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contributor on regulatory compliance and operational issues for several professional publications. Sandra was a hospital president for eight years and a hospital department administrator for several years prior to her development of surgery centers and regional positions with national ASC management companies. She is currently on the board of the AAAHC, an accreditation organization, and serves on the Standards and Survey Procedures Committee. She is a former board member of the ASC Association, the national membership, education and advocacy organization for ambulatory surgery centers where she served on Governance and other Committees. She was the ASC Association committee chair for the HIPAA Task Force and HIPAA guidebooks.Donna Slosburg, RN, BSN, LHRM, CASC is Executive Director of the Ambulatory Surgery Center Quality Collaboration. In this role, she oversees and participates in a broad range of quality-related projects on behalf of the ASC industry, and speaks across the country regarding ASC quality measurement. In addition to directing internal ASC quality measure development and overseeing the public reporting of ASC quality data, she has also collaborated with many other organizations focused on advancing quality, including recent work with the CDC and AHRQ.Donna has worked in the healthcare industry for over 30 years and joined the ASC industry in 1987. Her nursing experience has included working in the Intensive Care Unit, Peri-Operative care areas and nursing education. Her leadership roles include ASC nurse manager, ASC administrator and overseeing regional operations for an ASC management company. She was a senior vice president of surgery operations and national surgery specialist for HealthSouth, one of the nation’s largest healthcare services providers and received the HealthSouth Special Achievement Award for Clinical Excellence. Donna recently served on the editorial board for the Association of peri-Operative Registered Nurses and has also served on the Board of Directors for the Florida Society of Ambulatory Surgical Centers. Donna is currently a member of several Technical Expert Panels. She is a speaker for the AORN Administrator Skills Course. Donna is a Licensed Healthcare Risk Manager and was one of the first to receive the Certified Administrator Surgery Center industry certification. FSASC wishes to thank the reviewers of the first edition, Carol Hiatt, RN, LHRM, CASC and Patsy Lentz, RN, LHRM who served on the original task force in 2007, suggesting content, reviewing the initial draft, and making recommendations. Ambulatory Surgical Centers licensed in the State of Florida are required to have a Florida licensed health care risk manager. The following is information about the risk management requirements to provide guidance to the surgical center administrative staff in working with a licensed risk manager to achieve and maintain compliance.In 2009, the Agency for Health Care Administration (AHCA) released interpretive guidelines for licensing and risk management. The address for the location of these guidelines on the Internet is listed under Resources for Forms and Regulations on page 11.Additionally, the Medicare Conditions for Coverage Interpretive Guidelines, released in 2009 and updated last in January 2015, as of the publication of this white paper, include risk assessment of infection control, time out, prevention of surgical fires and other areas that emphasize the integration with quality improvement as well as governing body oversight. Full discussion of the Medicare Conditions for Coverage Interpretive Guidelines is not included in this publication. For a full text of the guidelines, go to FSASC.org for a link to that document. The development of appropriate measures to minimize the risk of adverse incidents to patients, including, but not limited to:Education and Training: Within 30 days of hire, risk management and risk prevention education for all non physician personnel must take place. In addition, there must be one hour minimum of annual education and training of all personnel working in clinical areas and providing patient care. Physicians are excluded from this requirement; allied health professionals are not. Therefore, education and training of CRNAs, PAs, or other allied health professionals who provide patient care in your surgical center must have this initial and annual education. Education must include risk management and risk prevention, including the importance of accurate and timely incident reporting; the legal obligation of all health care providers and all agents and employees of the facility to report incidents to the risk manager; reporting an adverse incident to the risk manager or risk manager designee within 3 business days; the statutory definition of an “adverse incident” and the required reporting to AHCA; the location of risk management policies, procedures, and the incident reporting form. A surveyor or inspector may interview staff and ask a staff member to state what training occurred, who is notified when an adverse event occurs, and where the reporting forms are located. Staffing in the Recovery Area (PACU): One staff member and at least one other person shall attend a patient in the recovery room. There shall always be two persons in the recovery area when a patient is recovering from anesthesia and the procedure. One of these persons must be a registered nurse. The second person may be any employee, a physician, or a significant other of the patient. Instead of two people, the facility can have (1) live visual observation, (2) electronic observation, or (3) any other reasonable measure taken to ensure patient protection and privacy. When electronic observation is used, live observation/monitoring of the camera must be occurring. The monitoring does not replace the requirement of one RN in PACU.Florida Risk Management and Related Regulations | 4th Edition - 3Unlicensed persons assisting or participating in any surgical procedures: There is a prohibition against an unlicensed person assisting or participating in any surgical procedure unless the facility has authorized the person to do so following a competency assessment of that unlicensed person. The unlicensed person must be under the direct and immediate supervision of a licensed physician. The activity cannot be one that may only be performed by a licensed health care practitioner. One example of a prohibition would be an equipment sales person without clinical skills actively participating in a procedure or other patient care activity.Development, implementation, and ongoing evaluation: The development, implementation, and ongoing evaluation of procedures, protocols, and systems to accurately identify patients, planned procedures, the correct site of the planned procedure, and the availability of correct implant, so as to minimize the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patient’s diagnosis of medical condition. The surveyors and inspectors may look for policies as well as observe the process of conducting a time out, marking of the site, and involvement of the patient and the physician in this process. The evaluation of the procedures, protocols and measures to reduce risk is closely tied to risk management integration into the performance improvement program and oversight of the governing body. In addition, this section is integral to the Medicare Conditions for Coverage requirement that the governing