He-Hea 1900

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.

(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).

(d) Demonstration of emergency transport shall be in the form of:

(1) A copy of the written agreement with an EMS service for emergency transport services; or

(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;

(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:

a. Extreme climate; and

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