^ lV.;.!i;n^'iift«),-IA'j1.flF:.nl(1/ ^ ^. )-1 ^ Certificate of Need ^ 20?0?.0 'J Determination of ' ,f-:r' -AL. ' •'' 'rL'. 7)'- '<T'!:' ?.' "I';'' Ambulatory Surgical Facility and Ambulatory Surgery Center; '^ ^ (Do not use this form for any other type of ASC/F project) - h :\ v Certificate of Need submissions must include a fee in accordance with Washington Administrative Code (WAC) 246-310-990. The Department of Health (department) will use this form to determine whether my ambulatory surgical center or facility requires a Certificate of Need under state law and rules. Criteria and consideration used to make the required determinations are Revised Code of Washington (RCW) 70,38 and Washington Administrative Code (WAC) 246-310. I certify that the statements in the submissions are correct to the best of my knowledge and belief. I understand that any misrepresentation, misleading statements, evasion, or suppression of material fact in this application may be used to take actions identified in WAC 246-310-500. My signature authorizes the department to verify any responses provided. The department will use such information as appropriate to further program purposes. The department may disclose this information when requested by a third party to the extent allowed by law. Owner/Operator Name of the surgical facility as it appears on the UBI/Master Business License Sight Partners Holdings, LLC Clinical Practice UBI #: 604491467 Surgery Center UBI #: 604491467 Mailing Address 3405188th SW #303 Lynnwood.WA 98037 Federal Tax ID (FEIN)# 83-3467355 Surgery Center Address 332NENorthgateWay Seattle, WA 98125 Website Address: www.sightpartners.com & www.nweyes.com Phone number (10-digit): 800.826.4631 Name and Title of Responsible Officer (Print): Lance Baldwin VP of Operations Email Address: lbaldv\[email protected]Sigpature^Re^ponsible Officer: //^)^;>.£ X-f'" ./-r'"^.-.- Date<6^STgriattfreT 17l\4arch2020 Identify the purpose of your request: D New Facility D Facility Expansion - Operating Room Increase D Change of Ownership D Facility Expansion - Service Increase Facility Relocation D Other (please provide a letter describing) DOH 260-014 June 2019
60
Embed
Ambulatory Surgical Facility and Ambulatory Surgery Center ...
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
^ lV.;.!i;n^'iift«),-IA'j1.flF:.nl(1/ ^ ^.
)-1^ Certificate of Need ^ 20?0?.0'J Determination of
' ,f-:r' -AL. ' •'' 'rL'. 7)'- '<T'!:' ?.' "I';''
Ambulatory Surgical Facility and Ambulatory Surgery Center; '^ ^(Do not use this form for any other type of ASC/F project)
- h :\ v
Certificate of Need submissions must include a fee in accordance with WashingtonAdministrative Code (WAC) 246-310-990.
The Department of Health (department) will use this form to determine whether my ambulatory surgicalcenter or facility requires a Certificate of Need under state law and rules. Criteria and considerationused to make the required determinations are Revised Code of Washington (RCW) 70,38 andWashington Administrative Code (WAC) 246-310. I certify that the statements in the submissions arecorrect to the best of my knowledge and belief. I understand that any misrepresentation, misleadingstatements, evasion, or suppression of material fact in this application may be used to take actionsidentified in WAC 246-310-500.
My signature authorizes the department to verify any responses provided. The department will usesuch information as appropriate to further program purposes. The department may disclose thisinformation when requested by a third party to the extent allowed by law.
Owner/Operator Name of the surgical facility as it appears on the UBI/Master Business License
Sight Partners Holdings, LLCClinical Practice UBI #: 604491467
Surgery Center UBI #: 604491467
Mailing Address3405188th SW #303Lynnwood.WA 98037
Federal Tax ID (FEIN)#
83-3467355
Surgery Center Address332NENorthgateWaySeattle, WA 98125
Identify the purpose of your request:D New Facility D Facility Expansion - Operating Room Increase
D Change of Ownership D Facility Expansion - Service Increase
Facility Relocation D Other (please provide a letter describing)
DOH 260-014 June 2019
Existing Facility Status, complete for all applications conperging existing facilities
1. The CN Program previously determined the facility was not subject to CN Revle^/(if yes, attach DOR letter)
^ Yes D No
Surgical Facility Owner/Operator Information
2. Provide a copy of any applicable governance documents, including operatingagreements, shareholder agreements or corporate governing documents.
Facility Information
3. Although you are not required to apply for an ASF license before a CNdetermination is issued, have you or do you intend to, apply for a license?*
^ Yes D No
*Your answer to this question will allow the CN program to effectively coordinatethe licensure process with other DOH offices.
4.
Number of existing operating and procedure rooms:Number of new operating and procedure rooms:
Total:33
Clinical and Surgical Services
aDDvaD
5. Check all surgical procedures currently performed in the facility.Ear, Nose, & Throat DPlastic Surgery DOrthopedics nOphthalmology DOther (describe)This is a new facility, no surgical procedures are currently performed
GynecologyGastroenterologyPodiatryPain Management
aaDn
Oral SurgeryMaxillo facialGeneral SurgeryUrology
Check all new surgical procedures proposed to performed in the facilityD Ear, Nose, & Throat DD Plastic Surgery Da Orthopedics Da Ophthalmoiogy nn Other (describe)
Gynecology DGastroenteroiogy DPodiatry DPain Management a
Oral SurgeryMaxillo facialGeneral SurgeryUrology
DOH 260-014 June 2019
6. A facility that receives more than 50% of their income or 50% of their visits fromsurgeries is subject to CN requirements. In order to determine If your project issubject to CN review, please provide the current (existing facility) or proposed (newfacility) percentages of income and visits for clinical and surgical services. Includeail assumptions used to determine the percentages provided.
Total revenue for clinical servicesprovided at this site.Total revenue for this site.Total clinical patient visits for thissite.
Total surgical visits at this site.Total patient visits at this site.
Most recent full year ofoperation at current
surgica! site
$12,199,800
$17,407,700
22,115
4.60426,719
Projected first full year ofoperation after thechange in location
$12,809,790
$18.278,805
23,220
4,83428,054
DOH 260-014 June 2019
Certificate of Need Program Revised Code of Washington (RCW)and Washington Administrative Code (WAC)
Construction Review Services Resources:Construction Review Services Program Web PaaePhone:(360)236-2944Email: [email protected]
DOH 260-014 June 2019
Exhibit 1NWES Seattle Assumptions
Goal of Application:
Sight Partner Holdings, LLC dba Northwest Eye Surgeons (NWES) is a physician ownedorganization with 4 ASCs and 7 clinics conducting business and performing ophthalmic eyesurgery in Washington, Due to the rising facility costs NWES is relocating its CON approvedlocation at 10330 Meridian Ave N, Seattle, WA within the planning area to 332 NE NorthgateWay, Seattle, WA. The application fora new CON has been submitted. The application iscurrently under a concurrent review process because of another organization's CONapplication.
