Transcript Document
Thank you for inviting me!
Charles Moore
Director Medical
Facilities
Bureau of Child Care
& Health Facilities
Agenda
Physician Response Time
Construction Requirements
Disaster Preparedness Plans
Budget Issues-Mission & Priority Document
Why Disaster Preparedness and
Plans are important.
KAR 28-34-3a
General Requirements - specifies
what measures the facility needs
to take with regard to internal
and external disaster plans.
CAH’s are also surveyed in
accordance with federal
regulations
C-0227
§485.623(c) Standard: Emergency Procedures
The CAH assures the safety of patients in nonmedical emergencies by-(1) Training staff in handling emergencies,
including prompt reporting of fires, extinguishing
of fires, protection and, where necessary,
evacuation of patients, personnel, and guests, and
cooperation with fire fighting and disaster
authorities;
Here is a sample of what CMS has directed our
survey to look for…….
• How does the CAH ensure that all personnel on its
staff, including new additions to the staff, are trained
to manage non-medical emergencies?
• Ask facility staff what they are supposed to do in
case of an emergency such as a tornado or a
blizzard.
• Review staff training documents and inservice
records to validate training.
• Review the CAH’S written fire control plans to
verify they contain the required provisions of the Life
Safety Code or State law.
• Verify that CAH staff reported all fires as required
to State officials.
• Interview staff throughout the facility to verify their
knowledge of their responsibilities during a fire (this
is usually done during the LSC survey, but health
surveyors may also verify staff knowledge).
Physician response time……
Physician Response Time in
CAH’s
42 CFR 485.618(d)
There must be a doctor of medicine or
osteopothy, a physician assistant, or a
practitioner with training or experience in
emergency care on call and immediately
available by telephone or radio contact,
and available on site within the following
time frames:
(A) Within 30 minutes, on a 24
hour a day basis, if the CAH is
located in an area other than an
area described as a frontier area:
or
(B)
Within 60 minutes, on a 24
hour basis, if the CAH is located in what
the state has determined is a frontier
county. Those counties that have been
defined as frontier (meaning fewer than
6 residents per square mile - see
following map and information)
Construction………
Remodeling, Renovation and
New Construction
Please remember to have your architect contact
me.
All hospital construction, including new buildings and additions or
alterations to existing buildings, shall be in accordance with the
standards set forth in the American institute of architects academy of
architecture for health, publication No. ISBN 1-55835-151-5, entitled
“1996-97 Guidelines for Design and Construction of Hospitals
and Health Care Facilities,” copyrighted in 1996, and hereby adopted
by reference in KAR 28-34-32b.
What about the new guidelines?
Architects can always ask
for an exception to have
portions or all of the new
construction or renovation
meet the 2001, 2006 or the
upcoming 2010
Guidelines.
Much like the entire health
care filed, there will
always be change.
Before commencing construction, the
architect shall certify, in writing, to the
Kansas Department of Health and
Environment (KDHE) that the contract
documents are in compliance with
subsections (a), (b), and (c) of KAR 2834-32b.
Federal Budget Issues
Funds are still
not sufficient in
FY 2009 budget
to conduct initial
surveys without
CMS approval.
What this means to the providers in
Kansas is that for initial certification
surveys…
…the burden is on the applicant to provide
data and other evidence that effectively
establish the probability of serious, adverse
beneficiary health care access consequences
if the provider is not enrolled to participate
in Medicare.
32 Initial Survey requests since
Oct 1, 2007
ESRD
ASC
HHA
Hospice
RHC
Hospital
Sw ing Bed
Corf
Employment and Staffing ??
While we have 11 full time
equivalents approved for our
budget we currently have 9
FTE’s with no possibility at this
time of hiring more health facility
surveyors or replacing any that
might leave.
Who to call:
Charles Moore, Director Medical Services
Bureau of Child Care & Health Facilities
1000 SW Jackson, Suite 200
Topeka, KS 66612
e-mail: [email protected]
Charles Direct Line
FAX:
785-296-0131
785-291-3419
Web site for Critical Access
Hospital (CAH) Federal
Regulations and Guidelines
Appendix W
http://www.kdheks.gov/bcchf/index.html
Click on Bureau of Health Facilities and then
forms to get to the above.
Other contacts in our Bureau:
Anita Hodge RN, State Survey Manager
Lynn Searles, Risk Management Specialist
Tamara Wilkerson, Licensure & Certification
Coordinator
Lois Wilkins, Sr. Admin Assist-Licensure
Theresa Carter, Sr. Admin Assist-Certification
(all are Area code 785)
296-0127
291-3552
296-1263
296-1258
296-1249
QUESTIONS?