CHAPTER He-Hea 1900 AMBULATORY SURGICAL FACILITIES
PART He-Hea 1901 PURPOSE
He-Hea 1901.01 Purpose.
(a) This chapter
implements a standard for the consideration of ambulatory surgical facility
construction, expansions, renovations and/or replacements that are subject to
CON review.
(b) These standards
are intended to:
(1) Improve the:
a. Quality of care;
b. Access and availability to ambulatory surgery
services; and
c. Cost effectiveness of ambulatory surgery
services provided, and
(2) Not be detrimental to the health care system
of the area.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
PART He-Hea 1902 DEFINITIONS
He-Hea 1902.01 Definitions.
(a) “Ambulatory
surgical facility” means “ambulatory surgical facility” as defined in RSA
151-C:2, I.
(b) “Ambulatory
surgical services” means those services the applicant proposes to provide at
the facility.
(c) “Application”
means a proposal prepared by a person and filed with the board for a
certificate of need.
(d) “Board” means
“board” as defined in RSA 151-C:2, IV.
(e) “Board
certified” means the confirmation given by a national or regional association
to a physician as having passed special examinations for his/her medical
specialty.
(f) “Certificate of
need (CON)” means “certificate of need” as defined in RSA 151-C:2, VIII.
(g) “Detrimental”
means an adverse impact on the ability to maintain the accessibility, quality
and cost of health care services in the area.
(h) “Essential
community services” means those basic health care services provided by a
hospital including emergency services, obstetrical services and
medical/surgical services.
(i) “Facility” means
“health care facility” as defined in RSA 151-C:2, XV-a.
(j) “Health care
services” means clinically related diagnostic, treatment or rehabilitative
services.
(k) “Letter of intent”
means a document submitted to the board which describes a proposed project and
identifies the cities and towns which represent the applicant’s proposed
service area.
(l) “Marshall
Valuation Service (MVS)” means an appraisal guide for the development and
reporting of replacement building and equipment costs used to estimate
construction costs of commercial buildings, 2008 edition.
(m) “Operating room”
means any room in a licensed hospital or ambulatory surgical facility equipped
and used to perform surgical cases.
(n) “Patient
charges” means the price charged for patient care services at a health care
facility.
(o) “Person” means
“person” as defined in RSA 151-C:2, XXVIII.
(p) "Project
costs" means all costs of a single project or an integrated project,
including but not limited to the following costs, as applicable:
(1) Legal fees, excluding those fees associated
with:
a. The preparation of a CON application; and/or
b. Prosecution of a CON application before the
board;
(2) Consulting fees;
(3) Financial feasibility fees;
(4) Architect and engineering fees;
(5) Other fees, which shall be specified;
(6) Real estate acquisition;
(7) Site preparation;
(8) Utilities;
(9) Soil survey and evaluation;
(10) Temporary relocation costs;
(11) Moving costs;
(12) Construction costs, including:
a. Labor costs for new construction;
b. Labor costs for renovations/alterations;
c. Materials for new construction;
d. Materials for renovations/alterations;
e. Fixed equipment costs for new construction;
f. Fixed equipment costs for
renovations/alterations;
g. Demolition costs;
h. Insurance costs during construction;
i. Interest costs during construction; and
j. Fixed
equipment;
(13) Moveable equipment;
(14) Bond discount; and
(15) Debt service reserve.
(q) “Public notice”
means any media advertisements, brochures, pamphlets, fact sheets or other form
of information conveyed to the public concerning an aspect of healthcare.
(r) “Quality
improvement plan” means a continuous plan of collection, screening and
evaluation of information concerning patient care, placement and clinical
performance leading to the methods of resolving and/or eliminating problems as
identified by professional and administrative staffs, patients and their
families, and other professionals in the delivery of health care services.
(s) “Renovation”
means the repair, remodel or reconfiguration of existing space that requires a
capital expenditure to accomplish.
(t) “Replacement”
means the rebuilding, in whole or in part, of an ambulatory surgical facility
on a new or original site that requires a capital expenditure to accomplish.
(u) “Service area”
means a geographic area which is served by each ambulatory surgical facility.
(v) “Story height
multiplier” means the number by which the base cost of a building is multiplied
to adjust for any variation in average story height from the base of 12 feet.
(w) “Uninsured”
means a person who:
(1) Is not covered or eligible for health care
insurance;
(2) Is eligible but not enrolled in a health
insurance plan; or
(3) Is otherwise covered by a health insurance plan
that does not cover the medically needed service(s) provided by the ambulatory
surgery center.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
PART He-Hea 1903 STANDARDS FOR AMBULATORY SURGICAL FACILITIES
He-Hea 1903.01 Service
Area. Applicants shall provide a
description of the proposed service area for the project in the form of town
name and zip code.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1903.02 Scope
of Services Provided.