NWES will continue with CON application but wishes to request an exemption for its newlocation until the CON decision is complete. This would allow NWES to begin construction andbegin services. NWES was previously a CON exempt ASC. NWES remains a physician ownedentity and only employed physicians provide surgery at the location.
Growth Assumption:
NWES determined that 5% growth in patients and revenue wi!l be accomplished throughimproved processes in the new location and better access for patients. Historicaily, NWES hasobtained a minimum of 5% growth year over year.
Exhibit2NWES OrganizationalChart and Ownership
Breakdown
1-6 Organizational Structure Chart
Governing Body/Executive Committee:
Kristi Bailey, MDBrett Bence, OD
Board of Directors:WernerCadera, MDBruce Cameron, MD
Aaron Kuzin, MDAudrey Tailey Rostov, MD
IManaging Partner: Kristi Bailey, MD
It
CEO: Spencer Michael
Procedure Review Board:
Director of NursingASC ManagersBilling and Coding Manager
1IVtedical Director: Aaron Kuzln. MD
Directors:
Director of OptometryDirector of NursingDirector of Clinical OperationsDirector of Finance
Risk Management Committee:
Director of Nursing
Director of Clinical OperationsDirector of Finance
CEOBilling and Coding Manager
Medical Advisors:
WernerCadera, MD
Audrey Talley Rostov, MD
Quality Assessment and PerformanceImprovement Committees:
Policy:Northwest Eye Surgeons (NWES) Governing Body assumes full lega! responsibility andensures policies are implemented in order to provide quality health care in a safeenvironment (CFR 416.41}. The Governing Body is regulated by a governing document thathas the consent of each member of the body, and each member will have equal votingauthority, and wi!l meet at least quarterly in one of the following manners: in person, phoneconference or email Minutes of each "official" Governance meeting are recorded and filedwith the original rules and regulations. The medical staff will be accountable to theGoverning Body (CFff 416.45).
Responsibilities of the Governing Body include, but are not limited to:> Determine the mission, goals, and objectives; ensuring the facilities and personnel
are adequate and appropriate to carry out the mission; formulating long-range plansin accordance with the mission, goals, and objectives.
> Ensure financial responsibiiity; establishing an appropriate system of financialmanagement and accountability.
> Review and take appropriate action on al! legai and ethical matters concerning theorganization and its staff
o Establish a policy for identifying and reporting healthcare providers whenunprofessional conduct occurs.
> Ensure that all marketing and advertising clearly focus only on care and servicesthat are provided by the organization.
> Provide full disclosure of ownership to employees and patients.> Establish the organizational structure.> Establish policy for how individual surgeons deal with each other and external
parties, and on surgeons ro!e in properly dealing with patients.> Establish a policy on "patient's rights";> Adopt and implement a policy for reporting suspected patient abuse.> Comply with the 'Equal Employment Act' and the 'American's With Disabilities Act'> Establish, implement, and monitor policies governing the ASC's total operation,
including ail necessary policies regarding drugs and biologicals. These will bereviewed and revised annually.
14
> Develop a "Quality Assessment and Performance Improvement Program", includingrisk management, infection control and WISHA programs; ensure quafity of care isevaluated and that identified problems are appropriately addressed; adopt a policyon continuing education for personnel.
> Develop a policy for notifying a patient of an unanticipated outcome.> Approve and ensure compliance of ail major contracts or arrangements affecting the
medicai care provided under its auspices, including but not limited to, thoseconcerning:
> The employment, contracting, and periodic review of health care professionals> The use of external pathology and medical laboratory services> The provision of after-hours patient care.> Centers for Medicare & MedicaEd Services (CMS)> Participation with a managed care organization for services> Adopt and implement a policy and procedure to address how ciinical trials wili be
authorized and reviewed.> Maintain effective communication throughout the organization; adopt policies and
procedures to resolve grievances and external appeals, as required by state andfederal law and regulations.
15
Exhibit 4NWES
1.8 Managing Partner,Medical Director and
Medical Advisors Policy
aPolicy and Procedure
NORTHWEST EYE SURGEONS
Title: Managing Partner, Medical Director and Advisors
Approval Date: 01/06/2018
Effective Date: 01/06/2018
P&P#:XXX
Review: Annual
1.8 Managing Partner, Medical Director and AdvisorsCMS CFR 416.41, WAC 246-330-115
The Board of Northwest Eye Surgeons will nominate the Managing Partner. The MANAGINGPARTNER will be the managing physician of Northwest Eye Surgeons, PC who will act as therepresentative of the Governing Body and, subject to its policies, is responsible for theefficient administration of all affairs of the organization and ambulatory surgical facility.
The Board of Northwest Eye Surgeons will appoint the Medical Director for a term of 2-3years, which can be extended by mutual agreement of the Board and Medical Director.
The Board of Northwest Eye Surgeons will designate two Medical Advisors for a term oftwelve months who, En the Medical Directors absence will exercise all of his/herresponsibilities. There will be no limitation on number of terms that may be served. TheMedicai Advisors will meet with the Medical Director and Board of Northwest Eye Surgeonsat least annually.
Managing Partner> Is a member of the Board.> Is a partner with the Board and Directors in achieving the organization's vision,
mission and values.
> In partnership with the Board and Directors, will establish lines of authority,accountability and supervision of personnel
> Provides leadership to the Board, who sets policy and to whom the CEO andDirectors is accountable.
> Chairs meetings of the Board after developing the agenda with the CEO.> Encourages Board's role in strategic planning.
o Participates in long and short range planning needs of NW Eye Surgeons asdetermined by the Governing Body
> Appoints the chairpersons of committees, in consultation with other Boardmembers.
> Serves ex officio as a member of Board or other committees and attends meetingswhen invited.
> Discusses issues confronting the organization with the CEO.> Helps guide and mediate Board actions with respect to organizational priorities and
governance concerns.
16
> Reviews with the CEO any issues of concern to the Board.> Monitors financial planning and financial reports.> Formally evaluates the performance of the CEO and evaluates the effectiveness of
the Board members.
