Healthcare Law Alert: NJDOH Issues Revised COVID-19 Protocols for ASCs Resuming Services



On June 16, 2021, the Commissioner of the New Jersey Department of Health (NJDOH) issued a Revised Executive Directive setting forth COVID-19 protocols for ambulatory surgery centers (ASCs) resuming elective surgeries and invasive diagnostic procedures. The protocols are in response to the declining number of COVID-19 cases and hospitalizations and the significant progress of the State’s vaccination program.

Additional Steps for ASCs to Protect Employees and Patients

ASCs resuming elective surgeries and invasive procedures must take steps to protect the healthcare workforce and patients, including:

  • Comply with New Jersey, Centers for Medicare and Medicaid Services (CMS), and Centers for Disease Control (CDC) guidelines to protect against further spread of COVID-19;
  • Institute screening of all healthcare personnel for symptoms of COVID-19 and have policies in place for removal of symptomatic employees, regardless of vaccination status;
  • Enforce physical distancing and use of well-fitting facemasks in work areas and common areas following CDC and NJDOH guidelines, whenever practicable;
  • Require use of well-fitting facemasks for all employees and patients regardless of vaccination status, except patients who are receiving services that prevent the use of a mask or are unable to in accordance with CDC guidance;
  • Continue to maintain an established plan for cleaning and disinfecting the facility, including equipment and high-touch surfaces prior to use and in between patients; and
  • Continue to monitor the community surge status and be prepared to modify clinical services as needed.

ASCs may resume full scope of services when possible and safe to do so. The physical layout and care delivery areas must be arranged so that physical distancing is maintained in accordance with CDC and NJDOH guidelines.

Requirements for PPE, Staffing, and Cleaning and Disinfecting

ASCs must, among other requirements:

  • Have a plan that is consistent with CDC and NJDOH guidelines for patient and support person use of personal protective equipment (PPE);
  • Require workers to wear appropriate PPE and follow universal source control, regardless of COVID-19 vaccination status;
  • Ensure workers treating COVID-19 positive and presumptive positive patients are appropriately trained in and have access to PPE, and that the ASC has an adequate supply on hand of PPE of at least 7 days;
  • Have appropriate PPE policies for non-direct patient care staff;
  • Have in place policies for conservation of PPE and surge capacity, and for extended use or reuse of PPE;
  • Implement guidance relating to frequency of patient and staff testing; and
  • Implement protocols for disinfecting and cleaning, including use of EPA approved SARS-CoV-2 surface disinfectant products.
Cohorting COVID-19 and Non-COVID-19 Patients

ASCs are not permitted to perform procedures on COVID-19 positive patients, unless excepted in Executive Order 109 as an urgent case. Facilities are not permitted to cohort COVID-19 patients and non-COVID-19 patients.

Requirements for Patients

The Executive Directive sets forth requirements for coordination of scheduling to promote physical distancing, requirements for pre-procedural COVID-19 testing and self-quarantine, counseling of each patient regarding requirements and procedures for the patient’s procedure to be performed as scheduled, and requirements for time-sensitive procedures that would endanger patient health if delayed.

Patient Support Persons

The Executive Directive also contains information about when and how patient support persons are permitted to accompany the patient undergoing same-day surgeries and procedures.

Additional Items

The Executive Directive provides additional information concerning policies surrounding visitors, vendors, consultants and students; discharge of patients after procedures are completed; and key resources and guidance documents.

For additional information or assistance, contact:

Lani M. Dornfeld, CHPC, Member, Healthcare Law, at 973-403-3136 or

John D. Fanburg, Managing Member and Chair, Healthcare Law, at 973-403-3107 or

Joseph M. Gorrell, Member, Healthcare Law, at 973-403-3112 or

Carol Grelecki, Member, Healthcare Law, at 973-403-3140 or

*This is intended to provide general information, not legal advice. Please contact the authors if you need specific advice.

Related Practices:   Healthcare Law