(a) Applicants shall
detail the surgical specialties which will be provided by the proposed
facility.
(b) In order to assess
the scope of ambulatory surgery
services provided, applicants shall indicate which of the following surgical
specialties will be provided at the proposed facility:
(1) Anesthesia;
(2) Cardiovascular;
(3) Dermatology;
(4) Gastroenterology;
(5) General;
(6) Neurological;
(7) Obstetrics/Gynecology;
(8) Ophthalmology;
(9) Oral/Maxillofacial;
(10) Orthopedic;
(11) Otolaryngology;
(12) Plastic;
(13) Podiatry;
(14) Thoracic;
(15) Urology; and
(16) Other, which shall be specified.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1903.03 Impact
on Health Care Services.
(a) Applicants proposing
to establish, expand or renovate an ambulatory surgical facility shall
demonstrate that the proposed facility shall maintain or improve, for the
proposed service area, the:
(1) Quality of care;
(2) Access to and availability of health care services;
and
(3) Cost effectiveness of health care services
provided.
(b) Demonstration
shall be made by submitting with the application:
(1) A copy of an existing or proposed quality
improvement plan;
(2) A report addressing physicians’ ability to
access resources which allow them to perform health care services or obtain
admitting privileges at existing ambulatory surgical facilities and hospital
outpatient operating rooms pursuant to He-Hea 1904.01(g) and (h) including correspondence from physicians intending to
refer patients to the proposed facility;
(3) To the extent data is available, a statistical report in the application
which shows how the proposed project is projected to affect health care
services in the proposed service area in terms of:
a. Utilization;
b. Patient charges;
c. Market share;
d. Physician referral patterns; and
e. Personnel resources;
(4) Any correspondence from other facilities in the service area regarding the impact of the proposed project
on their existing health care services including their continued ability to:
a. Maintain quality health care services;
b. Provide essential community services;
c. Provide emergency services; and
d. Provide charity care; and
(5) A report in the application addressing how
the establishment, expansion or renovation of an ambulatory surgical facility
will not have a detrimental impact on health services within the proposed
service area.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1903.04 Projected
Patient Volume.
(a) Applicants shall
document the projected patient volume for each service to be offered at the
proposed facility.
(b) Documentation of
patient volume shall include:
(1) The
assumptions used to determine the
projected patient volume; including:
a. Average number of cases for a twelve month
period;
b. Length of turnover time between cases on
average; and
c. Percentage of available operating room time
utilized on an annual basis.
(2) Letters from physicians, if any, indicating
their intent to refer patients to the facility and projected volume of
referrals; and
(3) A report in the application that identifies
patient origin data of the projected
patient volume by zip code or town name.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1903.05 Equipment. Applicants shall provide a list of equipment
to be used in the new or expanded ambulatory surgical facility. The applicant shall state if the equipment to
be acquired will be new, used or leased.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1903.06 Quality
Assurance Requirements.
(a) The applicant
shall demonstrate that:
(1) It has
entered a written agreement for the acceptance of and care for patients from
the ambulatory surgical facility who develop complications or require
postoperative confinement with:
a. The nearest acute care hospital; and/or
b. Any acute care hospital within 30 minutes’
travel time; or
(2) The surgeons providing care to patients at
the facility have admitting privileges at:
a. The nearest acute care hospital; and/or
b. Any acute care hospital within 30 minutes’
travel time.
(b) Demonstration
shall be in the form of a copy of the written agreement(s) or documented
admitting privileges with the acute care hospital(s).
(c) The applicant
shall demonstrate that it has made provisions for emergency transport of
patients.
(d) Demonstration of emergency transport shall be
in the form of:
(1) A copy of the written agreement with an
(2) A statement that the applicant will utilize
the ‘911’ emergency medical response system.
(e) Applicants shall
demonstrate the existence of written policies and procedures regarding
discharge planning.