> Along with the Board and Directors, evaluates annually the performance of theorganization in achieving its mission
> Guide management and employee actions by participating in development ofprocedures and methods that reinforce organization culture and values
> Establishes professional working relationships with our referring OD providers andprovider organizations, to support the development of successful partnerships
> Along with other Board Members, participate in the orientation and coaching of newphysicians
> Ensure legal compliance by monitoring and implementing as applicable " medical,federal, and state requirements; conducting investigations; maintaining records;representing the organization at hearings
> Take all reasonable steps to insure that NW Eye Surgeons facilities comply with ailapplicable provisions of the law and other regulations relating to the operation of thefacilities, including those required for participation in the federal United Statesgovernment Centers for Medfcare/Medicaid Service Programs
> Performs other responsibiiities assigned by the Board
Medical Director> Functions in the ro!e of medical leadership for the effective integration of
> Provide leadership and guidance in the quality and appropriateness of care,evaluate provider performance standards, advise management on how to bestresolve physicians issues and concerns; counsels with physicians and managementas needed
o Provides current medical expertise and direction for clinical policies,procedures and programs
o Oversees provider education regarding pharmacy, utilization, qualityimprovement and health care expenditures to improve clinical outcomes.
o initiates dialogue with providers as necessary to resolve differences inopinions concerning utilization management
> Along with other Board Members, participate in the orientation and coaching of newphysicians
> Participate in the development and maintenance of a QAPI programo Manages day-to-day quality improvement and medical management activitieso Monitoring and evaluating outcomes, including cllnica! and physician
services - lead the Peer Review Process
Medical Advisors> Act as liaison among the medical staff, the Medical Director and the Governing
Body.
17
> Reviewing policies and making appropriate recommendations to the GoverningBody.
> Reviewing the credentials of all applicants and making recommendations to theGoverning Body for staff membership and delineation of clinical privileges.
> Periodically reviewing Information regarding the performance and clinicalcompetence of medical staff members and, as a resuit of such review, makingrecommendations for reappointments and renewal of, or changes in, clinicalprivileges.
> Reviewing the credentials of any Assistant to Physician for whom an application hasbeen made by a member of the Medical staff and making recommendations forappropriate action.
> Comprehensively reviewing on an on-going basis the quality of care provided atNorthwest Eye Surgeons, PC and making recommendations to the Governing Body.Such review will include, but not be Hmited to, the medical necessity of proceduresand appropriateness of care.
18
ExhibitsNWES Seattle License
Verifications, CONVerification, AAAASF
Accreditation and SurveyReports
co(Dx
0E S
•INN*
^rf<0I—
^ IQ 0)(D 0n -^-1-^ ^c/) i-
0->—>
0)
(/)co
c002'3(0
,s.iu
^III
cn0>> <*?(0 (/)
ci s^^ *—
<2 ^^ *N~
0t^.
0<0
^ s§ Ia:>-Q-00N
0)k»
3in
0
0 -=i
3<aw
<0:3
<
0fflu_
"?00>3y)
?s(03.0
<•p
20u<
06ww<c(00'1-
fl)
<
0.ri.—J
(D
i<aQ«•*»*
-c0>V)
>.JQ"pQ>
^-*co<uOL6
r^.n^35 Sz sS 3^ ?c co(0 0>
s <I <y
0 *Fwco w0 <U^ (0
-*"J
(0~Qd)
•<-'
<000
(D
IEsZ ien
TO. §.t-t ~
c 00 a."p(D u-
w6 <
<u.•*->
03QC: M0 °'.p Ms° s.h: o0- ^X 0LU
<u^-1coQ <n
s §<M0
.<u^ <0LLJ °
ULI^ >.-§ p-2 °03 <
TO»»-•
1D0<uco
Lu-J°Q
§u,0
I0s</)
yy-J
^E
(^co<u.
0 ^ CO£ c/3 coQ ~y -^d) ^~ o>
2) S ^3 ^ CO</) ^ T-
C 00^ Ja 05^~s ^
iP-lii'Ill
-c
x>u_<1
ta<!(/c/LL
S) ATI'. 01-WASIUNCiTON
DEPARTMENT OF HEALTHPO Hox 47^2'Olympm, Wa^hm^on 9^04-78^2
November 6, 2018
CERTIFIED MAIL // 7017 3380 0000 0863 8406
Lance Baldwin, Director of Nursing
Northwest Eye Surgeons, PC1330 Meridian Avenue North, #370Seattle, Washington 98133
RE; Certificate of Need Application #18-25"North King County
Dear Mr. Baldwin:
Enclosed is Certificate of Need #1749 issued to Northwest Eye Surgeons, PC approving theestablishment of an ambulatory surgery center in Seattle, within North King County.
The certificate is not an approval for any other local, federal, or state statutes, rules, or regulations.
Such a project may also need Department of Health approval for a construction plan and facilitylicensing or certification, as well as other federal or local jurisdiction permits.
The Certificate of Need is valid for two years. The project must begin during this time. If there issubstantial and continuing progress, we may extend the certificate for one six month period. For
an extension, you must submit an extension request at least 120 days before the expiration. You
cannot begin a project after the expiration date.
This decision may be appealed. The appeal options are listed below.
Appeal Option 1:Any person with standing may request a public hearing to reconsider this decision. The requestmust state the specific reasons for reconsideration in accordance with Washington AdministrativeCode 246-310-560. A reconsideration request must be received within 28 calendar days from the
date of the decision at one of the following addresses:
Mailing Address:Department of HealthCertificnte of Need Program
Mail Stop 47852Olympia, WA 98504-7852
Physical Address:Department of HealthCertificate of Need Program
111 Israel Road SETumwater,WA9850l
Lance Baldwin, Northwest Bye Surgeons, PC
Certificate of Need App #18-25-North King CountyNovember 6, 2018Page 2 of 2
Appeal Option 2:Any person with standing may request an acljudicative proceeding to contest this decision within28 calendar clays from the date of this letter. The notice of appeal must be filed according to theprovisions of Revised Code ofWashington 34.05 and Washington Administrative Code 246-310-610. A request for an adjudicativc proceeding must be received within the 28 days at one of thefollowing addresses:
Mailing Address: Physical AddressDepartment of Health Department of HealthAdjuciicative Service Unit Acljudicative Service UnitMail Stop 47879 11 1 Israel Road SEOlympia, WA 98504-7879 Tumwatcr, WA 98501
We monitor projects until completed or the expiration date, whichever occurs last. We do this withquarterly progress reports. At least 30 days before the report's due date, you will receive a form to
complete and return.
If you have any questions, please contact Janis Sigman, Manager of the Certificate of Need
Program at (360) 236-2955.
Sincerely,
^//^-^// LmcyT^on, I^xecuti'Nancy T^oh, executive Director
Health Facilities and Certificate of NeedCommunity Health Systems
Enclosure
^ t'/.;';'m^'j^"('(.^ri!-.;i-;;ii'
^HealthThis Certificate is granted under the authority of RCW 70.38. Issuance of tliis Certificate does notconstitute approval under any other local, federal or state statute, implementing rules and regulations.Examples where additional approval may be necessary include, but are not limited to, construction plan
approval through the Construction Review Unit oftlic Department of Health, facility liccnsing/ccrtificationthrough the Department of Social and Health Services or Department of Health, and other federal or localjurisdiction permits.
