Critical Access Hospitals (CAH) What every CAH needs to know about the Conditions of Participation (CoPs)

2 Speaker  Sue Dill Calloway RN, Esq. CPHRM, CCMSCP  AD, BA, BSN, MSN, JD  President  Board Member Emergency Medicine Patient Safety Foundation www.empsf.org  614 791-1468  sdill1@columbus.rr.com 22

You Don’t Want One of These 3

4 Mandatory Compliance  Hospitals that participate in Medicare or Medicaid must meet the Conditions of Participation (COPs) for all patients in the facilities and not just those who are Medicare or Medicaid patients,  Hospitals accredited by the Joint Commission (TJC), AOA, CIHQ, or DNV Healthcare have what is called deemed status,

CAH Problematic Standards  Date and time on all orders and entries  Verbal orders, Cluttered hallways  H&Ps, Life safety code issues, EMTALA,  Informed consent, Cleanliness of dietary  Plan of care, Privacy and whiteboard,  Handling, dispensing, storage and administration of medications  Meeting the nutritional needs of patients  Healthcare services in accordance with P&P 5

CAH Problematic Standards  Medical record documentation must reflect the nursing process, Timing of medications  Legibility of the medical record, No orders  Equipment and supplies used in life saving procedure, Hand Hygiene & Gloving  R&S for PPS hospitals but CAH still need to do something, Failure to Monitor Patient for Safety (Suicide Precautions)  Infection control issues are big  What else should we add??? 6

Access to Hospital Complaint Data  CMS issued Survey and Certification memo on March 22, 2013 regarding access to hospital complaint data  Includes acute care and CAH hospitals  Does not include the plan of correction but can request  Questions to bettercare@cms.hhs.com  This is the CMS 2567 deficiency data and lists the tag numbers  Will update quarterly  Available under downloads on the hospital website at www.cms.gov 7

Access to Hospital Complaint Data  There is a list that includes the hospital’s name and the different tag numbers that were found to be out of compliance  Many on restraints and seclusion, EMTALA, infection control, patient rights including consent, advance directives and grievances  Two websites by private entities also publish the CMS nursing home survey data  The ProPublica website for LTC  The Association for Health Care Journalist (AHCJ) websites for hospitals 8

Access to Hospital Complaint Data 9

Updated Deficiency Data Reports 10 www.cms.gov/Medicare/Provider-Enrollment-and- Certification/CertificationandComplianc/Hospitals.html

11 Small or Rural Hospitals  American Hospital Association has Web site with good information for CAH  Has recent issues of interest to CAH  Excellent resources including current list of all CAHs in the US  Has CAH newsletters  go to http://www.aha.org/aha/issues/Rural- Health-Care/update-newsletters.html

AHA CAH Resources 12 www.aha.org/aha/issues/Rural- Health-Care/update- newsletters.html

AHA CAH Resources 13 www.aha.org/advocacy- issues/rural/update- newsletters.shtml

CMS Updated Website www.cms.gov 14

AHA Critical Access Website 15 www.aha.org/aha_app/issues/CAH/index.jsp

Rural Assistance Center 16 www.raconline.org

Rural Assistance Center 17 www.raconline.org

CMS CAH Website  CMS has a website for resources  Includes:  State operations manuals  Program transmittals  Guidance for laws and regulations for CAH  Medicare Learning network  Other helpful information 18

CMS CAH Website 19 http://www.cms.gov/Center/Provider- Type/Critical-Access-Hospitals- Center.html?redirect=/center/cah.asp ww.cms.gov/center/cah.asp

20 Critical Access Hospitals  Confusing when CMS says hospitals must do this but will specifically mention CAH must do…  Changes affecting CAH hospitals included Medicare Discharge Appeal Rights, Visitation and the Telemedicine  Verbal order Tag Number 297,H&P 320,  IV Medication and blood memo changed June 7, 2013  Informed consent 304 and 320,  Security of Medications 276,  Anesthesia assessments 321,  Infection control 278 but you should still look at these!  Privacy and confidentiality but you should look at these also!

21 The Conditions of Participation CoPs  First, published in the Federal Register  Federal Register available at no charge at www.gpoaccess.gov/fr/index.html  Next, CMS publishes Interpretive Guidelines and some include survey procedures,  Current CoP issued January 31, 2014  Changes to tag 162 and 226  CMS made many changes effective June 7, 2013  1 www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf

Subscribe to the Federal Register Free 22 http://listserv.access.gp o.gov/cgi- bin/wa.exe?SUBED1= FEDREGTOC-L&A=1

23 new website at www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf

24 www.cms.gov/manuals/Downloads/som107ap_w_cah.pdf and is critical access hospital CoPf

CAH Manual 232 Pages 25

CAH Services Direct Services or Contracts  CMS published more than 2 dozens changes to the hospital CoP in FR on May 16, 2012 and went into effect June 7, 2013  Several that impact CAHs  Currently. The CAH CoP requires that certain types of services be provided directly rather than through contracts or under arrangements  This included diagnostic and therapeutic services, lab and radiology services, and emergency procedures  CMS eliminated this requirement 26

CMS Final Changes Memo www.empsf.org 27

Feb 4, 2013 Proposed Changes  CMS issues 114 pages related to proposed changes to the CMS CoP  Hospital privileges for RD to write diet orders  Board must consult with chief medical officer for each individual hospital rea quality of medical care provided in the hospital  Confirmed each hospital must have separate medical staff  MS can include PharmD, dieticians, PA, NP, etc.  No requirement for board to include MD/DO 28

Feb 4, 2013 Proposed Changes  Allow practitioners not on MS to order outpatient services  Allow in-house preparation of radiopharmaceuticals on off hours without a physician or a pharmacist being present  3 changes for hospitals that are transplant centers  ASC change for radiology services incident to the surgery  Swing beds move to Part D so accreditation organizations can survey  CAH P&P committee deleted requirement for non staff member requirement 29

