Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 140 - DEPARTMENT OF HEALTH › Chapter 084 - MBULATORY SURGICAL CENTER LICENSING RULE › Section 13 140 084 - MBULATORY SURGICAL CENTER LICENSING RULE

Current through June, 2024
Section 1.0 Authority
This rule is adopted pursuant to
				  18 V.S.A. §
											2159.
Section 2.0 Purpose
This rule sets forth the standards that apply to the
				  licensing of Ambulatory Surgical Centers in Vermont. This rule applies to all
				  Ambulatory Surgical Centers in Vermont as defined in 18 V.S.A. Chapter
				  49.
Section 3.0 Definitions
3.1 "Accreditation" means the formal
				recognition by an CMS-approved accrediting body such as the Joint Commission
				that indicates conformity with the accrediting body's required set of standards
				and criteria.
3.2 "Ambulatory
				Surgical Center" means any distinct entity that operates primarily for the
				purpose of providing surgical services to patients not requiring
				hospitalization and for which the expected duration of services would not
				exceed 24 hours following an admission. The term does not include:
3.2.1 A facility that is licensed as part of
				a hospital; or
3.2.2 A facility
				that is used exclusively as an office or clinic for the private practice of one
				or more licensed health care professionals, unless one or more of the following
				descriptions apply:
3.2.2.1 The facility
				holds itself out to the public or to other health care providers as an
				ambulatory surgical center, surgical center, surgery center, surgicenter, or
				similar facility using a similar name or a variation thereof;
3.2.2.2 Procedures are carried out at the
				facility using general anesthesia, except as used in oral or maxillofacial
				surgery or used as used by a dentist with a general anesthesia endorsement from
				the Board of Dental Examiners; or
3.2.2.3 Patients are charged a fee for the
				use of the facility in addition to the fee for the professional services of one
				or more of the health care professionals practicing at the facility.
3.3 "CMS" means the
				Centers for Medicare and Medicaid Services of the U.S. Department of Health and
				Human Services.
3.4 "CMS
				Conditions for Coverage for Ambulatory Surgical Center" or "CfCs" means the
				following current Centers for Medicare and Medicaid Services rules from the
				Code of Federal Regulations (CFR) and related laws and regulations,
				interpretive guidelines, appendices and requirements, including 42 CFR §
				416.40-416.54.
3.5 "Commissioner"
				means the Commissioner of the Vermont Department of Health.
3.6 "Deemed Status" means the status granted
				to an Ambulatory Surgical Center by a CMS-approved national accrediting body,
				such as The Joint Commission, after it has surveyed the Ambulatory Surgical
				Center and determined it is in compliance with all CMS Conditions for Coverage.
3.7 "Deficiency" means a policy,
				procedure, practice or any other action by an Ambulatory Surgical Center that
				results in the Ambulatory Surgical Center not being in compliance with this
				rule or with the CMS Conditions for Coverage.
3.8 "Department" means the Vermont Department
				of Health.
3.9 "The Joint
				Commission" means the independent not for profit organization that accredits
				and certifies that healthcare organizations meet certain performance standards.
3.10 "Patient Complaint" means any
				expression of dissatisfaction related to the care and treatment provided by an
				Ambulatory Surgical Center, from a patient or the patient's representative. In
				this Rule, the term includes patient "grievance" which in the CfCs and CMS
				State Operations Manual specifically refers to complaints presented to and
				resolved or attempted to be resolved within the Ambulatory Surgical Center's
				internal system.
3.11 "Plan of
				Correction" means a written plan that a licensee is required to submit to
				address any identified Deficiency to bring an Ambulatory Surgical Center into
				compliance with this rule.
3.12
				"State Survey Agency" means the unit of Vermont state government designated by
				CMS to enforce the federal CfC for Ambulatory Surgical Centers in Vermont.
3.13 "Validation Survey" means a
				survey conducted by the State Survey Agency on behalf of CMS to ensure that an
				Ambulatory Surgical Center with Deemed Status is in compliance with the
				Conditions for Coverage.