Certificate of Need #1749 is issued to:
Applicant's Legal Name: Northwest Eye Surgeons, PC10330 Meridian Avenue North, ^370Seattle Washington 98133Ambulatory Surgical FacilityAmbulatory Surgical FacilityNorthwest Eye Surgeons10330 Meridian Avenue North, #370Seattle Washington 98133
Applicant's Address:
Facility TypeProject TypeFacility Name:
Facility Address:
ISSUANCE OF THIS CERTIFICATE OF NEED IS BASED ON THE DEPARTMENT'SRECORD AND EVALUATION DATED OCTOBER 24, 2018 (CN APP # 18-25)
Project DescriptionThis certificate approves the establishment of a two-operating room ambulatory surgical facility in Seattle, withinNorth King County. The surgery center will serve patients aged 5 years and older that require surgical servicesthat can be served appropriately in an outpatient setting. Surgical services within the two ORs are limited thoseassociated with ophthalmic surgical procedures, such as cataract extraction and laser eye surgery.
Service Area
North King County
ConditionsThe conditions are identified on page 2 of this certificate
Approved Capital ExpenditureThere is no capital expenditure associated with this project.
Tins Certificate authorizes commencement of the project from November 6, 2018 to November 6, 2020unless extended, withdrawn, suspended, or revoked in accordance with applicable sections of the
Certificate of Need law and regulations.
Date Certificate Issued: November 6, 2018i>
.^f. /^ x y—Nancy t^bfi, Executive DirectorHealth Facilities and Certificate of NeedWashington State Department of Health
This Certificate is not transferable
Certificate of Need #1749Page Two
Conditions
1. Northwest Eye Surgeons, PC agrees with the project description as statedabove. Northwest Eye Surgeons, PC further agrees that any change to theproject as described in the project description is a new project that requires anew Certificate of Need.
2. Northwest Eye Surgeons, PC will provide charity care in compliance with itscharity care. Northwest Eye Surgeons, PC will use reasonable efforts toprovide charity care consistent with the regional average or the amountidentified in the application - whichever is higher. The regional charity careaverage from 2014-2016 was 0.94% of gross revenue and 2.00% of adjustedrevenue. Northwest Eye Surgeons, PC will maintain records of charity careapplications received and the dollar amount of charity care discounts grantedat the location of the surgery center. The records must be available uponrequest.
3. Northwest Eye Surgeons, PC agrees that the ASF will maintain Medicare andMedicaid certification, regardless of facility ownership.
Thank you for participating in this important quality assurance and patient safety process administered by theAmerican Association for Accreditation of Ambulatory Surgery Facilities. The following report containsinformation relevant to the conclusion of your recent accreditation survey process including your facilityaccreditation demographic information/ accreditation decision, and recent survey history. AAAASF requires thatall standards be met in order to achieve accreditation and that 100% compliance must be maintained at all times.AAAASF reserves the right to conduct additional surveys to validate the findings of previous surveys and to ensurecontinued compliance with standards.
Attached you will find a report containing all of the deficiencies cited during the accreditation survey along withthe corrective action plans submitted to AAAASF. The Final Accreditation Decision based on the findings andcorrective action taken in response to your recent survey process is Full.
Survey Details Below
Accrediting Organization: AAAASF
Survey Identification Number: 24922
AAAASF Facility Identification Number: 5705
Program Type: ASC
CCN Number: 50C0001018
Provider/Supplier Name and Address:Northwest Eye Surgeons, P.C.
10330 Meridian Avenue North, Suite 370Seattle/ WA 98133United States
Survey Request Type: Self-Evaluation
Survey Type: Full Accreditation Survey
Page 1 of 2
Survey Began: Tuesday, May 28, 2019 Survey Ended: Tuesday, May 28, 2019
Date Acceptable Plan of Correction Received: N/A
Method of Follow Up: N/A
Accreditation Decision: Fu!
Effective Date of Accreditation: Wednesday/ June 19,2019
Expiration Date of Accreditation: Saturday, June 19, 2021
0 " ^^ C o LUP. C ^ -0ro ~ <y £3 w ^ ro0) w ° Ws'.° w .a>c £ -^ -'^
en w ^ S
'" 0<y a.T7
c' w
0
0) ^tp wgf
W Q)M -ao (/>
-0
>t>, (D
0 (V 0
enE .00 ^ C' -^0 2? <j <
-c £^o ^ " S
-0 c0
0
0 -^ 8§^ ^ §
Q 0
o 00 3ro -o
pC Q.® !„
Ig^ £c
ij
°. § wro Sc -c
>^
ro •D
.0
00 W
§JQ. <
0).QrouQ.Q.(0
-0
^ i ^fu a) .(5
^ "."
j^s0 w
n
0w 1- _^ .'-
w <B 0 <0."? % j5 fe;fc ^. -^ 2-(D 0' ^ 0^ Q- w °a) °- >. <y
"3 ^ "
<u£
JZ:c>
iIf)
Q> V)(D
(U (U
c 0-
0 Xlttlv> ^
^ ~Q ro^ ^a> w^ -c
(U > C .+-
IHI<y ro <yro -o (D 0o?
<y0[rt
.0
(00}
a> -5a>
c ."
(0
-0
u?0
(L>
10(U'§ ro
mE
~0p
® a.£ a>-P £
Ji^s^1<y a>
Q
"s> 0 0(0 .(U
(0 E" (0en en ^a> co <u
(U W 3<U w co
d? ..- </t (UV) •— i^
-S c w ^^00-0
U (Ua.-ro '? ^
a> ^
-5sc wco w
co '% "g LJL
i5i?ro ^
^ U) W ^E .c' -o -°
E ^ S
.? £
<u (p
J -^® Io. ." w Sa> ^ (u Q
0
X?
0 <]>
^.c <v(u c "0 <U CT
c m c
n? CB
^?I<y £ re ro
,(u ^ ^
/° ^<-> m
_o fo
0•o
<U <U 3.P C 0'5- ^ <y
E m co
o a>
0. 3
^ ^0) •'=
0c:<u
-D
-5 " ^ -5
010
0 " ^"o " .ro c^ s^ £'<5 1= •y? K•c S £ -£^ a? ^m a o£ E "0 0 roM " W0} -o
c o S
Ui
c 'a>ro '?
0£:
TO-Q Ew0<t>> '0 -^T3 (U Um -a .c
d) -5 -/-i ^
c TO0 .c
"V> "D
'0 -?
•^ -<u ^ 00 ® e .°-c s °- ^
S 3 ^ £6 ^ =; ov S- .^ -Qc ^- '€ co m m 5
P a.ro *" ^
IS^-j.0 •:
-Q.?= 5 •:=
</> s^(D
d)
0u ns >•< co
f.:0" s§^ c i
ny> >0 0
•I?^m £c roli
a? <n -^w c? COc co
0} ,c
co a>
^ Iro£ oitr
s ^i i"0 ,0-0 ^<Z ifim ro?r n±' ^.