Feb 4, 2013 Proposed Changes 30 www.ofr.gov/inspection.aspx

31 How to Find Changes  Have one person in your facility who goes out to this website once a month and checks for updates,  www.cms.hhs.gov/SurveyCertificationGenI nfo/PMSR/list.asp,  You can do a search for time frame and can add words to search,  Click on fiscal year to bring up most current memos  CMS issues transmittal before putting it into the CAH Manual

CMS Survey and Certification Website 32 www.cms.gov/SurveyCertific ationGenInfo/PMSR/list.asp# TopOfPage

CMS Transmittals 34 http www.cms.gov/Transmittals/01_overview.asp

CMS Memo on Safe Injection Practices  CMS issues a 7 page memo on safe injection practices  Discusses the safe use of single dose medication to prevent healthcare associated infections (HAI)  Notes exception which is important especially in medications shortages  General rule is that single dose vial (SDV)can only be used on one patient  Will allow SDV to be used on multiple patients if prepared by pharmacist under laminar hood following USP 797 guidelines 35

Safe Injection Practices 36 http:// www.cms.gov/Medicare/Provider- Enrollment-and- Certification/SurveyCertificationGenInfo/index.ht ml?redirect=/SurveyCertificationGenInfo/PMSR/li st.asp

CMS Memo on Safe Injection Practices  All entries into a SDV for purposes of repackaging must be completed with 6 hours of the initial puncture in pharmacy following USP guidelines  Only exception of when SDV can be used on multiple patients  Otherwise using a single dose vial on multiple patients is a violation of CDC standards  CMS will cite hospital under the hospital CoP infection control standards since must provide sanitary environment  Also includes ASCs, hospice, LTC, home health, CAH, dialysis, etc. 37

CMS Memo on Safe Injection Practices  Bottom line is you can not use a single dose vial on multiple patients  CMS has section in IC worksheet on this  CMS requires hospitals to follow nationally recognized standards of care like the CDC guidelines  SDV typically lack an antimicrobial preservative  Once the vial is entered the contents can support the growth of microorganisms  The vials must have a beyond use date (BUD) and storage conditions on the label 38

CMS Memo on Safe Injection Practices  Make sure pharmacist has a copy of this memo  If medication is repackaged under an arrangement with an off site vendor or compounding facility ask for evidence they have adhered to 797 standards  ASHP Foundation has a tool for assessing contractors who provide sterile products  Go to www.ashpfoundation.org/MainMenuCategories/Practic eTools/SterileProductsTool.aspx  Click on starting using sterile products outsourcing tool now 39

Not All Vials Are Created Equal 40

CMS Memo on Insulin Pens  CMS issues memo on insulin pens  Insulin pens are intended to be used on one patient only  CMS notes that some healthcare providers are not aware of this  Insulin pens were used on more than one patient which is like sharing needles  Every patient must have their own insulin pen  Insulin pens must be marked with the patient’s name 41

CMS Memo on Insulin Pens  Regurgitation of blood into the insulin cartridge after injection can occur creating a risk if used on more than one patient  Hospital needs to have a policy and procedure  Staff should be educated regarding the safe use of insulin pens  More than 2,000 patients were notified in 2011 because an insulin pen was used on more than one patient  CDC issues reminder on same and has free flier 42

CDC Reminder on Insulin Pens 43 www.cdc.gov/injectionsafety/clinical-reminders/insulin- pens.html

CDC Has Flier for Hospitals on Insulin Pens 44

VA Alert on Insulin Pens  Pharmacist found several insulin pens not labeled for individual use  Found used multi-dose pen injectors used on multiple patients instead of one patient use  New requirement that can only be stored in pharmacy and never ward stocked  Instituted new education for staff on use  Part of annual competency of staff  Instituted new policy of safe use of pen injectors 45

VA Issues Alert 46

VA Alert on Insulin Pens  Decided to prohibit multi-dose insulin pen injectors on all patient units except the following:  Patients being educated prior to discharge to use a insulin pen injector  Eligible patient is self medication program  Patient needing treatment and no alternative formulation is available  Patients participating in a research protocol requiring an insulin pen  Pen injectors dispensed directly to patients as an outpatient prescription 47

FDA Issues An Alert in 2009 48

Insulin Pen Posters and Brochures Available 49 www.oneandonlycampaign.org /content/insulin-pen-safety

Pt Safety Briefs Free at www.empsf.org 51

Luer Misconnections Memo  CMS issues memo March 8, 2013  This has been a patient safety issues for many years  Staff can connect two things together that do not belong together because the ends match  For example, a patient had the blood pressure cuff connected to the IV and died of an air embolism  Luer connections easily link many medical components, accessories and delivery devices 52

Luer Misconnections Memo 53

PA Patient Safety Authority Article 54

June 2010 Pa Patient Safety Authority 55

ISMP Tubing Misconnections www.ismp.org 56

TJC Sentinel Event Alert #36 www,jointcommission.org 57 http://www.jointcommission.org/sentine l_event_alert_issue_36_tubing_misco nnections— a_persistent_and_potentially_deadly_ occurrence/

CMS Hospital Worksheets Third Revision  October 14, 2011 CMS issues a 137 page memo in the survey and certification section  It was pilot tested in hospitals in 11 states and on May 18, 2012 CMS published a second revised edition  Piloted test each of the 3 in every state over summer 2012  November 9, 2012 CMS issued the third revised worksheet which is now 88 pages  Memo discusses surveyor worksheets for hospitals by CMS during a hospital survey  Addresses discharge planning, infection control, and QAPI (performance improvement) 58

CMS Hospital Worksheets  This is the third and final pilot and in 2014 will be revised  Will use whenever a validation survey or certification survey is done at a hospital by CMS for PPS hospitals  Not currently being used for CAH  However, highly suggest that every CAH review and be aware of what is in these three forms  Helps to understand how the guidelines are interpreted 59

