cms hospital conditions of participation (cops) 2011 what pps hospitals need to know
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CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2011 What PPS Hospitals Need to Know. Speaker. Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD President Patient Safety and Healthcare Education 5447 Fawnbrook Lane - PowerPoint PPT PresentationTRANSCRIPT
CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2011
What PPS Hospitals Need to Know
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Speaker
Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD
President Patient Safety and Healthcare Education 5447 Fawnbrook Lane Dublin, Ohio 43017
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Regulations first published in 1966
Many revisions since with final interpretive guidelines June 5, 2009 (Tag 450 Medical Record) and anesthesia (December 11, 2009, February 5, 2010, May 21, 2010 and February 14, 2011) and Respiratory and Rehab Orders August 16, 2010 and Visitation 2011
First regulations are published in the Federal Register first-42 CFR Part 4821
CMS then publishes Interpretive Guidelines2
Hospitals should check this website once a month for changes
1www.gpoaccess.gov/fr/index.html 2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
The Conditions of Participation
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Respiratory and Rehab Orders Published in the August 16, 2010 Federal Register
Allows a qualified licensed practitioner who is responsible for the care of the patient (such as a PA or NP)
Who is acting within their scope of practice under state law
Can order respiratory or rehab order (physical therapy, occupational therapy, speech)
Must be privileged (authorized) by the MS
Must have hospital P&P to allow also6
Visitation Effective January 19, 2011
Must rewrite policy on visitation including visiting hours in ICU
Must inform each patient of their visitation rights
Must include any restrictions on those rights
Can not restrict or deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity or disability
For example same sex partner may present visitation advance directive
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Federal Register Visitation Changes
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CMS Proposed New Rule
CMS proposed new rule for notifying beneficiaries of their right to file a quality of care complaint
Give beneficiaries written notice of their right to contact their state QIO or Quality Improvement Organization
Also include
Currently, only hospital inpatients receive this information
Includes 10 facilities such as clinics, CAH, LTC, hospices, home health agencies, ASCs, comprehensive outpatient rehab facilities, portable X-ray services and rural health clinics
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Medicare Patients, Complaints and the QIO
The proposed rule was published in the Federal Register on February 2, 2011
at http://www.gpo.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-2275.pdf
QIOs must conduct a review of all written complaints about the quality of care for Medicare patients only
Current hospital CoP includes a requirement that the grievance process must include a mechanism for timely referral to the QIO of beneficiary concerns regarding quality of care
Must also give Medicare patients a copy of their IM Notice
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Medicare Patients, Complaints and the QIO
Since 9th scope of work started August 1, 2008, QIOs have received 6,379 inpatient and 4,1116 outpatient requests
Feel number is inadequate because Medicare patients do not know they can complain to their QIO
Expanding now that Medicare patients, or their representative, will receive written notice at the start of their care, of their right that they can complain about quality of care issues to the QIO in other settings
Such as time of admission or in advance of furnishing care11
Medicare Patients, Complaints and the QIO Medicare patient who is competent can also decide to have
the written notice given to their surrogate such as a friend or family member
Remember if need to use an interpreter for limited English proficiency (LEP) or deaf/hard of hearing patients
Unless patient signs a waiver declining interpreter
Remember the 2011 TJC patient centered communication standards
Also 7 of the 10 providers must include information to contact the state agency
Hospitals, HH, RHC, CORF, FQHCs, Hospices, clinics12
Specific Requirements
For example an ASC, hospice, hospitals, home health, hospice etc. would have to do the following;
Give the patient a written notice of their right to notify the QIO
Must include at the time of admission or in advance of furnishing care
Must include name, telephone number, email address, and mailing address
Must document in the medical record that the notice was given
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Proposed FR February 2, 2011
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TJC has published many changes over the past two years
Many of the changes reflected in their standards is to be in compliance with the CMS CoP
Standards are for hospitals that use them to get deemed status to allow payment for M/M patients
This means hospitals do not have to have a survey by CMS every 3 years
Can still get a complaint or validation survey
So now TJC standards crosswalk closer to the CMS CoPs (not called JCAHO any more)
TJC Revised Requirements
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http://www.cms.hhs.gov/manuals/downloads/
som107_Appendicestoc.pdf
4th Anesthesia Changes February 14, 2011
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Respiratory and Rehab Changes
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Hospitals that participate in Medicare or Medicaid must meet the COPs for all patients in the facilities and not just those patients who are Medicare or Medicaid
Hospitals accredited by TJC, AOA, or DNV Healthcare have what is called deemed status
These are the only 3 that CMS has given deemed status to for hospitals
This means you can get reimbursed without going through a state agency survey
States can still institute a survey and be more restrictive
Mandatory Compliance
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All Interpretative guidelines are in the state operations manual and are found at this website1
Appendix A, Tag A-0001 to A-1163 and 370 pages long
You can look up any tag number under this manual
Manuals
Manuals are now being updated more frequently Still need to check survey and certification website
once a month and transmittals to keep up on new changes 2
1http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
2 http://www.cms.gov/Transmittals/01_overview.asp
CMS Hospital CoPs
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http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
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Important interpretive guidelines for hospitals and to keep handy
A- Hospitals and C-Critical Access Hospitals
C-Labs
V-EMTALA (Rewritten May 29, 2009 and amended July 2010)
Q-Determining Immediate Jeopardy
I-Life Safety Code Violations
All CMS forms are on their website
Conditions of Participation (CoPs)
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Resource is your state department of health or regional CMS office
The American Hospital Association or state hospital association may be of assistance
Note that when changes are published in the Federal Register there is always the name and phone number of a contact person at CMS
Contact for Questions
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Step one is publication in Federal Register
Step two is where CMS publishes the interpretive guidelines
The interpretive guidelines provide instructions to the surveyors on how to survey the CoPs
These are called survey procedure
Not all the standards have survey procedures
Questions such as “Ask patients to tell you if the hospital told them about their rights”
Survey Procedure
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Surveyors use the information contained in the interpretive guidelines
They do not replace or supersede the law
Should not be used as basis for citation
They do contain authoritative interpretations and clarifications which can assist surveyors in making determinations of compliance
Interpretive Guidelines
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Assign each section of the hospital CoPs to the manager of that department
Do a side by side gap analysis like the TJC PPR for each section
Have standard on left side and go line by line and document compliance on the right side
Keep a hard copy of CoP and analysis
Designate someone in charge if a validation, complaint, or unannounced survey occurs
Commonly referred to as the CoP king or queen
Compliance Recommendation
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These will be discussed throughout presentation:
Restraint and seclusion (annual)
Abuse, neglect and harassment (annual)
Infection control
Advance directive
Organ donation
IVs and blood and blood products
ED common emergencies, IVs and blood and blood products for ED
CMS Required Education
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Life Safety Code Compliance
Infection Control and CMS gets $50 million grant to enforce in 2011
Patient Rights especially R&S and grievances
EMTALA
Performance Improvement (CMS calls it QAPI)
Medication Management
Dietary and cleanliness of dietary
What’s Really Important
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What’s Really Important Verbal orders
History and physicals
Need order for respiratory and rehab (such as physical therapy)
Need order for diet, medications, and radiology
Anesthesia (updated four times)
Standing orders and protocols
Medications within 30 minute time frame
Outpatient under one person (Tag 1078)
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First 37 pages list the survey protocol, including sections on:
Off-survey preparation
Entrance activities
Information gathering/investigation
Exit conference
Post survey activities
Survey Protocol
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Survey done through observation, interviews, and document review
Usually surveys are done Monday - Friday but can come on weekends or evenings
Federal law allows CMS or department of health surveyors access to your facility
CAH rehab or psych (behavioral health) is surveyed under this section even though CAH has separate manual
Survey Protocol
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Mid-sized hospital with a full survey
Two to four surveyors for three or more days and at least one RN with hospital survey experience
Team based on complexity of services offered
SA (state agency) decides or RO (regional office) for federal teams
Have an organized plan for an unannounced survey with designated persons to accompany surveyors
Include education of security or those who attend to the front desk where surveyors could enter in the morning
Survey Team
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Team coordinator gathers information about provider (ownership, types of services offered, locations)
Determines if provider based, remote locations, PPS-exempt services offered
Information collected from CMS database such as previous surveys and findings, size of facility, and average daily census
Team should enter together and usually goes to administration
Task 1 – Off Site Survey Prep
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Team will explains purpose and scope of survey
ENTRANCE CONFERENCE – sets the tone for entire survey
Give surveyors conference room, telephone
Give names of department heads, their location and phone numbers
CMS has a list of documents they may ask for so be ready and know what is on this list
Provide organizational chart
Task 2 – Entrance Activities
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Provide additional information
Infection control plan
Names and addresses of all off-site locations and provider numbers
List of employees
Medical staff bylaws, rules and regulations
List of contracted services
Copy of floor plan
List of current patients with room numbers, doctors
Give preliminary date and time for exit conference
Task 2 – Entrance Activities
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Purpose is to determine compliance with CoPs thru observation, interviews, and document review
Will visit patient care areas including ED and outpatient, Imaging, rehab, and remote locations
Observe actual care (IV, tube feeding, wound dressing changes)
May observe a nurse pass medications
Review copies of materials
Use interpretive guidelines to guide survey
Task 3 – Information Gathering
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Use Appendix Q if Immediate Jeopardy is suspected
Surveyor has discretion whether to allow staff to accompany the surveyor
All significant adverse events should be brought to the team coordinator’s attention immediately
Surveyors must respect patient privacy and confidentiality
Work with surveyor so they do not take peer-review protected documents with them
Task 3 – Information Gathering
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If surveyor makes copies of documents ask to make one for the hospital
No federal review law but if in PSO surveyor can not see
Review and analyze all information gathered
Determine if CoPs are met and if PPS exclusionary criteria (42 CFR Part 412, subpart B) or swing bed (42 CFR 482.66)
Prepare exit conference report
If noncompliance with CoP then determine if at standard or condition level and how dangerous it is
Task 4 Analysis of Finding
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Condition level - (NOT GOOD) due to noncompliance with requirement in a single standard or several standards within the condition or single tag but represents a severe or critical health breach, (need to have conversation)
Standard level - noncompliance as above but not of such a character to limit facility’s capacity to furnish adequate care - no jeopardy or adverse effect to health or safety of patient
Try and work with the surveyor to resolve the issue before CMS leaves the building
Deficiency
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Objective - inform facility of preliminary findings
Policy is to do exit conference
Can refuse if hostile environment or
Counsel tries to turn into evidentiary hearing
If recorded, must provide two tapes and tape recorders
Tape at same time and give surveyor one
Official findings are provided in writing on Form CMS 2567 (all forms on CMS website now)
Task 5 Exit Conference
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Surveyor can set ground rules
Present findings of noncompliance
Statement of deficiencies will be mailed and have 10 working days to fix (Form 2567)
This form is made public no later than 90 days after survey
So try and fix before the surveyor leaves
List deficiencies, plans for correction, timelines and opportunity to refute findings
Task 5 Exit Conference
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Objective is to complete the survey and certification requirements and notify staff regarding survey results
Complete hospital restraint/seclusion death reporting worksheet as appropriate
Enter information into hospital Medicare database
Certification of providers with deficiencies if acceptable plan of correction
Task 6 Post-Survey Activities
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Starts with a tag number, example A-0001
“A” refers to the hospital CoPs
Goes from 0001 to 1163
The three sections from Federal Register (CFR) include the regulation, interpretive guidelines and survey procedure
Survey procedure
Not in every section
Explains survey process, policies that will be reviewed, questions that will be asked and documents reviewed
Interpretive Guidelines
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The hospital must be in compliance with all federal, state, and local laws
Survey procedure tells surveyor to interview CEO or other designated by hospital
Refer non-compliance to proper agency with jurisdiction such as OSHA (TB, blood borne pathogen, universal precautions, EPA (haz mat or waste issues), or Rehabilitation Act of 1973
Will ask if cited for any violation since last visit
Compliance with Laws A-0020
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Hospital must be licensed or approved for meeting standards for licensure, as applicable Personnel must be licensed or certified if required by state
(doctors, nurses, PT, PA, etc.)
If telemedicine used must be licensed in state patient located and where practitioner is located See proposed changes on telemedicine
Verify that staff and personnel meet all standards (such as CE’s) required by state law
Review sample of personnel files to be sure credentials and licensure is up to date
Compliance with Laws 0023, 0022
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Hospital must have an effective governing body responsible for the conduct of the hospital as an institution
Written documentation identifies an individual as being responsible for conduct of hospital operations
Board makes sure MS requirements are met
Board must determine which categories of practitioners are eligible for appointment to medical staff (MS), as allowed by your state law (CRNA, NP, PA’s, nurse midwives, chiropractors, podiatrists, dentists, etc.)
Governing Body (Board) A-0043
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Board appoints individuals to the MS with the advice and recommendation of the MS (0046)
Will review board minutes to make sure they are involved in appointment of MS
Board must assure MS has bylaws and they comply with the CoPs (0047)
Board must make sure they have approved the MS bylaws and rules and regulations (0048) and any changes
TJC MS.01.01.01 as to what goes into a bylaw or R/R
Medical Staff and Board
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Board must ensure MS is accountable to the board for the quality of care provided to patients (0049)
All care given to patients must be by or in accordance with the order of practitioner who is operating within privileges granted by the Board
Need order for any medications
Need to document the order even if there is a protocol approved by the medical board for it
ED nurse starts IV on patient with chest pain and documents it in the order sheet
Discussed later under section 407 and 450
Medical Staff and Board
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Board ensures that criteria for selection of MS members is based on (0050)
MS privileges describe privileging process and ensure there is written criteria for appt to MS
Individual character, competence, training, experience and judgment
Make sure under no circumstances is staff membership or privileges based solely on certification, fellowship, or membership in a specialty society (0051)
TJC has a tracer now on this
Board and Medical Staff
TJC Tracer MS Credentialing and Privileging
Will look at the design of the MS and look at verification of credentials, limitations or relinquishing privileges, health status, morbidity and mortality, peer recommendations etc
Consistent process for all practitioners
Scope of the MS process to determine if all LIPs and other practitioners are reviewed
The link between results of ongoing professional practice evaluation and focused professional performance evaluation and the adherence to criteria.
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TJC Tracer MS Credentialing and Privileging
How the organization is monitoring the performance of all licensed independent practitioners on an ongoing basis
How does the hospital evaluates performance of LIPs who do not have current performance documentation (FPPE)?
How does the hospital evaluate LIPs who performance has raised concerns regarding safe quality care?
Will look to see if state opted out supervision with CRNAs, P&Ps for supervision of CRNAs, etc
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CMS Guidance issued to clarify it is a recommendation that MS must conduct appraisals of practitioners at least every 24 months Need to do every 24 months if TJC accredited
MS must examine each practitioner’s qualifications and competencies to perform each task, activity, or privilege
Included current work, specialized training, patient outcomes, education, currency of compliance with licensure requirements MS section repeated in tag 338-363 so will not duplicate
Board and the Medical Staff
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Board must appoint a CEO who is responsible for managing the hospital
Verify CEO is responsible for managing entire hospital
Verify the board has appointed a CEO
CEO is a very important position and CMS has only a small section
TJC in the leadership standard has more detailed information on the role of the CEO
CEO A-0057
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Board must make sure every patient has to be under the care of a doctor (or dentist, podiatrist, chiropractor, psychologist, et. al.)
Practitioners must be licensed and a member of MS
If LIPs can admit (NP, Midwives) still need to see evidence of being under care of MD/DO –
If state law allows needs policies and bylaws to ensure compliance
Exception is a separate federal law where no supervision required by midwives for Medicaid patients
Care of Patients 0063-0068
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Evidence of being under care of MD/DO must be in the medical record
Verify with your state department of health what documentation is required
Board and MS establish P&P and bylaws to ensure compliance
Board must make sure doctor is on duty or on call at all times, doctor of medicine or osteopathy is responsible for monitoring care M/M patient Interview nurses and make sure they are able to call the
on-call MD/DO and they come to the hospital when needed
Care of Patients 0063-0068
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Patient admitted by dentist, chiropractor, podiatrist etc., needs to be monitored by a MD/DO, as allowed by state law Each state has a scope of practice which talks about what
they can do
The board and MS must have policies to make sure Medicare/Medicaid patient is responsible for any care OUTSIDE the scope of practice of the admitting practitioner
What is the scope of practice in your state for NP, CRNAs, Midwifes, and PAs?
Care of Patients 0067-68
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Need institutional plan
Include annual operating budget with all anticipated income and expenses
Provide for capital expenditures for 3 year period
Identify sources of financing for acquisition of land improvement of land, buildings and equipment
Must be submitted for review TJC has similar standards in its leadership chapter
Plan and Budget 0073-0077
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Plan and Budget
Need institutional plan
Must include acquisition of land and improvement to land and building
Must be reviewed and updated annually
Must be prepared under direction of board and a committee of representatives from the Board administrative staff, and MS (077)
Verify that all 3 participated in the plan and budget
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Board responsible for services provided in hospital (0083) Whether provided by hospital employees or under
contract
Board must take action under hospital’s QAPI program to assess services provided both by employees and under direct contract
Identify quality problems and ensure monitoring and correction of any problems TJC has more detailed contract management standards
in LD chapter, revised 7-1-10
Contracted Services
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Board must ensure services performed under contract are performed in a safe and efficient manner
Increased scrutiny on contracted services
Review QAPI plan to ensure that every contracted service is evaluated
Maintain a list of all contracted services (85)
Contractor services must be in compliance with CoPs Consider adding section to all contracts to address CoP
requirements
Contracted Services
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Remember to see the EMTALA separate CoP
Revised May 29, 2009 and amended July 2010 and now 64 pages
Consider doing yearly education on EMTALA to your ED staff and for on call physicians
If hospital has an ED, you must comply with section 482.55 requirements
If no ED services, Board must be sure hospital has written P&P for emergencies of patients, staff and visitors
Emergency Services 0091
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Qualified RN must be able to assess patients
Verify that MS has P&P on how to address emergency procedures
Need P&P when patient’s needs exceed hospital’s capacity
Need P&P on appropriate transport
Train staff on what to do in case of an emergency
Should not rely on 911 for on-campus and need trained staff to respond to the code or emergency
Emergency Services 0091
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If emergency services are provided at the hospital but not at the off campus department then you need P&P on what to do at the off-campus department when they have an emergency
Do whatever you can to initially treat and stabilize the patient etc
Call 911 (off campus only!)
Provide care consistent with your ability
Includes visitors, staff and patients
Make sure staff are oriented to the policy
Emergency Services 0091
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Changes many standards related to grievances and restraint and seclusion (R&S)
Sets forth standards regarding R&S staff training and education
Sets forth standards on R&S death reporting
TJC also has chapter on 14 patient rights or RI “Rights and Responsibilities of the Individual” starting with RI.01.01.01 thru 02.02.01
Patient Rights
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Minimum protections and rights for patients
Right to notification of rights and exercise of rights
Privacy and safety
Confidentiality of medical records
Restraint issues (50 pages of restraint standards)
Grievances
Advance directives
Visitation rights
Patient Rights Standards 0115-0214
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Notice of Patient Rights and Grievance Process
Hospital must ensure the notice of patient rights are met
Provide in a manner the patient will understand
Remember issue of limited English proficiency (LEP) as with patients who does not speak English and low health literacy
20% of patients read at a fifth grade level
Must have P&P to ensure patients have information necessary to exercise their rights
Standard # 1
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Rule #1 - A hospital must inform each patient of the patient’s rights in advance of furnishing or discontinuing care
Must protect and promote each patient’s rights
Must have P&P to ensure patients have information on their rights and this includes inpatients and outpatients
Must give Medicare patient IM Notice within two days of admission and in advance of discharge if more than two days
Notice of Patient Rights 116
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Confidentiality and privacy
Pain relief
Refuse treatment and informed consent
Advance directives
Right to get copy for Medicare patients of Important Message from Medicare (IM Notice) or detailed notice)
Right to be free from unnecessary restraints
Right to determine who visitors will be
Notice of Patient Rights
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When appropriate, this information is given to the patient’s representative
Document reason, patient unconscious, guardian, DPOA, parent if minor child et. al.
Consider having a copy on the back of the general admission consent form and acknowledgment of the NPP
Have sentence that patient acknowledges receipt of their patient rights
Right to contact the QIO or state agency of problems
Notify Patient of Their Rights
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Rule #2 - A hospital must ensure interpreters are available
Make sure communication needs of patients are meet
Recommend qualified interpreters
Must comply with Civil Rights law
Be sure to document that the interpreter was used See TJC 2011 Patient Centered Communications Standards
Interpreters
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Consider posting a sign in several languages that interpreting services are available
Include in yearly skills lab for nurses to make sure your staff knows what to do and they understand P&P
Review your policy and procedure and the five 2011 standard TJC requirements
If hospital owned physician practices ensure interpreters are present in prescheduled appointments
Interpreters
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Rule #3 - The hospital must have a process for prompt resolution of patient grievances
Hospital must inform each patient to whom to file a grievance
Provides definition which you need to include in your policy
If TJC accredited combine P&P with complaint section complaint standard at RI.01.07.01 in which is similar to CMS now with one addition
Use the CMS definition of grievance
Grievance Process A-0118
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Definition: A patient grievance is a formal or informal written or verbal complaint
when the verbal complaint about patient care is not resolved at the time of the complaint by staff present
by a patient, or a patient’s representative,
regarding the patient’s care, abuse, or neglect, issues related to the hospital’s compliance with the CMS CoP or a Medicare beneficiary billing complaint related to rights
Grievance Process A-0118
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Remember it is not a grievance if resolved by “staff present”
Document this in medical record
Expanded definition of what is meant by “staff present”
Now includes any hospital staff present at the time of the complaint or who can quickly be at the patient’s location
Such as nursing administration, nursing supervisors, patient advocates or anyone else who can resolve the patient’s complaint
“Staff Present” Grievances
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Hospitals should have process in place to deal with minor request in more timely manner than a written request Examples: change in bedding, housekeeping of room,
and serving preferred foods
Does not require written response
If complaint cannot be resolved at the time of the complaint or requires further action for resolution then it is a grievance
All the CMS requirements for grievances must be met
Grievances A-0118
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If someone other than the patient complains about care or treatment
Contact the patient and ask if this person is their authorized representative
Get the patient’s permission to discuss protected health information with designed person because of HIPAA
Document in the file that the patient’s permission was obtained– Some facilities get a HIPAA compliant form signed
Patient or Their Representative
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Not a grievance if patient is satisfied with care but family member is not
Billing issues are not generally grievances unless a quality of care issue
A written complaint is always a grievance whether inpatient or outpatient (email and fax is considered written)
Information on patient satisfaction surveys generally not a grievance unless patient asks for resolution or unless the hospital usually treats that type of complaint as a grievance
Grievances 0118
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If complaint is telephoned in after patient is dismissed then this is also considered a grievance
All complaints on abuse, neglect, or patient harm will always be considered a grievance
Exception is if post hospital verbal communication would have been routinely handled by staff present
If patient asks you to treat as grievance it will always be a grievance
Grievances 0118
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Review the hospital policy to assure its grievance process encourages all personnel to alert appropriate staff concerning grievances
Hospital must assure that grievances involving situations that place patients in immediate danger are resolved in a timely manner
Conduct audits and PI to make sure your facility is following its grievance P&P
Grievance Process - Survey Procedure
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Surveyor will interview patients to make sure they know how to file a complaint or grievance
Including right to notify state agency (state department of health and QIO with phone numbers)
Remember to add email address and address of both
Document that this is given to the patient
Remember the TJC APR requirements
Should be in writing in patient rights section
Grievance Process - Survey Procedure
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Rule #4 – The hospital must establish a process for prompt resolution
Inform each patient whom to contact to file a grievance by name or title
Operator must know where to route calls
Make form accessible to all
Grievance Process 0119
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Rule #5 – The hospital’s governing board must approve and is responsible for the effective operation of the grievance process
Elevates issue to higher administrative level
Have a process to address complaints timely
Coordinate data for PI and look for opportunities for improvement
Read this section with the next rule
Most boards will delegate this to hospital staff
Grievance Process A-0119
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The hospital’s board must review and resolve grievances
Unless it delegates the responsibility in writing to the grievance committee
Board is responsible for effective operation of grievance process
Grievance process reviewed and analyzed thru hospital’s PI program
Grievance committee must be more than one person and committee needs adequate number of qualified members to review and resolve
Rule #6 A-0119-120
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Go back and make sure your governing board has approved the grievance process
Look for this in the board minutes or a resolution that the grievance process has been delegated to a grievance committee
Does hospital apply what it learns?
Grievance Survey Procedure
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Rule #7 – The grievance process must include a mechanism for timely referral of patient concerns regarding the quality of care or premature discharge to the appropriate QIO
Each state has a state QIO under contract from CMS and list of QIOs1
QIO are CMS contractors who are charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting
1http://www.qualitynet.org/dcs/ContentServer?pagename=Medqic/MQGeneralPage/GeneralPageTemplate&name=QIO%20Listings
Grievance Process-A-0120
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Hospital to provide a Medicare patient with an Important Message from Medicare ( IM notice ) within 48 hours of admission
The hospital must deliver to the patient a copy of this signed form again if more than two days and within 48 hours of discharge
About 1% of Medicare patients voice concern about being discharge prematurely
These patients must be given a more detailed notice and request the QIO to review their case
New forms IM “You Have the Right” and “Detailed Notice”
Website for beneficiary notices1
1www.cms.hhs.gov/bni
IM and Detailed Notice Forms
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Hospital must have a clear procedure for the submission of a patient’s written or verbal grievances
Surveyor will review your information to make sure it clearly tells patients how to submit a verbal or written grievance
Surveyor will interview patient to make sure information provided tells them how to submit a grievance
Must establish process for prompt resolution of grievances
Grievance Procedure 121
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Rule #8 – Hospital must have a P&P on grievance
Specific time frame for reviewing and responding to the grievance
Grievance resolution that includes the patient with a written notice of its decision, IN MOST CASES
The written notice to the patient must include the steps taken to investigate the grievance, the results and date of completion
Hospital Grievance Procedure 0122
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Facility must respond to the substance of each and every grievance
Need to dig deeper into system problems indicated by the grievance using the system analysis approach
Note the relationship to TJC sentinel event policy and LD medical error standards, CMS guidelines for determining immediate jeopardy, HIPAA privacy and security complaints, and risk management/patient safety investigations
Hospital Grievance Procedure
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Timeframe of 7 days would be considered appropriate and if not resolved or investigation not completed within 7 days must notify patient still working on it and hospital will follow up
Most complaints are not complicated and do not require extensive investigation
Will look at time frames established
Must document if grievance is so complicated it requires an extensive investigation
Grievances
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Explanation to the patient must be in a manner the patient or their legal representative would understand
The written response must contain the elements required in this section - not statements that could be used in legal action against the hospital
Written response must the steps taken to investigate the complaint
Surveyors will review the written notices to make sure they comply with this section
Grievances A-0123
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CMS says if patient emailed you a complaint, you may email back response Be careful as many hospital policy on security do not
allow this since email is not encrypted
Must maintain evidence of compliance with the grievance requirements
Grievance is considered resolved when patient is satisfied with action or if hospital has taken appropriate and reasonable action
Grievances A-0123
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TJC has complaint standard RI.01.07.01 with changes 7-01-09 and 2 010 and continued in 2011
Will not cover but provided for reference
TJC calls them complaints
CMS calls them grievances
TJC has eliminated several standards in 2011 that are still CMS standards
More closely cross walked now
TJC Complaint Standard
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RI.01.07.01 Complaints & Grievances
Standard: patient and or her family has the right to have a complaint reviewed, (RI 2.120 previously),
EP1 Hospital must establish a complaint and grievance (C&G) resolution process
See also MS.09.01.01, EP1
EP2 Patient and family is informed of C&G resolution process
EP4 Complaints must be reviewed and resolved when possible
99
RI.01.07.01 Complaints & Grievances
EP6 Hospital acknowledges receipt of C&G that cannot be resolved immediately
Hospital must notify the patient of follow up to the C&G
EP7 Must provide the patient with the phone number and address to file the C&G with the relevant state authority
EP10 The patient is allowed to voice C&G and recommend changes freely with out being subject to discrimination, coercion, reprisal, or unreasonable interruption of care
100
RI.01.07.01 Complaints and Grievances
EP 17 Board reviews and resolves grievances unless it delegates this in writing to a grievance committee (eliminated but still CMS requirement)
EP 18 Hospital provides individual with a written notice of its decision which includes (DS);
Name of hospital contact person
Steps taken on behalf of the individual to investigate the grievance
Results of the process
Date of completion of the grievance process
101
RI.01.07.01 Complaints
EP19 Hospital determines the time frame for grievance review and response(DS)
EP20 Process for resolving grievances includes a timely referral of patient concerns regarding quality of care or premature discharge to the QIO
EP21 Board approves the C&G process (eliminated but still CMS standard)
102
Have a Policy to Hit All the Elements
103
Right to participate in the development and implementation of their plan of care
Right to refuse care and formulate advance directives
Right to have a family member or representative of his or her choice notified if requested
Called support person in the final visitation regulations
Right to have his or her physician notified promptly of the patient's admission to the hospital if patient requests this
2cd Standard Exercise of Rights
104
Rule #1 – Patients have the right to participate in the development and implementation of their plan of care
Includes inpatients and outpatients
Includes discharge planning and pain management
Requires hospital to actively include the patient in developing their plan of care including changes
Standard #2 Exercise of Rights 0129
105
If patient refuses to participate, document this
Include patient’s legal representative if patient minor or incompetent
Plan of care is frequently cited
Patients needing post-hospital care are given choice home health or nursing homes
Includes choice to pain management, patient care issues, and discharge planning
Section 1802 of SSA guarantees free choice by Medicare patients for LTC or home health
Patient Participate in Plan of Care
106
To make informed decision regarding their care
Being informed of their diagnosis and prognosis
To request or refuse treatment Right to sign out AMA
Remember EMTALA requirements if patient is transferred
Have patient sign the transfer agreement
Rule #2 - Patients Have a Right:
107
CMS has 3 sections in the hospital CoP manual on informed consent
Section on informed consent in patient rights on informed decisions, medical records and surgical services
The patient has the right to make informed decisions
Informed Consent 0131
108
Right to delegate the right to make informed decisions to another (DPOA, guardian)
Patient has a right to an informed consent for surgery or a treatment
Right to be informed of health status and to be involved in care planning and treatment
Informed decision on discharge planning to post acute care
Right to request or refuse treatment and P&P to assure patient’s right to request or refuse treatment
Informed Consent 0131
109
Right to informed decisions about planning for care after discharge
Right to receive information in a manner that is understandable (issue of healthcare literacy)
Right to get information about health status, diagnosis and prognosis
Hospital has to have process to ensure these rights
Required to have policies and procedures on all of these
Informed Consent
110
There are two disclosures that must be in writing
If physician owned hospital
If a doctor or an ED physician is not available 24 hours a day to assist in emergencies
Must provide information at beginning of inpatient stay or visit
Includes notice in your general consent form/notice of privacy practice that all inpatients and outpatients sign
Disclosures to Patients 131
111
Right to make and have the advance directives followed when unconscious or incapacitated
Staff must provide care that is consistent with these directives
P&P must include delegation of patient rights to representative if patient incompetent
Note rights as inpatient outpatient AD requirements of Joint Commission
Patient Rights 0132
112
Your policy should have clear statement of any limitations such as conscience
At a minimum, clarify any difference between facility wide conscience objections and those raised by individual doctors
You must provide written information to the patient on their rights under state law, at time of admission
Both inpatients and outpatients have rights but don’t have to give it in writing to outpatients
Document whether or not they have an AD
Advance Directives
113
Cannot condition treatment on whether or not they have one
Not construed as a mechanism to demand inappropriate or medically unnecessary care
Ensure compliance with state laws on AD Inform patients they may file with state survey and
certification agency
Provide and document advance directives education
Staff on P&P and community
Advance Directives 132
114
Includes the right for medical decisions such as pain management
Disseminate policy on advance directive, identify state authority permitting an objection
Includes Psychiatric or behavioral health AD
The visitation regulations are one of the newest patient rights
Patient Rights
115
The right to personal privacy
To receive care in a safe setting
To be free from all forms of abuse or harassment
Rule #1 – The right to personal privacy
Right to respect, dignity, and comfort
Privacy during personal hygiene activities (toileting, bathing, dressing, pelvic exam)
3rd Standard Privacy and Safety 143
116
Person not involved with care may not be present while exam is being done unless consent required (medical students who are observing not those caring for patient)
Need consent for video/electronic monitoring
Such as cameras in patient rooms (sleep lab, ED safe room, eICU) and not in hallways or lobbies
Include in your general admission consent form that all patients sign on admission or make sure patients are aware such in ICU
Personal Privacy
117
Surveyor will conduct observations to determine if privacy provided during exams, treatments, surgery, personal hygiene activities, etc.
Surveyor will look to see if names or patient information is posted in plain view
Survey procedure will ask if patient names are posted in public view No white boards with patient names and other PHI
Personal Privacy
118
Rule #2 – The right to receive care in a safe setting
Includes following standards of care and practice for environmental safety, infection control, and security such as preventing infant abductions, preventing patient falls and medication errors
Very broad authority for patient safety issue
Right to respect for dignity and comfort
Privacy and Safety 144
119
Includes washing hands between patients - see CDC or WHO hand hygiene and TJC Measuring Hand Hygiene Adherence
Review and analyze incident or accident reports to identify problems with a safe environment
Review policies and procedures
How does facility have P&P to curtail unwanted visitors or contraband materials
Care in a Safe Setting
120
Rule #3 – The patient has the right to be free from all forms of abuse or harassment and neglect
Must have process in place to prevent this
Criminal background checks as required by your state law
Must provide ongoing (yearly) training on abuse, harassment, and neglect
Privacy and Safety 145
121
Consider annual training in yearly skills lab
Must have P&P on this
Adequate staffing section
Have proactive approach to identify events that could be abuse
TJC and CMS have definitions of what is abuse and neglect
Privacy and Safety 145
122
Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish
Includes staff neglect or indifference to infliction of injury or intimidation of one patient by another
Include state laws in your P&P on abuse and neglect
Remember TJC has standard and definitions, RI.01.06.03
Freedom From Abuse and Neglect
123
Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness
Investigate all allegations of abuse or neglect
Do not hire persons with record of abuse or neglect
Report all incidents to proper authority, board of nursing, etc.
Freedom From Abuse and Neglect
124
Includes freedom abuse from not just staff but other patients and visitors
Hospital must have a mechanism in place to prevent this
Effective abuse program includes prevention Adequate number of staff who have been screened
Identify events that could lead to or contribute to abuse
Protect during investigation
Investigate and report and respond
Freedom From Abuse and Neglect
125
Make sure you have a policy in place for investigating allegations of abuse
Make sure staffing sufficient across all shifts
Make sure appropriate action taken if substantiated
Make sure staff know what to do if they witness abuse and neglect
Abuse and Neglect
126
Remember to include Joint Commission’s standard, RI.01.06.03, and definitions of abuse and neglect into your policy also if accredited
Patients have the right to be free from abuse, neglect, and exploitation This includes physical, sexual, mental, or verbal
abuse and Joint Commission has definitions for all of these terms
TJC Abuse and Neglect
127
Determine how you will protect patients while they are receiving care from abuse and neglect
Evaluate all allegations that occur within the hospital
Report to proper authorities as required by law
TJC Abuse and Neglect
128
Rule #1 – Patients have a right to confidentiality of their medical records and to access of their medical records (0146) Sufficient safeguards to ensure access to all information
HIPPA compliant authorization for release
MR are kept secure and only viewed when necessary by staff involved in care
Do not post patient information where it can viewed by visitors
TJC IM.02.01.01 standard requires that hospital protects the privacy of health information, maintain security of same (white boards)
Standard #4 Confidentiality
129
Rule #2 – Patients have the right to access the information contained within their medical records
Right to inspect their record or to get a copy
30 day rule under HIPAA unless state law or P&P more stringent
Limited exceptions such as psychotherapy notes, prisoners if jeopardize health of themselves or others, information could cause harm to another, under promise of confidentiality, etc.
Patient Records
130
Rule #3 – Access to the medical record must be within a reasonably time frame and hospitals can not frustrate efforts of patients to get records
If patient is incompetent then to the personal representative and should sign as the personal representative such as guardian, parent, or DPOA
Reasonable cost for copying, postage or summary no retrieval fee allowed under federal law
Access to Medical Records (PHI)
131
Many changes were made
Combined the two sections on medical surgical and behavioral restraints into one section
Changes went into effect January 8, 2007 and 50 pages of interpretive guidelines April 11, 2008 and 10-17-08 and references added 6-5-09
Need to rewrite policies and procedures and train all staff
5th Standard Restraints 0154-0214
132
CMS has restraint worksheet1 which is not an official OMB form Cannot mandate hospital fill out but will save time on
phone from them asking you the information
Must still notify regional office by phone the next business day Document this in medical record
CMS has manual to address complaint surveys
Put regional office contact information in your P&P1
1www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter06-31.pdf
1www.cms.hhs.gov/RegionalOffices/01_overview.asp
Restraint Worksheet
133
134
New changes only affect regular hospitals and Critical Access Hospitals have own manual
CAH do not have a patient rights section and not required to follow new R&S section
CAH must have P&P so they can either use TJC standards or select some or all of hospital ones Some CAH have adopted all if in system with regular
hospitals
Restraints
135
Rule #1 – Patients have a right to be free from physical or mental abuse, and corporal punishment
This includes that restraint and seclusion (RS)
Will only be used when necessary
Not as coercion, discipline, convenience or retaliation
Only used for patient safety and discontinued at earliest possible time
R&S guidelines from CMS apply to all hospital patients even those in behavioral health
Standard #5 Restraints
136
Hospitals should consider adding it to their patient rights statement if not already there
Patients are required to be provided a copy of their rights (staff must document or have patient sign that they received their rights) Could include information in admission packet
If patient falls do not consider using R&S as routine part of fall prevention (154)
Right to be Free From Restraint
137
Like TJC, leadership is responsible for creating a culture that supports right to be free from R&S
LD must make sure systems and processes in place to eliminate inappropriate R&S and monitors use thru PI process
LD makes sure only used for physical safety of patient or staff
LD ensure hospital complies with all R&S requirements (154)
Rule #2 Hospital Leadership’s Role
138
CMS previously did not recognize or allow the use of protocols like Joint Commission does
Protocols are now not banned by the new regulations (168) but still need separate order for R&S
Must contain information for staff on how to monitor and apply like intubation protocol
Restraints Protocols
139
Requires an order even with a protocol is basically the same process hospitals were doing previously
Medical record must include documentation of individualized assessment, symptoms and diagnosis that triggered protocol
Need MS involvement in developing and review and quality monitoring of their use
Protocols
140
If a patient becomes violent or has self destructive behavior (V/SD) in the ICU or ED, CMS has one set of standards that apply
Decision to use R&S is not driven from diagnosis but from assessment of the patient
TJC standards changed July 1, 2009 10 new standards
All the 2009 R&S standards were eliminated except two (forensic and one on behavioral management) for hospital who use TJC for deemed status
Restraint Standards
141
Joint Commission calls it behavioral health and non-behavioral health
CMS calls it violent and or self destructive (V/SD) and non-violent and non-self destructive
CMS says it is not the department in which the patient is located but the behavior of the patient
Restraint Standards Medical Patients
142
New definition: Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely
Mechanical restraints include belts, restraint jackets, cuffs, or ties
Manual method of holding the patient is a restraint
Rule #3 Know Definition 159
143
144
A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or standard dosage for the patient's condition (160)
Use of PRN drug is only prohibited if medication meets definition of drug Ativan for ETOH withdrawal symptoms is okay
Restraint Definition
145
Medication is within pharmacy parameters set by FDA and manufacturer for use
Use follows national practice standards
Used to treat a specific condition based on patient’s symptoms
Standard treatment would enable patient to be effective or appropriate functioning
When Drug is not a Restraint
146
Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving (162)
Seclusion may only be used for the management of violent or self-destructive behavior (V/SD behavior) that jeopardizes the immediate physical safety of the patient, a staff member, or others
Is not being on a locked unit with others or for time out if patient can leave area (162)
Definition of Seclusion
147
It is when they are alone in a room and physically prevented from leaving
May only use seclusion for management of V/SD behavior that is danger to patient or others
Seclusion
148
Learning from Each Other - Success stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health, tools and forms in appendix
Published in 2003 by many organizations such as American Psychiatric Nurses Assn, National Association of Psychiatric Health Systems (NAPHS) with support of AHA
See NAPHS and AHA guiding principlesSources: www.naphs.org; www.apna.org, www.psych.org, or
www.apna.org, www.naphs.org/catalog/ClinicResources/index.html
Learning From Each Other
149
Time limits on length of order apply such as four hours for an adult
One hour face to face evaluation must be done (183)
Therapeutic holds to manage V/SD patients are a form of restraint
Restraint and Seclusion
150
Forensic restraints such as handcuffs, shackles, or other restrictive devices applied by law enforcement or police are not R&S (0154)
Closely monitor and observe for safety reasons
Orthopedically prescribed devices, surgical dressings or bandages, protective helmets (161)
Methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests (161)
Restraints Do Not Include
151
Protecting the patient from falling out of bed Cannot use side rails to prevent patient from getting out
of bed if patient can not lower
Striker beds or the narrow carts and their use of side rails are not a restraint
IV board unless tied down or attached to bed
Postural support devices for positioning or securing (161)
Device used to position a patient during surgery or while taking an x-ray
Restraints Do Not Include
152
Recovery from anesthesia is part of surgical procedure and medically necessary (161)
Mitts unless tied down or pinned down or unless so bulky or applied so tightly patient can not use or bend their hand (161)
Mitts that look like boxing gloves are a restraint
Padded side rails put up when on seizure precaution
Giving child a shot to protect them from injury (161)
Physically holding a patient for forced medications is a physical restraint
Restraints Do Not Include
153
Tucking in a sheet so tight patient could not move (159)
Use of enclosed bed or net bed unless the patient can freely exit the bed such as zipper inside the bed
Freedom splint that immobilizes limb
Remember that is it not the thing but what the thing does to the patient in which their movement is restricted
Restraints Do Include
154
Devices with multiple purposes - such as side rails or Geri chairs, when they cannot be easily removed by the patient
Restrict the patient’s movement constitute a restraint
If belt across patient in wheelchair and he can unsnap belt or Velcro then it is not a restraint (159)
If patient can lower side rails when she wants then it is not a restraint but document this
If a patient can remove a device it is not a restraint
Restraints
155
Stroller safety belts, swing safety belts, high chair lap belts, raised crib rails, and crib covers (161) are okay as long as age or developmentally appropriate
Use of these safety intervention must be addressed in your policy
Holding an infant or toddler is not a restraint
Restraints
156
CMS does not consider the use of weapons by hospital staff on patients as safe in the application of restraint (154)
Could use on criminal breaking into building
Weapons include pepper spray, mace, nightsticks, tazers, stun guns, pistols, etc.
Okay if patient is arrested and use by law enforcement such as non-employed staff like police as state and federal laws
Weapons 154
157
Should do comprehensive assessment and assess to reduce risk of slipping, tripping or falling
To identify medical problems that could be causing behavioral changes (0154) such as increased temp, hypoxia, low blood sugar, electrolyte imbalance, drug interactions, etc.
Use of restraint is not considered routine part of a falls prevention program (154)
Assessment
158
Surveyor will look to see if there is evidence that staff determined the reason for the R&S (154)
This should be documented and be specific
Consider a field on the order sheet to include this
Usually to prevent danger to the patient or others
Danger to self, maintain therapeutic environment such as to prevent patient from removing vital equipment, physically attempting to harm others or property, patient demonstrated lack of understanding to comply with safety directions
Determine Reason for R&S
159
(Check all that apply)
Unable to follow directions
High risk of falls
Aggressive
Disruptive/combative
History of hip fracture/falls
Self injury
Interference with treatments
Removal of medical devices
Other: ____________________________
Reasons to Restrain
160
161
Restraints can only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm (154, 164, 165,)
Type or technique used must also be least restrictive
Is what the patient doing a hazard? Allowing sundowners to walk or wander at night (154)
Request from patient or family member is not sufficient basis for using if not indicated by condition of patient
Rule #4
162
Must do an assessment of patient
Must document that restraint is least restrictive intervention to protect patient safety based on assessment
What was the effect of least restrictive intervention
You must train on what is least restrictive interventions
Less Restrictive
163
Side rails…………...
Hand mittens……….
Lap board…………..
Roll belt/lap belt……
2 point soft restraint..
Wrap IV site ………..
Hand mitten………...
Freedom splint is a restraint!
Net bed
soft extremity restraint
Geri chair
vest restraint
3 or 4 point soft
arm board
soft wrist restraint
Least Restrictive Restraint to More
164
Alternatives should be considered along with less restrictive interventions (186)
What are other things you could do to prevent using R&S such as sitter or family member stays with patient
Distractions such as watching video games or working on a laptop computer
Try nonphysical intervention skills (200)
Considering having a list of alternatives in the toolkit
Rule # 5 Alternatives
165
Bed sensor
Close to nurses station
Activity apron
E-Z release hugger (if can release)
Reality orientation/familiarize patients to room
Verbal instructions/support
Frequent visits with patient (hourly except night shift)
Consider Alternatives
166
Skin sleeves
Sensor alarm
Posey lateral wedges
Access to call cordLower chairs
Allow wandering, if possible
Food/hydration
Low beds or mattress on floor
Encourage family visits
Pain/discomfort relief
Diversion activities such as TV, CDs, DVDs, music therapy, picture books, games
Provide structured, quiet environment
Exercise/ambulate
Toileting routine
Consider Alternatives
167
Be calm and reassuring
Approach in non-threatening manner
Wrap around Velcro band while in wheelchair (if can release)
Relaxation tapes
Do photo album
Back rubs or massage therapist
Wanderguard system
Limit caffeine
Alternatives to Restraints
168
Watching TV
Massage or family can hire massage therapist
Punching bag
Avoid sensory overload
Fish tanks
Tapes of families or friends
Alternatives to Restraints
169
170
171
172
Rule #6 LIPs can write orders for restraints
Any individual permitted by both state law and hospital policy for patients independently, within the scope of their licensure, and consistent with granted privileges, to order restraint, seclusion
NP, licensed resident, PA, but not a medical student
Remember must specify who in your P&P (168)
Restraints LIP Can Write Orders
173
Rule #7 - Any established time frames must be consistent with asap (not in 1 or 3 hours)
Hospital MS policy determine who is the attending physician
Hospital P&P should address the definition of asap (182,170)
RN or PA who does 1 hour face-to-face must notify attending physician and discuss findings (182)
Be sure to document if LIP or nurse notifies physician
Restraints Notify Doctor ASAP 170
174
Rule #8 An order must be received for the restraint by the physician or other LIP who is responsible for the care of the patient (168)
Include in P&P use in an emergency
P&P to include category of who can order (PA, NP, resident, can not be med student)
PRN order prohibited if for medication used as a restraint, okay if not a restraint
No PRN order for restraints either (167, 169), except for 3 exceptions (169)
Restraints Order needed
175
Repetitive self-mutilating behavior (169), such as Lesch-Nyham Syndrome
Geri chair if patients requires tray to be locked in place when out of bed
Raised side rails if requires all 4 side rails to be up when the patient is in bed
Do not need new order every time but still a restraint
PRN Order 3 Exceptions
176
Restraints must be used in accordance with a written modification to the patient's plan of care (166)
What was the goal of the plan of care
Use of restraint should be in modified plan of care
Care plan should be reviewed and updated in writing
Within time frame specified in P&P (166)
Plan reflects a loop of assessment, intervention, evaluation and reevaluation
Rule #9 Plan of Care
177
178
Orders are time limited and this is included in the plan of care
For patient who is V/SD may want to debrief as part of plan of care but not mandated by CMS
Debriefing no longer mandated by TJC for behavioral patients (deemed status)
Can add information on debrief to R&S toolkit
Restraints - Plan of Care
179
Restraints must be discontinued at the earliest possible time (154, 174)
Regardless of the time identified in the order
If you discontinue and still time left on clock and behavior reoccurs, you need to get a new order
Temporary release for caring for patient is okay (feeding, ROM, toileting) but a trial release is seen as a PRN order and not permitted (169)
Rule #10 End at Earliest Time
180
Restraints only used while unsafe condition exists
The hospital policy should include who has authority to discontinue restraints (154, 174)
Under what circumstances restraints are to be discontinued and who is allowed to take them off
Based on determination that patients behavior is no longer a threat to self, staff, or others (put this in your P&P)
Surveyors will look at hospital policy
Policy should also include procedures to follow when staff need to apply in an emergency
Restraints - End at Earliest Time
181
Staff must assess and monitor patient’s condition on ongoing basis (0154, 174, 175)
Physician or LIP must provide ongoing monitoring and assessment also (175)
One reason to determine is if R&S can be removed
Took out word continually monitored except for V/SD patients and says at an interval determined by hospital policy
Rule #11 Assessment of Patient
182
Intervals are based on patient’s need, condition and type of restraint used (V/SD or not)
CMS doesn’t specify time frame for assessment like TJC use to (TJC use to say every 2 hours for medical patients and every 15 minutes for behavioral health patients)
CMS says this may be sufficient or waking patient up every 2 hours in night might be excessive
This must be in your hospital P&P frequency of evaluations and assessments (175) and document to show compliance
Rule #11 Assessment of Patient
183
Most hospital use special documentation sheet for assessment parameters, including frequency of assessment, and hospital policy should address each of these (175, 184)
If doctor writes a new order or renews order need documentation that describes patients clinical needs and supports continued use (174)
Document; fluids offered (hydration needs), vital signs
Toileting offered (elimination needs)
Removal of restraint and ROM and repositioning
Mental status, circulation
Rule #12 Documentation
184
Attempts to reduce restraints, skin integrity, and level of distress or agitation, et. al.
Document the patient’s behavior and interventions used
Behavior should be documented in descriptive terms to evaluate the appropriateness of the intervention (185)Example, patient states the Martians have landed and
attempting to strike the nurses with his fists. Patient attempting to bite the nurse on her arm. Patient picked up chair and threw it against the window
Rule #12 Documentation
185
Document clinical response to the intervention (188)
Symptoms and condition that warranted the restraint must be documented (187)
Have the restraint toolkit where you have the documentation sheet with the requirements, the order sheet, manufacturer instructions for the restraints, articles, etc.Many have separate order sheets for V/SD (behavioral
health) and non V/SD (non behavioral health)
Rule #12 Documentation
186
Document Type of Restraint
187
188
189
Hospital take actions thru QAPI activities
Hospital leadership should assess and monitor use to make sure medically necessary
Consider log to record use-shift, date, time, staff who initiated, date and time each episode was initiated, type of restraint used, whether any injuries of patient or staff, age and gender of patient
Log and QAPI
190
191
192
Restraints and seclusion must be implemented in accordance with safe, appropriate restraining techniques (167)
As determined by hospital policy in accordance with state law
Use according to manufacturer’s instructions and include in your policy as attachment
Follow any state law provision or standards of care and practice
Was there any injury to patient and if so fill out incident report
Rule #13 Use as Directed
193
The lighting rod for public comment and AHA sued CMS over this provision
Standard for behavioral health patients or V/SD
Time limits for R&S used to manage V/SD behavioral and drugs used as restraint to manage them(178)
Must see (face to face visit) and evaluate the need for R&S within one hour after the initiation of this intervention
Rule #14 One Hour Rule
194
Big change is face to face evaluation can be done by physician, LIP or a RN or PA trained under 482.13 (f)
Physician does not have to come to the hospital to see patient now, telephone conference may be appropriate
Training requirements are detailed and discussed later
To rule out possible underlying causes of contributing factors to the patient’s behavior
One Hour Rule 178
195
Must see the patient face-to-face within 1-hour after the initiation of the intervention, unless state law more restrictive (179)
Practitioner must evaluate the patient's immediate situation
The patient's reaction to the intervention
The patient's medical and behavioral condition
And the need to continue or terminate the restraint or seclusion
Must document this (184) and change documentation form to capture this information
One Hour Rule Assessment 482.13 (f)
196
Include in form evaluation includes physical and behavioral assessment (179)
This would include a review of systems, behavioral assessment, as well as
Patient’s history, drugs and medications and most recent lab tests
Look for other causes such as drug interactions, electrolyte imbalance, hypoxia, sepsis etc. that are contributing to the V/SD behavior
Document change in the plan of care
Must be trained in all the above (196)
One Hour Rule Assessment 482.13 (f)
197
Time limits apply- written order is limited to (171)
4 hours for adults 2 hours for children (9-17) 1 hour for under age 9
Related to R&S for violent or self destructive behavior and for safety of patient or staff
Standard same now for Joint Commission time frame for how long the order is good for and closely aligned now
Rule #15 Time Limited Orders
198
199
The original order for both violent or destructive may be renewed up to 24 hours then physician reevaluates
Nurse evaluates patient and shares assessment with practitioner when need order to renew (171, 172)
Unless state law if more restrictive
After the original order expires, the MD or LIP must see the patient and assess before issuing a new order
Rule #16 Renew Order
200
Each order for non violent or non-destructive patients may be renewed as authorized by hospital policy (173)
Remember TJC requires an order to renew restraints on medical patients (which they now call non-behavioral health patients) every 24 hours
Not daily but every 24 hours
CMS and TJC the same
Rule #16 Renew Order
201
Will interview staff to make sure they know the policy (154)
Consider training on policy in orientation and during the annual in-service and when changes made
Remember hitting restraints hard in the survey process
Surveyor to look at use of R&S and make sure it is consistent with the policy
Rule #17 Need Policy on R&S
202
203
New staff training requirements
All staff having direct patient contact must have ongoing education and training in the proper and safe use of restraints and able to demonstrate competency (175)
Yearly education of staff as when skills lab is done
Document competency and training
Hospital P&P should identify what categories of staff are responsible for assessing and monitoring the patient (RN, LPN, Nursing assistant, 175)
Rule #18 Staff Education
204
Patients have a right to safe implementation of RS by trained staff (194)
Training plays critical role in reducing use (194)
Staff, including agency nurses, must not only be trained but must be able to demonstrate competency in the following:
The application of restraints (how to put them on), monitoring, and how to provide care to patients in restraints
Rule #18 Staff Education
205
This must be done before performing any of these functions (196)
Training must occur in orientation before new staff can use them on a patient
Training must occur on periodic basis consistent with hospital policy
Have a form to document that each of the education requirements have been met
Rule #18 Staff Education
206
Again consider yearly during skills lab
Remember that the Joint Commission PC.03.03.03 and 03.02.03 requires staff training and competency now
The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following
Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require RS
Rule #18 Staff Education
207
Consider document in your tool kit although not required by CMS or TJC now (deemed status)
Teach staff what is de-escalation and not just staff on the behavioral health unit
Avoid confrontation and approach in a calm manner
Active listening
Valid feelings such as “you sound like you are angry”
Some have personal de-escalation plan that lists triggers such as not being listening to, feeling pressured, being touched, loud noises, being stared at, arguments, people yelling, darkness, being teased, etc.
De-escalation
208
209
The use of non-physical intervention skills (200)
Choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition (201)
The safe application and use of all types of R&S used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia, 202)
Staff Education
210
Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary (204)
Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation (205)
Staff Education
211
Including respiratory and circulatory status, skin integrity, VS, and special requirements of 1 hour face to face
The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification (206) Patients in R or S are at higher risk for death or injury
All staff who apply, monitor, access, or provide care to patient in R must have education and training in first aid technique and certified in CPR
To render first aid if patient in distress or injured
Develop scenarios and develop first aid class to address these
Staff Education
212
Staff must be qualified as evidenced by education, training, and experience
Hospital must document in personnel records that the training and competency were successfully completed (208)
Security guards respond to V/SD patients would need to train
Many give a 8 hour CPI course
Don’t want someone going into the room of a V/SD patient without training to prevent injury to staff and patient
Staff Education
213
Individuals doing training program must be qualified (207)
Trainers must have high level of knowledge and need to document their qualifications
Train the trainer programs are done by many facilities
CMS said need to revise your training program every year which should take person 4 hours to do
Can have librarian do literature search for new articles on evidenced based restraint research
Training Cost
214
National Association of Psychiatric Health Systems (NAPHS), initial training in de-escalation techniques, restraint and seclusion policies and procedures
Recommended 7-16 hours of training but number of hours not mandated by CMS
In fact, in Federal Register recommended sending one person to CPI training class as a train the trainer
1http://www.crisisprevention.com
Training Time and Time Spent
215
Physician and other LIP training requirements must be specified in hospital policy (176)
At a minimum, physicians and other LIPs authorized to order R or S by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion
Hospitals have flexibility to determine what other training physicians and LIPs need
Education Physicians and LIPs
216
The following requirements will be superseded by existing state laws that are more restrictive (180)
State laws can be stricter but not weaker or they are preempted
States are always free to be more restrictive
Many states have a state department of mental health which has standards for patients that are in a behavioral health unit
Rule #19 Stricter State Laws
217
For behavioral health patients- which CMS now calls violent or self destructive behavioral that is a danger to self or others
Can’t use R&S together unless the patient is visually monitored in person face to face or by an audio and video equipment
Person to monitor patient face to face or via audio & visual must be assigned and a trained staff member
Must be in close proximity to the patient (183)
There must be documentation of this in the medical record
Rule #20 1:1 Monitoring R&S 0183
218
Documentation will include least restrictive interventions, conditions or symptoms that warranted RS, patient’s response to intervention, and rationale for continued use
This needs to be in hospitals P&P
Modify assessment sheets to include this information
Consider sitter policy to ensure does not leave patient unsupervised
Rule #20 1:1 Monitoring RS 0183
219
Report any death associated with the use of restraint or seclusion
Remember, the SMDA also requires reporting
Sentinel event reporting to Joint Commission is voluntary but need to do RCA within 45 days
See Hospital Reporting of Deaths Related to RS, OIG Report, September 2006, OEI-09-04-003501
1www.oig.hhs.gov
Rule #21 Deaths
220
The hospital must report to CMS each death that occurs while a patient is in restraint or in seclusion at the hospital
Must report every death that occurs within 24 hours after the patient has been removed from R&S
Each death known to the hospital that occurs within 1 week after R&S where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death
Rule #21 Deaths 0214
221
“Reasonable to assume” includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation
Must be reported to CMS regional office by telephone no later than the close of business the next business day following knowledge of the patient's death
This is in the regulation even though some of the regional offices are telling hospitals just to fax in the form
Rule #21 Deaths 0214
222
Staff must document in the patient's medical record the date and time the death was reported to CMS
This includes patients in soft wrist restraints
Hospitals should revise post mortem records to list this requirement
Hospitals need to rewrite their policies and procedures to include these requirements
Rule #21 Deaths 0214
223
CMS issued new hospital COPs for QA and Performance Improvement
Effective March 25, 2003 and amended 4-11-08 and 10-17-08 and no changes 6-5-09
Starts with tag number 0263
Short section because the hospital compare program is not part of the CMS CoPHospital compare is the indicators that must be sent to
CMS to receive full reimbursement rates
Hospital CoPs for QI
224
Must have PI program that is ongoing and shows measurable improvements, that identifies and reduces medical errors
Diagnostic errors, equipment failures, blood transfusion injuries, or medication errors
Medical errors may be difficult to detect in hospitals and are under reported
Make sure incident reports filled out for errors and near misses
Hospital CoPs for QI)
225
Triggers can help hospitals find errors
Trigger tools available on IHI website1
Program must incorporate quality indicator data including patient data (274)
Look at information submitted to or from QIO
1www.ihi.org
CMS Hospital CoPs
226
QIO to advance quality of care for Medicare patients
Sign up with your state QIO to get newsletters and other information
Use data to monitor safety of services and quality of care (275)
Identify opportunities for improvement (276)
Board determines frequency and detail of data collection (277)
Focus on high risk, high volume, or problem prone (285)
CMS Hospital CoPs
227
Must not only track medical errors and adverse events but also analyze their causes (287, 310)
RCA is one tool to measure causes
Hospital must take action based on data (289) and measure its success (290)
Example; process hospitals took to get MI patient timely thrombolytics and timely antibiotics and blood culture for pneumonia patients
TJC moving toward accountability measures and CMS toward value based purchasing
QAPI
228
Hospital needs to document and track performance to make sure improvements are sustained (291)
Continue to track antibiotics given timely in the OR before surgical procedure and prophylactic treatment to prevent DVT/PE in major surgery patients
Number of PI projects depends on scope and complexity of hospital services so large hospital doing CABG would measure indicators on this
Hospital may want to develop and implement IT system to improve patient safety and the quality of care (299)
QAPI
229
Hospital must document what PI projects are being done and the reason for doing them (301) and progress on it (302)
Board, MS, and administration are responsible for and accountable for ongoing program (309)
Decide which are priorities (312) and address issues to improve patient safety (313)
Clear expectations for patient safety are established (314)
Need adequate resources for PI and patient safety (315, 316)
QAPI
230
This means people who can attend meetings, data so analysis can be made and other resources
Safer IV pumps, new anticoagulant program, implement central line bundle, sepsis, and VAP bundle, preventing inpatient suicides, wrong site surgery, retained FB, new processes for neuromuscular blocker agents, implement policy on Phenergan administration and Fentanyl patches
So what’s in your PI and Safety Plans?
QAPI Patient Safety
231
Medical staff
Dietary
Nursing services
Laboratory services
Radiology
Medical records services
Autopsies
Pharmacy services
Next Sections
232
Hospital must have an organized MS that operates under bylaws approved by Board
May only have one MS for entire hospital campus (all campuses, provider based-locations, satellites and remote locations)
Integrated into one governing body with the MS bylaws that apply equally to all
See previous MS sections 0044-94
These have been discussed previously
Medical Staff 482.22(A) 0338
233
MS must periodically conduct appraisals of its members
MS bylaws determine frequency of appraisals
Recommends at least every 24 months (TJC is 24 months)
To be sure they are suitable for continued membership
Medical Staff 0340
234
Must evaluate MS qualifications and competencies, within scope of practice or privileges requested
Look at special training, current work practice, patient outcomes, education, maintenance of CME, adherence to MS rules, certification, licensure and compliance with licensure requirementsWant to be sure the MS is credentialed and privileged to
do what they are competent to perform
Medical Staff 0340
235
Appraisal procedures must evaluate each member
To determine if should be continued, revised, terminated or changed
If requests for privileges goes beyond the specified list for that category of practitioners need appraisal by MS and approval by the board
Must keep separate credentials file for each MS member
If limit privileges must follow laws such as reporting to NPDB
MS bylaws need to identify process for periodic appraisals
Medical Staff Appraisals
236
MS must examine credentials and make recommendations to the board on appointment of the candidates and must look at the following
Request for privileges, evidence of current licensure, training and professional education, documented experience, and supporting references of competence
Can’t make a recommendation based solely on presence or absence of board certification although can require board certification
Medical Staff 0341
237
MS is accountable to Board for quality of medical care provided
If MS has executive committee, majority of members must be MD/DO
MS must be well organized-formalized organizational structure and lines are delineated between the MS and the Board
MS must have bylaws and must enforce bylaws and Board must approve bylaws
Medical Staff Organization 347
238
MS must adopt and enforce bylaws (353)
Board must approve bylaws and any changes also (354)
TJC has MS.01.01.01 which tells when to put things in the by-laws, rules or responsibilities or policies
TJC does C&P tracer since such an important area
MS bylaws must include statement of duties and privileges in each category, ( eg. participate in PI, evaluate practitioner on objective criteria, promote appropriate use of health care resources, 355)
Medical Staff
239
Privileges for each category ( eg. active, courtesy, consulting, referring, emergency case)
Can not assume every practitioner can perform every task/activity/privilege that is specified for that category of practitioner
Individual ability to perform each must be individually assessed (core privileging, 355)
Medical Staff
240
MS bylaws must describe organizational structure of the MS (356)
Lay out R&R which make it clear what are acceptable standards of patient care for diagnosis, medical, surgical care, and rehab
Survey procedure-describe formation of MS leadership
Survey procedure-verify bylaws describe who is responsible for review and evaluation of the clinical work of MS
Medical Staff
241
MS bylaws must describe the qualifications to be met by a candidate for membership on the MS (eg. provide level of acceptable care, complete medical records timely, participate in QI, be licensed, Tag 357)
Survey procedure-MS bylaws describe qualifications as character, training, experience, current competence, and judgment
Medical Staff
242
Repeated in tag number 461 and 463
CMS changes standard to be consistent with TJC standard
MS must adopt bylaws to carry out their responsibilities on H&Ps
The bylaws must include a requirement that a H&P be completed no more than 30 days before or 24 hours after admission on each patient
Must be on chart before surgery
H&P 358
243
There needs to be an updated entry in the medical record to reflect any changes
Person who does the H&P must be licensed and qualified
Example, family physician does H&P 2 weeks ago for patient having CABG today
Surgeon would review, update, and determine if any changes since it was done and authenticate document
H&P Admission
244
Can include in progress notes or has stamp sticker, check box, or entry on H&P form
Should say that H&P was reviewed, the patient examined, and that “no change” has occurred in the patient’s condition since the H&P was completed
There needs to be a complete H&P in the chart for every patient except in emergencies and can make entry in progress notes
History and Physicals
245
New regulation expands the number of categories of people who can do a H&P
If state law and the hospital allows (which most do) a PA or NP may perform
Physician is still responsible for the contents and must sign off the H&P when done by one of these allied health professionals
Need to do PI to make sure all H&P are on the chart especially when the patient goes to surgery
History and Physicals
246
EP4 requires H&P no more than 30 days old and done within 24 hours
EP5 if done within 24 hours update, update prior to surgery (also RC.01.03.01)
EP7 that requires an update to a history and physical (H&P) at the time of the admission
RC.02.01.03 EP3 document H&P in MR for operative or high risk procedure and for moderate and deep sedation
MS.01.01.01 requires H&P process be in MS bylaws (2010)
TJC PC.01.02.03 H&P
247
EP6 Specifies minimal content (can vary by setting, level of service, tx & services
EP7 MS must monitor the quality of the H&Ps
EP8 Medical staff requires person be privileged to do H&P and requires updates
EP9 As permitted by state law, allow individuals who are not LIPs to perform part or all of the H&P
EP10 MS defines when it must be validated and countersigned by LIP with privileges
MS defines scope of H&P for non inpatient services
TJC MS.03.01.01 H&P
248
MS should attempt to secure autopsies in all cases of unusual deaths
Must define mechanism for documenting permission to perform an autopsy
Must be system for notifying MS and attending doctor when autopsy is performed
TJC has similar section
Autopsies 0364
249
Must have an organized nursing service that provide 24 hour nursing services
Must have at least one RN furnishing or supervising 24 hours
SSA at 1861 (b) states you must have a RN on duty at all times (except small rural hospitals under a waiver)
Survey procedures-determine nursing services is integrated into hospital PI
Make sure there is adequate staffing
Survey procedure - look for job descriptions including director of nursing
Nursing Services 0385
250
DON must be RN, A-386 (often referred to as chief nursing officer)
DON responsible for determining types and numbers of nursing personnel
DON responsible for operation of nursing service
Survey procedure-look at organizational chart
May read job description of DON to make sure it provides for this responsibility
May verify DON approves patient care P&P’s
Director of Nursing Service
251
Nursing service must have adequate number of nurses and personnel to care for patients
Must have nursing supervisor
Every department or unit must have a RN present (not available if working on two units at same time)
Survey procedure-look at staffing schedules that correlate number and acuity of patients
Nurse Staffing 392
252
There are 3 recent evidenced based studies that show the importance of having adequate staffing which results in better outcomes
Study said patients who want to survive their new hospital visit should look for low nurse-patient ratio
Nurse Staffing and Quality of Patient Care, AHRQ, Evidence Report/Technology Report Number 151, March 2007, AHRQ Publication No. 07-E0051 1http://www.ahrq.gov/downloads/pub/ evidence/pdf/nursestaff/nursestaff.pdf
Nurse Staffing 392
253
IOM study also linked adequate staffing levels to patient outcomes
Limits to number of hours worked to prevent fatigue
Suggests no mandatory overtime for nurses
Never work a nurse over 12 hours or 60 hours in one week (or will have 3 times the error)
Nursing Linked to Safety
254
Also showed medication error rate, falls, pressure ulcers, UTI, surgery site infections, gastric ulcers, codes, LOS, etc. linked to staffing
Redesigning the work forceSee Keeping Patients Safe:Transforming the Work Environment of Nurses 20041
1www.nap.edu/openbook/0309090679/html/23/html
Nursing Linked to Safety
255
AHRQ 2008 has published 3 volume, 51 chapter handbook for nurses at no cost
Great resource that every hospital should have
Nurse Staffing and Patient Care Quality and Safety
Again shows that patient safety and quality is affected by short staffing
Patient Safety and Quality: An Evidence-Based Handbook for Nurses, 20081
1http://www.ahrq.gov/qual/nurseshdbk
Nursing Staffing Linked to Safety
256
Must have procedure to ensure nursing personnel have valid and current license
Survey procedure-review licensure verification P&P
Can verify licensure on line by most state boards of nursing onlineConsidered primary source verification
Can print out information for employee file
Verify Licensure 394
257
A RN must supervise and evaluate the nursing care for every patient
RN must do admission assessment
Must use acceptable standard of care
Evaluation would include assessing each patient’s needs, health status and response to interventions
RN for Every Patient A-395
258
Hospital must ensure that nursing staff develop and keeps a current, nursing care plan for each patient
Starts upon admission, includes discharge planning, physiological and psychosocial factors
Based on assessing the patient’s needs
Care plan is part of the patient’s medical records and must be initiated soon after admission, revised and implemented
Nursing Care Plan A-396
259
Agency nurses (CMS calls them non-employee nurses) must adhere to P&P’s
DON must provide adequate supervision and evaluate (once a year) activities of agency nurses
Includes other personnel such as volunteers
Orientation must include to hospital and to specific unit, emergency procedures, nursing P&P, and safety P&P’s
Agency Nurses 398
260
Drugs must be prepared and administered according to state and federal law (404)
Need an practitioner’s order
Surveyor will observe nurse prepare and pass medications
Medications must be prepared and administered with acceptable national standards of practice (TJC MM chapter), manufacturer’s directions and hospital policy
Preparation/Admin of Drugs 404
261
Medication management is a hot topic with CMS and TJC
All drugs administered under the supervision of nursing or other personnel if permitted by law
In accordance with approved medical staff P&P’s
Surveyor will review sample of medication records to ensure it conforms to physician’s order
Administration of Meds 0405
262
Surveyor will make sure medication given within 30 minutes of scheduled time
So if medication ordered at 9 am must give between 8:30 am and 9:30 am
Check QAPI activities to see if administration of drugs is monitored
Many hospitals have changed to this 30 minute time frame but some still have one hour on either side and feel this is appropriate since only a survey procedure
Administration of Meds 0405
263
CMS issues standing order memo 10-24-08
Also includes preprinted orders and use of stamps
Flu and pneumovax can be given by protocol approved by the MS after assessment of contraindications
Orders for drugs must be documented and signed by practitioners allowed to write them
Doctors and if allowed NP and PAs
Rubber stamps - will not be paid for order for M/M patients and some insurance companies so many hospitals do not allow rubber stamps
Physician Order 406
264
Order must have name of patient, age and weight (if applicable), date and TIME of order, drug name, strength, frequency, dose, route, quality and duration, and special instructions for use, and name of pre scriber
Have a culture so can ask questions
Now allowed to have written protocol or standing orders with drugs and biologicals that have been approved by MS
Can implement them but be sure provider signs, dates, and times the order
Physician Order 406
265
Chest pain protocol or asthma protocol with Albuterol and Atrovent are an example of initiation of orders
Code teams gives ACLS drugs in an arrest
Timing of orders should not be a barrier to effective emergency response
Preprinted order - should send memo so doctors and providers are aware of new guidelines
Physician Order 406
266
Must date and time when the order set is signed
Must indicate on last page the total number of pages in the order set
If want to strike out something in the order sheet or delete it or add order on blank line then physician needs to initial each place
Should add this to the MR audit sheet to make sure there is compliance with this guideline
Preprinted Order Sets
267
Verbal orders are a patient safety issue
Have lead to many errors
Joint Commission has standard and NPSG, CMS has standard in CMS hospital CoPs, QIO 7th scope of work, National Coordinating Council recommendations
Rewrite your P&P and Medical staff by-laws to be consistent with these standards
Repeated VO section in MR starting with tag 454 and reiterated area of verbal orders offer too much room for error
Changed language from prescribing to ordering practitioner
Verbal Orders 407
268
Emphasizes to be used infrequently and never for convenience of the physicians
This means that physician should not give verbal orders in nursing station if he or she can write them
Can be used in emergency or if surgeon is scrubbed in during surgery
New regulation broadens category of practitioners who can sign orders off
CMS Verbal Orders
269
Limitations on VO such as not for chemotherapy
List the elements for a complete VO (such as patient name, drug, dose, frequency, name of person giving and taking order, et al.)
Define who can receive VO and the method to ensure authentication
Provide guidelines for clear and effective communications
Verbal Orders P&P Should Include
270
Physician must sign off a verbal order, date, and time it when signed off
Any physician on the case can sign off any VO
This practice must be addressed in the hospital’s P&P
Now a NP or PA may sign off a verbal order, if within their scope (where they had authority to write order) and allowed by state law, hospital policy and delegated to this by the physician
Signing Off Verbal Orders
271
New regulation states that verbal orders should be authenticated based on state law
Some states require order to be signed off in 24 hours or 48 hour and if no state law then within 48 hours
Need hospital P&P to reflect these guidelines
Write it down and repeat it back
Verbal Orders
272
RC.02.03.03 (IM 6.50) requires that qualified staff receive and record VO
Define in writing who can receive and record VO
Date and document identity of who gave, received, and implemented the order
Authenticated within time frame law/regulation
Write it down and read back the completed order or test result (NPSG 2009)
Joint Commission Verbal Orders
273
Blood Transfusions and IVs 409
Blood transfusions and IV medications must be administered with state law and MS bylaws
Must have special training for this and within scope of practice
Survey procedure- determine if personnel have special training which should include fluid and electrolyte imbalance and blood and blood components, and venipuncture technique
274
There must be procedure for reporting transfusion reactions, adverse drug reactions and errors in administration of drugs (410)
Survey procedure - request procedure for reporting-they may review the incident reports or other documentation through QAPI program
Incident Reports
275
Must have MR services and have an administrator responsible for MR and will sample 10% of daily census and at least 30 records
Must keep MR on every patient and have one unified MR service responsible for all MR, both inpatient and outpatient
MR includes radiology films and scans, pathology slides, computerized information, et al
Medical Record Services 0432
276
Organization must be appropriate for size and must employ adequate personnel to ensure prompt completion, filing, and retrieval
Must have proper education, skills, qualifications and experience to meet state and federal law
Ensure proper coding and indexing of records
Surveyor will look at job descriptions and staffing schedules
Staffing of Medical Records 432
277
MR on each patient
Both inpatients and outpatients
MR must be accurate (contains all orders, test results, care plans, treatment and response to treatment), complete, retained and accessible (accessible 24 hours a day)
Use a system of author identification and protect security of all records
Protected from fire, water damage and other threats
Retention of Record A-438
278
Must be promptly completed and within 30 days
Kept at least 5 years (439) in original, microfilm, computer memory or other electronic storage
Certain medical records may be retained longer if required by state or federal law (OSHA, EPA, FDA)
See retention law memo from AHIMA
Will request records from 48-60 months ago
Medical Records
279
Retrieval A-0440
Must have a system of coding and indexing that allows timely retrieval of MR
Must be able to retrieve by diagnosis and procedure to support medical care studies
MR have to be accessible for departments that need them like the emergency department
280
Must have a procedure for ensuring confidentiality of MR
Copies may only be released to authorized individuals and written authorization by proper person, DPOA, guardian, etc.
Surveyor will ask for policy
Release only for court orders, subpoenas, in house education purposes, etc.
Confidentiality 441 and 442
281
Contain records, notes, reports assessment to justify
Admission
Continued hospitalization
Support the diagnosis
Describe the patient’s progress
Describe response to medications and to interventions, care, and treatment
Records must be promptly filed in chart
Content of Records A-449
282
All entries must be legible, complete, dated and timed
Must be authenticated by the person responsible for ordering, providing, or evaluating the service provided
Specify in MS or hospital policy who can make entries in medical record
Need method to identify author (written signatures, initials, computer key, or other code) and a list of written signatures must be available
Legible and Authenticated 450 6-5-09
283
Legible and Authenticated
Must have P&P if electronic medical record
If non MD does H&P or document exams, must be authenticated
MS R&R address countersignature when required by policy or state law and this is defined in MS R&R
Section on standing orders (preprinted order sets)
Sign, date, and time the last page
Include total number of pages such as page 3 of 3
Initial any changes, additions, or deletions
284
If rubber stamp used-must have signed statement only that individual will use it, but do not allow for signature or you may not be paid for care
Just don’t allow stamps for signatures on orders
Also CMS issued in a separate Program Integrity manual April 2010 stamps are not allowed
If electronic MR must demonstrate how alterations are prevented
Can’t use system of auto authentication that says can not review because not transcribed yet
Medical Records 450
CMS Signature Guidelines April 16, 2010 CMS issues new signature guidelines and says no rubber
stamps
CMS issued a change request updating the Program Integrity Manual on signature guidelines for medical review purposes
Requires legible identifier in form of handwritten or electronic signature
Third exception is cases where national coverage determination (NCD), local coverage determination (LCD) or if CMS manual has specific guidelines takes precedence over above
285
286
287
288
289
Verbal Orders 454 and 457Recall verbal order section starting in MS section at tag
number 407 is repeated and already discussed
All doctor can sign VO for any other doctor on case for five years
Person who takes VO must read it back and write it down with date and time
When doctor or LIP authenticates and signs off order must date and time it also
Sign off 48 hours unless state law specifies specific time frame, even all lab orders
Can’t sign off within 30 days unless state law is that specific and not just records be completed within this time frame
290
Repeats same provisions on H&P as in medical staff section under tag number 358 and 359
H&P done within 24 hours, not older than 30 days old and updated within 24 hours and updated and on chart before patient goes to surgery
PA and NP can do if allowed by hospital and all state laws allow and physician reviews and authenticates with date, time, and signature
History and Physical 458 and 461
291
Must have admitting diagnosis in chart (463)
All consults and findings by clinical staff and others must be documented (464)
Information must be promptly filed in the MR so staff has access to it (464)
Must document complications and hospital acquired infections (HAI) and unfavorable reactions to drugs and anesthesia (465)
It is important for all practitioners to be aware of the need to document complications and how to do this correctly
MR Must Contain 464 and 465
292
Interpretive guidelines issued on April 13, 2007, and minor changes October 17, 2008
Now three separate sections related to informed consent in patient rights, medical record and surgical services
Properly executed informed consent for procedures and treatments specified by MS
Need list of all surgeries (as defined now by ACS and AMA) and procedures with yes or no
Informed Consent A-466
293
Minimum elements in an informed consent
Name of hospital
Name of procedure or treatment
Name of responsible practitioner who is performing
Statement that benefits, material risks and alternatives were explained
Signature of patient
Date and time form is signed
Informed Consent MR Mandatory
294
CMS has list of optional elements which they call a well designed consent form
Medical record must contain an informed consent for procedures and treatments specified as requiring on and MS by-laws should address this
Consider state laws requiring informed consent such as for invasive procedures and any federal laws such as informed consent for research
Medical Records 466
295
Procedure Name Requires Informed Consent
Ablations Yes
Amniocentesis Yes
Angiogram Yes
Angiography Yes
Angioplasties Yes
Arthrogram Yes
Arterial Line insertion (performed alone) Yes
Aspiration Cyst (simple/minor) No
Consider List of Procedures
296
Procedure Name Requires Informed Consent
Aspiration Cyst (complex) Yes
Blood Administration Yes
Blood Patch Yes
Bone Marrow Aspiration Yes
Bone Marrow Biopsy Yes
Bronchoscopy Yes
Capsule Endoscopy Yes
Consider List of Procedures
297
Need for all surgeries
Exception is emergencies
All inpatients and outpatients
For all procedures specified
Needs to reflect a process
Form must follow policies
Must include state or federal requirements
Must contain minimum requirements (mandatory)
Informed Consent Forms
298
Medical record must contain an informed consent for procedures and treatments specified as requiring one
Medical staff by-laws should address this
Consider state laws requiring informed consent such as for invasive procedures
Consider any federal laws such as informed consent for research, and state laws on informed consent
Medical Records
299
Name of the practitioner who conducted the informed consent discussion with the patient or the patient’s representative
It is required to tell the patient this but optional to put it in writing
Date, time, and signature of witness
Indication or listing of the material risks of the procedure or treatment that were discussed with the patient or the patient’s representative
Well designed (optional) may also include:
300
Statement, if applicable, that physicians other than the operating practitioner, including but not limited to residents, will be performing important tasks related to the surgery, in accordance with the hospital’s policies and, in the case of residents, based on their skill set and under the supervision of the responsible practitioner
Still have to inform patient if someone is doing important parts of the surgery but having it in writing is optional
Well designed (optional) may also include
301
Statement, if applicable, that QMP who are not physicians who will perform important parts of the surgery
or administration of anesthesia will be performing only tasks that are within their scope of practice,
as determined under State law and regulation,
and for which they have been granted privileges by the hospital
Well designed (optional) may also include:
302
Verify hospital has assured MS has list of procedures and treatments that require consent
Verify informed consent forms six mandatory elements
Compare the hospital standard informed consent form to the P&Ps to make sure consistent
Make sure any state law requirements are included
Survey Procedure
303
Medical record must contain all orders, nursing notes, reports, medication records, radiology, lab reports, and vital signs
Orders must be authenticates or signed off
All reports of treatment which includes complications
Any other information used to monitor the patient’s condition
Chart Must Contain 467
304
All medical records must have a discharge summary with outcome of hospitalization
Disposition of the patient
Provisions for follow up care
Follow-up care includes post hospital appointments, how care needs will be met, and any plans for home health care, LTC, hospice or assisted living
Can delegate to NP or PA if allowed by state law but physician must authenticate and date it and time it
Discharge Summary 468
305
Every medical record has to have a final diagnosis
Medical records must be completed within 30 days (same as TJC)
NQF 2010 34 Safe Practices recommends discharge summaries be dictated at discharge and sent promptly to PCP
Includes inpatient and outpatient charts
Final Diagnosis 469
306
Hospital must have a pharmacy to meet the patient’s needs and need to promote safe medication use process
Must be directed by registered pharmacist or drug storage area under constant supervision
MS is responsible for developing P&P to minimize drug error
Function may be delegated to the pharmacy service
Pharmaceutical Services 490
307
Provide medication related information to hospital personnel
Medication Management is important to CMS and TJC and TJC has a medication management chapter
Contains list of functions of the pharmacist (collect patient specific information, monitor effects, identify goals, implement monitoring plan with patient, et.al.)
Flag new types of mistakes
Pharmacy 0490
308
High alert medication-dosing limits-packaging, labeling and storage (policy at www.wpsi.org and ISMP (Institute for Safe Medication Practice) and USP have list of high alert medications)
Limiting number of medication related devices and equipment-no more that 2 types of infusion pumps (490)
Availability of up to date medication information
Pharmacist on call if not open 24 hours
Pharmacy Policies include:
309
Pharmacy Policies include:
Avoid dangerous abbreviations
All elements of order; dose, strength, route, units, rate, frequency
Alert system for sound alike/look alike (LASA)
Use of facility approved pre-printed order sheets whenever possible
“Resume preop orders” is prohibited
Voluntary, non-punitive reporting system to monitor and report adverse drug events
310
Preparation, distribution, administration and disposal of hazardous medications (chemotherapy)
Drug recall
Patient specific information that should be readily available (TJC tells you exactly what this is, like age, sex, allergies, current medications, etc.)
Means to incorporate external alerts and recommendation from national associations and government for review and policy revision (Joint Commission, ISMP, FDA, IHI, AHRQ, Med Watch, NCCMER, MEDMARX)
Pharmacy Policies include:
311
Identification of weight based dosing for pediatric populations
Requirements for review based on facility generated reports of adverse drug events and PI activities
Policy to identify potential and actual adverse drug events (IHI trigger tool, concurrent review, observe med passes etc.)
Must periodically review all P&P’s
Pharmacy Policies Include (490)
312
Pharmacy Policies Include
Need a multidisciplinary committee - committee of medicine, nursing, administration, and pharmacy to develop P&P
MS must develop P&P or have policy that this function is fulfilled by pharmacy
Surveyors will make sure staff is familiar with all the medication P&P’s
Need policies to minimize drug error
313
Pharmacy or drug storage must be administered in accordance with professional principles (TJC 03.01.01 and problematic standard)
This includes compliance with state laws (pharmacy laws), and federal regulations (USP 797), standards by nationally recognized organizations (ASHP, FDA, NIH, USP, ISMP, etc.)
Pharmacy director must review P&P periodically and revise
Pharmacy Management 0491
314
Drugs stored as per manufacture’s
Pharmacy employees provide services within the scope of their licensure and education
Sufficient pharmacy records to follow flow from order to dispensing/administration
Maintain control over floor stock
Pharmacy Management 491
315
Pharmacist A-491
Ensure drugs are dispensed only by licensed pharmacist
Must have pharmacist to develop, supervise, and coordinate activities of pharmacy
Can be part time, full time or consulting
Single pharmacist must be responsible for overall administration of pharmacy
316
Pharmacist A-491
Job description should define development, supervision, and coordination of all activities
Must be knowledgeable about hospital pharmacy practice and management
Must have adequate number of personnel to ensure quality pharmacy service, including emergency services
Sufficient to provide services for 24 hours, 7 days a week
317
Pharmacy Delivery of Service 500
Keep accurate records of all scheduled drugs
Need policy to minimize drug diversion
Drugs and biologicals must be controlled and distributed to ensure patient safety
In accordance with state and federal law and applicable standards of practice
Accounting of the receipt and disposition of drugs subject to COMPREHENSIVE DRUG ABUSE PREVENTION AND CONTROL ACT OF 1970
318
Delivery of Service A-0500
Pharmacist and hospital staff and committee develop guidelines and P&P to ensure control and distribution of medications and medication devices
System in place to minimize high alert medication (double checks, dose limits, pre-printed orders, double checks, special packaging, et.al.)
And on high risk patients (pediatric, geriatric, renal or hepatic impairment)
High alert meds may include investigational, controlled meds, medicines with narrow therapeutic range and sound alike/look alike
319
All medication orders must be reviewed by a pharmacist before first dose is dispensed
Includes review of therapeutic appropriateness of medication regime
Therapeutic duplication
Appropriateness of drug, dose, frequency, route and method of administration
Real or potential med-med, med-food, med-lab test, and med-disease interactions
Allergies or sensitivities and variation from organizational criteria for use
Delivery of Service 500
320
Sterile products should be prepared and labeled in suitable environment
Pharmacy should participate in decisions about emergency medication kits (such as crash carts)
Medication stored should be consistent with age group and standards (such as pediatric doses for pediatric crash cart)
Must have process to report serious adverse drug reactions to the FDA
Delivery of Service 500
321
Policy to address use of medications brought in
P&P to ensure investigational meds are safely controlled and administered
Medications dispensed are retrieved when recalled or discontinued by manufacturer or FDA (eg. Vioxx)
System in place to reconcile medication that are not administered and that remain in medication drawer when pharmacy restocks
Will ask why it was not used?
Not the same as medication reconciliation as in the TJC NPSG which all hospitals should still do from a patient safety perspective
Delivery of Service 500
322
All compounding, packaging, and disposal of drugs and biologicals must be under the supervision of pharmacist
Must be performed as required by state of federal law
Staff ensure accuracy in medication preparation
Staff uses appropriate technique to avoid contamination
Compounding of Drugs 501
323
Use a laminar airflow hood to prepare any IV admixture, any sterile product made from non-sterile ingredients, or sterile product that will not be used within 24 hours (see USP 797)
Meds should be dispensed in safe manner and to meet the needs of the patient
Quantities are minimized to avoid diversion, dispensed timely, and if feasible in unit dose
All concerns, issues, or questions are clarified with the individual prescriber before dispensing
Compounding of Drugs
324
Locked Storage Areas A-502
Drugs and biologicals must be kept in a secure and locked area
Would be considered a secure area if staff actively providing care but not on a weekend when no one is around
Schedule II, III, IV, and V must be kept locked within a secure area (see also 503)
Only authorized person can get access to locked areas
325
Persons without legal access to drugs and biologicals can have not have unmonitored access
They can not have keys to storage rooms, carts, cabinets or containers with unsecured medications (housekeeping, maintenance, security)
Critical care and L&D area staffed and actively providing care are considered secure
Setting up for patients on OR is considered secure such as the anesthesia carts but after case or when OR is closed need to lock cart
Locked Storage Areas A-502
326
Securing Medications
So all controlled substances must be locked
Hospitals have greater flexibility in determining which non controlled drugs and biologicals must be kept locked
Medications should not be stored in areas readily accessible to unauthorized persons such in a private office unless visitors are not allowed without supervision of staff
P&P need to address security of any carts containing drugs
327
May allow patients to have access to urgently needed drugs such as Nitro and inhalers
Need P&P on competence of patient, patient education and must meet elements in TJC MM standard on self administration
Measures to secure bedside medications
Securing Medications
328
Locked Storage Areas A-254
Saline flushes need to be secure to prevent tampering so under constant supervision or locked up
Consider having safe injection practices P&P and follow CDC 10 guidelines
If medication cart is in use and unlocked, then someone with legal access must be close by and directing monitoring the cart, like when the nurse is passing meds
Need policy for safeguarding, transferring and availability of keys
329
Locked Storage Areas A-502
Drugs and biologicals must be kept in a secure and locked area
Would be considered a secure area if staff actively providing care but not on a weekend when no one is around
Schedule II, III, IV, and V must be kept locked within a secure area (see also 503)
Only authorized person can get access to locked areas
330
Persons without legal access to drugs and biologicals can have not have unmonitored access
They can not have keys to storage rooms, carts, cabinets or containers with unsecured medications (housekeeping, maintenance, security)
Critical care and L&D area staffed and actively providing care are considered secure
Setting up for patients on OR is considered secure such as the anesthesia carts but after case or when OR is closed need to lock cart
Locked Storage Areas A-502
331
Securing Medications
So all controlled substances must be locked
Hospitals have greater flexibility in determining which non controlled drugs and biologicals must be kept locked
Medications should not be stored in areas readily accessible to unauthorized persons such in a private office unless visitors are not allowed without supervision of staff
P&P need to address security of any carts containing drugs
332
May allow patients to have access to urgently needed drugs such as Nitro and inhalers
Need P&P on competence of patient, patient education and must meet elements in TJC MM standard on self administration
Measures to secure bedside medications
Securing Medications
333
Locked Storage Areas A-254
Saline flushes need to be secure to prevent tampering so under constant supervision or locked up
If medication cart is in use and unlocked, then someone with legal access must be close by and directing monitoring the cart, like when the nurse is passing meds
Need policy for safeguarding, transferring and availability of keys
334
335
These are available off the ASA website1
Security of medications in the operating room
See also preanesthesia and post anesthesia position statements
1http://www.asahq.org/publicationsAndServices /sgstoc.htm
ASA Standards, Guidelines, Statements
336
337
CMS states that they expect hospital P&P to address
The security and monitoring of any carts including whether locked or unlocked if contains drugs and biologicals
In all patient care areas to ensure safe storage and patient safety
P&P to keep drugs secure, prevent tampering, and diversion
Policy and Procedure
338
Self administered medications are safely and accurately administered
If you allow self administration, need procedure to manage, train, supervise, and document process
TJC MM stands for medication management standard MM 5.20 or MM.06.01.03
TJC Self Administered Meds
339
If non-staff member administers (patient or family) must train and make sure competent to do so (give info on nature of med, how to administer, side effects, and how to monitor effects)
Patient has to be determined to be competent before allowed to self administer
Mentioned TJC in Federal Register but not in IG
TJC Self Administered Meds
340
Outdated or Mislabeled Drugs 505
Outdated, mislabeled or otherwise unusable drugs and biologicals must not be available for patient use
Hospital has a system to prevent outdated or mislabeled drugs
Surveyor will spot check individual drug containers to make sure have all the required information including lot and control number, expiration date, strength, etc.
341
If no pharmacist on duty, drugs removed from storage area are allowed only by personnel designated in policies of MS and pharmacy service
Must be in accordance with state and federal law
Routine access to pharmacy by non-pharmacist for access should be minimized and eliminated as much as possible
E.g. night cabinet for use by nurse supervisor
Need process to get meds to patient if urgent or emergent need
No Pharmacist on Duty A-0506
342
No Pharmacist on Duty A-0506
TJC does not allow nurse supervisor in pharmacy so would need to call the on call pharmacist
Access is limited to set of medications that has been approved by the hospital and only trained prescribers and nurses are permitted access
Quality control procedures are in place like second check by another or secondary verification like bar coding
Pharmacist reviews all medications removed and correlates with order first thing in the morning
343
Medications Errors A-0508
Hospital must monitor, implement, and enforce the automatic stop order system
Drug errors, adverse drug reaction, and incompatibilities must be immediately reported to the attending MD/D and to the hospital PI program
Definition of med error or ADE should be broad enough to include NEAR MISSES
Recommend use of definition by National coordinating council medication error reporting and prevention definition
344
Medications Errors A-0509
Hospital must proactively identify med errors and ADE and can not rely solely on incident reports
Proactive includes observation of med passes, concurrent and retrospective review of patient’s clinical record, ADR surveillance, evaluation of high alert drugs and indicator drugs (Narcan, Romazicon, Benadryl, Digibind, et al) or generate a review for potential ADE
Remember FMEA (failure mode and effect analysis) and IHI adverse event trigger tool is great
345
Abuses and losses of controlled substances must be reported pharmacist and CEO and in accordance with any state or federal laws
Surveyor will interview pharmacist to determine their understanding of controlled substances policies
What is procedure for discovering drug discrepancies?
Abuses and Losses 509
346
Drug Interaction Information 510
Information on drug interactions and information on drug side effects, toxicology, dosage, indication for use and routes of administration must be available to staff
Texts and other resources must be available for staff at nursing stations and drug storage areas
Staff development programs on new drugs added to the formulary and how to resolve drug therapy problems
347
Formulary system must be established by the MS to ensure quality pharmaceuticals at reasonable cost
Formulary lists the drugs that are available
Processes to monitor patient responses to newly added medication
Process to approve and procure meds not on the list
Process to address shortages and outages including communication with staff, approving substitution and educating everyone on this, and how to obtain medications in a disaster
Formulary A-0511
348
Radiology A-529
Hospital has radiology services to meet needs of patients
Radiology services should be provided in accordance with accepted standards of practice
Radiology, especially ionizing procedures, must be free from hazards for patients and personnel
Must have policy that provides for safety of both
349
Safety 535 Proper safety precautions maintained against
radiology hazards
Including shielding for patients and personnel as well as storage, use, and disposal of radioactive materials
Need order of practitioner with privileges or practitioners outside the hospital who have been authorized by MS to order as allowed by state law
Period inspection of equipment and fix any hazard (537)
Check radiation workers by use of badge tests or exposure meters (538)
350
Personnel
Qualified radiologist must supervise ionizing radiology services
Must interpret those tests that are determined by the MS to require a radiologist’s specialized knowledge
Written policy approved by MS to designate which tests require interpretation by radiologist
If telemedicine is used, radiologist interpreting must be licensed and meet state law requirements (state medical board requirements), (546, see 023)
351
Personnel A-546
Supervision of radiology by radiologist who is member of the MS, Supervision should include the following
Ensure reports are signed by the practitioner who interpreted them
Assign duties to personnel based on their level of training, experience and licensure
Enforce infection control standards
Ensure emergency care if patient experience ADR to diagnostic agent
352
Radiology A-547 Ensure files, records are kept in secure area and
retrievable, train staff on how to operate equipment safely
Written policy, approved by the MS on who can use radiology equipment and administer procedures
Only qualified personnel may use radiology equipment
Surveyor will review personnel folders to make sure they are qualified as established by the MS for the tasks they perform
353
Radiology Records
Radiology records must be maintained for all procedures performed (553)
Must contain copies of all reports and printouts and any films, scans, or other image records
Must have written P&P that ensure the integrity of authentication and protect privacy of radiology records - must be secure and retrievable for five years
Radiologist or other practitioner who performs radiology services must sign the report of his or her interpretation
They have to be signed by the one who read and evaluated the x-ray (not the partner who is reviewing the dictated report ), A-0554
354
Laboratory Services A-0576
Must have adequate lab services to meet the needs of the patient
All lab services must in any hospital department has to meet these guidelines
All services must be provided in accordance with CLIA requirements (Clinical Laboratory Improvement Act) and have CLIA certificate
Can provide lab services directly or as contracted service
355
Lab Services
All lab services, including contracted services, must be integrated into hospital wide PI
Lab results are considered medical records and must meet all MR CoPs
Must have lab services available either directly or indirectly
Must meet needs of its patients and in each location of the hospital
TJC has lab standards also
356
Emergency Lab-Services available 583 Must provide emergency lab services 24 hours a
day, 7 days a week - directly or indirectly (contracted)
Hospital with multiple campuses must have available 24/7 at each campus
MS must determine what lab tests will be immediately available
Should reflect the scope and complexity of the hospital’s operations
Written description of emergency lab services available
Written description of test available are provided to MS on routine and stat basis
357
Tissue Specimens A-0584
Written instructions for the collection, preservation, transportation, receipts, and reporting of tissue specimen results
MS and pathologist determine when tissue specimens need macroscopic (gross) and microscopic examination
Need written policy on this
TJC has new chapter in 2009 on transplant safety and FAQs which continues into 2010
358
Blood Banks A-592
Potentially infectious blood and blood components
This section completely rewritten so have person in charge of P&P in this area and the look back program to review these changes
Will need to update P&Ps
TJC has similar sections in transplant safety chapter starting with TS.01.01.01 through TS.03.03.01 and PC chapter for blood and blood components
359
360
Blood and Blood Components
Potentially HIV infectious blood and hepatitis C virus (HCV) and blood products are collected from a donor who tests negative
If on a later donation tests positive then more specific test or follow up testing is done as required by FDA
If services provided by outside blood collecting establishment (blood bank) then need agreement to govern procurement, transfer and availability of blood and blood products
Agreement with blood bank must require blood bank to notify hospital promptly (HIV and added HCV)
361
Blood Banks A-592 Time depends on if tested positive on this unit or
tested negative but on later donation tested positive
Within 3 calendar days if blood tested is positive later
Follow up of notification within 45 calendar days after reactive screening test was positive for additional tests
See look back procedures required by 21 CFR 610.45 et seq. and FDA regulations
Hospital will dispose any contaminated blood from donor if not given (TJC PC.05.01.01)
362
Patient Notification
If administered potentially HIV/HCV infected blood hospital must make reasonable attempts to notify patient over period of 12 weeks unless patient already notified or unable to locate in 12 weeks
Records of the source and disposition of all units of blood and blood components must keep records ten years
363
Patient Notification
A fully funded plan to transfer these records to another hospital if the hospital closes (TJC PC.05.01.05 maintains records on receipt, testing and disposition of all blood and blood components and fully funded plan to transfer records to another organization if hospital ceases operation for any reason)
Must have P&P that meet federal and state laws on notification of patients
364
Patient Notification Must document in MR
Must conform to confidentiality requirements
Must have 3 things in the content of the notice; explanation of need for HIV and HCV testing and counseling
Enough written or oral information so can make an informed decision
List of programs where can get counseled and tested
If minor or incompetent or deceased then notify legal representative
365
Food and Dietetic Services 618
Hospital must have organized dietary services
Must be directed and staffed by qualified personnel
If contract with outside company need to have dietician and maintain minimum standards and provide for liaison with MS on recommendations on dietary policies
Dietary services must be organized to ensure nutritional needs of the patient are met in accordance with physician orders and acceptable standard of practice
366
Dietary A-618
Availability of diet manual and therapeutic diet menus
Frequency of meals served
System for diet ordering and patient tray delivery
Accommodation of non-routine occurrences (parenteral nutrition (tube feeding), TPN, peripheral parenteral nutrition, early/late trays, nutritional supplements
367
Dietary A-0618)
Integration of food and dietetic services into hospital wide QAPI and infection control programs
Guidelines on acceptable hygiene practices of personnel and kitchen sanitation
Compliance with state or federal laws
368
Organization A-0620
Must have full time director who is responsible for daily management of dietary services
Must be granted authority and delegation by the Board and MS for the operation of dietary services
Job description should be position specific and clearly delineate authority for direction of food and dietary services
Includes training programs for dietary staff and ensuring P&Ps are followed
369
Dietary Policies
Safety practices for food handling
Emergency food supplies
Orientation, work assignment, supervision of work and personnel performance
Menu planning
Purchase of foods and supplies
Retention of essential records (cost, menus, training records, QAPI reports)
Service QAPI program
370
Dietitian 621 Qualified dietician must supervise nutritional aspects
of patient care and approve patient menus and nutritional supplements
Patient and family dietary counseling
Perform and document nutritional assessments
Evaluate patient tolerance to therapeutic diets when appropriate
Collaborate with other services (MS, nursing, pharmacy, social work)
Maintain data to recommend, prescribe therapeutic diets
371
Personnel 622
Must have administrative and technical personnel competent in their duties
Menus must be nutritional, balanced, and meet special needs of patients
Screening criteria should be developed to determine what patients are at risk
Once patient is identified nutritional assessment should be done (TJC PC.01.02.01)
Patient should be evaluated
372
Nutritional Assessment 628
TJC requires to be done within 24 hours (PC.01.02.03)
If require artificial nutrition by any means (tube feeding, TPN)
If medical or surgical condition interferes with ability to digest, absorb, or ingest nutrients
If diagnosis or signs and symptoms indicate a compromised nutritional status such as anorexia, bulimia,electrolyte imbalance, dysphagia, malabsorption, ESRD
Adversely affected by nutritional intake (diabetes, CHF, taking certain meds)
373
Therapeutic Diets 629 Therapeutic diets must be prescribed by practitioner in
writing by the practitioner responsible for patient’s care
Dietician can make recommendations but diet must be ordered by doctor
Document in the MR including information about the patient’s tolerance
Evaluate for nutritional adequacy
Manual must be available for nursing, FS, and medical staff
Dieticians can only make recommendations and can’t order
374
Nutritional Needs 630
Must be met in accordance with recognized dietary practices
Follow recommended dietary allowances -current Recommended Dietary Allowances (RDA) or Dietary Reference Intake (DRI) of Food and Nutritional Board of the National Research Council
“Dietary Guidelines for Americans 2005”1
Surveyor will ask hospital what national standard you are using
1www.heathierus.gov/dietaryguidelines
375
Next Sections
Utilization review
Infection Control
Discharge Planning
Organ and Tissue
Surgery and Anesthesia
Nuclear Medicine
Emergency Services
Respiratory
Rehab
376
Utilization Review A-0652
Hospital must have a UR plan that provides for review of services furnished by the institution and the members of the MS to Medicare and Medicaid beneficiaries
UR plan should state responsibility and authority of those involved in the UR process
Surveyor will make sure activities performed as in UR plan
UR important to determine medical necessity especially with increased RACs
CMS issue UR CoP Memo June 22, 2007
377
Two Exceptions
Hospital has an agreement with the QIO in their state to assume binding review
Many hospitals have K with QIO to review admissions, quality, appropriateness and diagnostic information related to Medicare inpatients, will look to see signed contract
CMS has determined that the UR procedures established by the state are superior to the ones required under this section and state requires hospital to meet UR requirements for Medicaid program (there are none approved)
378
Composition of UR Committee 654
Consists of 2 or more practitioners who carry out UR function
At least 2 members must be doctors
The UR committee must be either a staff committee of the hospital or an group outside that has been established by the local medical society for hospitals in that locale and established in a manner approved by CMS
379
UR Committee 654
A committee may not be conducted by an individual who has a direct financial or ownership interest (5% or more)
Who was professionally involved in the care of the patient whose case is being reviewed
Surveyor will look to see if the governing board has delegated UR function to a outside group if impracticable to have a staff committee
380
Frequency of Review 655
UR plan must provide review for Medicare/Medicaid (M/M) patients with respect to medical necessity
Admissions (before, at, or after admission)
Duration of stay
Professional services furnished including drugs and biologicals
381
Scope of Reviews A-0655
Reviews may be on a sample basis except for reviews of cases assumed to outlier cases because of extended stay cases or high costs
Surveyor will examine UR plan to determine if medical necessity is reviewed for admission, duration of stay and services provided
If IPPS hospital there should be a review of the duration of stay in cases assumed to be outlier
382
Admissions or Continued Stay
Determination that admission or continued stay is not medically necessary is made by one member of UR committee if MD concurs with determination of fails to present their views when afforded the opportunity
Must be made by two members in all other cases (656)
383
Admissions or Continued Stay
Before determination not medically necessary, UR committee must consult the MD responsible for the care and afford opportunity to present their views
Then committee must provide written notification no later than two days after determination to the hospital, patient and practitioner responsible for care
384
Admissions or Continued Stay
If attending doctor does not respond or contest the findings of the committee, the findings are final
If physician of UR committee finds not medically necessary no referral of committee is necessary and he may notify the attending doctor
If non-physician makes the determination it must go to the committee
A non-physician can not make this final determination
385
Physical Environment A-0700
Hospital must be constructed, arranged, and maintained to ensure the safety of patient
And to provide diagnosis and treatment and for services appropriate for the community
This CoP applies to all locations of the hospital, all campuses, all satellites
386
Physical Environment
Hospital’s maintenance and hospital departments responsible for the buildings and equipment must be incorporated into the QAPI program
Must also be in compliance with the QAPI requirements
Survey of physical environment should be conducted by one surveyor
LIFE SAFETY CODE survey may be conducted by specially trained surveyor
LS code very important and being hit hard in the surveys
387
Life Safety Code
Separate CoP
Both Joint Commission and CMS using 2000 version
Hospitals should do review of LSC for gap analysis
Joint Commission hospitals will all have separate life safety surveyor and larger hospitals might have one for two days
Also TJC surveyors have had training on LSC
No cluttered hallways in the nursing units
388
Buildings A-0701
Condition of physical plant and overall hospital environment must be developed and maintained for the safety and well being of patients
Making sure that a routine and PM activities are done, as manufacturer requires and by state and federal law
Conduct ongoing maintenance inspections
Routine and PM and testing activities should be incorporated into hospital QAPI plan
389
Buildings A-0701 Includes developing and implementing emergency
preparedness plans and capabilities
Must coordinate with federal, state, and local emergency preparedness and health authority (dept of health)
To identify risks for their area (natural disasters, bio-terrorism threats, disruption of utilities like water, sewer, electrical, communication, fuel, nuclear accident)
Lists 14 things to consider in developing this
390
Buildings
Transfer of hospital equipment to another facility
Transfer or discharge of patients to home or other hospitals
Security of patients and walk in patients and supplies from misappropriation
Pharmacy, food, and other supplies and equipment that may be needed
Communication among staff
Training needed to implement emergency procedure
391
Emergency Power and Lighting
Must be emergency power and lighting in OR, PACU, ED, and stairwells
All other areas must have emergency supply source, battery lamps, and flashlights available
Must comply with 2000 LSC-National Fire Protection amendment NFPA 101, and NFPA-99 on Health care facility for emergency lighting and emergency power
Doors with no roller latches, need positive latching
392
Emergency Gas and Water
Must be facilities for emergency gas and water supply (703)
To provide care to inpatients
Includes making arrangements with local utility company for emergency sources of gas/water
One source of water is Federal Emergency Management Agency (FEMA)
Gas includes propane, natural gas, fuel oil, as well as gases used such as oxygen, nitrous oxide, nitrogen
393
Life Safety from Fire A-709
Must meet 2000 LSC of the NFPA
CMS may waive specific provisions, after consideration by state survey agency, if would result in unreasonable hardship but only if waiver will NOT adversely affect the health and safety of patients
Must follow state fire and safety code and CMS may allow surveyor to apply instead of LSC
394
Trash A-0713
Proper storage and disposal of trash
Trash includes bio-hazardous waste
Storage of trash must be in accordance with state and federal law (EPA, CDC, OSHA, state environmental health and safety regulations)
Need policies for storage and disposal of trash
H2E program - no fee (waste reduction, mercury, et al.)1
1 www.h2e-online.org
395
Fire Control Plan A-715
Need fire control plan
Must contain section on prompt reporting of fires, extinguishing fires, protection of patients and guests, evacuation and cooperation with fire fighting authorities
Surveyor will review fire plan
Verify all fires are reported to state officials
Will interview staff to make sure they know what to do during a fire
Amended for alcohol based hand dispensers
396
Facilities
Keep written evidence of regular inspections and approval by state or local fire control agencies
Maintain adequate facilities for its service - designed and maintained in accordance with federal, state, and local laws
Toilets, sinks, and equipment should be accessible
Make sure water acceptable for its intended use - drinking, lab water, irrigation - review water quality monitoring
397
Ventilation, Light, Temperature
Proper ventilation in areas using ethylene oxide, nitrous oxide, guteraldehydes, or other hazardous substances
Temperature controls in pharmacy and food preparation
Ventilation where O2 is transferred, in isolation rooms and lab
Adequate lighting in patient rooms and food and medication preparation areas (shown to reduce medication errors)
398
Ventilation, Light, Temperature
Temperature, humidity, and airflow in OR within acceptable standards to inhibit bacterial growth
Each OR room should have a separate temperature control - have temp and humidity tracking logs
Incorporate AORN – American Association of Perioperative Registered Nurses should be incorporated into hospital policy
399
Infection Control 747
Updated to reflect changing infectious and communicable disease threats
Including current knowledge and best practices
Very important in today’s healthcare environment
CDC estimates there are 1.7 million HAI in hospitals every year and 99,000 deaths
CMS gets $50 million dollar grant to enforce
Interpretive guidelines are 12 pages long1www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
400
Infection Control)
TJC has chapter on Infection Prevention and Control
APIC now calls infection preventionists (IPs)
Hospital must have sanitary environment to avoid sources and transmission of infection and communicable diseases (750)
Active IC program for prevention, control, and investigation of infections and communicable diseases
401
Infection Control (IC) A-0750
Standards apply to all departments of hospitals both on and off campus
Infection prevention must include monitoring of housekeeping and maintenance including construction activities
Areas to monitor include food storage preparation, serving and dish rooms, refrigerators, ice machines, air handlers, autoclave rooms, venting systems, inpatient rooms, supply storage and equipment cleaning
402
Infection Control (IC) A-0747
Must all standards of care and practice (APIC (Association for Professionals in Infection Control and Epidemiology), CDC, SHEA (Society for Healthcare Epidemiology of America), OSHA, etc.
Need to investigate infections and communicable diseases for inpatients and from personnel working in hospitals including volunteers
Must have active surveillance program that includes specific measures for infection detection, data collection, analysis monitoring, and evaluations of preventive interventions
403
Infection Control
Must have sampling or other mechanism in place to identify and monitor infections and communicable diseases
Infection control must be integrated in PI
Surveillance activities should be conducted in accordance with recognized surveillance practices such as those used by CDC NHSN (National Healthcare Safety Net)
Requirement for hospitals to report central line infections to NHSN
404
IC Officer’s Responsibilities
Many have added these to their job descriptions
Maintain sanitary hospital environment (ventilation and water controls, construction - make sure safe environment, safe air handling in areas of special ventilations such as the OR and isolation rooms, techniques for food sanitation, cleaning and disinfecting surfaces, carpeting and furniture, how is pest control done, and disposal of trash along with non-regulated waste)
405
IC Officer’s Responsibilities
Develop and implement IC measures (hospital staff, contract workers, volunteers)
Mitigation of risks associated with patient infections present upon admission and risks contributing to HAI
Active surveillance
Monitoring compliance with all P&Ps, protocols and other infection control program requirements
406
IC Officer’s Responsibilities
Program evaluation and revision of the program, when indicated
Coordination as required by law with federal, state, and local emergency preparedness and health authorities to address communicable disease threats, bioterrorism and outbreaks
Complying with the reportable disease requirements of the local health authority
Make sure IC program is integrated into hospital wide QAPI
407
Infection Control (IC) A-749
Long list of IC policies that hospitals must have
Maintain a sanitary physical environment
Hospital staff related measures (evaluate hospital staff immunization status for infectious diseases as per CDC and APIC, how you screen hospital staff for infections likely to cause significant infectious disease to others, policy on when staff are restricted from working)
408
IC Policies to Include: New employees and what they need in orientation
(including handwashing)
P&P to mitigate risk when patient admitted with infection - must be consistent with the CDC isolation guidelines, staff knowledge of PPE
Mitigate risk that cause or contribute to HAI such as SCIP measures, appropriate hair removal, timely antibiotics in OR, DC in 24 hours except 48 hours for cardiac patients, beta blockers during perioperative periods for select cardiac patients, proper sterilization of equipment, etc.
409
410
411
Medical Equipment and Supplies Resources
Multi-Society Guidelines for Reprocessing Flexible Gastrointestinal Endoscopes by APIC at www.apic.org/AM/Template.cfm?Section=Guidelines_and_Standards&template=/CM/ContentDisplay.cfm§ion=Topics1&ContentID=6381
Disinfection of Healthcare Equipment Chapter in Guidelines for Disinfection and Sterilization in Healthcare Facilities Nov 2008 at www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf
Single Use Device Reprocessing at http://cms.h2e-
online.org/ee/waste-reduction/waste-minimization/
412
IC Policies
Isolation procedures for highly immuno-suppressed patients (HIV or chemo patients)
Isolation procedures for trach care, respiratory care, burns, and other similar situations
Other HAI risk mitigation includes promotion of hand hygiene, and measures to prevent organisms that are antibiotic resistant such as MRSA and VRE
Things such as central line bundle, VRE bundle or sepsis bundle, prompt removal of foley catheter
Disinfectants, antiseptics, and germicides must be used in accordance with manufacturers instructions
413
IC Policies
Appropriate use of facility and medical equipment (hepa filters and negative pressure room, UV lights and other equipment to prevent the spread of infectious agents
Patients, visitors, care givers, and staff must receive education on infection and communicable diseases
There must be active surveillance system, method for getting data to determine if there is a problem
Policy on getting cultures from patients, etc.
414
Policies and Organization
Need IC officer and IC committee
IC officer must develop and implement policies on control of infection and communicable diseases
Person must be designated in writing who is qualified through education and experience
Lists the responsibilities of this person - consider putting into job description
415
Log of Incidents 750
Must maintain a log related to infections and communicable diseases, including HAI
Includes information from patients and staff so need information from employee health nurse
Includes employees, contract staff such as agency nurses, and volunteers
Includes surgical site infections, patients or staff with MDRO, patients who meet isolation requirements
Log can be paper or electronic, TJC IC.01.01.01
416
CEO, DON, and MS A- 756
The CEO, DON, and MS must ensure that there is hospital wide QA and training program that address problems identified by IC officer
And implement a successful corrective action plan in affected problem areas
Train staff in problems identified
Problems must be reported to nursing, MS, and administration
417
Discharge Planning A-800
Must have a discharge planning process that applies to all patients (inpatients and outpatients)
P&P must be in writing
Written discharge planning process must reveal a clear process to be followed
Necessary to prevent readmission
Surveyor will review patient care plans for discharge planning interventions
418
Identification of Patients 806
Must identify at early stage of hospitalization, all patients who are likely to suffer adverse consequences if no discharge planning
No national tool to do this
May include factors as functional status, cognitive ability and family support
Patients at high risk should be identified from screening process
419
Discharge Planning Evaluation
Hospital must provide a discharge planning evaluation to patients or upon the request of the physician
Needs assessment can be formal or informal
Assess factors on what the patient will need when discharged; bio-psychosocial needs and patient and caregiver’s understanding of discharge needs
Can be a tool or protocol
Surveyor will ask how patients are made aware of their right to request a discharge plan
Are they given the pamphlet “important message from Medicare”
420
Discharge Planning Responsibility
RN, SW, or qualified person must develop and supervise the development of the evaluation (807)
Person who does discharge planning evaluation needs to have experience and knowledge of social and physical factors that affect functional status to meet patient needs (emphysema -coordinate respiratory therapy, nursing care, financials for home health)
Ideally, discharge planning is interdisciplinary process
421
Evaluation 809
Discharge planning evaluation must include likelihood of needing post-hospital services and availability of services
Keep complete file on community based services such as LTC, sub acute care, and home care
Is physical, speech, OT or RT needed
Use QAPI program to determine if discharge planning process is effective
422
Self Care Evaluation
Discharge planning evaluation must include if patient can do self care and return to pre-hospital environment
Willingness of patient and family to do
Inform patient of freedom to choose providers or post hospital care (823)
Give list of Medicare certified HHA that serve your area (SSA 1861) including ownership information
Must assess if need hospice and give list of Medicare certified hospices and LTC (809)
Counsel patient and family for post hospital care (822)
423
Discharge Plan
If in MCO hospital must indicated which ones have contract with home health or LTC (825)
Hospital must now document in the medical record that the list of home health or LTC facilities was presented to the patient (827)
Rewrite your P&P to include this
Hospital must inform patient of freedom to choose post hospital provider (828) and respect their wishes (829)
HHA must request to be on the list
424
Timely Discharge Evaluation
Hospital must complete the evaluation timely
So appropriate arrangements can be made
Assessment should start soon after admission
Surveyor will review several patient discharge plans for appropriate coordination of health and social resources
Also need to reassess discharge planning process on an ongoing basis (843)
425
Transfer or Referral 837
Must transfer or refer patients to appropriate facilities, agencies, or outpatient services for follow up care
Must send along necessary medical records
Make sure patients get appropriate post hospital care
Must document if patient refuses discharge planning services
Written authorization before release of information
426
Organ, Tissue, and Eye A-884
Hospital must have written P&P to address its organ procurement
Must have agreement with OPO
Must timely notify OPO if death is imminent or patient has died
OPO to determine medical suitability for organ donation
Defines what must be in your written agreement (definitions, criteria for referral, access to your death record information)
TJC has similar standards in TS or transplant safety chapter
427
Organ, Tissue, and Eye)
Board must approve your organ procurement policy
Must integrate into hospital’s PI program
Surveyor will review written agreement with the OPO to make sure it has all the required information
Check off the long list to ensure all elements are present
428
Tissue and Eye Bank
Need an agreement with at least one tissue and eye bank
OPO is gatekeeper and notifies the tissue or eye bank chosen by the hospital
OPO determines medical suitability
Don’t need separate agreement with tissue bank if agreement with OPO to provide tissue and eye procurement
429
Family Notification
Once OPO has selected a potential donor, person’s family must be informed of the donor’s family’s option
OPO and hospital will decide how and by whom the family will be approached
Have to work cooperatively with the OPO and in educating staff
OPO can review death records
430
Organ Donation
Person to initiate request must be a designated requestor or organized representative of tissue or eye bank
Designated requestor must have completed course approved by OPO
Encourage discretion and sensitivity to the circumstances, views and beliefs of the families
Surveyor will review complaint file for relevant complaints
431
Organ Donation Training
Patient care staff must be trained on organ donation issues
Training program at a minimum should include: consent process, importance of discretion, role of designated requestor, transplantation and donation, QI, and role of OPO
Train all new employees, when change in P&P, and when problems identified in QAPI process
432
Organ Donation
Hospital must cooperate with OPO to review death records to improve id of potential donors
Surveyor will verify P&P that hospital works with OPO
Maintain potential donors while necessary testing and placement of donated organs take place
Must have P&P to maintain viability of organs
Ensure patient is declared dead within acceptable timeframe
433
Organ Transplantation
Hospital in which organ transplants are performed must be member of OPTN-Organ Procurement and Transplantation Network
Must abide by its rules - 42 USC 274, section 372 of the Public Health Service Act
Must provide data to OPTN, Scientific Registry and OPO (Organ Procurement Organization)
434
Surgical Services 940 If provide surgical services, service must be well
organized
If outpatient surgery, must be consistent in quality with inpatient care
Must follow acceptable standards of practice, AMA, ACOS, APIC, AORN
Must be integrated into hospital wide QAPI
Will inspect all OR rooms
Access to OR and PACU must be limited to authorized personnel
435
Surgical Services 940
Conform to aseptic and sterile technique
Appropriate cleaning between cases
Room is suitable for kind of surgery performed
Equipment available for rapid and routine sterilization
And it is monitored, inspected and maintained by biomed program
Temperature and humidity controlled
ACS and AORN have P&P on many of these
436
Surgery 942
OR must be supervised by experienced RN or MD/DO
Must have specialized training in surgery and management of surgical service operation
Will review job description
LPN’s and OR techs can serve as scrub nurses under supervision of RN
Qualified RN may perform circulating duties in OR - LPN or surg tech may assist in circulating duties - if allowed by state law
437
Surgical PrivilegesSurgical privileges must be delineated for all
practitioners performing surgery, in accordance with competence of each practitioner
Surgery service must maintain roster specifying the surgical privilege
Privileges must be reviewed every two years
Current list of surgeons suspended must also be retained Discussed in the earlier sections
438
Surgical Privileges
MS bylaws must have criteria for determining privileges
Surgical privileges are granted in accordance with the competence of each
MS appraisal procedure must evaluate each practitioner’s training, education, experience, and demonstrated competence
As established by the QAPI program, credentialing, adherence to hospital P&P, and laws
439
Surgical Privileges 945
Must specify for each practitioner that performs surgical tasks including MD, DO, dentists, oral surgeon, podiatrists
RNFA, NP, surgical PA, surgical tech, et. al.
Must be based on compliance with what they are allowed to do under state law
If task requires it to be under supervision of MD/DO this means supervising doctor is present in the same room working with the patient
440
Surgery Policies 951 Aseptic and sterile surveillance and practice,
including scrub technique
Id of infected and non-infected cases
Housekeeping requirements/procedures
Patient care requirements pre-op work area
patient consents and releases
safety practices
patient identification process and clinical procedures
441
Surgery Policies A-0951
Duties of scrub and circulating nurses
Safety practices
Surgical counts
Scheduling of patients for surgery
Personnel policies in OR
Resuscitative techniques
DNR status
Care of surgical specimens
442
Surgery Policies A-0951
Malignant hyperthermia
Protocols for all surgical procedures
Sterilization and disinfection procedures
Acceptable OR attire
Handling infectious and biomedical waste
Outpatient surgery post op planning
443
Preventing OR Fires 951
Read detailed section on use of alcohol based skin prep and how to prevent an OR fire
AORN has very detailed policy on flammable prep in the OR and how to prevent fires
Special precautions developed by NFPA and incorporated into NPSG by TJC
ASA has good document on preventing fires in the OR
Pa Patient Safety Authority has great recommendations
444
H&P A-0952
See prior sections on H&P
H&P must be on the chart before the patient goes to surgery
Except in emergencies
P&P specify what is an emergency
445
Consent 955
Informed consent is in three sections of the CoPs and each is different and not a repeat
Third section in the surgery chapter
Surgical services
Consent must be in chart before surgery
Exception for emergencies
446
Informed Consent
Recommend anesthesia consent now (955)
Lists elements for well designed process, which are the optional elements
Mandatory elements were under MR section
Specifies what must be in the consent policy
Who can obtain
Which procedures need consent
447
Informed Consent Policy
When is surgery an emergency
Content of consent form
Process to obtain consent
If consent obtained outside hospital how to get it into medical records
448
Informed Consent 955
Must disclose if residents, RNFA, Surgical PAs Cardiovascular Techs are doing important tasks
Important surgical tasks include: opening and closing, dissecting tissue, removing tissue, harvesting grafts, transplanting tissue, administering anesthesia, implanting devices and placing invasive lines
But requirement to have this in writing in under optional list or well designed list
449
Surgery Equipment A-0956
Call-in system
Cardiac monitor
Defibrillator
Aspirator (suction equipment)
Trach set (cricothyroidotomy is not a substitute)
TJC PC.03.01.01 includes this plus ventilator, and manual breathing bags
450
PACU 957
Must be adequate provisions for immediate post-op care
Must be in accordance with acceptable standards of care
Separate room with limited access
P&P specify transfer requirements to and from PACU
PACU assessment includes level of activity, respiration, BP, LOC, patient color (Aldrete)
Follow ASPAN standards
451
OR Register A-0958
Patient’s name, id number
Date of surgery
Total time of surgery
Name of surgeons, nursing personnel, anesthesiologist, and assistants
Type of anesthesia
Operative findings, pre-op and post-op diagnosis
Age of patient
See TJC RC.02.01.03 which are now the same
452
Operative Report A-959
Name and id of patient
Date and time of surgery
Name of surgeons, assistants
Pre-op and post-op diagnosis
Name of procedure
Type of anesthesia
453
Operative Report A-959
Complications and description of techniques and tissue removed
Grafts, tissue, devises implanted
Name and description of significant surgical tasks done by others (see list-opening, closing, harvesting grafts
454
Anesthesia A-1000 Must be provided in well organized manner under qualified
doctor
Optional service
Must be integrated into hospital PI
MS establish criteria for director’s qualifications
Revised December 11, 2009, Feb 5, 2010, May 21, 2010 and February 14, 2011
Will review job description of director - see elements
Wherever anesthesia is done - radiology, OB, OR, outpatient surgery areas
State exemption process of MD supervision for CRNA
CMS Anesthesia Standards Changes
Hospitals are expected to have P&P on when medications that fall along the analgesia-anesthesia continuum are considered anesthesia
P&P must be based on nationally recognized guidelines
Must specify the qualifications of practitioners who can administer analgesia
CMS further clarified pre-anesthesia and post-anesthesia evaluations
CMS added FAQs which are very helpful Hospitals should review these as many changes and clarifications
were made455
4th Change Effective February 14, 2011
456
CMS Added FAQs
457
458
Epidural or Spinal in OB The administration of a regional (epidural or spinal)
for the purpose of analgesia during labor and delivery
Is not considered anesthesia
Therefore, it is not subject to the supervision requirements for CRNA
Unless subsequent administration of medication for operative delivery like a C-section then the anesthesia standards apply
This section was removed even though this has always been CMS’s position
459
Anesthesia A-1000 If hospital provides any degree of anesthesia service
must comply with all CoPs
Anesthesia involves administration of medication to produce a blunting or loss of;
pain perception (analgesia)
Voluntary and involuntary movements
Memory and or consciousness
Analgesia is use of medication to provide pain relief thru blocking pain receptor in peripheral and or CNS where patient does not lose consciousness
It is a continuum
460
Monitored Anesthesia Care (MAC)
Anesthesia care that includes monitoring of patient by an anesthesia professional (like anesthesiologist or CRNA)
Include potential to convert to a general or regional anesthetic
Deep sedation/analgesia is included in a MAC
Deep sedation where drug induced depression of consciousness during which patient can not easily be aroused but responds purposefully following repeated or painful stimulus
461
Anesthesia Services 1000
Services not subject to anesthesia administration and supervision requirements
Topical or local anesthesia ; application or injection of drug to stop a painful sensation
Minimal sedation; drug induced state in which patient can respond to verbal commands such as oral medication to decrease anxiety for MRI
Moderate or conscious sedation; in which patients respond purposely to verbal commands, either alone or by light tactile stimulation
462
Anesthesia Services 1000
Rescue capacity
Sedation is a continuum and not always possible to predict how patient will respond so need intervention by one with expertise in airway management
Must have procedures in place to rescue patients whose sedation becomes deeper than initially intended
Anesthesia services must be under one anesthesia services under direction of qualified physician no matter where performed
Operating room, both inpatient and outpatient
OB, radiology, clinics, ED, psychiatry, endoscopy etc.