0 o03 Q.
•aw c(U CO
ff?& £:0 ^S <t>
.<u .-
if= <"0 ^^: roc .'"ro ':
-p
(JQLL
0J3E<u
<
c(0m
-& °<y
CD D> 7-;
aj a> ro
-0c (3 ^ -^TO ^ "CO .(uv> ro-G £
Q>
c.&'
^.c
sw
'
0 a?^ s> ^ E2 S f ^ec -c ^ (3
0 _"?
<6 ena> s>co '-c i-ffl <u-c -c
o s
u
a
•o(D£<D
<00oit(D(rt(0.c
0c(Dp>
CL
@
uQ-
wz0UJuorZ)wLU>LU
(D
..9
eQ.
>'-
.Xfto
<M01
-0
w
<11
c
^sc
^ 1- <u
^ ^ w£ -C ,<i)(0^ §0 ° ^? <ol.£'0 -0 0)
p)c
0~0
-c
pw
c<u£ro0.
(0.0.
u
OJ^ Q>•£ <a'
<nfp
<0
0-.<&&
w ^^ro^c
^^ "I ^ ^
<u yc -^.' a>
^ 8^^:v> w v",
Us""^ ^° ^J 5SH? §£?-CJi s^)<ij oj a, ^
? -p ?
iL
i-
^Q.
-ctf>
0_")
?i>
¥a.
<?p00
^ ^ ~0~0 ° -T-
w^ 0 cfc CO 3
s^(0 3
0
w.<y <f>
§ .^3 'C: £Q- £ g, £p y ® po~) ri aw /u p^ s ^ ?
Uj? -y
^ <u & "0 ^ m .w
!l?j?rilsh 0 (D ?=•mi
s.^'
U)^1
c1)eto
3-0.w"0
•o
cffl
<t>
S»H<f ^ u
y ^ .^o,"-3 uTC w" ~Z o -S
.£ w ^ •>-.
0<^
w!i (^ ^~ i? ^ '°1^c w
0^1^ ^6>r°?'£.0; ."
SQ
IU0>ff1>
^ £»£ e ^~i TO
-? c 3s ft, gi
.C tti!B
^.1^TO ass ?
c-1^
wc0
I -U10
y
w •^ •fr
s
A> —.1
.s —<0 ,c"
&, T) -c^ ^ ^ 0>3) W § -c
c ,„ o>s ^ ^ <»'
wdQ-(13
r>
p)c
-^csv.0>>
y,£
a.
y>
g'r c° ?Jj-.^w ^ i?s;S' Xr PU 'o o ,w c
>-- •'-J r\i ic
<B^ 5 «;
sVl
,rodccuc~
it=
•p
iro0.1)
.0-Q
^ ? 2' ? ^ ^ i<u p 4) £ Q) ^?" i^-s ^
p S is v><B C ?
LL
I c u g? -Q<u PS Q ^ ^
0. (Uu
^ .">a aI g
0->. --.
? ws s
wc^p00
fD
c-is,-c
ree.0
•u(D
3 t? ia> .0)
1 ji i t?^f(00.
00
0>s:
0Q.it)
or
cttt
£f3cr<u
0Q.
</)^0UJ0or-)(f)
10§^
0
Exhibit 8NWES
1.11 Credentialing andPrivileging Policy
Policy and ProcedureNORTHWEST EYE SURGEONS
Title: Credentiallng and Privileging
Approval Date: 01/06/2018
Effective Date: 01/06/2018
P&P#:XXX
Applies to: RASC, MVASQ SASC, SQASC
1,11 Credentialing and PrivilegingCMS CFR 426.41, CMS CFR 416.45
Policy:Northwest Eye Surgeons will complete a process to assess and validate the qualifications ofan individual who provides services to ensure that the individual has, and maintains, thespecialized professional background which he or she claims and that the position requires.
Process:The process for "CREDENTIALING & PRIVILEGING" is completed by ensuring:
1. Applicant has completed the required application
2. Relevant education, training and experience are verified and appiicabie documentsobtained:
> Professional diplomas> Board certifications or eligibility> Source verifications as appropriate for schooling including residencies,
fellowships and so forth> Curriculum vitae> Former employment and references
3. Current competence is verified in writing by three (3) individuals personally familiarwith the applicant's clinical, professional and ethica! performance and whenavailable, by data based on analysis of treatment outcomes.
4. Current llcensures and certifications are obtained> Professional license> DEA license> BLS or ACLS
5. Proof of current medical liability coverage
6. Health file with TB screen and Hepatitis B immunization status
7. Other pertinent information is reviewed> Professional IJabiHty claims history> Licensure revocation, suspension, voluntary relinquishment, licensure
probationary status, or other licensure conditions or iimitations> Complaints or adverse action reports filed against the applicant with a local,
state, or national professional society or licensure board> Refusal or cancellation of professional liability coverage
24
> Denial, suspension, limitation, termination, or non-renewai of professional
privileges at any clinic, hospital, health plan, or other institution> DEA or state license action> Disclosure of any Medicare/Medicaid sanctions> Conviction of a criminal offense> Current physical, mental heafth, or chemical dependency problems that
would interfere with an applicant's ability to provide high quality patient careand professional services
> Signed statement releasing Northwest Eye Surgeons from liability andattesting to the correctness and compfeteness of submitted Information
8. Applicant's requested privileges falls within the dinica! procedures and treatmentsoffered at Northwest Eye Surgeons and that he or she has the qualifications relatedto training and experience to perform them.
9. Completed applications will be submitted to the Governing Body. The GoverningBody will evaluate the character, qualifications, professional standing and suitabilityof the applicant and will make and record their recommendation concerningacceptance, deferment or denial of the applicant. The Governing Body will haveultimate authority En all decisions concerning appointments or re-appointments ofapplicants.
10. Applicants are reappointed at least every 2 years and must include peer reviews inaddition to the standard credentialing and privileging requirements.
11. CORRECTIVE ACTION:Whenever the activities or professional conduct of any physician with clinicalprivileges are not consistent with the standards of the medica! staff, are disruptiveto the operations of the facility or are detrimental to patient care, corrective actionmay be requested by any member of the Medical Staff, Governing Body orAdministrator. A!l requests will be made in writing to the Governing Body and will besupported by references to the specific activity or conduct which constitutes suchgrounds for the request.