Third Revised Worksheets 60 www.cms.gov/SurveyCertificationGe nInfo/PMSR/list.asp#TopOfPage

62 CMS Hospital CoPs  Appendix W, Tag C-0150 to C 0408,  See visitation memo adding tag1000- 1002 which is after tag 298  Interpretive guidelines updated more frequently now  About 232 pages long,  Manual includes swing beds in CAHs,

CMS Hospital CoPs  Consider doing a gap analysis,  Take each section and on left hand side of page document how you comply with each section,  Time consuming but will have with compliance,  Include policies and yellow section that corresponds to the required P&P in the CoP  Have one person in charge who can keep up with changes and who knows what to do if CMS shows up for validation or complaint survey 63

64 Rehab or Behavioral Health Dept CAH  Remember, CAH can have up to a ten bed rehab or psych (behavioral health) unit  If so it is surveyed under the regular hospital CoP program even though CAH has a separate manual  It is Appendix A  Last updated January 31, 2014

65 TJC Revised Requirements  TJC or the Joint Commission (not called JCAHO anymore) has made many changes to bring their standards into closer alignment with CMS  Having less differences is helpful to hospitals,  Have some that are for hospitals that use them to get deemed status (DS) or payment for M/M patients,  Will specify DS after the standard

66 Condition Level Requirement Noncompliance

67 Deficiency  Condition level- (NOT GOOD) due to noncompliance with requirement in a single standard or several standards within the condition or single tag but represents a severe or critical health breach, (need to have conversation)  Standard level- noncompliance as above but not of such a character to limit facility’s capacity to furnish adequate care- no jeopardy or adverse effect to health or safety of patient,

68 Introduction  Medicare CoPs are found at 42 CFR Part 485 Subpart F.  Authority to make copies of things is at 42 CFR 489.53,  Recommend you have surveyor make you a copy also,  Please ask surveyor not to make copy of peer review material not to copy-abstract out what is needed,  Can get all CFR now electronically off Internet free at GPO access at www.gpoaccess.gov  Click on Code of Federal Regulations and can do search or click on e-CFR, or http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl,

69 Resources to Keep Handy  Appendix W Hospital CoPs (“C”)  Unless CAH has a separate rehab or behavioral health unit and then you need Appendix A- Hospital CoP also for these departments  Survey protocol and module,  Q- Immediate jeopardy.  V-EMTALA,  W-Hospital swing beds-if you have these,  B- Home health  I-Life safety code

70 Survey Procedure  The interpretive guidelines provide instructions to the surveyors on how to survey the CoPs-like questions to the test,  They have survey procedure instructions to determine the hospital policy for notifying patients of their rights,  Ask patients to tell you if the hospital told them about their rights,  Deficiency citation show how the entity failed to comply with regulatory requirements and not the guidelines!

71 Survey Protocol  First 26 pages list the survey protocol, Includes a section on:  Off-survey preparation,  Entrance activities,  Information gathering/investigation,  Preliminary decision making and analysis of finding,  Exit conference,  Post survey activities,

72 Swing Bed Module  When patients need brief transitional care at the hospital at the end of their acute care stay,  If swing beds then do survey under CAH swing- bed requirements found at 42 CFR Part 485.645,  Reimbursement is for Skilled Nursing care as opposed to Acute Care,  Term is for reimbursement and has no relationship to geographic location in the hospital, ..

73 Swing Bed Module  May be in acute care status one day and then in swing bed status the next day,  3-day qualifying stay for the same spell of illness in any hospital or CAH is required prior to admission to swing- bed status,  Actual swing-bed survey requirements are referenced in the Medicare Nursing Homes requirements at 42 CFR Pt 483

74 Swing Bed Counts  Surveyor will verify 25 bed rule,  Will count inpatient beds but not observation beds,  Does not count OR, PACU, L&D, newborn nursery or ED stretchers, exam tables, or observation beds (210),  Do count birthing beds where patients remain after giving birth,  Do not count beds in Medicare certified rehab or psychiatric distinct part units,  Will conduct open record review on all swing bed patients,  Swing bed deficiencies are documented on a separate form even though survey done simultaneously,

75 Regulation/Interpretive Guidelines  Starts with a tag number, example C-0150,  C refers to the CAH CoPs,  Recall first is the section from federal register (CFR)  Then the section called the “interpretive guidelines”,  Some have a section called “Survey Procedure” and will explain how it is surveyed or what policies will be reviewed, what questions to ask or documents to look at,

76 Compliance with Laws C-150  Standard: The CAH must be in compliance with all federal, state, and local laws,  Surveyor may interview CEO or other designated by hospital to determine this,  May refer non-compliance to proper agency with jurisdiction such as OSHA  TB, blood borne pathogen, universal precautions, or EPA (haz mat or waste issues),

Advance Directives 151 2013  Standard: CAH must be in compliance with federal laws and regulations related to the health and safety of patients  Inpatients and outpatients have the right to make advance directives  Staff must comply with their advance directives  Patients have the right to refuse treatment  Make have a DPOA or another person such as a support person/patient advocate 77

Advance Directives 151  May use advance directives to designate a support person for a person of exercising the visitation rights  If patient incapacitated and DPOA then must give this information to make informed decisions and consent for the patient  CAH must also seek the consent of the patient’s representative when informed consent is required for a care decision  Surrogate decision makers step into shoe of patient when incompetent 78

Advance Directives 151  Must provide advance directive information to the competent patient when admitted  Must also give to the outpatient if in the ED, observation, or same day surgery patient  Must document you gave it in the medical record  If incapacitated then to the family or surrogate  Has conscience objector clause but must still allow DPOA or support person to make decision if incapacitated 79

