Salem Hospital Plan of Correction 6-11-12

7/28/2019 Salem Hospital Plan of Correction 6-11-12

1/4

Plan of Correction OHA, Health Care Regulation & Quality ImprovementCenters for Medicare and Medicaid ServicesProvider Number 38-0051 Complaint Number #s OR7583 and OR 7617

RESPONSE TO PREFIX TAG A 131CFR 482.13(b)(2) PATIENT RIGHTS: INFORMED CONSENTThe patient or his/her representative has the right to make informed decisions regarding his/her care.This STANDARD is not met as evidenced by 1 of 3 pediatric patients who received anesthesia services,it was determined that the hospital failed to ensure the patient representative's right to be fully informedof the patient's health status, including the outcome and treatments provided during recovery fromanesthesia services.Plan of Correction:

1. Develop an Anesthesia policy describing the communication processes needed whenunanticipated outcomes or adverse events occur in children undergoing anesthesia, even ifthe risk of the occurrence or event was discussed in the informed consent process(Procedure, Alternatives, Risk and Benefits (PARQ).2. Achieve approval of the policy from the Vice-President of Surgical Services and theAnesthesia Section by 8/10/2012.

3. Educate all applicable physicians and clinical staff by 8/24/2012 prior to policyimplementation on that date.4. Finalize metrics and monitoring plan in collaboration with Anesthesia Section and nursingstaff and implement monitoring by 8/27/2012. Suggested metrics include:

a. Track and analyze unanticipated outcomes and take appropriate actions as needed.b. # of times communication with family/representatives is documented when PACUrecovery is >90 minutes/total number of cases with recovery time of >90 minutes(pediatric cases). Target: 95%c. Monitoring will occur until target is reached and sustained for 2 months, and thenrandomly thereafter.d. Results to be reported to Anesthesia Section Chief and Vice President SurgicalServices monthlyResponsible Parties: Section Chief, AnesthesiaVice President, Surgical ServicesTime of Completion: As noted above

RESPONSE TO PREFIX TAG A 1003CFR 482.52(b)(2) ANESTHESIA RECORDA pre-anesthesia evaluation is completed and documented by an individual qualified to administeranesthesia, performed within 48 hours prior to surgery or a procedure requiring anesthesia services.

This STANDARD is not met as the hospital failed to fully develop and implement an anesthesia policyand procedure to ensure a pre-anesthesia evaluation was completed and documented within 48 hours,

1


2/4

Plan of Correction OHA, Health Care Regulation & Quality ImprovementCenters for Medicare and Medicaid ServicesProvider Number 38-0051 Complaint Number #s OR7583 and OR 7617and that that the evaluation was dated and timed to show that it occurred prior to induction ofanesthesia.A routine audit of anesthesiologist documentation was done in February, 2012. The results were sharedwith the Anesthesia Section Chief who coached the Anesthesia members to comply with the regulatoryrequirements for documentation of pre-anesthesia evaluations, and the need to ensure that the note wastimed. A second audit was completed in July which showed improved performance.Plan of Correction:

1. Develop a Medical Staff policy for performance and documentation of a pre-anesthesiaevaluation2. Achieve approval of the policy from the Anesthesia Section and the Medical ExecutiveCommittee by 8/10/2012.3. Educate all applicable practitioners prior to policy implementation date of 8/24/2012.4. Monitor for compliance beginning 8/27/2012. Metrics are:

a. Sample size: 1 case per credentialed anesthesiologist per monthb. Number of pre-anesthesia evaluations documented/Total number of cases in sample.

Target: 100%c. Number of pre-anesthesia evaluations dated and timed/total number of cases in sample.Target: 100%d. Monitoring will focus on anesthesiologists who cannot achieve and sustain performanceat target.

5. The Anesthesia Section Chief will continue to have one-to-one conversations with individualanesthesiologists who are not compliant with documentation requirements.6. Continued non-compliance following the discussion with the Section Chief will be handledthrough the Contract Management process.

Responsible Party: Anesthesia Section ChiefVice President, Surgical ServicesDate of Completion: As noted above

RESPONSE TO TAG A 1005CFR 482.52(b)(3) POST-ANESTHESIA EVALUATIONA post-anesthesia evaluation is completed and documented by an individual qualified to administeranesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services.

This STANDARD is not met as the hospital failed to fully develop and implement its anesthesia policiesto ensure a post-anesthesia evaluation was completed no later than 48 hours after surgery as required.A routine audit of anesthesiologist documentation was done in February, 2012. The results were sharedwith the Anesthesia Section Chief who coached the Anesthesia members to comply with the regulatoryrequirements for documentation of pre-anesthesia evaluations, and the need to ensure that the note wastimed. A second audit was completed in July which showed improved performance.Plan of Correction:

2


3/4

Plan of Correction OHA, Health Care Regulation & Quality ImprovementCenters for Medicare and Medicaid ServicesProvider Number 38-0051 Complaint Number #s OR7583 and OR 76171. Develop a Medical Staff policy for performance and documentation of a post-anesthesiaevaluation2. Achieve approval of the policy from the Anesthesia Section and the Medical ExecutiveCommittee by 8/10/2012.3. Educate all applicable practitioners prior to policy implementation date of 8/24/2012.4. Monitor for compliance beginning 8/27/2012. Metrics are:a. Sample size: 1 case per credentialed anesthesiologist per month

b. Number of post-anesthesia evaluations documented{fotal number of cases in sample.Target: 100%

c. Number of post-anesthesia evaluations dated and timed/total number of cases insample. Target: 100%d. Monitoring will focus on anesthesiologists who cannot achieve and sustain performanceat target.

5. The Anesthesia Section Chief will continue to have one-to-one conversations with individualanesthesiologists who are not compliant with documentation requirements.6. Continued non-compliance by specific anesthesiologists will be handled through the ContractManagement process.

Responsible Party: Anesthesia Section ChiefVice-President, Surgical ServicesDate of Completion: As noted above

RESPONSE TO TAG A 9999OAR 333-505-0030{3)(d) ORGANIZATION

Hospital policies which required that a hospital adopt, maintain, and follow writ ten patient care policiesthat include all patient care services provided by the hospital.Plan of Correction:Refer to Tags A 1003 and A 1005 as stated above.

OAR 333-505-0033 PATIENT RIGHTSRequires that a hospital comply with the requirements for patient rights set out in 42 CFR 482.13Plan of Correction:Refer to Tag A 131 as stated above.

3


4/4

Plan of Correction OHA, Health Care Regulation & Quality ImprovementCenters fo r Medicare and Medicaid ServicesProvider Number 38-0051 Complaint Number #s OR7583 and OR 7617

4

Salem Hospital Plan of Correction 6-11-12

Documents

Transcript of Salem Hospital Plan of Correction 6-11-12