GROUNDS:Grounds for requesting corrective action include but are not limited to:
> Professional conduct inconsistent with standards of Medical Staff> Substandard practices which may or may not have caused patient injury> Unethical practices> Failure to keep adequate records> Signs of physical or mental impairment which impact the quality of care
rendered> Loss of DEA license> Loss of malpractice insurance> Revocation or suspension of medical license
INVESTIGATION:Upon receipt of such request the Governing Body will investigate the matter. TheGoverning Body may appoint an Ad Hoc committee from the shareholders tomanage the investigation. The fact finding committee will conduct an investigation
25
within 14 days after receipt of the request to determine the facts and circumstancesof the incident that is the basis of the request for corrective action. If the committeecannot complete the investigation within the 14 days, they may ask for additionaltime, however, the additional time cannot exceed a total of 30 days from the receiptof the request. The Governing Body will review the results and recommendations ofthe investigation committee and make a written report of its findings and any actionto be taken within 14 days of the receipt of the investigation committee report. TheGoverning Body will have ultimate authority in any decisions concerning correctiveaction.
REPORTING:The Governing Body is responsible for reporting affirmed acts of unprofessionalconduct as well as voluntary restrictions or terminations by a healthcare provider tothe Department of Health (RCW 70.230.120) within 15 days of its findings. TheGoverning Body will provide a copy of the investigation committee report in additionto all available contact information for the individual.
NOTE: My changes in ownership or physician staff must be reported in writing tothe AAAASF office within 30 days of such change, with copies of the appropriatecredentials of any new staff. Including current medical license, ABMS BoardCertification or letter of eligibility and current documentation of appropriate hospitafprivileges or satisfactory explanation for the fack thereof. Any action affecting thecurrent medical license of a member of the medical staff, such as revocation orsuspension, must also be reported in writing within 10 business days of such action.
26
Exhibit 9NWES Seattle
Historic Services;Identified by Top 30
CPT Codes
NWES Seattle Historic Services; Identified by Top 30 CPT Codes
Brow Ptosis - SupercHiary - Mid-Forehead or Corona!
167900 Approach
165730 Corneaf Transplant (Non-Aphakia)
165760VC Lasik - VC - Facility
165426 Pterygium
i65760 LasikStrabismus - Recession/Resection - One Horizontai
[67311 MuscSe
166999CRIVC Corneal Relaxing incision - VC
166250 Bleb RevisionStrabismus - Recession/Resection - One Vertical
167314 Muscle (Excluding Superior Oblique)
166986 iOL Exchange
165820 Goniotomy
!66170T Trabeculectomy
166999PRK PRK - Facility
IS0812 PTK
166999RLE Refractive Lens Exchange
i66175 Canalopiasty with Stent
I0191T iStent Implantation
SVCPRK PRK-VC
2015
1,844
396
235
103
62
44
80
34
43
79
48
43
34
43
35
58
21
3
22
28
18
15
21
6
26
17
11
16
12
22
2016
2,068
379
126
92
2
72
45
52
30
13
24
33
19
19
26
44
25
34
14
13
9
2
1
7
19
6
11
15
26
2017
1,945
414
42
157
2
63
54
40
36
28
32
27
30
63
17
27
21
7
20
11
20
13
32
Total 3,419 3,226 3,101
Exhibit 10NWES Seattle
2.14 Patient Admission,Assessment and Discharge
Policy
Policy and ProcedureNORTHWEST EYE SURGEONS
Title: Patient Admission, Assessment and Discharge
Approval Date: 03/22/17
Effective Date: 03/22/17
Review: Annual
Applies to: RASC, MVASC, SASC, SQASC
2-14 Patient Admission, Assessment and DischargeQ-0260, 416.52 CMS Condition for Coverage, WAC 246-330-205
NWES will ensure each patient has the appropriate pre-surgical and post-surgicalassessments and that all elements of the discharge requirements are completed.
1. Not more than 30 days before the date of the scheduled surgery, each patient musthave a comprehensive medical history and physical assessment completed by aqualified practitioner legally authorized to practice in Washington and providingservices within their authorized scope of practice. Such practitioner may be thepatient's primary care provider rather than a member of NWES' medical staff. CO-0261, 416.52(a)(l) Standard: Admission and Pre-Surgical Assessment)
a. The patient's medical history must assess the patient's readiness forsurgery and is required regardless of the type of surgical procedure. (Q-0261,416.52(a)(l) Standard: Admission and Pre-Surgical Assessment)
b. NWES will not require a genitourinary or rectal examination2. Patients must meet NWES Pre-Operative Guidelines. Final determination of
clearance for surgery will be at the sole discretion and responsibility of the operatingsurgeon.
a. NWES patients must fall within the ASA Anesthesia Classifications I, II, andIll
Class!Class HClass III
Class !V
Class V
Healthy patientMild systemic diseaseNon-incapacitating severe systemicdiseaseSevere systemic disease—constantthreat to lifeNot expected to live without surgicalintervention
No physical limitationsWell-controlled disease of one body systemControlled disease of more than one bodysystemPoorly controlled or end-stage with at least onesevere diseaseDanger of death imminent
NWES patients must be abie to effectively transfer on own with and withoutsedation or bring personnel familiar with and able to transfer patientNWES will attempt to obtain the primary care physician chart note dated fromwithin the last 12 months of surgery patients for review by surgical team.NWES patients assessed with any of the following will be referred to theirPOP or condition managing physician for further evaluation and risk control:
i. Pulse iess than 50, more than 100, or irregular without prior historyduring surgery consultation visit
ii. Blood pressure more than 180 systolic, more than 100 diastolicduring surgery consultation visit
35
iii. Serious cardiac event within the last 6 months, to include but notlimited to: Unstable angina as indicated by increased frequency ofepisodes, increased use of nitroglycerin for relief, or angina at rest
iv. Unstable congestive heart failure as indicated by increased dyspneaon exertion, or dyspnea at rest
v. Stroke within the previous 6 monthsvi. Chemotherapy within the previous 3 months
vli. Current ronal diQlyoiGNew diaiysls patient of less than 1 yearvlii. Referrals to PCP or managing physician will be documented in the
patient's medical record.
e. NWES patients must be able to understand and follow instructions.f. NWES requires the following labs pre-operatively
i. INR within 24hrs of scheduled surgery for patients onWarfarin/Coumadin
1. INR expected to be less than 3.0 for regional blockanesthesia
2. INR expected to be !ess than 3.5 for topical and localanesthetic
Ei. Diabetic patients will have blood sugar tested preoperatively; FSBSis expected to be less than 350.