Advance Directives 151  Can not require one  Document in the medical record  Must make sure staff is educated on the P&P  This includes the right to make a psychiatric advance directive or mental health declaration  Should still give consideration even if not a state specific law  Must provide community education 80

Physician Ownership Disclosures 151  Must disclose if physician owned hospital  This includes ownership by immediate family member and must be in writing  If none of physician owner refer then the hospital must sign attestation to this effect  Physicians must also disclose to patients who they refer  This must be as a condition for getting MS privileges  Disclose in writing if physician not on premise 24 hours a day for emergencies  Sign acknowledgement if patient admitted 81

Compliance with Laws/Licensure  Standard: Patient care services must be provided with in accordance with laws (152),  Ensure delegation as allowed by law,  Ensure practicing according to scope of practice, such as NP, CNS, PA,  Standard: Hospital must be licensed (153)  Personnel must be licensed or certified if required by state (Tag 154: doctors, nurses, PT, PA, OT, x-ray tech. et. al.),  Review sample of personnel files to be credentials and licensure is up to date, 82

83 Status/Location 160  If CAH moves then status and location must be reassessed  Harder to relocate now, See tag 166 on relocation  Many changes to relocation and allows for grandfathering (see SOM Manual 2)  Criteria for determining mountainous terrain, revised definitions of primary and secondary roads, documentation needed to relocate CAH and 75% rule,

Status and Location 160-162 2013  CAH must meet the location requirements at the time of the initial survey (160)  Compliance is reconfirmed at the time of every subsequent full survey  Tag 162 discusses information regarding if the CAH has been classified as an urban hospital  Discusses CAH located outside any area that is a metropolitan statistical area  CAH must be in a rural area 84

Q&A 85

Location in a Rural Area 8-30-13 86

87 Agreement with Network Hospitals 191  Standard: CAH that is a member of a rural network must have agreement with at least one hospital that is a member of the network  A CAH must develop agreements with an acute care hospital related to patient referral and transfer, communication, emergency and non-emergency patient transportation  Will ask how CAH communicates with other hospitals- do you keep a communication log?

88 Working with the Other Hospital  What P&P related to communication system?  Will review any written agreements with local EMS  Need to provide for transport between the two facilities  Do the two hospitals have electronic sharing of patient data, telemetry and medical records? (193)

89 Credentialing and QA Agreement 195  Standard: The CAH has to have an agreement with a hospital that is a member of the network or QIO for quality improvement and credentialing  State networking requirements vary.  Agreement for QA need to include a medical record review as part of quality and to establish medical necessity of care at CAH,  Surveyor will review P&P to determine how information is obtained, used and how confidentiality is maintained,

Telemedicine Agreements C&P 196  Standard: Agreements for C&P Telemedicine Physicians  Board must make sure agreement with distant- site hospital (DSH) or distant-site telemedicine entity (DSTE)  Decide what category of practitioners are eligible for appointment to the MS  Board appoints with recommendation of the MS  Board approves the MS bylaws and other MS rules and regulations 90

Telemedicine December 22, 2011 91

Agreements for C&P 196  Make sure MS is accountable to the board for quality of care provided to the patients  Must have and follow criteria for selection of MS that is based on individual character, competence, training, experience, and judgment  Make sure under no circumstance is privileges based solely on certification, fellowship, or membership in a special body or society 92

Telemedicine C&P 197 93

94 Emergency Services 200  Standard: Must provide emergency care necessary to meet the needs of its inpatients and outpatients,  The ED cannot be a provider-based off-site location,  Must comply with acceptable standards of practice,  Including those established by national professional organizations such as ACEP, ENA, ACS, ANA, AMA, American Association for Respiratory Care,

95 Emergency Services  Need qualified medical director,  MS must have P&P regarding the care provided in the ED,  Policies current and revised based on QA activities,  MS must establish qualifications to get privileges to provide ED care,  ED must be adequately staffed,  Must have adequate equipment,

96 Emergency Services 200  Must determine the categories and numbers of staff needed in the ED  MD/DO, RN, ward clerks, PA, NP, EMTs,  The scope of diagnostic and/or therapeutic respiratory services offered by the CAH should be defined in writing, and approved by the medical staff  CT scans, venous Doppler's, ultrasound et. al.,

97 14 ED Written Policies  P&P must be developed approved by MS,  And mid-level practitioners who work in the ED,  Need triage procedures,  Each type of service provided,  Qualifications, education, training, of personnel authorized to perform respiratory care services and if supervision is needed,

98 ED Written Policies Equipment assembly and operation; Safety practices, including infection control measures; Handling, storage, and dispensing of therapeutic gases; Cardiopulmonary resuscitation; Procedures to follow in the advent of adverse reactions to treatments or interventions; Pulmonary function testing;

99 ED Written Policies Therapeutic percussion and vibration; Bronchopulmonary drainage; Mechanical ventilatory and oxygenation support; Aerosol, humidification, and therapeutic gas administration; Administration of medications; and Procedures for obtaining and analyzing ABGs.

100 ED Staff Training Surveyor will interview ED staff to make sure knowledgeable including (so include in education of ED staff): 1.Parenteral administration of electrolytes, fluids, blood and blood components; 2.Care and management of injuries to extremities and central nervous system; 3.Prevention of contamination and cross infection; and 4. Provision of emergency respiratory services.

