Critical Access Hospitals
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Transcript Critical Access Hospitals
Critical Access
Hospitals
CAH
Introductions
• Background of program
– Reasons for mock surveys
– Planning for more than a year
Background of participants
– Hospitals
– Mock Surveyors
• Background of presenter
www.kdheks.gov
KDHE Vision - Healthy Kansans living in Safe Sustainable Environments
Objectives
Program Objectives
• Assist CAHs in meeting their goals of
providing the best patient care with best
practices
– Understanding the state and federal regulations
– Providing new eyes – recognize problem areas
– Providing possible corrective action that has
been successful in other hospitals
– Providing resources for assistance
Mock Surveyor Objectives
• Understand the survey methods used by
KDHE and CMS to survey CAHs
• Understand the difference between a CoP
and a standard regulation
• Understand the content of the CAH CoPs
including the use of interpretive guidelines
& procedures in Appendix W
• Be able to assist their CAH in meeting state
and federal regulations & improving patient
care.
Mock Survey Program
• One day of classroom – 8 hours
• 4 days of on the job training – Avg 30 hrs
– Reviewing
– Interviewing
– Observing
• Information Analysis, decision making and
writing up the report – Avg 6 hrs
• Exit interview – Avg 2 hrs
Mock Survey Process
• Pre-Entrance meeting
• Entrance conference
• Information gathering and investigation
– Observations, interviews and record reviews
• Daily conference with CEO
• Exit conference
PROCEDURES
• Focus on actual & potential patient outcomes
• Assess care & services provided including
appropriateness of care.
• Visit all care units, all campuses, outpatient areas,
surgery, ED, X-ray & rehabilitation areas.
• Observe actual care provided
• Check QA - has it been incorporated into each
department?
So What did we Find?
• 61 Federal & State regulatory concerns
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48 Federal
5 State
6 Risk Management
2 EMTALA
• 55 Federal & State regulatory concerns
– 42 Federal
– 7 State
– 6 Risk Management
• 32 Federal & State regulatory concerns
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23 Federal
5 State
1 Risk Management
3 EMTALA
CoP 0150
Compliance with State, Federal
and Local Laws and Regulations
Credentialing files
keeping up to date between times of
credentialing
CoP (C-0190 CFR 485.616)
Agreements
C195 CFR 485.616(b)
Agreements for Credentialing
and
Quality Assurance
COP - C0200 CFR 485.618
Emergency Services
Meets the needs of its IPs & OP’s
Problems noted
• Outdated Policies & Procedures
• What to do if H1N1 or TB symptoms
• Outdated supplies & drugs
• Equipment not checked
CoP
C0210 CFR 485.620
Number of Beds
Observation Patient Services
• IG require one person named to coordinate
OP services
Cop C0220 CFR 485.623
Physical Plant & Environment
• C0222(1)Housekeeping & preventative
maintenance programs that ensure
• Essential mechanical, electrical, & pt-care equipment is
maintained in safe operating condition
• C0223(2)Proper routine storage & prompt disposal
of trash
• C0224(3)Drugs & biologicals appropriately stored
• C0225(4)Premises are clean & orderly
Standard C0227 CFR 485.623(c)
Emergency Procedures
Non-medical emergencies
• Disaster Drills
CoP
CFR 485.627
Organizational Structure
(1) Governing Body/Responsible Individual
(2) The person responsible for the operation of the CAH
(3) The person responsible for the medical direction
Standard C0262 CFR 485.631(c)
PA, NP & CNS
Responsibilities
(1) Participate in development, execution & periodic review of the
policies
(2) Participate with physician in periodic review of patient records
CoP
C0270 CFR 485.635
Provision of Services
*Standard C0271 CFR 485.635(a)
Patient Care Policies
C0280 CFR 485.635(a)(4)
Policies reviewed annually by the
group of professional personnel
(1) Services are furnished in accordance with appropriate written
policies consistent with state laws
(2) A description of the services furnished directly & those
furnished through agreement or arrangement
(3) Policies include the following:
(1) Emergency medical services
(2) Guidelines for management of health problems including
those that require consultation &/or referral, maintenance
of health records, procedures for periodic review &
evaluation of services furnished by the CAH
(3) Rules for storage, handling, dispensation, &
administration of drugs & biologicals. In accordance with
accepted principles, current & accurate records kept, &
outdated, mislabeled. Or otherwise unusable drugs are not
available for pt use.
Standard C0285 CFR 485.635(c)
Services Provided Through
Agreements or Arrangements
• Must be well defined, but contracts not
needed – evidence that Gov Body is
responsible for services.
• Revised as needed
• QA – Gov Body assures services provided
according to acceptable standards
C0291 CFR 485.635(c)(3)
CAH maintains a list of all services
furnished under arrangements or
agreements with nature and scope of
services.
