1. www.FletcherAllen.org 1 Fletcher Allen Health Care Burlington, VT Is a CMS Survey in Your Future? Dawn LeBaron, Vice President for Hospital Services Jack Conry, Director of Security, Safety, and Parking Lindsay Harbour, Safety Specialist

2. www.FletcherAllen.org 2 Is a CMS Survey in Your Future? Fletcher Allen Health Care Three Main Campuses:  Medical Center Campus  Fanny Allen Campus  University Health Center (UHC) Campus  45+ Satellite Campuses

3. www.FletcherAllen.org 3 Is a CMS Survey in Your Future? Medical Center Campus  Largest Campus – hospital occupancy  Facility = 1.5 million SF  Surface Parking & Grounds = 1 million SF  Two Garages = 585,000 SF

4. www.FletcherAllen.org 4 Is a CMS Survey in Your Future? Fanny Allen Campus  2 nd Largest Campus – hospital occupancy  Facility = 118,000 SF  Surface Parking & Grounds = 948,000 SF

5. www.FletcherAllen.org 5 Is a CMS Survey in Your Future? University Health Center Campus  Physician Offices – business occupancy  Facility = 250,000 SF  Surface Parking & Grounds = 273,000 SF

6. www.FletcherAllen.org 6 Is a CMS Survey in Your Future? Serving a population of one million:  Level 1 Trauma Center  562 licensed beds, 458 staffed  2,183 births  50,419 inpatient and outpatient admissions  60,356 emergency department visits  1,108,682 physician encounters

7. www.FletcherAllen.org 7 Is a CMS Survey in Your Future?  2.4 million lab tests  1.44 million meals served  6,700 employees (including per diem & part- time)  450 UVM Medical Group physicians (770 total medical staff)  280 house staff (physicians in specialty training); 15 residency programs  $8.7 million in charity care

8. www.FletcherAllen.org 8 Is a CMS Survey in Your Future? Today’s Discussion:  Health care regulatory agencies  CMS overview  What lead to a full CMS survey at Fletcher Allen  The CMS Life Safety tour and findings  Life Safety hot spots  EOC hot spots  Fletcher Allen’s full Joint Commission Survey

9. www.FletcherAllen.org 9 Is a CMS Survey in Your Future? Regulatory Agencies Fletcher Allen is reviewed by 30+ agencies. Primary agencies are:  Joint Commission  Centers for Medicare /Medicaid Services ( CMS)  State / Local Licensing Agencies

10. www.FletcherAllen.org 10 Is a CMS Survey in Your Future? Fletcher Allen Health Care FY11 (3 quarters) 10/1/10 – 6/30/11 27 Regulatory “Site Visits” AgencyNameOn-Site Visits Division of Licensing and Protection10 CMS3 Food and Drug Administration3 VOSHA2 Joint Commission2 American Association of Blood banks1 American College of Surgeons Trauma1 Division of Alcohol and Drug Abuse Program1 Division of Mental Health1 Environmental Protection Agency (EPA)1 Homeland Security1 Nuclear Regulatory Commission1

11. www.FletcherAllen.org 11 Is a CMS Survey in Your Future?

12. www.FletcherAllen.org 12 Is a CMS Survey in Your Future? Fletcher Allen Regulatory Site Visits:  Division of Licensing and Protection/ CMS (13)  Complaint Allegation Surveys (10)  Full Survey (1)  Durable Medical Equipment (2)

13. www.FletcherAllen.org 13 Is a CMS Survey in Your Future?  Other agencies (14)  Joint Commission (2)  1 in response to CMS findings  1 Stroke Certification  Environmental Protection Agency (1)  Nuclear Regulatory Commission (1)  FDA (3)  Department of Mental Health (1)  American College of Surgeons (1)  VOSHA (2)  American Association of Bloodbanks (1)  Homeland Security (1)  Division of Alcohol and Drug Abuse (1)

14. www.FletcherAllen.org 14 Is a CMS Survey in Your Future? Regulatory Costs:  Year to Date = $177, 000  Includes: Escort, coordination of surveys, survey interview sessions, development of POC and writing of plans.  Other costs:  TJC follow up survey = $5,000  Total = $182,000

15. www.FletcherAllen.org 15 Is a CMS Survey in your Future? CMS

16. www.FletcherAllen.org 16 Is a CMS Survey in Your Future? Who is CMS?  A branch of the U.S. Department of Health and Human Services.  A federal agency that:  administers the Medicare program and  monitors the Medicaid programs offered by each state.  The United States is set up into sections of CMS boards  Vermont reports to the Boston section.

