In the context of ambulatory surgical centers (ASCs), the discharge of a patient without a responsible adult to accompany them raises several important considerations. This article explores the regulatory requirements and best practices for ensuring patient safety and compliance with state and federal regulations.
STATE AND FEDERAL REGULATIONS
ASCs must comply with all applicable federal and state statutes and regulations. For example, according to the Colorado Department of Public Health and Environment (CDPHE) regulations, all patients admitted to an ASC must be under the direct care of a member of the medical staff. The medical staff is responsible for ensuring continuity of care, including pre-operative, intra-operative, and post-operative care. All necessary instruction and education shall be provided to each patient prior to admission (for pre-surgical care) and discharge (for post-surgical care).1
If a patient is to receive sedation or anesthesia that results in impaired mental status following surgery, they must be accompanied upon discharge by a responsible adult, unless exempted in writing by the attending physician.2 Patients shall be in a stable condition which will not endanger their continued well-being or shall be transferred to a licensed hospital, convalescent center or other treatment facility. There shall be written procedures and assigned responsibilities for implementing such procedures, including provisions for transportation. The center shall provide verbal and written patient instructions regarding post-operative or post-procedure care, physician follow-up, and physician contact information.3
CMS CONDITIONS FOR COVERAGE
The CDPHE regulations example mirrors the federal Centers for Medicare & Medicaid Services (CMS) conditions for coverage regulations for ASCs regarding a patient discharge. According to 42 CFR § 416.52(c), the ASC must ensure that each patient has a discharge order signed by the physician who performed the surgery or procedure. Additionally, all patients must be discharged in the company of a responsible adult, except those exempted by the attending physician.
Interpretive Guidelines
The CMS Interpretive Guidelines provide further clarification on these provisions.4
Interpretive Guidelines: §416.52(c)(2): No patient may be discharged from the ASC unless the physician who performed the surgery or procedure signs a discharge order. The ASC must ensure that physicians follow applicable State laws as well as generally accepted standards of practice and ASC policy when determining that a patient has recovered sufficiently from surgery and may be discharged from the ASC, or, as applicable, that the patient must be transferred to another healthcare facility that can provide the ongoing treatment that the patient requires and that the ASC is unable to provide. It is permissible for the operating physician to write a discharge order indicating “the patient may be discharged when stable.” (73 FR 68721). In such cases there must be documentation of when patient was stable. It is expected that a patient will actually leave the ASC within 15–30 minutes of the time when the physician signs the discharge order or when he or she was found to be stable, whichever happens later.
Interpretive Guidelines: §416.52(c)(3): Unless the physician who is responsible for the patient’s care in the ASC has exempted the patient, the ASC may not discharge any patient who is not accompanied by a responsible adult who will go with the patient after discharge. ASCs would be well-advised to develop policies that address what criteria a physician should consider when deciding a patient does not need to be discharged in the company of a responsible adult. Exemptions must be specific to individual patients, not blanket exemptions to a whole class of patients.
KEY POINTS FOR DISCHARGING WITHOUT A RESPONSIBLE ADULT
To discharge a patient without a responsible adult, the following key points should be considered:
- Ensure that the patient understood and agreed to, prior to the procedure, that they have a responsible adult take them home.
- Have a treating provider assess the patient prior to discharge to ensure they have appropriate decision-making capability and understand the risks of discharge without a responsible adult.
- Develop policies that address what criteria a physician should consider when deciding a patient does not need to be discharged in the company of a responsible adult. Exemptions must be specific to individual patients, not blanket exemptions to a whole class of patients.
- Don’t allow a patient to sign out against medical advice (AMA) if they lack the appropriate decision-making capacity.
- Consider transferring a patient to a facility where they can be appropriately observed prior to discharge if they lack decision-making capacity and would be discharged to a potentially unsafe environment.
A provider will also be held to the medical standard of care when discharging a patient—what a reasonably careful physician in the same specialty would have done at the same time and under the same circumstances.
Conclusion
Discharging a patient from an ASC without a responsible adult requires careful consideration of regulatory requirements and patient safety. By following the guidelines and best practices outlined in this article, ASCs can ensure compliance and provide safe and effective care for their patients.
1 6 CCR § 1011-1.20-9.1.
2 6 CCR § 1011-1.20-9.4(C).
3 6 CCR § 1011-1.20-9.5
4 CMS State Operations Manual, Appendix L.
The information provided herein does not, and is not intended to constitute legal, medical, or other professional advice; instead, this information is for general informational purposes only. The specifics of each state’s laws and the specifics of each circumstance may impact its accuracy and applicability, therefore, the information should not be relied upon for medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation.
Article originally published in Copic's 2Q25 Facility Focus newsletter.