3. The patient's medical history and physical must be placed in the patient's medicalrecord prior to the surgical procedure. (Q-02G3,4l6.52(a)(3) Standard: Admission and Pre-Surgical Assessment)
a. NWES requires that En most cases the comprehensive H&P be submittedprior to the patient's scheduled surgery date, in order to allow sufficient timefor review and adjustments if necessary, including postponement orcancellations of the surgery. (Q-0263, 416.52(a)(3) interpretive Guidelsnes)
b. In some situations, it may not be possible to have an H&P performed prior tothe date of surgery. The comprehensive medical history and physical maybe performed on the same day if:
i. It is performed by qualified personnel, is comprehensive and isplaced in the patient's medical record prior to surgery. At aminimum, it must be placed in the medical record prior to the pre-surgical assessment, since that assessment must first consider thefindings of the H&P before examining the patient for changes. (Q-0263, 416.52^3) Interpretive Guidelines)
ii. The referring physician indicates on the medical record that it ismedically necessary for the patient to have the surgery on thesame day as the referral to the ASC, and that surgery in an ASCsetting is suitable for the patient. (Q-0261,4i6.52(a)(l) Standard: Noticeof Rights, Interpretive Guidelines)
c. Rarely, the pre-surgicai H&P may not be available when the patient reportsfor surgery. In this case, at the so!e discretion and responsibiiity of the
36
operating surgeon, the H&P may be done on the date of surgery subject toS.b.i, above.
4. Upon admission, each NWES patient must have a pre-surgical assessmentcompleted by a physician to evaluate the risk of the anesthesia and of theprocedure for that patient that includes, at a minimum, an updated medical recordentry documenting an examination for any changes in the patient's condition sincecompletion of the H&P, including documentation of any allergies to drugs orbiologicals. (Q-OOGl, 416.42(a) Standard: Anesthetic Risk and Evaluation) (Q-0262, 416.52(a)Standard: Admission and Pre-Surgical Assessment) The pre-surgical assessment will includeat a minimum:
a. Review of H&Pb. Review of current medications
c. Review of allergiesd. Examination
5. Each patient will be assessed prior to discharge (Q-0264, 416.52, Standard: post-surg'icai
Assessment according to the foiiowing criteria:a. Return to preoperative baseline level of consciousnessb. Stability of vital signs (no dyspnea, oximetry 92% or above, systolic blood
pressure +/- 20% of admission BP with a minimum of 90 systolic and amaximum of 100 diastolic)
c. Absence of protracted nausea
d. Adequate pain controle. Return of motor sensory control to preoperative baselinef. Saline lock discontinued as applicable
6. NWES will ensure that each patient has a discharge order, signed during the post-operative period by the physician who performed the surgery or procedure. (Q-0266,416.52(0} Standard: Discharge)
7. NWES will ensure that each patient is provided with written discharge instructions,prescriptions as needed and overnight supplies as needed.
Policy:NWES will ensure all patients, or their representative, are informed of their rights as patientsin advance of the day of surgery, and will actively protect and promote the exercise of suchrights regardless of the type of procedure performed. NWES will provide required verbal andwritten notifications in a language or manner which the patient, or the patient'srepresentative understands. A written copy of NWES Patient Rights & Responsibilities will bedisplayed In an area where it can be seen by ati patients, or their representative, enteringthe ASC.
> At the time a surgical procedure is scheduled, the patient will be verbally informedthat they have certain rights as a patient in our ASC.
> Patients will be given the information needed to make decisions regarding their carebefore a surgical or minor procedure is performed.
> When a patient schedules in person, a written copy of their rights andresponsibilities will be provided to them in addition to verbal notification. If thepatient schedules by phone, written notification of rights and responsibilities will besent in a time frame which assures the patient, or their representative, receives itprior to the day of surgery.
> The only circumstance in which a patient is informed of their rights as a patient onthe day of surgery, is when the referral to the ASC is made on the same day, thereferring physician indicates in writing that it is medically necessary for the patientto have surgery on the same day, and that the ASC is a suitable setting for thatpatient. With such situations, notice must be provided prior to obtaining thepatient's informed consent and prior to the start of the surgical procedure.
> When necessary, NWES will make use of translation services to communicate in aclear and thorough manner. If it is not possible to translate the written notificationinto a language the patient understands, comprehensive verbal communication andunderstanding of the patient's rights via translator will be documented in thepatients record.
> When the patient arrives on the day of surgery, the signed and dated Patient'sRights & Responsibilities form will be included in the patient's record.
> Reported incidents of abuse, neglect or harassment will be investigated (seeGoverning Policies, Patient Abuse or Neglect).
> NWES will not take punitive action or discriminate against patients who exercisetheir rights.
> Patient consent will be obtained prior to permitting the presence, during treatment,of anyone not Involved in the care of the patient.
> if a patient has been adjudged incompetent under applicable State iaws by a courtof proper jurisdiction, the person appointed under State law to act on the patient'sbehaif may exercise any and all rights afforded to NWES patients.
aPolicy and Procedure
NORTHWEST EYE SURGEONS
Title: Grievances
Approval Date: 01/06/2018
Effective Date: 01/06/2018
P&P#:XXX
Applies to: RASC. MVASC> SASC, SQASC
1.3 GrievancesCMS CFR 416.50(a)(3)
Policy:Northwest Eye Surgeons (NWES) will provide a process for documenting the existence,submission, investigation and disposition of a patient's written or verbal grievance to theAmbulatory Surgical Facility or the clinic. Alleged violations may include, but not be limitedto, mistreatment, neglect, verbal, mental, sexuai or physical abuse, or ASF compliance
issues. Grievances may be filed by a patient or by the patient's representative.
It is the obligation of staff members to report grievances to the Medical Director or amember of the Governing Body who has the authority to address grievances.
> Information regarding the submission of patient concerns to a NWES representative,the Washington State Department of Health or the Office of Medicare BeneficiaryOmbudsman will be included in the written notification of Patient Rights &Responsibilities.
> Patients will be verbally advised and furnished with a printed copy of the PatientRights & Responsibilities notice in the instructional information packet which ismailed to them In advance of their initial appointment.
> Patients shall provide written acknowledgement of receipt and understanding ofNWES Patient Rights & Responsibilities notice.
> A copy of the Patient Rights & Responsibilities will be prominentiy displayed in allNWES facilities.
> Complaints resolved at the time they are registered are exempt from the grievanceprocess, as is information obtained from patient satisfaction surveys, unless thepatient attaches a written compiaint to the survey requesting resolution.
> Investigation will include a thorough review of systemic problems which may havecontributed to the grievance via the Quality Assessment and PerformanceImprovement Committee.
> The start of an investigation will commence upon receipt of a grievance.> NWES will make every effort to conclude investigations and provide a response to
the patient or the patient's representative within 14 days of having received agrievance.
> NWES will document all Investigation findings, how the complaint was addressed,and pertinent details of the decision process.
Exhibit 12NWES Seattle
Non-Discrimination Policy
NORTHWEST EYE SURGEONS
NORTHWEST EYE SURGEONS, P.C. - PATIENT RIGHTS & RESPONSIBLITIES
As a patient of Northwest Eye Surgeons P.C., you have the right to:• Receive care in a safe setting regardless of race, color, gender, national origin, religion, or sexual
preference.