17. www.FletcherAllen.org 17 Is a CMS Survey in Your Future? What Triggers a CMS Survey?  Complaint Allegation  Self Report – Obligated to report:  Allegations of abuse  “Critical Incidents” in Mental Health (VT)  Validation Survey  Within 60 days of TJC survey  A quality check on TJC

18. www.FletcherAllen.org 18 Is a CMS Survey in Your Future? CMS Survey Results: “Statement of Deficiencies”  No Findings  Standard Level Finding  Conditional Level Finding  Immediate Jeopardy

19. www.FletcherAllen.org 19 Is a CMS Survey in Your Future? Standard Level Finding:  Typically do not require a response  However if an organization is found to be out of compliance at the condition level from a previous finding – they require response/ follow up survey Condition Level Finding:  Requires a formal organizational response.  It triggers:  A follow-up “focused survey” and  A full CMS survey

20. www.FletcherAllen.org 20 Is a CMS Survey in Your Future? Immediate Jeopardy:  Defined by CMS as: “A crisis situation in which the health and safety of individuals are at risk (see §SOM 3010).”  It carries a threat of termination procedures if “conditions” are not resolved within 23 days.  The hospital can lose Medicare funding.  Requires a formal response by organization  It triggers:  A follow-up “focused survey” and  A CMS “full survey” and  A follow-up “Joint Commission” survey

21. www.FletcherAllen.org 21 Is a CMS Survey in your Future? So, what happened at Fletcher Allen?

22. www.FletcherAllen.org 22 Is a CMS Survey in Your Future? Monday, December 20, 2010  3 surveyors arrive unannounced for a 3 day survey  4 complaint allegations, 1 involving the Cardiac Cath Lab Cath Lab complaint allegation involved patient complaint about consent (only physician can treat).  No EOC involvement at this point Tuesday, January 11, 2011  2 surveyors arrive unannounced for a 2 day survey  Follow-up from the 12/20/10 survey  Focus of survey is Cardiac Cath Lab and EP (Electrophysiology) Service Tuesday, January 11, 2011  End of the day tour of Cath Lab.  Debris and brown stains on the floor.  Cleaning process described. Wednesday, January 12, 2011  7:30 am continuation of the Cath Lab tour from 1/11/11.  Room Cleaning – Trash emptied, but debris and stains still on floor.  Patient scheduled for 8:00 am

23. www.FletcherAllen.org 23 Is a CMS Survey in Your Future? Cath Lab Survey Results-1/13/11 Four “Condition Level” Findings :  Governance  Medical Staff  Infection Control  Patient Rights & Ethics  Plan for Correction (POC) due 2/8/11  Sparked a full unannounced CMS survey

24. www.FletcherAllen.org 24 Is a CMS Survey in Your Future? Statement of Deficiencies & Plan of Correction  Corrective action the hospital will being implementing  Plan for educating  Plan for monitoring CMS Form 2567

25. www.FletcherAllen.org 25 Is a CMS Survey in Your Future? Wednesday, January 19, 2011  3 surveyors arrive unannounced for a 3 day survey (complaint allegation)  Survey focused on the Emergency Department and EMTALA  EMTALA Emergency Medical Treatment and Labor Act  Perform medical screening exam  Treat/ stabilize

26. www.FletcherAllen.org 26 Is a CMS Survey in Your Future? EMTALA Survey Results Immediate Jeopardy!  Posting of Signs (489.20.q)  Medical Screening Exam (489.24.c)  Stabilizing Treatment (489.24.c.1-3)  Plan of Correction  Sparked a CMS focused survey  Sparked another CMS full survey!  Sparked a JC follow-up survey

27. www.FletcherAllen.org 27 Is a CMS Survey in Your Future? Tuesday, March 8, 2011 Full CMS Survey:  13 surveyors arrive unannounced for a 4 day full CMS full survey (includes 2 Life Safety Surveyors)  Originally sparked by December 2010 Cath Lab complaint allegation.  Full Survey offers CMS surveyors the opportunity to look at all self reports. Thursday, March 10, 2011  1 TJC surveyor arrives unannounced for a 1 day survey  A follow-up survey to the EMTALA finding.

28. www.FletcherAllen.org 28 Is a CMS Survey in Your Future? Surveyor 1  Surgical Services  Medical Records  Infection Control  Nursing: SICU Surveyor 2  Discharge Planning  UR  Emergency Services  Nursing: OB, NICU, Pedi ICU Surveyor 3 & 4  Rehab: Cost reporting  Rehab Services  Outpatient Services  Nursing: McClure 6 Surveyor 5  Psych Unit (with Surveyor 9)  Psych Unit Complaints (2)  Organ & Tissue Procurement Surveyor 6  Compliance with local, state, federal laws  Governing Body  Emergency Services (with Surveyor 2)  Medical Staff  Nursing: Administrative Review Surveyor 7  Pharmacy with 1 complaint  Radiology  Nuclear  Nursing: MICU, Baird 6 Surveyor 8  Laboratory Services  Physical Environment  Respiratory Services  Nursing: Shepardson 6, Baird 4 Surveyor 9  Psych Unit (with surveyor 5)  Shepardson 3, Shepardson 6 Surveyor 10 & 11  Anesthesia Services  Patient Rights  QAPI Surveyor 12 (Life Safety)  ½ of Medical Center Campus  Fanny Allen Campus  4 Satellite Campuses Surveyor 13 (Life Safety)  ½ of Medical Center Campus  UHC Campus  2 Satellite Campuses