(f) Demonstration
required by (e) above shall be in the form of a copy of the written policies
and procedures which include:
(1) Designation of responsible personnel;
(2) Participation by the:
a. Patient;
b. Family;
c. Guardian; or
d. Significant other;
(3) Documentation of any follow-up health care
services provided; and
(4) Evaluation of the effectiveness of the
follow-up health care services.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1903.07 Staffing
Requirements. Applicants shall
provide a list of staffing for the new or expanded ambulatory surgical
facility.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1903.08 Access
to Public Transportation. Where
possible, ambulatory surgical facilities shall be located where access is
gained by public transportation.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
PART He-Hea 1904 CRITERIA FOR EVALUATING ALL AMBULATORY SURGICAL
FACILITY APPLICATIONS
He-Hea 1904.01 Criteria. In addition to the criteria included in
He-Hea 303.02 through He-Hea 303.09 and the standards in He-Hea 1903,
applicants shall meet the following criteria when applying for a CON for
ambulatory surgical facilities:
(a) Proposed
ambulatory surgical facility projects shall be financially feasible;
(b) In order to
assess the current and long-range financial feasibility of the proposed
project, each applicant shall demonstrate that resources:
(1) Are available to fund the proposed capital
costs and operating costs;
(2) Will be available to maintain operations in
the event of interruptions to cash flow; and
(3) Will be available to ensure the continued
operation of the proposed project;
(c) Demonstration of
financial feasibility shall be made by providing with the application:
(1) For an existing facility, copies of the
facility’s financial statements for:
a. The past 3 fiscal years; or
b. Since the facility has been in existence, if
less than 3 years;
(2) For all facilities, documentation in the form
of projected financial statements through 3 fiscal years after project
completion;
(3) A statement of the sources of funds to
finance the proposed project; and
(4) Documentation from the applicant’s lender,
underwriter or other anticipated source of capital which includes:
a. Financed amount;
b. Rate of interest; and
c. Term of debt;
(d) Applicants shall
provide a description of the proposed service area, which includes the
following:
(1) Demographic characteristics of the proposed
service area by age and sex compositions;
(2) Income levels of the area populations;
(3) Anticipated payer source by population totals
and percentages expressed as:
a. Medicare;
b. Medicaid;
c. Private insurance companies;
d. Self-pay; and
e. Health maintenance organizations;
(e) Applicants shall
assess the medical needs of the proposed service area which would be met by the
proposed project;
(f) Assessment of
the medical needs of the proposed service area shall be made in the form of a
report included with the application which addresses:
(1) Demographics of the
service area population, which shall include:
a. Age; and
b. Sex;
(2) Geographic access problems, such as excessive
travel times and distances to existing facilities; and
(3) Lack of specialized ambulatory surgery
services in the proposed service area to meet the medical need of the current
population;
(g) The applicant
shall document physicians’ difficulty in performing ambulatory surgery services
or obtaining admitting privileges at existing ambulatory surgical facilities and
hospital outpatient surgery rooms in the proposed service area;
(h) Demonstration of
difficulty pursuant to (g) above
shall be made in the form of a report in the application addressing physicians’
difficulty in performing ambulatory surgery services or obtaining admitting
privileges including but not limited to:
(1) Medical reasons;
(2) Availability and cost of ambulatory surgery
services; and
(3) Staffing;
(i) In order to
determine the financial feasibility of the project pursuant to RSA 151-C:7, II,
applicants shall submit an assessment of costs and methods of construction of
the proposed project.
(j) The assessment
shall be made by providing preliminary floor plans showing space allocations
expressed on a per square foot basis;
(k) Applicants shall
provide a comparison of the anticipated proposed construction cost per square
foot to the 2008 edition of the Marshall Valuation Service, section 15, for the
proposed class and type of construction;
(l) Applicants shall
include a report with the application which provides:
(1) Details of all the project costs and space of
the proposed project;
(2) An analysis of the class and quality of construction
pursuant to section one of the 2008 edition Marshall Valuation Service;
(3) The allocation of costs within a multiple use
building;
(4) The calculations of site costs and land costs
where facilities are proposed to have multiple uses;
(5) The methodology used in calculating
construction costs for renovations;
(6) The methodology used in calculating
construction costs involving leasehold improvements; and
(7) The anticipated useful life of the building
for depreciation purposes;
(m) Construction
costs to be compared with the 2008 edition of the Marshall Valuation Service
shall include:
(1) Labor;
(2) Materials;
(3) Fixed equipment;
(4) Building permits;
(5) Architectural and engineering fees;
(6) Site preparation for the building;
(7) Utilities from structure
to street;
