Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys...
Transcript of Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys...
![Page 1: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/1.jpg)
Critical Access
Hospitals
CAH
![Page 2: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/2.jpg)
Introductions
• Background of program– Reasons for mock surveys– Planning for more than a year
Background of participants– Hospitals– Mock Surveyors
• Background of presenter
![Page 3: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/3.jpg)
www.kdheks.gov
KDHE Vision - Healthy Kansans living in Safe Sustainable Environments
![Page 4: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/4.jpg)
![Page 5: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/5.jpg)
Objectives
![Page 6: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/6.jpg)
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
![Page 7: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/7.jpg)
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.
![Page 8: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/8.jpg)
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
![Page 9: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/9.jpg)
Mock Survey Process
• Pre-Entrance meeting
• Entrance conference
• Information gathering and investigation– Observations, interviews and record reviews
• Daily conference with CEO
• Exit conference
![Page 10: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/10.jpg)
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?
![Page 11: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/11.jpg)
So What did we Find?
![Page 12: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/12.jpg)
• 61 Federal & State regulatory concerns– 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– 23 Federal
– 5 State
– 1 Risk Management
– 3 EMTALA
![Page 13: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/13.jpg)
CoP 0150Compliance with State, Federal
and Local Laws and Regulations
Credentialing files
keeping up to date between times of credentialing
![Page 14: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/14.jpg)
CoP (C-0190 CFR 485.616)Agreements
C195 CFR 485.616(b)
Agreements for Credentialing and
Quality Assurance
![Page 15: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/15.jpg)
COP - C0200 CFR 485.618Emergency Services
Meets the needs of its IPs & OP’s
![Page 16: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/16.jpg)
CoPC0210 CFR 485.620
Number of Beds
![Page 17: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/17.jpg)
Observation Patient Services
• IG require one person named to coordinate OP services
![Page 18: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/18.jpg)
Cop C0220 CFR 485.623Physical 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
![Page 19: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/19.jpg)
Standard C0227 CFR 485.623(c)Emergency Procedures
Non-medical emergencies
• Disaster Drills
![Page 20: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/20.jpg)
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
![Page 21: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/21.jpg)
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
![Page 22: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/22.jpg)
CoP C0270 CFR 485.635Provision of Services
*Standard C0271 CFR 485.635(a) Patient Care Policies
![Page 23: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/23.jpg)
C0280 CFR 485.635(a)(4) Policies reviewed annually by the group of professional personnel
![Page 24: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/24.jpg)
(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.
![Page 25: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/25.jpg)
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
![Page 26: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/26.jpg)
C0291 CFR 485.635(c)(3)CAH maintains a list of all services furnished under arrangements or agreements with nature and scope of services.
![Page 27: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/27.jpg)
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.)
![Page 28: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/28.jpg)
C0298 CFR 485.635(d)(4)Nursing Care Plan must be
developed & current for each pt
![Page 29: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/29.jpg)
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.
![Page 30: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/30.jpg)
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
![Page 31: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/31.jpg)
CoP C0330 CFR 485.641Periodic 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
![Page 32: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/32.jpg)
HANDWASHINGMEDICAL ERRORS
INFECTION CONTROL
![Page 33: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/33.jpg)
SWING BEDC0360 CFR 485.645(d)
SNF Services
![Page 34: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/34.jpg)
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.
![Page 35: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/35.jpg)
C0404 CFR 483. 55Dental Services
• The CAH must assist residents in obtaining routine and 24 hr emergency dental care
![Page 36: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/36.jpg)
STATE REGULATIONS
![Page 37: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/37.jpg)
• 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
![Page 38: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/38.jpg)
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
![Page 39: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/39.jpg)
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
![Page 40: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/40.jpg)
KAR 28-34-13Central Sterilizing & Supply
• Expired sterile supplies
![Page 41: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/41.jpg)
KAR 28-34-8aPersonnel
• 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
![Page 42: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/42.jpg)
Risk Management
First Do No Harm
![Page 43: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/43.jpg)
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.
![Page 44: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/44.jpg)
InvestigationMultiple 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.
![Page 45: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/45.jpg)
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
![Page 46: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/46.jpg)
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
![Page 47: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/47.jpg)
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
![Page 48: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/48.jpg)
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
![Page 49: Critical Access Hospitals CAH Introductions Background of program –Reasons for mock surveys –Planning for more than a year Background of participants.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649e2b5503460f94b19145/html5/thumbnails/49.jpg)
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