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– 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

CoP 0150Compliance 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 485.618Emergency Services

Meets the needs of its IPs & OP’s

CoPC0210 CFR 485.620

Number of Beds

Observation Patient Services

• IG require one person named to coordinate OP services

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

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 485.635Provision 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 485.641Periodic 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

HANDWASHINGMEDICAL ERRORS

INFECTION CONTROL

SWING BEDC0360 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. 55Dental 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 28-34-13Central Sterilizing & Supply

• Expired sterile supplies

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

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.

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.

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