Standard C0294 CFR 485.635(d)
Nursing Services
• Ensure adequate training , orientation, supervision
of all nursing staff and non-CAH nursing staff and
that their clinical activities are evaluated and know
the P & Ps (a CAH-employed RN should conduct
the supervision & evaluation of the clinical
activities of non-CAH staff.)
C0298 CFR 485.635(d)(4)
Nursing Care Plan must be
developed & current for each pt
CoP
C0300 CFR 485.638
Clinical Records
• Legible, complete, accurate, readily
accessible, organized
• Confidentiality of record information and
provides safeguards against loss,
destruction, or unauthorized use.
Standard C0322 CFR 485.639(b)
Anesthesia Risk & Evaluation
• Each pt must be evaluated for proper
anesthesia recovery by a qualified staff
– Include-cardiopulmonary status; level of
consciousness; any follow-up care/observations;
and any complications during recovery
CoP C0330 CFR 485.641
Periodic Evaluation & QA
• Standard C0331 CFR 485.641(a) Periodic
evaluation – all services at least annually
• C0332 - # of patients served & volume of services
• C0333 - Review of active & closed records
• C0334 - Health care policies – reviewed as part of
QA program
• C0335 – The utilization of services was
appropriate, established policies were followed &
changes were made as needed
HANDWASHING
MEDICAL ERRORS
INFECTION CONTROL
SWING BED
C0360 CFR 485.645(d)
SNF Services
C0385 CFR 483.15(f) Rights
Activities
• Provide ongoing program of activities designed to
meet, according to comprehensive assessment,
the interests & physical, mental, & psychosocial
well-being of each resident.
C0404 CFR 483. 55
Dental Services
• The CAH must assist residents in obtaining
routine and 24 hr emergency dental care
STATE REGULATIONS
• KAR 28-34-10a(c) Meds requiring
refrigeration must be stored in refrigerators
dedicated to drug storage only
• KAR 28-34-10a(d) P&T committee must
meet at least quarterly with med staff,
nursing & Pharmacist
• KAR 28-34-17b Must have a policy that
determines the circumstances which require
the presence of an assistant during surgery
and determine whether the assistant should
be a physician or nonprofessional personnel
KAR 28-34-18 OB & Newborn Services
– Must have continuous coverage by a qualified
member of nursing staff with qualified RN
immediately available
– Safety of newborn
– Nursery available
– Policy for flow of staff - OB & other areas
– Peri-Natal committee with appropriate medical
staff & nursing
KAR 28-34-28(c)
ICU or CCU
•
•
•
•
Distinctly identifiable
Headed by qualified RN
Staffed by qualified person when occupied
Sufficient equipment to carry our intensive
care
• Intensive care or coronary care committee
of the medical staff
• Policies & procedures
KAR 28-34-13
Central Sterilizing & Supply
• Expired sterile supplies
KAR 28-34-8a
Personnel
• P & P reviewed at least every 2 years
• Personnel files for each staff member which
include education, training, experience,
periodic work evaluations
• Health records-initial health exam upon
employment, appropriate to duties of the
employee, including x-ray or TB skin
testing. Subsequent medical exams or
health assessments per facility policy
Risk Management
First Do No Harm
To Error is Human
• To Error is Human-view errors as
opportunities for improvement
• You will not minimize occurrences unless
you know all the facts.
• In order to know all of the facts you must
look at the process as well as the individual.
Investigation
Multiple Issues/Providers
KAR 28-52-4 (b)
• Separate standard of care determinations
shall be made for each involved provider
and each clinical issue reasonably presented
by the facts.
Prevention of harm to patients is
achievable but is not a static
condition. It is a never ending
process that requires strong
leadership commitment at all
levels of the organization
Remarks from Hospitals
• All three facilities felt it was a great success
• – gave them insight into problem areas & ideas
on how to improve QA/QI/PI to make it more
valuable in improving care
– Staff discussions with participants (they aren’t
alone in their struggle to provide the best care
possible)
– Having a better understanding of the
regulations and need to comply
– It was great to hear about the things needing
improvement and doing so without it being
official
Remarks from Mock Surveyors
• It was an opportunity to learn the standards
and different ways they can be met or
violated. Knowing about a rule is one thing
but truly understanding why the rule exists
and sometimes the many ways it can be
applied. It takes someone with knowledge
to connect the dots
• The sharing/networking of information and
resources both with the facility and the
other mock surveyors has been invaluable
Accomplishments
• We now have 18 CAHs with a mock
surveyor to lead their hospitals in improving
patient care
• Those 18 surveyors and their hospitals have
approved the plan of these 18 teaming up
with 2 per hospital and completing a mock
survey at 9 more CAHs.
• That could total as many as 27 CAHs with
an increase of knowledge of the regulations
and ways to improve patient care
What Next
• Support/resources needed for mock
surveyors
• Assignment by KHA for the 18 trained
mock surveyors to survey other CAHs (9
total CAHs) – this needs to be completed
ASAP