• Be treated with respect and dignity, free from abuse, neglect or harassment, and be given access toprotective services.
• File grievances without fear of discrimination, reprisal, or denial of care.
• Be provided appropriate personal privacy, spiritual care and communication, and be informed ifcommunication restrictions are necessary for the care and safety of yourself or others in the facility.
• Expect disclosures, information and records to be treated confidentiaily and, except when required bylaw, be given the opportunity to approve or refuse their release.
• Review your records and receive a copy of them. You may also ask to amend your healthcare record.• Know the names, professional status and responsibilities of your healthcare providers.• Seek another medical opinion and change primary or specialty healthcare providers.
• Receive, to the degree known, complete information concerning your diagnosis, evaluation, treatmentand expected, or unanticipated, outcomes. When medically inadvisable to give such information to apatient, the information is provided to a person designated by the patient or to a legally authorizedperson.
• Make informed decisions about your treatment and care. When patient participation or exercise of anyright is contraindicated due to medical incapacity or adjudged incompetence, a legally authorizedperson may participate in decision making and act on the patient's behalf to exercise any and all rights.
• Refuse a recommended treatment or plan of care, to the extent permitted by law, and to be informed ofany medical consequences related to that decision.
• Be informed if you will be part of research, investigational or clinical trials. Access to care will not bedenied or hindered if you refuse to participate in research or trials.
• Know that Northwest Eye Surgeons P.C. has an Advance Directives Policy (described on the reverse ofthis form). Questions about our policy may be directed to the physician performing your procedure or toour surgical coordinating staff.
• Resolve problems with care decisions and voice grievances regarding care or service which is (or fails tobe) provided without fear of reprisal or discrimination. Grievances will be investigated and a responseprovided within 14 days. Complaints and grievances may be verbal or written and directed to:
o Spencer Michael, CEO 206-528-6000 ext. 3880
• Know the following physician shareholders who practice at NWES have an ownership interest in all ofNWES's faciiities.
o Kristi Baiiey o WernerCadera o Aaron Kuzino Brett Bence o Bruce Cameron o Audrey TaHey Rostov
As a Northwest Eye Surgeons P.C. patient, you have the responsibility to:
• Provide complete and accurate medica! information.• Participate with providers in making decisions about your treatment or plan of care.
• Follow the treatment plan to which you agreed or let us know if you do not understand or cannot followyour healthcare instructions.
• Arrive for scheduled appointments on time or give notice at least 24 hours in advance if you mustcancel or reschedule an appointment (NWES reserves the right to terminate services if you miss two ormore appointments without calling in advance to cancel).
• Know your health plan benefits, provide complete insurance information and timely notification of anychanges.
• Pay your bili in a timely fashion or seek assistance for discussing payment options.• Treat our staff and physicians with respect and dignity and respect the rights of others.• Let us know if you have concerns or complaints about any aspect of your care.• Respect that we prohibit smoking, the use of alcohol or illegal drugs, and carrying firearms or other
weapons in our facilities.5
NOTICE OFADVANCE DIRECTIVES POLICY
An Advance Directive is a document which allows patients to give direction about future medical care in theevent they are unable to express their wishes or make medical decisions on their own behalf. AdvanceDirectives are generally in the form of a living will, durable power of attorney for healthcare, or a !Efe-sustainingprocedures declaration (POLST). As allowed by Washington State Law, Northwest Eye Surgeons, P.C. and ourASC staff decline to honor non-resuscitative elements which may be contained in an Advance Directive orPOLST.
• Compliance with the 1990 Patient Self-Determination Act Is intended when individuals with anadvanced life-limiting illness are admitted to an in-patient facility.
• In Washington State, the directive is used only if you have a terminal condition where life-sustainingtreatment would artificiatiy prolong the process of dying, or Ef you are in an irreversible coma and thereis no reasonable hope of recovery.
• Healthcare providers at Northwest Eye Surgeons, P.C.'s Ambulatory Surgery Centers, are conscEentiousiycommitted to do all in their power to assure the safe recovery of every surgical patient, includingresuscitation if it becomes necessary.
Because Northwest Eye Surgeons. P.C. may not honor all elements contained within an Advance Directive, youmay request to have your procedure or surgery performed at a facility or hospital which does honor them.Please notify your surgeon, a surgical coordinator, oroneof our healthcare staff, and we will make every effortto accommodate your request.
For more information on Washington State law regarding Advance Directives, or to obtain a printable AdvanceDirective form, please visit the following websites or ask us to print the desired information for you:
Office of the Medicare Beneficiary OmbudsmanhttD://www.medicare.gov/claims-and-ap_peals/medicare-rights/fiet^help/ombudsman.htm
Medicare Help and Support: 1-800-MEDICARE
I was verbally informed of my rights as a patient and have read and understand Northwest Eye Surgeons'Patient Rights & Responsibilities and Advance Directives Policy.
Patient Name: _ Date Received_ Time_Patient/Guardian Signature: _ Date_ Time.Relationship to Patient
Federal regulations require that you sign this document prior to the day of your procedure and bring it withyou to the Surgery Center.
Exhibit 13NWES Seattle
1.23 Charity Care andCommunity Service Plan
Policy
3 -...„.•Policy and Procedure
NORTHWEST EYE SURGEONS
Title: ASC Staffing Strategy
Approval Date: 01/06/18
Effective Date: 01/06/18
Applies to: RASC, SASC/ MVASC, & SQASC
P&P#:XXX
Review: Annual
1.23 Charity Care & Community Service
PurposeNWES allows for a charity care discount of up to 100% off the total visit cost to provide carefor local indigent population.
PolicyThe NWES charity care policy of up to 100% will be extended to eiigibfe patients uponnotification from the physician or billing department that the patient meets the NWES-identified criteria noted below. Application for charity Is available upon request at NWES ASClocations. Patients will also be provided information of charity care prior to extraordinarycollection actions.
ProcedureIn order to qualify for the charity care discount, patients must satisfy the followingconditions:
l. if physician or clinic is a DSHS provider, the patient's monthly income must be at, orbelow, 150% of the Federa! Poverty Level (see table below); or
2. If physician or clinic is not a DSHS provider, and the patient presents with a valid,current DSHS coupon:
a. The physician elects to see the patient;b. The patient acknowledged financial responsibility.
3. Notification of charity care is provided in patient's billing documentation.4. NWES administration reserves the right to select patients for charity care discount
without satisfying above conditions.
2016 POVERTY GUIDELINES FOR THE 48CONTIGUOUS STATES AND THE DISTRICTOF COLUMBIAPERSONS IN FAMILY/HOUSEHOLD POVERTY GUIDELINEFor families/households with more than 8persons, add $4,160 for each additionalperson.