(8) Insurance costs during construction; and
(9) Interest costs during construction;
(n) The applicant
shall follow the outline of the calculator method set forth in section 10 of
the 2008 edition of the Marshall Valuation Service to determine construction
costs according to the Marshall Valuation Service;
(o) The costs and
factors to take into account pursuant to (n) above shall include:
(1) The base cost found in the outpatient
surgical center table in section 15, page 25 of the 2008 edition of the
Marshall Valuation Service;
(2) An adjustment to heating, ventilating, and
air conditioning costs for:
b. A different type of HVAC
system from that assumed in the table, if necessary;
(3) All fire protection system costs;
(4) Elevator costs if not included in base cost;
(5) Number of stories multiplier;
(6) Story height multipliers;
(7) Floor area - perimeter multipliers; and
(8) Cost multipliers from section 99 of the 2008
edition of the Marshall Valuation Service;
(p) The report of
project costs shall also list the alternatives considered in developing the
proposed project and the reasons for accepting or rejecting these alternatives;
(q) Applicants shall
document the impact of projected patient charges as a result of the proposed
project;
(r) Documentation of
patient charges shall be made in the form of a report included with the
application identifying:
(1) For an existing facility, a schedule of
patient charges for:
a. The past 3 fiscal years; or
b. Since the facility has been in existence, if
less than 3 years;
(2) For all facilities, a schedule of patient
charges projected through 3 years after project completion;
(s) Ambulatory
surgery services shall be provided in a safe and efficient manner;
(t) In the case of
existing facilities, demonstration of safe ambulatory surgery services shall be
made by providing with the application:
(1) Copies of inspection surveys and reports from
state, federal and/or accrediting agencies;
(2) Copies of corrective action plans if
deficiencies have been cited by state, federal and/or accrediting agencies;
(3) A report detailing how patients will be protected
from hazards which might occur during the construction/renovation project; and
(4) A signed statement made by the applicant per
He-Hea 303.05 (c) or (d);
(u) resources shall
be available to support the proposed ambulatory surgery project;
(v) Demonstration of
sufficient personnel resources for the ambulatory surgery project shall be made
by providing a report with the application which provides:
(1) The staffing pattern pursuant to the
applicable licensing requirements of RSA 151;
(2) A schedule of all personnel:
a. For an existing facility, for:
1. The past 3
fiscal years; or
2. Since the facility
has been in existence, if less than 3 years;
b. For all facilities, projected through 3 years
after project completion; and
(3) The number of medical staff employed by or
with admission privileges to the facility, by specialty; and
(w) Applicants shall
identify the source of any data or information provided pursuant to paragraphs
(d) through (v) above.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
PART He-Hea 1905 APPLICATION PROCEDURES FOR AMBULATORY
SURGICAL FACILITIES
He-Hea 1905.01 Process. Applications shall be processed in accordance
with the requirements of RSA 151-C:8.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1905.02 Requests
for Applications (RFA).
(a) The board shall:
(1) Issue a request for applications per He-Hea
1905.02(b); and
(2) Accept applications for ambulatory surgery
services that are based upon the requirements of He-Hea 1900.
(b) An RFA shall be
issued for ambulatory surgery services semi annually beginning on October 1,
2008 pursuant to RSA 151-C:8, I, if potential need has been determined based
upon the receipt of a letter of intent from a provider.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1905.03 Submission
of Applications. Applications shall
be:
(a) Prepared using the
board’s application form pursuant to He-Hea 302; and
(b) Submitted to the
board within 90 days after a request for applications has been issued by the
board.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
He-Hea 1905.04 Granting
Certificates of Need.
(a) In order to
grant a CON to an applicant(s), the board shall make a finding that the
application demonstrates and satisfies the requirement of He-Hea 1903.03(a).
(b) The board’s
finding shall be made based upon the applicant’s response to the standards and
criteria outlined in He-Hea 1903 and He-Hea 1904.
(c) Upon making a
finding per (b) above, the board shall grant a certificate of need to an
applicant who demonstrates full compliance with and satisfies the requirements
of He-Hea 1903 and He-Hea 1904.
(d) Notwithstanding
He-Hea 1905.04(c), in the event of competing applicants, the board shall award
a certificate of need to the applicant(s) who, pursuant to RSA 151-C:9, II,
demonstrates superiority in cost effectiveness, quality and affordability and
best meets the standards and criteria of He-Hea 1903 and He-Hea 1904.
Source. #7269, eff 5-10-00, EXPIRED: 5-10-08
New. #9261, eff 9-13-08
RULE |
STATUTE IMPLEMENTED |
|
|
He-Hea 1901 |
RSA 151-C:1, I |
He-Hea 1902 |
RSA 151-C:2 |
He-Hea 1903.01-1903.05 |
RSA 151-C:5, II(f) |
He-Hea 1903.06 |
RSA 151-C:7, IV |
He-Hea 1903.07 |
RSA 151-C:5, II(f) and RSA
151-C:7, II |
He-Hea 1903.08 |
RSA 151-C:5, II(f) and RSA
151-C:7, III |
He-Hea 1904 |
RSA 151-C:7, I-IV |
He-Hea 1905 |
RSA 151-C:8 |