101 EMTALA and ED 24 hours  Must still meet EMTALA (anti-dumping) requirements,  Revised July 16, 2010 into 68 pages,  Must have 24 hour ED services available,  A CAH without inpatients is not required to have emergency staff on site 24 hours a day (If no patients, CAH may close),  Can have NP, PA, or MD on site within 30 minutes,

EMTALA, CAH & Telemedicine Memo  CMS welcomes the use of telemedicine by CAH  CAH not required to have a doctor to appear when patient comes to the ED  PA, NP, CNS, or physician with emergency care experience must show up within 30 minutes  If MD/DO does not show up must be immediately available by phone or radio contact 24 hours a day 102

CMS S&C Memo EMTALA & CAH 103

104 Availability of Drugs 201  CAH must maintain the types, quality and numbers of supplies, drugs and biologicals, blood and blood products, and equipment,  Required by state and local law and in accordance with accepted standards of practice,  Surveyor will ask how you make sure equipment, supplies, and medications are always available,

105 Emergency Drugs 203 Drugs used in life-saving procedures, includes;  Analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensive, diuretics, and electrolytes and replacement solutions.  Know how you maintain your inventory and how drugs are replaced,

106 Emergency Equipment 204 Equipment and supplies commonly used in life-saving procedures, includes;  Airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters.

107 Emergency Equipment 204  Make sure staff know where the equipment is located,  Know how supplies are replaced and who is responsible for doing this,  Will examine sterilized equipment for expiration dates,  Will check for equipment maintenance schedule (defibrillator),

108 Blood and Blood Products 205  Need services for the procurement, safekeeping, and transfusion of blood, including the availability of blood products needed for emergencies on a 24-hours a day basis,  No requirement to store blood on site,  Can provide in emergency directly or through arrangement,  Some cases more practical to transport patient to where the blood is,

109 Blood and Blood Products  If CAH does tests on blood will be surveyed under CLIA if tests are done,  If collecting blood you must register with the FDA,  If only storing blood for transfusion and refers all tests to outside lab then not performing test as defined by CLIA,  Need agreement in writing regarding the provision of blood between CAH and testing lab,

110 Blood and Blood Products  Blood must be appropriately stored to prevent deterioration,  If types and cross matches must have necessary equipment  Or can keep 4 units O Neg on hand at all times,  Release to give, signed by doctor, is needed if not cross matched when indicated in an emergency

111 Blood Storage 206  Blood storage must be under the control and supervision of a pathologist or other qualified doctor,  If blood banking done under arrangement, the arrangement has to be approved by MS and administration,  Will look for an agreement,

112 Staffing Personnel 207  Must have practitioner (physician, PA, NP) with training in emergency care on call and immediately available within 30 minutes,  60 minutes if CAH in frontier area (with less than 6 residents per sq. mile and area meets criteria for remote by the state and CMS) and state determines longer time than 30 minutes needed is only way to provide care,  Will review call schedules,  Will ask staff if they know who is on call,

113 Staffing Personnel 207  Will review documentation that PA, NP, or MD was on site within this time frame,  RN will satisfy this if for temporary period and CAH has less than 10 beds and is in frontier area (state governor has to sent letter to CMS as part of rural health plan),  CAH must submit this letter to surveyor and demonstrate shortage and unable to provide,  Also if state law has more stringent staffing requirements, like MD on duty 24 hours, must follow,  See CMS Memo

114 Coordination with EMS 209  Must coordinate with EMS,  Have a procedure where available by phone or radio on 24 hour basis to receive calls,  Should have policies and procedure in place to ensure MD/DO is available by phone or radio contact,  And when emergency instructions are needed,

115 25 Available Beds 211  CAH maintains no more than 25 acute care beds at any one time  Doesn’t include observation beds  Any of the 25 beds can be used to provide acute or long term care (swing beds) dependent on patient need  Does not count if CAH has up to 10 bed rehab unit or behavioral health unit  Average basis of 96 hours per patient,

116 Observations/LOS 211  Previously, could not operate distinct units,  Observations stay is usually not more than 48 hours, unless more strict state limit of 24 hours,  Rewrite your policy on observation beds to meet this section and the 2 midnight rule,  They do not count observation beds in 25 bed count now or in calculating average LOS,  Make sure you are using appropriately,  See the CMS memo on the two midnight rule  Place in an outpatient observation bed  Admit as an inpatient to telemetry

Two Midnight Rule  Need an order and need to document medical necessity  For inpatient CAH services only, the physician must certify that the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH.  Time as an outpatient at the CAH does not count towards the 96 hours requirement.  The clock for the 96 hours only begins once the individual is admitted to the CAH as an inpatient.  Time in a CAH swing-bed also does not count towards the 96 hour inpatient limit. 118

119 Observations 211  Inappropriate use of observation beds subjects Medicare beneficiary to increased coinsurance liability  20% of CAH customary charges then if properly admitted as inpatient,  Observation is not appropriate for :  Substitute for inpatient admission  For continuous monitoring  Medically stable patients who need diagnostic testing or outpatient procedure (blood chemo, dialysis)

120 Observation Not Appropriate  Patients awaiting nursing home placement  For convenience to the patient or family  For routine prep or recovery prior to or after diagnostic or surgical services  As a routine stop between the ED and inpatient admission  No prescheduled observations services  Observation services begin and end with the order of the physician

121 Observation 211  Must provide documentation to show that observation bed is not an inpatient bed  Need specific criteria for observation services  Must be different than inpatient criteria  10 bed observation unit might be disproportionately large  Surveyor might determine observation is actually inpatient overflow unit

122 Don’t Count in 25 Bed Count 211  Exam or procedure tables  Stretchers  OR tables and PACU bed  Newborn bassinets and isolettes for well baby boarders  OB beds if active labor but do count birthing rooms where patient stays after giving birth  ED carts  10 bed distinct unit rehab or behavioral health

123 Beds/ LOS Hospice 211  Observation starts and ends with order  No standing orders for observation  Hospice beds can be dedicated are also counted as part of the 25 beds,  Except 96 hour average LOS rule does not apply,  Medicare does not reimburse the CAH for hospice patients only the Hospice,  So the CAH has to negotiate payment from the hospice through an agreement,

124 Length of Stay 212  That does not exceed, on an annual average basis, 96 hours per patient,  State Fiscal Intermediary (FI) will determine compliance with this CoP,  Calculate the CAH’S length of stay based on patient census data,  If CAH exceeds the length of stay limit, the FI will send a report to the CMS-RO as well as a copy of the report to the SA,  CAH will have to do plan of correction,

125 Part 2

Construction 6-7-2013  Standard: CAH is constructed, arranged, and maintained to ensure access to and safety of patients  Additionally, it must provide adequate space to provide care to patients  Must be constructed in accordance with state and federal law  Will look to see if maintained in a manner to ensure safety of patients  Conditions of ceilings, walls, and floors 126

127 Physical Environment 222  Must have housekeeping and preventative maintenance programs,  All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition  These means facilities, supplies and equipment must be maintained,  How do you ensure your equipment is maintained properly  Boilers, elevators, air compressors, ventilators, X-ray equipment, IV pumps, stretchers, IV equipment, air compressors, elevators, maintenance log,

CMS Hospital Equipment Maintenance 128

129 Physical Environment  Dept responsible for building and dept must be incorporated into hospital QA process.  Applies to all campuses, satellites, inpatient and outpatient locations,  Is there adequate space for providing direct patient care?,  Will tour to make sure space to ensure patient safety,  Will look at housekeeping and preventive maintenance (PM) programs,  Evaluate to be sure trash is disposed of properly and promptly,

130 Disposal of Trash 223  Standard: There is proper routine storage and prompt disposal of trash,  Includes biohazardous waste,  Must be disposed of in accordance with standards (EPA, OSHA, CDC, environmental and safety),  Includes radioactive materials,  Will look for policies for proper storage and disposal,

131 Storage of Drugs 224  Standard: Drugs and biologicals must be appropriately stored,  Must be properly locked in the storage area,  Make sure medication carts in C-section rooms are locked  Make sure drugs are not left out in open in tube system or on dumb waiter ledge  Surveyor will ask what standards, guidelines, or law you using to make sure they are stored,

132 Physical Environment 225  Standard: Premises clean and orderly  Means uncluttered with equipment not stored in corridors,  Area is neat and well kept  Spills not left unattended,  No peeling paint or floor obstructions,  No visible water leaks or plumbing problems

Proper Ventilation 226 1-31-14  Standard; There must be proper ventilation, lighting, and temperature controls,  In pharmaceutical, patient care and food preparations  Proper ventilation in areas with nitrous oxide, glutaraldehyde, xylene, pentamidine, or other potentially hazardous substances,  Isolation rooms comply with laws such CDC 2007 Isolation Guidelines, OSHA, NIH, et al, 133

134 Physical Environment 226  Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection,  Including anesthetizing locations where inhalation anesthesia agents are used  Excessive humidity in the operating room is conducive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies,  RH at 35% or greater unless waiver is used of 20% or greater  Acceptable standards such as from AORN or the Facilities Guideline Institute or FGI) should be incorporated into CAH policy.

CMS Memo April 19, 2013  CMS issues memo related to the relative humidity (RH)  AORN use to say temperature maintained between 68-73 degrees and humidity between 30-60% in OR, PACU, cath lab, endoscopy rooms and instrument processing areas  CMS says if no state law can write policy or procedure or process to implement the waiver  Waiver allows RH between 20-60%  In anesthetizing locations- see definition in memo 135

Humidity in Anesthetizing Areas 136

Proper Ventilation & Lighting 1-31-14 137

CMS Memo April 19, 2013  CMS issues memo related to the relative humidity (RH)  AORN use to say temperature maintained between 68-73 degrees and humidity between 30-60% in OR, PACU, cath lab, endoscopy rooms and instrument processing areas  CMS says if no state law can write policy or procedure or process to implement the waiver  Waiver allows RH between 20-60%  In anesthetizing locations- see definition in memo 138

139 Physical Environment 226  Must have adequate number of refrigerators to make sure foods and meds are stored,  Surveyor will verify these areas are well lit,  Surveyor will verify compliance with ventilation in patients with TB or other airborne diseases,  Surveyor will verify food products are stored under appropriate conditions (time, temperature, packaging) based on national sources like USDA and FDA,

140 Emergency Procedures 227  Standard: Assure safety of patients in non-medical emergencies,  Staff trained in handling emergencies such as reporting and extinguishing of fires, evacuations, et al.,  Report all fires to the state officials,  Will interview staff to make sure they know what to do in case of a fire,

141 Physical Environment 227  How do you ensure all personnel are trained to manage non medical emergencies?  Ask staff what to do in case of a tornado, hurricane, earthquake, or blizzard,  Review staff training documents and in-service records to confirm training,

142 Physical Environment 228  Standard: Provide for emergency power and lighting in ED and for battery lamps or flashlights in other areas,  Must comply with the applicable provisions of the Life Safety Code,  National Fire Protection Amendments (NFPA) 101, 2000 Edition and applicable references such as NFPA-99: Health Care Facilities, for emergency lighting and emergency power,

143 Emergency Fuel and Water 229  Standard: Provide for emergency fuel and water supply (snow bound or flooding),  Must have system to provide emergency gas and water as needed to provide care to inpatients and other persons who may come to the CAH in need of care,  Includes making arrangements with local utility companies and others for the provision of emergency sources of water and gas,  Source of information on water is FEMA,  Have a plan for prioritizing their use until adequate supplies are available,

Emergency Preparedness Plan 230  Develop a comprehensive plan to ensure that the safety and well being of patients are assured during emergency situations,  Coordinate with Federal, State, and local emergency preparedness and health authorities to identify likely risks for their area (e.g., natural disasters, bioterrorism threats, disruption of utilities such as water, sewer, electrical communications, fuel; nuclear accidents, industrial accidents, and other likely mass casualties, etc.)  Develop appropriate responses that will ensure the safety and well being of patients. 144

CMS Revised Checklist Memo  CMS issues 8 page memo on Feb 28, 2014  Regarding checklist for emergency preparedness (EP)  Update provides information about patient tracking, supplies and collaboration  Discusses Oct 24, 2007 memo on EP  This updated checklist can be found at S&C Emergency Preparedness Website http://www.cms.hhs.gov/SurveyCertEmergPr ep 145

CMS Revised Checklist 146

Proposed Changes EP Requirements  CMS publishes proposed rule in the Federal Register on December 27, 2013  Requires hospitals that accepts Medicare or Medicaid to adequately plan for disasters  Whether natural or man made  Would have to coordinate with federal, state, and local emergency preparedness systems  To enhance patient safety during an emergency 148

Proposed Changes EP Requirements 149

150 Emergency Preparedness Plan The following issues should be considered when developing the comprehensive emergency plans:  Differences needed for each location where the certified CAH operates;  Special needs of patient populations treated at the CAH (e.g., patients with psychiatric diagnosis, patients on special diets, newborns, etc.);  Security of patients and walk-in patients;  Security of supplies from misappropriation;

151 Emergency Preparedness Plan  Pharmaceuticals, food, other supplies and equipment that may be needed during emergency/disaster situations;  Communication to external entities if telephones and computers are not operating or become overloaded (e.g., ham radio operators, community officials, other healthcare facilities if transfer of patients is necessary, etc.);  Communication among staff within the CAH itself;

152 Emergency Preparedness Plan  Qualifications and training needed by personnel, including healthcare staff, security staff, and maintenance staff, to implement and carry out emergency procedures;  Identification, availability and notification of personnel that are needed to implement and carry out the CAH’S emergency plans;  Identification of community resources, including lines of communication and names and contact information for community emergency preparedness coordinators and responders ;

153 Emergency Preparedness Plan  Provisions for gas, water, electricity supply if access is shut off to the community;  Transfer or discharge of patients to home or other healthcare settings,  Methods to evaluate repairs needed and to secure various likely materials and supplies to effectuate repairs.

FIRE Inspections 231-233  Must meet LSC of National Fire Protection Association such as NFPA-99 (231)  CMS can allow state surveyor to apply state’s fire and safety code if CMS finds that it adequately protects patients  CMS can waive specific provisions of the LSC if it would result in unreasonable hardship  But only if the waiver does not put patients at risk 154

155 FIRE Inspections 234  Maintains written evidence of regular inspection and approval by State or local fire control agencies,  Surveyor will examine copies of inspection and approval reports from State and local fire control agencies,

156 Governing Body 241  Standard; CAH has a governing body or individual that assumes legal responsibility for implementing and monitoring P&Ps,  Must have 1 governing body or responsible person,  Board must determine what categories of practitioners are eligible for appointment and reappoint to MS (NP, PA, dentist, CRNA) and there is written criteria for staff appointments,  Done with advice of MS,

157 Governing Body 241  Must be consistent with state and federal law requirements,  Board approves MS bylaws and any revisions  Surveyor will look for this,  Board responsible for conduct of CAH and for quality of care to patients,  All patients must be under the care of a member of the MS  Or under care of member of MS under their supervision

158 Governing Body  Criteria for MS is based on individual character, competence, training, experience and judgment,  Surveyor will look to see Board or written documentation of person responsible for CAH,  Will look to verify that Board has categories of practitioners for appointment to MS,  Confirm that Board appoints all members to the MS,

159 Disclosure 242  CAH discloses the names and addresses of its owners or those with controlling interest,  Either directly or indirectly has 5% or more ownership,  Surveyor will look for policy on reporting changes of ownership,  Need policy on how to reporting changes for person responsible for operation of hospital (CEO) to state agency and also for reporting changes in medical director (243,244),

160 Staffing 250  Standard: CAH has professional staff that includes one or more physicians, and may include PA, NP, or CNS,  Need to have organizational chart which shows names of all MD/DO and mid-level providers  PA, NP, or CNS  Surveyor will review work schedules,

161 Staffing 252  Standard: All ancillary staff must be supervised by professional staff,  Have sufficient staff to take care of patients  Emergency services, nursing services, Tag 253,  Will review staffing schedules and daily census records,  Make sure answer call lights promptly  Make sure address monitor that alarms timely

162 Staffing 254  MD, DO, NP, PA, or CNS must be available at all times to furnish care,  Must show practitioner is available and shows up when patient presents to the hospital,  Doesn’t mean they have to be there 24 hours a day,

163 Nurse on Duty 255  Standard: Must have a RN, CNS, or LPN on duty whenever there is one or more inpatients,  Surveyor will review staff schedules to make sure,

164 Physician Responsibilities 257  Standard: MD/DO must provide medical directions and supervision of staff,  Surveyor will make sure is available for consultation and supervision of staff,  Physicians must periodically review charts of PA and NP and surveyor will look for documentation of same (259),  MD/DO must provide orders for patients and must review and sign all MR cared by PA, NP, or CNS (260),

165 Physician Supervision  Must have a doctor on staff and must perform medical oversight,  Must be present for sufficient period of times or at least once every two week to provide direction  Will want evidence that the Dr. provides oversight and is available for consultation or patient referral,  What evidence the there is periodic review of patient records by the doctor?

