CMS SOM App. L, Tag Q-0041

When services are provided through a contract with an outside resource, the ASC

must assure that these services are provided in a safe and effective manner.

Interpretive Guidelines: §416.41(a)

The ASCs may contract with third parties for provision of the ASC’s services, including

the ASC’s environment. However, such a contract does not relieve the ASC’s governing

body from its responsibility to oversee the delivery of these ASC services. Given that

many ASCs operate closely with a physician practice or clinic, or that some ASCs share

space with other ASCs or other types of healthcare facilities operating at different times,

use of a wide range of contract services may be common in ASCs. The ASC must assure

that the contract services are provided safely and effectively. Contractor services must

be included in the ASC’s QAPI program.

For example:

• If the ASC contracts for cleaning of the ASC, including its ORs/procedures

rooms, the ASC’s governing body is still responsible for the sanitary condition of

the ASC and must exercise oversight over its contractor to assure that standard

sanitary practices are employed.

• If the ASC contracts for the provision of nursing services, the ASC remains

responsible for assuring that all contract nurses are properly licensed and trained

and oriented to perform their duties within the ASC. The ASC is responsible for

the direction of nursing staff, regardless of whether they are employees or

provided under contract.

• If the ASC contracts for provision of anesthesia services, the ASC remains

responsible for reviewing the credentials of all anesthesiologists and anesthetists

providing anesthesia services and granting them privileges to do so.

• If the ASC contracts (for example, with an associated adjacent physician practice)

for provision of receptionist services, the ASC is responsible for assuring that

such services are provided in a manner that complies with the patients’ rights CfC

requirements.

• If the ASC contracts for medical records services, it must ensure that the

contractor meets all requirements of the medical records CfC.

Survey Procedures: §416.41(a)

• Ask the ASC for a complete list of its currently contracted services.

• Review the personnel files of contract personnel to determine, as applicable, their

credentials, privileges, evidence of training, evidence of periodic evaluation, etc.

• If the ASC is one that shares space (temporally separated) with other entities, ask

the ASC whether it contracts or has some other formalized arrangement with any

of those other entities for services when the ASC is in operation. If employees of

an entity other than the ASC perform services while the ASC is in operation, and

the ASC has no contract or other formal documentation of an arrangement with

the other entity that governs the provision of such services, then the governing

body fails to exercise its responsibility for the administration of the ASC’s

programs.

• Ask the ASC how it assesses the safety and effectiveness of the services provided

by each contractor, including how contractor services are incorporated into its

QA/PI program. Select several contractors from the list and ask for

documentation of the most recent assessment of each by the ASC.

• Ask the ASC management what process it uses to correct deficiencies in

contracted services. Ask if there are any cases where it has identified deficiencies

and taken corrective action, and if so, ask to see documentation of these cases.