29. www.FletcherAllen.org 29 Is a CMS Survey in Your Future? Fletcher Allen’s Survey Plan:  CMS survey team assigned a large conference room as their home base.  Each CMS surveyor assigned a Fletcher Allen point of contact and escort.  Fletcher Allen home base established in close proximity to the CMS home base.

30. www.FletcherAllen.org 30 Is a CMS Survey in Your Future? CMS Full Survey: An opportunity for surveyors to review all “self reports”  Plastic wrist restraints  Pepper spray  Immediate Jeopardy!

31. www.FletcherAllen.org 31 Is a CMS Survey in Your Future? Full Survey “Hot Spots” Infection Prevention  Dressing changes  Sterile technique  Toys in waiting rooms  Cleaning of glucometers Medication Security  Med carts locked  Handling of meds EOC  Refrigerator logs  Hallway clutter  Alarm response Patient Confidentiality  Use of WOW’s Resuscitation Carts  Checked per written policy Medical Records  Were orders carried out  Documentation of action taken Pain Assessment  Multidisciplinary assessment  Documenting assessments  Completion of care plans  Assessment per policy Restraints  Written order  Documentation according to policy Quality & Safety  Explain PI process and projects

32. www.FletcherAllen.org 32 Is a CMS Survey in Your Future? Environment of Care Issues: Remember: 13 surveyors look at all of the EOC  Goose neck faucets on Psychiatric Unit  Shower controls on Psychiatric Unit  Loose handrails in hallways  Emergency Lighting in “procedure rooms”  Security of the Operating Room  Access signs for the Operating room  Refrigerator temperature logs in Dietary  Temperature and humidity logs in CSR  Cracked vinyl (tables and mattresses)

33. www.FletcherAllen.org 33 Is a CMS Survey in Your Future? BeforeAfter

34. www.FletcherAllen.org 34 Is a CMS Survey in Your Future? Before After

35. www.FletcherAllen.org 35 Is a CMS Survey in Your Future?

36. www.FletcherAllen.org 36 Is a CMS Survey in Your Future? CMS Life Safety Tour:  Two Life Safety surveyors – Both state fire marshals  Two Fletcher Allen escorts  Four Facilities Management/Safety escorts  Survey locations divided in two  Main hospital campus and two satellites  Fanny Allen campus and four satellites

37. www.FletcherAllen.org 37 Is a CMS Survey in Your Future? Life Safety ‘Hot Spots”  Fire stopping  Door closers  Fire doors close and latch  Stairwell storage  Door jambs with no doors  Delayed egress signs  Emergency lighting tests  Obstructed pull stations  GFCI outlets – 6’ from water  Extension cords  Smoke Detectors  spacing  36” from air supply  Power cord daisy chains  Sprinkler heads in storage closets  Storage within 18” of sprinkler  Electrical Panels  Labeling (including spares)  Open spaces  Broken latches

38. www.FletcherAllen.org 38 Is a CMS Survey in Your Future? CMS Home Base  13 Surveyor talking among themselves  Life Safety surveyor to Ambulatory Site surveyor: “Did you know that they are doing surgery at their Plastic Surgery site without emergency lighting?”  Immediate Jeopardy!

39. www.FletcherAllen.org 39 Is a CMS Survey in Your Future? 90 Life Safety Findings:  GFCI outlets (22)  Smoke detector/air handler (8)  Power strips interconnected (7)  Electrical panel labeling (5)  Smoke detector spacing (4)

40. www.FletcherAllen.org 40 Is a CMS Survey in Your Future? 90 Life Safety Findings (continued):  Penetrations/fire stopping (4)  Sprinkler head needed (4)  Door self closer needed (4)  Fire door does not close and latch (3)

41. www.FletcherAllen.org 41 Is a CMS Survey in Your Future? 90 Life Safety Findings (continued):  Electrical panel, open spaces (3)  Extension cords (3)  Electrical panel, broken latch (2)  Stairwell storage (2)  Kitchen hoods needed for frying (3)

42. www.FletcherAllen.org 42 Is a CMS Survey in Your Future? 90 Life Safety Findings (continued):  Emergency light malfunction (1)  Emergency light needed in generator room (1)  Pull station blocked (1)  Store room door removed (1)  Pre-action valve in stairwell (1)  Dirty smoke detector (1)  Storage 18” of sprinkler (1)  Strobe light blocked (1)  Outlet cover broken (1)  Cabinet on power cord (1)

43. www.FletcherAllen.org 43 Is a CMS Survey in Your Future? 90 Life Safety Findings (continued):  Suspended light blocking sprinkler (1)  Breaker lock missing (1)  Delayed egress sign (1)  Delayed egress not approved (1)  Fire proofing spray on metal beam (1)  Cooking staff knowledge of fire suppression system (1)  Wires above ceiling not supported (1)  Emergency light malfunction (1)

44. www.FletcherAllen.org 44 Is a CMS Survey in Your Future?

45. www.FletcherAllen.org 45 Is a CMS Survey in Your Future? CMS Lessons Learned:  It doesn’t matter how old the building. It is still held to current standards.  Know your “procedure rooms”.  Alert others in advance about the route of the tour.  In most cases, arguing gains nothing.  Surveyors take pictures and share with other surveyors.

46. www.FletcherAllen.org 46 Joint Commission Survey Joint Commission Full Survey  Monday, August 15, 2011  Seven (7) surveyors including one (1) Life Safety Engineer  Full five (5) day survey  Two (2) day Life Safety survey

47. www.FletcherAllen.org 47 Joint Commission Survey Environment of Care & Emergency Management Session: Documents provided upon arrival:  EOC Committee Meeting Minutes  Management Plans  Emergency Operation Plan  Annual Program Evaluations  Hazard Vulnerability Analysis  Inventory of Assets and Resources

48. www.FletcherAllen.org 48 Joint Commission Survey EOC & EM Issues:  EM.02.02.13 (EP2) – Not documented in the medical staff bylaws who may grant disaster privileges.  EC.02.06.01 (EP1) – Clean utility room with storage stacked too high to the ceiling. Hazardous to staff.  EC.02.02.01 (EP5) – Unlocked soiled utility room with hazardous items accessible to children (used AA batteries and bottles of cleaning solution).  IC.02.02.01 (EP3) – Expired surgical gloves, biogel gloves, and tampons.

49. www.FletcherAllen.org 49 Joint Commission Survey  LD.04.01.01 (EP3) – Exposed pipes under sinks in handicapped bathrooms (ADA violation).

50. www.FletcherAllen.org 50 Joint Commission Survey Life Safety Survey: Day One: Documentation Review Day Two: Building Tour

51. www.FletcherAllen.org 51 Joint Commission Survey TJC Life Safety Survey: Fletcher Allen Issues  EC.02.03.05 (EP6) – Documentation that electric fire pumps were run weekly for 10 minutes.  EC.02.03.05 (EP10) – No documentation for the quarterly inspection of water supply connections.  EC.02.03.05 (EP19) – No inventory of fans to ensure that all air handling units shut down properly.  EC.02.05.07 (EP4) – 42 days between generator tests one month of the year.  EC.02.05.07 (EP6) – 42 days between automatic transfer switch test one month of the year.

52. www.FletcherAllen.org 52 Joint Commission Survey TJC Life Safety Survey: Fletcher Allen Issues (continued)  EC.02.05.07 (EP7) – No documentation that emergency generator was operated for 4 continuous hours at least every 36 months.  EC.02.05.07 (EP8) – No documentation that emergency generator was operated at 30% nameplate rating for 4 continuous hours at least every 36 months.  LS.01.02.01 (EP3) – Written ILSM risk assessments not completed for each SOC Plan for Improvement.  LS.02.01.10 (EP5) – Fire door did not close and latch with vertical gap greater than 1/8”.

53. www.FletcherAllen.org 53 Joint Commission Survey TJC Life Safety Survey:| Issues continued:  LS.02.01.01 (EP6) – Fire door with kick plate larger than 16”.  LS.02.01.20 (EP13) – Hallway clutter (medication carts and soiled linen hampers).  LS.02.01.35 (EP4) – Conduit and HVAC duct resting on sprinkler pipes.

54. www.FletcherAllen.org 54 Joint Commission Survey Joint Commission Lessons Learned:  Documentation – Get it to the surveyors early.  Binders – Develop binders for documents the surveys are likely to request.  Have a plan for replacing organizational “experts”, if they are “on vacation”.

55. www.FletcherAllen.org 55 Is a CMS Survey in Your Future? Questions?

56. www.FletcherAllen.org 56 Is a CMS Survey in Your Future? Fletcher Allen Contact Information: Dawn LeBaron, Vice President for Hospital Services  802-847-2805  Dawn.lebaron@vtmednet.org Dawn.lebaron@vtmednet.org Lindsay Harbour, Safety Specialist  802-847-2284  Lindsay.harbour@vtmednet.org Lindsay.harbour@vtmednet.org Jack Conry, Director of Security, Safety, and Parking  802-847-2812  Jack.conry@vtmednet.org Jack.conry@vtmednet.org