The Surgery Center at Lutheran is licensed by the state health department. Obtaining a license requires strict adherence to state regulations as outlined in 6CCR 1011-1, CH 2 & 20 (Colorado).
We are also accredited by the Accreditation Association for Ambulatory Health Care, Inc. and the Center for Medicare & Medicaid Services (CMS). ASCs with these accreditations are regularly surveyed for compliance to regulations.
Certification by Centers for Medicare & Medicaid Services (CMS)
For an ASC to receive reimbursement for services provided to Medicare or Medicaid recipients, the ASC must be certified by CMS. Obtaining certification requires the same strict adherence to federal regulations outlined in Code for Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 416. To qualify for certification, the ASC is evaluated for compliance to regulations by undergoing an unannounced survey. A plan of correction is required to address any non-compliance to regulations.
An ASC chooses to voluntarily seek accreditation from an accreditation organization. There are three to choose from: AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities), TJC (The Joint Commission). Regardless of the accreditation organization selected by an ASC, securing and maintaining accreditation status requires vigilant attention to elements of performance and best practice standards. The goal for any ASC is to integrate state, federal, and accreditation association standards into everyday performance by members of medical staff and ASC personnel.
Our ASC has chosen AAAHC as our accreditation organization. Unannounced surveys are typically conducted every three years. Our ASC works tirelessly to address standards as outlined by our accreditation organization. We sustain our performance of these ongoing activities by assigning specific tasks and oversight to key personnel within our ASC. If deficiencies are identified during survey conditions, we submit a plan of correction and must demonstrate adoption and sustained improvement to validate we have met all accreditation requirements. Achievement of accreditation is the gold standard for delivery of care and services. We take pride in our sustained accreditation status.
For more information on the patient care standards set forth by CMS and AAAHC, please visit the following resources: