state survey for licensure of hospitals george mason university college of nursing and health...
TRANSCRIPT
State Survey
for
Licensure of Hospitals
George Mason UniversityCollege of Nursing and Health Science
Regulatory Requirements for Health SystemsSummer 2004
2
State Board of Health
12 VAC 5-410
Rules and Regulations for the Licensure of Hospitals in
Virginia
Center for Quality Health Care Services and Consumer ProtectionVirginia Department of Health
Richmond, Virginia
3
Governing Body
Administrator/president
Asst.. Administrator/ Vice President
Governing body by-laws
•Date of last revision
•Documentation of lines of authority for operation of hospital
•Organizational chart
•Board meeting minutes review
•Frequency of meetings
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Results of Other Surveys
Last JCAHO survey Last CAP survey State fire Marshall Inspection Sprinkler system compliance status OSHA New services since last survey: Construction projects:
5
Administrative Policies for Review
Licensure/certification verification policyOrgan donation Moderate sedation policy Restraint policy Incident reporting policy
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Contracted Services
List of contracted services Review two contracts in-depthReview of a Service Contract may include:
•Scope of service
•Quality Assurance Responsibilities
•Participation in Performance Improvement Projects
•Supervision of personnel
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Medical StaffPresident medical staff:
Total medical staff number:
•Active:
•Courtesy/consult:
Medical staff status:
•Dentists/oral surgeon
•Podiatrists
Allied health professionals practicing (e.g. certified registered nurse anesthetists and physician assistants)
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Medical Staff – Bylaws, Rules & Regulations
Medical staff organization (diagram if available) departmental/department of the whole
Medical staff appointment criteria
•Initial appointment
•provisional period
•Transition procedure from provisional to active status
•Reappointment frequency
•Board certification requirements
•Temporary privileges/locum tenens
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Medical Staff – Bylaws, Rules & Regulations (continued)
Allied health appointment criteria
•Reappointment frequency
Medical records
•Time frame for completion
•H & P time frames (medical & surgical)
•H & P for admissions of podiatrists and dentists
•Verbal orders - 24 hours
10
Completeness of Credentialing ProcessCurrent license
Data Bank Query - (within 12 months of appointment . or re-appointment)
Q.A. Review documentation
Board certification status
Documentation of other hospital queries when applicable
Initial appointment. -Verification of credentials/ character
Delineation of clinical privileges/approval signature
Hospital Governing Board approval
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Infection Control
Meeting with Infection control officer and medical director
Review Infection control plan
Surveillance
•Hospital-wide
•Focused/targeted
•Inpatient
•Outpatient
Nosocomial infection rates
12
Infection Control
Reported outbreaks
Isolation categories
Negative pressure rooms (whole house)
TB control
•Respirators used - length of use
•Number of confirmed cases last year
•Number of PPD conversions
•Policy for PPD testing - who & how often
13
Infection Control
Method of monitoring compliance
Education programs
•Orientation/annual/ongoing
•Hand washing
Small blood spill policy
•Location of spill kits if used
•Products used
14
Infection Control
Infection control committee
•Frequency of meetings
•Meeting minutes
•Approval areas
Biomedical waste disposal
Linen procedures
Sterilization equipment & proceduresHousekeeping chemicals
15
Quality Management
Meeting with Quality management director
Organization Performance Written Plan
Organizational reporting structure (diagram)
Hospital tracking system.
Clinical/critical pathways
Medical staff reviews, Reporting for re-credentialing
Quality council and QI Teams
Committee meetings: frequency, minutes
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Fire and Safety
Meet Fire and safety safety officer
Review fire plan
Fire drills (one per shift per quarter)
•Who participated
•What procedures practiced
•What areas were involved
•Performance evaluation
•Corrective actions if indicated
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Fire and Safety
Construction drills (two per shift per quarter)
Interview employees re: Fire plan (at least 3)
Safety committee
•Frequency of meetings
•Review of committee meeting minutes
•Committee safety surveys of departments
•Frequency, Who participates
•Scope of survey/checklist used
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Initial use check - policy - how documented
•Hospital owned equipment
•Privately owned equipment
•Patient use
•Personnel use
Hospital bed preventive maintenance
•Frequency
•How documented
Electrical Equipment Checks
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Biomedical Equipment Checks
Biomedical equipment checks
•By whom
•List of frequency categories
•How tracked and documented
Emergency generator log
•Number of emergency generators
•Frequency of testing
•Log of testing and actual use
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Disaster and Mass Casualty
Meet the chairman of the disaster plan
Review written plan - Last revision
Documented rehearsals twice a year
•Dates of drills
•Drills evaluated with corrective actions
•Documentation of drills kept 2 years
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Emergency Services
Meet emergency department manger
Emergency dept. Medical director must be Board Certified
Number of rooms
Number of patients seen last year average
Number of patients seen/day
Average transfers/month
Average number of patients that leave
Against Medical Advice (AMA)/month
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Emergency DepartmentStaffing
Nursing
•RN on duty all shifts
Physicians
•Physician on-call duty roster - posted
•Obstetric - newborn roster of physicians with clinical privileges
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Continuing EducationWritten plan for unit specific continuing education
•Documentation of education activities for last year
•Plans for current year
Required personnel competencies and skills
•Required frequency of validation
•Checklist of content
•Certifications, ACLS, PALS, Other
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PYXIS SUR-MED Other
Refrigerated medications
•Secure
•Thermometer
Irrigation solutions
•policy for use
•Timed/dated
Medication
Administration
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Medication
Administration
Buffered Xylocaine use
•policy for mixing
•Multiple dose vials
•policy for use
Single dose vials
Compliance with one use poison control center used
Telephone number posted
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Other Checks
EMTALA (The Emergency Medical Treatment and Active Labor Act ) signage posted in waiting room triage
Triage protocols/Triage privacy
Crash carts
•Number of cart: Adult and Pediatric
•Documented shift checks
•Who checks carts for outdates
•How documented
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Other Checks
Toxicology reference materials
Master file of MSDS sheets
•where kept if not in E.D.
•24 hour availability
HAZMAT facilities
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Nursing
Medical/Surgical Units
Medication system used
•Pyxis Sur-Med Med carts other
•Policy for multi-dose vials/irrigation solutions
•Refrigerated medications
•Temperature monitoring
•Sharps container compliance
Blood glucose machines
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Nursing
Medical/Surgical Units
Documented quality controls crash cart with defibrillator
•Documented daily checks
•Who checks outdates-how documented linen storage
Clean/soiled equipment storage
Clean/soiled
Stretcher/Wheel chair cleaning schedule
•Who is responsible for cleaning
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Nursing
Medical/Surgical Units
Hallways must be totally clear for fire egress
Clinical resource information
•Current pharmaceutical manual
•Infection control manual
•Clinical pathway information-if applicable
•MSDS sheets
•Fire plan and disaster plan
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Nursing
Medical/Surgical Units
Unoccupied room check Call bell
•Wall oxygen and suction outlets
•Electrical & biomedical equipment checked
•Emergency electrical plugs identified
•Sharps box/gloves
Negative pressure rooms
•Current isolation
•Respirator storage (if applicable)
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Nursing
Medical/Surgical Units
Restraint use
•Observation of patient
•Chart review for orders and documentation
Clean/dirty utility rooms
•Hazardous waste storage/disposal
•Dirty linen storage
Kitchen/nourishment room
•Ice machine, Refrigerator/ Temp and Contents monitoring
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Nursing
Medical/Surgical Units
Housekeeping
•Janitor's closet
•Chemical storage
•Housekeeping cart
•No food or drink
•Parking/storage
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Critical Care Unit
Number of beds
Nursing /manager medical director:
Unit designed and equipped for special function
Crash carts/emergency equipment
•Documentation of checks
Medication system:
•Pyxis Sur-Med other
•Stock drugs - who monitors for outdates
•Refrigerated medications - temperature monitoring
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Critical Care Unit
Blood glucose machine:
•Documented quality controls
Nursing assessment/documentation
•Use of critical pathways
•Other care planning used
•Critical care nursing assessment tool used
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Critical Care UnitStaffing:
•Staffing policy,Staffing schedules
•last 3 months/with census
•Categories of personnel assigned to unit
•RN LPN Aide/Tech Respiratory therapist
Continuing education
•Written plan for unit specific continuing education
•Documentation of plans and activities
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Critical Care Unit
Required personnel competencies and skills.
•Frequency of re-qualification
•Documentation/checklist
•ACLS
•Certifications of personnel
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Nursing Service
Chief Nurse Executive
Director of nursing:
Organizational Chart
Staffing:
•Acuity/system used
Procedure used for verification of current licensure
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Nursing Service
Required training/continuing education.
•Blood glucose monitoring
•Active participation in conscious sedation
Policies
•Administration of blood and blood products
•Restraint
•Moderate sedation
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Employee Health
Hepatitis B vaccine
•Policy
•Who is eligible
Tuberculin testing (PPD - x-ray)
•Policy
•Methods used
•Conversions/follow up
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Obstetric ServicesAdministrative manager
Nurse manager:
•Postpartum, L&D, Newborn services
Medical director
Board Certified or Board Eligible
Appointment by Governing Body
Responsibilities in writing
Joint Committee - Ob & Newborn services
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Obstetric Services
Joint conference committee meeting, Minutes.
Services management plan
•Protocol for pregnant women who present in labor
•Copy at each nurses station
Policies & procedures
•Identification of high risk patients
•Anesthesia personnel available on site within 30 min.
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Obstetric ServicesPolicies & procedures
•Ob physician accessible within 10 min during oxytocic administration
•Criteria for use of Labor & Delivery Rooms/Labor, Delivery, Recovery, and Postpartum Rooms
•Gynecologic patients - definition - if cared for on Ob
Infection control.
•Written criteria for isolation or segregation for mothers and infants
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Obstetric Services
Physician availability:
•Ob physician - 30 min. On-call
•Accessible - 10 min during oxytocic admin-
•On-call duty schedule posted at each Ob nurses station
•Roster of Ob & Neoborn services physicians with privileges at each nurses station
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Obstetric ServicesStaffing schedules: (available for last 3 months) 1.
•Ratios:
•Post Partum: 1:6-8
•Mother/baby: 1:4
•L&d: 1:1-2
•Post op recovery: 1:2
•Policies for use of personnel from other hospital Areas
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Obstetric Services
Education & training
•Written plan for unit specific continuing education with documentation of activities for last year and current year
•Training for identification of substance abuse in women & infants
•Required competencies & skills
•Frequency of validation
•Certifications, CPR - Adult - Neonatal
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Obstetric ServicesDischarge planning
•Policy and Procedure/substance abusing post Partum women
•Appropriate referrals
•Include father and/or family members
•Documented in Medical Record
•Family planning information given to patient
•Documented
•Discharge teaching documentation
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Obstetric Services
Control plan
•Control station
•Visibility of unit
•Bracelet system used
•Cameras
Medication system
•Pyxis Sur-Med Med cart other
•Refrigerated medication - temp monitoring
•Sharps containers
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Obstetric Services
Crash cart/defibrillator
•Daily monitoring with documentation
•Documentation of outdate monitoring
Unit design
•Separate and distinct unit
•Soiled workroom & janitor's closet - exclusive use by Ob
•Patient bath facilities with showers
•Staff clothing change areas
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Newborn Services
Nurse Manager
Medical director
•Qualified for highest level of newborn services offered
•Appointed by governing body
•Responsibilities in writing
•Conduct joint conference with Ob Physicians quarterly
•Participation in Performance Improvement Initiatives
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Newborn Services
Written medical protocols
•To include management of medical conditions offered
•Consultation - stabilization - transfer
•Copy in nursery
•Approved by governing body
•Hospital to have written collaborative agreements with other hospitals providing higher levels of care
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Newborn Services
Newborn physician coverage:
•On-call - on-site - 30 minutes
•On-call duty schedule - posted - each nurses station
•Roster of newborn services physicians with clinical privileges at each nurses station in newborn unit.
Policies & procedures
•Care of eyes, skin & cord, Formula use
•Assessment with Apgar Scores
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Newborn Services
Breast milk use & storage
Education & training
•Written plan for unit specific continuing education with documentation of activities for last year and current year
•Training for identification of substance abuse women & infants
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Newborn Services
•Required competencies & skills
•Frequency of validation
•Certifications, CPR - Adult - Neonatal
Staffing
Ratios - according to level of care offered
•General - intermediate - specialty - sub-specialty
•LPN - student nurses - nurse aides - require direct supervision of a registered nurse in newborn services
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General Level Nursery
Nurse manager
Medical director
•If not Board Certified or Board eligible, a Pediatrician-written agreement with Board certified or board eligible Pediatrician for 24 hr. Consult by phone
If no 24 hour basis Neonatologist on staff at the hospital, there must be a written agreement with another hospital for 24 hr telephone consult with a Board certified or Board eligible Neonatologist
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General Level Nursery
Hospital written collaborative Agreements providing higher levels of care
Staffing Ratios:
•Newly born/close observation 1:4
•Routine care 1:8
•Mother/baby care 1:4
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General Level Nursery
Identification & control
•Bracelet system
•Two Bracelets on infant
•One on mother
•Bassinet/incubator ID card
•Policy for transport
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General Level Nursery
Design Criteria•No more than 16 bassinets/nursery
•Special care area required for close observation.
•If 16 beds or less - require 2 nurseries - 8 beds each for cohorting
•Minimum of 24 sq.. Ft. floor area.Three ft. between bassinets
•25% more bassinets than Ob beds.Multiple births
•One electrical outlet for each bassinet
•One incubator for every 10 bassinets
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Intermediate Level Nursery StaffingNurse manager
Medical director, Board Certified or Board Eligible Pediatrician
If no 24 hour basis Neonatologist on staff, the hospital, must have written agreement with another hospital for 24 hr telephone consult with a Board Certified Or Board Eligible Neonatologist
Hospital written collaborative agreements with other hospitals providing higher levels of care
Routine care 1:4 All personnel neonatal CPR trained
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Intermediate Level Nursery
Design CriteriaNo more than 16 bassinets/nursery
50 sq.. Ft. Floor area - 4 ft. Between bassinets and five feet wide aisles - (if renovated after 8/10/95)
Eight electrical outlets/infant station _ checked monthly
Two oxygen outlets/infant station
Two pressed air outlets/infant station
Two suction outlets/infant station
Portable x-ray machine outlet/nursery
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Specialty Level Nursery StaffingNurse manager:. Advance training for high risk
neonates Medical director:Bd. Cert or bd. Elig. Neonatologist Hospital written collaborative agreements with other hospitals providing higher level of care. May have more than one. Nursing Ratios: Routine care 1:3. All personnel must be neonatal CPR trained Education requirement for RNs: Advanced training and experience in management of neonatal specialized care and ventilation care
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Specialty Level Nursery
Design Criteria
No more than 16 bassinets/nursery 80 sq.. Ft. Floor area - 6 ft. Between bassinets and eight feet wide aisles - (if renovated after 8/10/95)Twelve electrical outlets/Infant station checked monthly Two oxygen outlets/Infant station Two compressed air outlets/Infant station Two suction outlets/infant station Portable x-ray machine outlet/nursery
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Sub-Specialty Level Nursery StaffingNeonatal clinical specialist
Medical director: Bd. Cert or Bd. Elig. Neonatologist
Nursing Ratios:
•Sub-specialty care: 1:2
•Multi-system support care 1:1
Education requirements for RNs
•Advanced training and experience in Management of high risk neonates, Unstable neonates and Multisystem problems
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Sub-Specialty Level Nursery Design CriteriaNo more than 16 bassinets/Nursery
80 sq.. Ft. Floor area - 6 ft. Between bassinets and eight feet wide aisles - (if renovated after 8/10/95)
Twelve electrical outlets/infant station - checked monthly
Two oxygen outlets/infant station
Two compressed air outlets/infant station
Two suction outlets/infant station
Portable x-ray machine outlet/nursery
65
Surgical ServicesNurse manager
Operating room register:
•Computerized
Roster of surgical privileges
•Current medical staff
•Temporary & locum tenens
•Non employee pass and scrubs
•Manufacturer's reps & visitors
Safety policies and procedures posted or check sheet on chart for h&p- informed consent - pre op diagnosis
66
Surgical Services
Medication system used: Pyxis Sure-Med Other
Crash cart for OR
•Where located, Documented checks daily
•Medication outdate checks, how documented?
Linen and hazardous waste disposal procedure
Equipment storage
Education
•Written plan for surgical unit specific continuing education documented activities for last year & current year
•Certifications
67
Post Anesthesia Care Unit
Nurse manager
Medication system used:
•Pyxis Sur-Med Other
•Documentation of narcotic use/waste
•Sharps boxes
Small blood spill policy awareness
linen storage: Clean, Soiled
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Post Anesthesia Care Unit
Crash cart/defibrillator:
•Documented daily checks
•Medication outdate checks - how documented
Unit specific written continuing education plan
•annual activities
•May be combined with surgery
69
Anesthesia Service
Chief of anesthesia
Number of anesthesiologists number of CRNAs
Contracted service?
Medication system used
Narcotic use and waste documentation
Anesthesia carts
•Standardized-
•Who checks for outdated medications
70
Anesthesia ServiceAnesthesia policies
Pre-anesthesia evaluation
•Done by a physician
•Review of pt's condition just prior to induction
•Both events recorded
Post-anesthesia evaluation
•Inpatients - (within 24-36 hours)
•Outpatient - may be done by another physician
Epidurals for pain management: Where performed
71
Sterile Supply Service
Physical barrier between contaminated work areas and clean work areas
Cleaning, prep, sterilizing, aeration, storage
Sterilizers/autoclaves
•New equipment approved by infection control committee
Written procedures
•Approved by infection control committee
•a. Sterilizing and storage procedures
•b. Waste disposal
Safety procedures/personnel/patients
72
Laundry Services
Distinct areas for the separate storage and handling of clean and soiled linens
Soiled areas - negative pressure
Transport of clean linens
•Transported in containers exclusive for clean linen
•Stored in areas designated exclusively for this purpose
73
Respiratory Therapy Service
Compliance with infection control policies
Compliance with oxygen safety policies
CLIA number if applicable
Number of blood gas machines
74
Physical Therapy
Number of physical therapists
Number of occupational therapists
Number of speech therapists
Verification of current license for all
•License posted
Whirlpool culture policy
•Frequency/review of culture results if done
•Debridement procedures done by pt
75
Physical Therapy
Compliance with infection control policies
Linen storage
Thermometers for hydroculators thermometers for refrigerator
Preventive maintenance for equipment
76
Pharmaceutical Services
Pharmacy director/chief pharmacist
Personnel
•Number of pharmacists: Full time & Part time
•Technicians
current license posted
•Pharmacists
•Pharmacy
Hours of operation:
•Access to pharmacy after hours, Method of access
77
Pharmaceutical Services
Number of satellite pharmacies:
•Where located
Medication systems used:
•Pyxis Sur-Med Med carts
•Refrigerated medication monitoring
•Outdate monitoring
•Policy for multi-dose vial use
Procedure for destruction of drugs:
•Outdated, Narcotics, and Others
78
Pharmaceutical Services
Procedure for reconciliation of In-house use of narcotics:
•Anesthesia
•Other clinical areas
Quality assurance:
•Pharmacy & Therapeutics Committee
•Adverse drug reaction reporting
•Definition, Average number/month, Number last year
•Formulary
79
Pharmaceutical Services
Laminar hoods
•Horizontal
•Date of last certification
•Vertical
•Date of last certification
Chemical bio-hazardous waste
(chemotherapy)
80
Dietary Services
Contracted service:
Food services manager:
Dietitian:
•Number of dietitians
•Full time/part time/consultant
•Consultant reports with hours and activities
•Policies for patient consult
•Assessment/teaching documentation
81
Dietary Services
Approved diet manual
•Frequency of approval
Sanitation check:
•Frequency,Last report
Temperature monitoring policy
•Refrigerator/freezers
•Checksheet with temp guides/action taken
•Who reviews checksheet
82
Dietary Services
Dish machine
•Final rinse temp.
•Who reviews temp. Log
Over range hood cleaning
•Frequency -(directly over range)
•Exhaust ducts
•Inspected and/or cleaned 2x/year
•By whom
83
Dietary Services
Dry storage
•6 inches from floor
•8 inches below sprinkler heads
•36 inches circumference around sprinkler head
Chemical/housekeeping storage - separate from food storage
Covered dumpster fly control
Employee interviews:
• Fire plan and dietary fire extinguishing equipment