Anesthesia Services 1000
There is no bright line between anesthesia and analgesia
TJC has standards also on how to safely perform moderate or procedural sedation and anesthesia in the PC chapter
Also references the need to follow nationally standards of practice such as ASA (American Society of Anesthesiologists), ACEP (American College of Emergency Physicians) and ASGE (American Society for GI Endoscopy), AGA etc.
463
Anesthesia Services 1000
Hospitals need to determine if sedation done in the ED or procedures rooms is anesthesia or analgesia
This standard also sets forth the supervision requirements for staff who administer anesthesia
P&Ps need to establish minimum qualifications and supervision requirements including moderate sedation
MS credentialing standards and the nursing standards exist to make sure staff are qualified and competent
Must have P&P to look at adverse events, medication errors and other safety and quality indicators
464
465
Anesthesia Services and Policies 1002
Anesthesia must be consistent with needs of patients and resources
P&P must include delineation of pre-anesthesia and post-anesthesia responsibilities
Policies include;
Consent
Infection Control measures
Safety practices in all areas
How hospital anesthesia service needs are met
466
Anesthesia Policies Required 1002
Policies required (continued);
Protocols for life support function such as cardiac or respiratory emergencies
Reporting requirements
Documentation requirements
Equipment requirements
Monitoring, inspecting, testing and maintenance of anesthesia equipment
Pre and post anesthesia responsibilities
467
Pre-Anesthesia Assessment 1003
Pre-anesthesia evaluation must be performed with 48 hours prior to the surgery
Including inpatient and outpatient procedures
For regional, general, and MAC
Not required for moderate sedation but still need to do pre sedation assessment
Preanesthesia assessment must be done by some one qualified person to administer anesthetic (non-delegable)
468
Organization and Staffing 1003
Pre-anesthesia assessment done by someone who can administer anesthesia such as;
Qualified anesthesiologist or CRNA, Qualified doctor other than anesthesiologist
Anesthesiology assistant (AA) under the supervision of anesthesiologist who is immediately available if needed
Dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under state law
CRNA may not require supervision if state got an exemption1
1 List of 16 state exemptions at www.cms.hhs.gov/CFCsAndCoPs/02_Spotlight.asp Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin, Montana, Colorado, and California.
Pre-anesthesia Evaluation 1003
Can not delegate the pre-anesthesia assessment to someone who is not qualified
Must be done within 24hours
Delivery of first dose of medication for inducing anesthesia marks end of 48 hour time frame
However, some of the elements in the evaluation can be collected prior to the 48 hours time frame but it can never be more than 30 days
o if you saw a patient on Friday for Monday surgery would need to show that on Monday there were no changes
469
470
Pre-Anesthetic Assessment 1003 Must include;
Review of medical history, including anesthesia, drug, and allergy history (within 48 hours)
Interview and exam the patient – Within 48 hours and rest are updated in 48 hours but can be
collected within 30 days
Notation of anesthesia risk (such as ASA level)
Potential anesthesia problems identification (including what could be complication or contraindication like difficult airway, ongoing infection, or limited intravascular access)
471
Pre-Anesthetic Assessment 1003
Pre-anesthetic Assessment to include (continued);
Additional data or information in accordance with SOC
Including information such as stress test or additional consults
Develop plan of care including type of medication for induction, maintenance, and post-operative care
Of the risks and benefits of the anesthesia
472
ASA Physical Status Classification System
ASA PS I – normal healthy patient
ASA PS II – patient with mild systemic disease
ASA PS III – patient with severe systemic disease
ASA PS IV – patient with severe systemic disease that is a constant threat to life
ASA PS V – moribund patient who is not expected to survive without the operation
ASA PS VI – declared brain-dead patient whose organs are being removed for donor purposes
473
Survey Procedure Pre-anesthesia Evaluation
Surveyor to review sample of inpatient and outpatient records who had anesthesia
Make sure pre-anesthesia evaluation done and by one qualified to deliver anesthesia
Determine the pre-anesthesia evaluation had all the required elements
Make sure done within 48 hours before first does of medication given for purposes of inducing anesthesia for the surgery or procedure
ASA and AANA has pre-anesthesia standards
474
Pre-anesthesia ASA Guideline Preanesthesia Evaluation 1
Patient interview to assess Medical history, Anesthetic history, Medication history
Appropriate physical examination
Review of objective diagnostic data (e.g., laboratory, ECG, X-ray)
Assignment of ASA physical status
Formulation of the anesthetic plan and discussion of the risks and benefits of the plan with the patient or the patient’s legal representative
1 www.asahq.org/publicationsAndServices/standards/03.pdf
475
476
477
Intra-operative Anesthesia Record 1004
Need policies related to the intra-operative anesthesia
Need intra-operative anesthesia record for patients who have general, regional, or MAC
Intra-operative Record must contain the following:
Include name and hospital id number
Name of practitioner who administer anesthesia
Techniques used and patient position, including insertion of any intravascular or airway devices
478
Intra-operative Anesthesia Record
Intra-operative Record must contain the following (continued):
Name, dosage, route and time of drugs
Name and amount of IV fluids
Blood/blood products
Oxygenation and ventilation parameters
Time based documentation of continuous vital signs
Complications, adverse reactions, problems during anesthesia with symptom, VS, treatment rendered and response to treatment
Post-anesthesia Evaluation 1005
Post-anesthesia evaluation must be done by some one who is qualified to give anesthesia
Must be done no later than 48 hours after the surgery or procedure requiring anesthesia services
Must be completed as required by hospital policies and procedures
Must be completed as required by any state specific laws
P&Ps must be approved by the MS
P&Ps must reflect current standards of care479
480
Post Anesthesia Evaluation 1005
Document in chart within 48 hours for patients receiving anesthesia services (general, regional, MAC)
For inpatients and outpatients now
So may have to call some outpatients if not seen before they left the hospital
Note different for CAH hospitals under their manual
Does not have to be done by the same person who administered the anesthesia
481
Post Anesthesia Evaluation
Has to be done only by anesthesia person (CRNA, AA, anesthesiologist) or qualified doctor
48 hours starts at time patient moved into PACU or designated recovery area (SICU etc.)
Evaluation can not generally be done at point of movement to the recovery area since patient not recovered from anesthesia Patient must be sufficiently recovered so as to participate
in the evaluation e.g. answer questions, perform simple tasks etc.
Post Anesthesia Evaluation
For same day surgeries may be done after discharge if allowed by P&P and state law
If the patient is still intubated and in the ICU still need to do within the 48 hours
Would just document that the patient is unable to participate
If patient requires long acting anesthesia that would last beyond the 48 hours would just document this and note that full recovery from regional anesthesia has not occurred
482
483
Post-Anesthesia Assessment to Include
Respiratory function with respiratory rate, airway patency and oxygen saturation
CV function including pulse rate and BP
Mental status,
Temperature
Pain
Nausea and vomiting
Post-operative hydration
Post-Anesthesia Survey Procedure
Surveyor is review medical records for patients having anesthesia and make sure post-anesthesia evaluation is in the chart
Surveyor to make sure done by practitioner who is qualified to give anesthesia
Surveyor to make sure all postanesthesia evaluations are done within 48 hours
Surveyor to make sure all the required elements are documented for the postanesthesia evaluation
484
485
Post Anesthesia ASA Guidelines
Patient evaluation on admission and discharge from the postanesthesia care unit
A time-based record of vital signs and level of consciousness
A time-based record of drugs administered, their dosage and route of administration
Type and amounts of intravenous fluids administered, including blood and blood products
Any unusual events including postanesthesia or post procedural complications
Postanesthesia visits
486
487
American Association of Nurse Anesthetists
AANA has excellent website1
Information on how to become a CRNA
Has position statement on documenting the standard of care for the anesthesia record
Sample forms
1www.aana.com/resources.aspx?ucNavMenu_TSMenuTargetID=51&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=713
488
Six FAQs
How can the same drugs be used in the OR for anesthesia but in the ED for a sedative?
What nationally recognized guidelines are available for hospitals to use to develop their P&Ps?
What is the appropriate training for a sedation nurse?
Why is there a particular mention in the interpretive guidelines on ED sedation policies?
Can hospital adopt a P&P that all anesthesia agents in lower doses can be used for sedation (NO!)
489
490
491
492
493
Nuclear Medicine A-1026
Services must meet needs of patients
Optional service
Radioactive material must be prepared, labeled, uses, transported, stored and disposed of in accordance with acceptable standards of practice
Will not discuss but be sure to provide to your director if you do nuclear medicine
494
Nuclear Medicine Hospital must have written safety standards for
radioactive material
Handling of equipment and material
Protection of patients and staff from radiation hazards
Labeling of materials and waste
Transportation of same
Security of radioactive material
Testing of equipment for radioactive hazards, et. al.
495
Equipment and Supplies
Must be appropriate for types of nuclear med services offered
Must function in accordance with federal and state laws governing radiation safety - see 21 CFR Subpart J, Radiological Health
See 10 CFR. Chapter 1, Part 20, US Nuclear Regulatory Commission Standards for Protection against Ionizing Radiation
496
Nuclear Med
Must be maintained in safe operating condition
Inspected, tested, and calibrated annually by qualified person
Sign and date reports of nuclear interpretation, consults, and procedures
Keep copies for five years of records
497
Nuclear Med
Practitioner who interprets test must sign and date the test and be approved by MS to interpret
Must maintain records of the receipt and distribution of radio pharmaceuticals
Nuclear med studies must be ordered by practitioners who scope of federal or state licensure allow such referrals and who has staff privileges to perform
498
Outpatient Services A-1076
Services must meet the needs of the patient
Optional service
Must be in accordance with standards of practice
Both on and off campus
Outpatient services must be integrated into hospital QAPI
Theme in rest of slides with being involved in PI, qualified director, follow SOCs, and met needs of patients
499
Outpatient Services
Must be integrated with inpatient services
Medical records, radiology, lab, anesthesia, including pain management, diagnostic tests
Hospital must coordinate the care of the patient
Make sure pertinent information in medical record
500
Outpatient Services
Assign person responsible for this dept.
Have appropriate professional and nonprofessional personnel
Define in writing the qualifications and competencies necessary to direct the department
Will review P&P to determine person’s responsibility
Need to be sure that one person is overlooking all of ambulatory patients care and treatment (1079)
Outpatient Tag 1079
The outpatient services department must be accountable to a single individual
who directs the overall operation of the hospital’s entire outpatient services (all locations, all outpatient services).
Survey Procedures 482.54(b)
Verify that one person is assigned to manage and be responsible for outpatient services.
Review the organization’s policies and procedures to determine the person’s responsibility.
501
502
Emergency Services A-1100
Hospital must meet needs of patients
Optional for Medicare
Must follow acceptable standards of practice
Must be integrated into hospital wide QAPI
Need qualified MS director
503
Emergency Services
Services must be integrated with other dept in hospital
Surgery, lab, medical records, et al.
Includes communications between departments
Immediate availability of services, equipment, and resources of hospital
Length of time to transport between departments is appropriate
504
Emergency Services
Other departments must provide emergency patients the care within safe and appropriate times
If offer urgent care on premises or in provider based clinics must follow these regulations
Remember there is a separate COP on EMTALA
Will review policies, including triage policy
505
Emergency Services
Must have appropriate equipment
Periodic assessments of its needs
Work with state and feds in emergency preparedness
Surveyor will interview staff to see if knowledgeable about blood, IV fluid, parenteral administration of electrolytes, injuries to extremities, CNS and prevention of infection
506
Rehab Services A-1123
If provides rehab, PT, OT, speech language pathology, audiology, must be staffed and organized to ensure safety of patients
These staff must be qualified as specified by MS and state law
Meet standards - American Physical Therapy Association, American Speech and Hearing Association, American Occupational Therapy Association, American College of Physicians, AMA
507
Rehab Services
Must be integrated into hospital wide QAPI
Must have proper equipment and personnel
Scope of service should be defined in writing
Review medical records to verify each person documents
Director must be knowledgeable and experience and capable
Will review job description
Services must be furnished in accordance with written plan of care
508
Rehab Services
Must be given in accordance with order of practitioner (no longer says physician only)
Orders must be incorporated in the medical record
Plan of care must meet criteria such as based on assessment, measurable short and long term goals, updated as needed
509
Respiratory Services A-1151
Must meet needs of patients
Acceptable standard of practice
Appropriate equipment and number of qualified personnel
Scope of service should be defined in writing
Director who is doctor with experience to supervise service
List of written policies you must have
510
Respiratory Policies
Equipment assembly, operation, PM
Safety practices including IC for sterile supplies, biohaz waste, posting of signs and gas line id
CPR
Pulmonary function testing
Procedure to follow for adr
Therapeutic percussion and vibration
Bronchopulmonary drainage
511
Respiratory Policies Mechanical ventilation
Aerosol, humidification, and therapeutic gas administration
Storage, access and control of medications
ABG procedure for analyzing
CMS working on changes to respiratory and rehab section so stayed tuned
Need order but can be from physician or LIP as allowed by state (scope of practice) and hospital and PA or NP credentialed by Medical Staff
512
Respiratory Services 1163 (Last CoP)
If blood gases or other clinical lab tests are performed in unit then the applicable lab standards must be met
Need order of practitioner
Will review medical records
Will review to make sure all required policies and procedures are written
513
Statement of Deficiencies and Plan of corrections
Based on documentation of surveyor worksheet or notes and form CMS-2567
514
Condition Level Requirement Noncompliance
515
The End Questions?
Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD
Medical Legal Consultant 5447 Fawnbrook Lane Dublin, Ohio 43017
516
Websites
Center for Disease Control CDC – www.cdc.gov
Food and Drug Administration - www.fda.gov
Association of periOperative Registered Nurses at AORN - www.aorn.org
American Institute of Architects AIA - www.aia.org
517
Websites (continued)
Occupational Safety and Health Administration OSHA – www.osha.gov
National Institutes of Health NIH - www.nih.gov
United States Dept of Agriculture USDA - www.usda.gov
Emergency Nurses Association ENA - www.ena.org
518
Websites (continued)
American College of Emergency Physicians ACEP - www.acep.org
Joint Commission Joint Commission - www.JointCommission.org
Centers for Medicare and Medicaid Services CMS - www.cms.hhs.gov
American Association for Respiratory Care AARC - www.aarc.org
519
Websites (continued)
American College of Surgeons ACS -www.facs.org
American Nurses Association ANA - www.ana.org
AHRQ is www.ahrq.gov
American Hospital Association AHA - www.aha.org
520
Websites (continued)
CMS Life Safety Code page - http://new.cms.hhs.gov/CFCsAndCoPs/07_LSC.asp
COPs available in word and PDR at http://www.access.gpo.gov/nara/cfr/waisidx_04/42cfr485_04.html
American College of Radiology- www.acr.org
Federal Emergency Management Agency (FEMA)- www.fema.gov
521
Websites (continued)
Drug Enforcement Administration –www.dea.gov (copy of controlled substance act)
US Pharmacopeia - www.usp.org, (USP 797 book for sale)
National Patient Safety Foundation at the AMA -www.ama-assn.org/med-sci/npsf/htm
The Institute for Safe Medication Practices - www.ismp.org
522
Websites (continued)
U.S. Pharmacopeia (USP) Convention, Inc. - www.usp.org
U.S. Food and Drug Administration MedWatch -www.fda.gov/medwatch
Institute for Healthcare Improvement - www.ihi.org
AHRQ at www.ahrq.gov
523
Websites (continued)
Sentinel event alerts at www.jointcommission.org
American Pharmaceutical Association - www.aphanet.org
American Society of Heath-System Pharmacists -www.ashp.org
524
Websites (continued)
Enhancing Patient Safety and Errors in Healthcare -www.mederrors.com
National Coordinating Council for Medication Error Reporting and Prevention - www.nccmerp.org,
FDA's Recalls, Market Withdrawals and Safety Alerts Page: www.fda.gov/opacom/7alerts.html
525
Infection Control Websites
Association for Professionals in Infection Control and Epidemiology (APIC) infection control guidelines at www.apic.org
Centers for Disease Control and Prevention - www.cdc.gov
Occupational Health and Safety Administration (OSHA) at www.osha.gov
526
Infection Control Websites (continued)
The National Institute for Occupational Safety and Health NIOSH at www.cdc.gov/niosh/homepage.html
AORN at www.aorn.org
Society for Healthcare Epidemiology of America (SHEA) at www.shea-online.org
527
Resources
To obtain a copy of Survey and Certification Memo 9-10 go to the CMS website at www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/itemdetail.asp?filterType=dual,%20date&filterValue=30|d&filterByDID=-1&sortByDID=4&sortOrder=ascending&itemID=CMS1216415&intNumPerPage=10
To see a copy of the final interpretive guidelines issued on October 17, 2008 for hospitals, Appendix A (the regular hospital conditions of participation) which is also part of the State Operations Manual (SOM) go to www.cms.hhs.gov/transmittals/downloads/R37SOMA.pdf
528
The End Questions
Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD
Medical Legal Consultant 5447 Fawnbrook Lane Dublin, Ohio 43017