required to develop and maintain a Communication Plan that is compliant with all local, state, and federal laws. It must also be reviewed and updated at least annually.

The Communication Plan must include all of the following:

• Names and contact information for staff, entities providing services under arrangement, patients’ physicians, and volunteers.
• Contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance.
• Primary and alternate means of communicating with ASC's staff, Federal, State, tribal, regional, and local emergency management agencies.
• A method for sharing information and medical documentation for patients under the ASC's care, as necessary, with other health care providers to maintain the continuity of care.
• A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
• A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4).
• A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

An Ambulatory Surgical Center's Communication Plan does not require:

• Occupancy information,
• Arrangements with other ASCs and other providers to receive patients in an emergency event, or
• Names and contact information for other Ambulatory Surgical Centers.

Training and Testing

Facilities are also required to maintain a training and testing program. This program must be reviewed annually.

Training

Ambulatory Surgical Centers must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles. An additional emergency preparedness training must be offered at least annually to all staff, volunteers, and other individuals providing services. The annual training must be documented and demonstrate staff knowledge of the facility's emergency operations plan.

Testing

In addition to an initial and annual staff training, ASCs are required to conduct exercises to test the emergency plan at least annually.

• One exercise must be a functional exercise that is facility-based, or when possible a community-based (including partner organizations and response agencies); however, an ASC is not required to conduct or participate in community-based functional or full-scale exercises.
• The second exercise could be an additional functional exercise or a tabletop exercise that is designed to challenge an emergency plan.

Facilities must analyze the facility's response to and maintain documentation of all exercises and drills, in addition to real-world events that activate the facility's Emergency Operations Plan. The plan should be revised as needed based on the outcomes of these events and exercises.