166 PA, NP, CNS 263  Must be members of CAH staff,  Must participate in development and review of P&P,  Interview them to determine their participation and knowledge of policies,  Will interview to determine their level of involvement in development of P&Ps and make updated,  Policies also need to be consistent with state standards of practice,

167 Transfer of Patients 267  Standard: Arrange for transfer of patients who need services that can not be furnished,  Must sent the patient’s medical records,  Remember EMTALA is a separate CoP that every CAH must follow,  Make sure you have a transfer policy and it should be consistent with EMTALA,

168 Patient Admission 268  Standard: Whenever a patient is admitted by NP, PA, or CNS, a physician on the staff must be notified,  CMS requires that Medicare and Medicaid patients be under the care of a MD/DO if patient has medical or psych problems that are outside of the scope of their practice,  Admitting privileges must be consistent with what state law allows,  Surveyor will look to make sure MD/DO monitor care for any medical problem outside their scope of practice,

169 Patient Care Policies 271  Standard: Services are provided in accordance with appropriate P&P,  Will review policies,  Review sampled records,  Observe staff delivering care to the patient,  P&P need to be developed by group of professional person sand include 1 MD/DO and 1 or more PA, NP, CNS if on staff and one member is who not a member of the staff (272),  Will change section about person not member of the staff  Will interview CNO to determine role in policy development (272),

170 Policies (Scope of Services) 273 2013  Standard: Need P&P on scope of services provided by CAH directly or through agreement,  Should include statements like “taking complete medical histories, providing complete physical examinations, laboratory tests including” (with a list of tests provided) would satisfy this requirement,  Should include arrangements made with Hospital X for providing the following services with list of specialized diagnostic and lab testing,

171 Emergency Medical Services 274  Need P&P for emergency medical services,  Policies should show how the CAH would meet all of its emergency services requirements,

172 Guideline for Medical Management 275  Guidelines on managing health problems that include when medical consultation is needed,  And patient referral (275),  Guidelines on maintaining medical records and procedure for periodic review and evaluation of the services provided at the CAH,

173 Medical Management 275  Needs to include the scope of medical acts which may be done by PA or NP,  What medical procedures can PA or NP do?  Guidelines need to describe the medical conditions, signs or development that require consultation,

174 Part 2

175 The End! Questions??  Sue Dill Calloway RN, Esq. CPHRM, CCMSCP  AD, BA, BSN, MSN, JD  President  Board Member Emergency Medicine Patient Safety Foundation www.empsf.org  614 791-1468  sdill1@columbus.rr.com 175

176 Drugs and Biologicals 276  Rules for the storage, handling, dispensing, and administration of drugs and biologicals,  Need to store drugs in accordance with acceptable standards of practice,  Keep accurate records of the receipt and disposition of all scheduled drugs,  And all outdated, mislabeled, or otherwise unusable drugs are not available for patient use,

177 Pharmacy 276  The pharmacy director, with input from appropriate CAH staff and committees, develops, implements and periodically reviews and revises P&P on the provision of pharmaceutical services,  Store drugs as required by manufacturer,  Pharmacy records detailed to follow flow of drugs from entry to dispensing and administration,  Employees provide pharmacy services within scope of license and education,  Pharmacy must maintain control over all drugs and medications including floor stock,

178 Dispensing of Drugs 276  Drugs must be dispensed by licensed pharmacist,  Only pharmacists or pharmacy supervised personnel compound, label and dispense drugs or biologicals,  How do you make sure accurate records of receipt and disposition of scheduled drugs,  Who has access and keys to drug area?  How do you make sure no outdated drugs or mislabeled drugs?  Will inspect the pharmacy,

179 Pharmacy 276  Pharmaceutical services can be provided as direct services or through an agreement,  Does not require continuous on-premise supervision at the CAH’S pharmacy,  May be accomplished through regularly scheduled visits, and/or telemedicine in accordance with law and regulation and accepted professional principles,  A single pharmacist must be responsible for the overall administration of the pharmacy,

180 Pharmacist 276  The pharmacist must be responsible for developing, supervising, and coordinating all the activities of the CAH-wide pharmacy service,  And must be thoroughly knowledgeable about CAH pharmacy practice and management,  Job description or the written agreement for the responsibilities of the pharmacist should be clearly defined and include development, supervision and coordination of all the activities of pharmacy services,

181 Pharmacy 276  Pharmacy must have sufficient staff in types, numbers, and training to provide quality services, including 24 hour, 7-day emergency coverage,  Must have enough staff to provide accurate and timely medication delivery, ensure accurate and safe medication administration,  Staff to participate in PI,  System so medication orders get to the pharmacy and drugs back to patients promptly,

182 Pharmacy 276  Must keep records of the receipt and disposition of all scheduled drugs,  Pharmacist must make sure all drug records are in order and that an account of all scheduled drugs is maintained and reconciled,  From point of entry to administration to patient or destruction or return of drug to manufacturer,  Must have a P&P and system to identify loss or diversion of all controlled substances,

183 Pharmacy 276  The P&P established to prevent unauthorized usage and distribution must provide for an accounting of the receipt and disposition of drugs,  All prescribers’ medication orders (except in emergency situations) should be reviewed for appropriateness by a pharmacist before the first dose is dispensed,  Note in next slide where CAH cited if no initial pharmacy review done when pharmacy closed (use tele-pharmacy)

184 First Dose Rule  Therapeutic appropriateness of a patient’s medication regimen;  Therapeutic duplication,  Appropriateness of the route and method of administration;  Medication-medication, medication-food, medication- laboratory test and medication-disease interactions;  Clinical and laboratory data to evaluate the efficacy of medication therapy to anticipate or evaluate toxicity and adverse effects; and  Physical signs and clinical symptoms relevant to the patient’s medication therapy.

Drug Interactions Checker 185 www.drugs.com/drug _interactions.php

Drug Interaction Checker 186 http://reference.medscape.com/drug- interactionchecker

Pediatric Drug Interaction Checker 187

Drug Interaction Checker 188 http://dir.pharmacy.dal.ca/dr ugprobinteraction.php

Epocrates Online Checker 189 https://online.epocrates.com/home

Incompatibility Charts 190 hwww.ivmedic ationcompatib ilitychart.com/

191 Pharmacy USP 797 276  Sterile products should be prepared and labeled in a suitable environment by appropriately trained and qualified personnel,  Remember the USP 797, officially introduced on 1-1-04 and became enforceable by FDA,  Also adopted by TJC and many state pharmacy boards,  Information is available at www.usp.orgwww.usp.org

192 Pharmacy  Pharmacy should participate in CAH decisions about emergency medication kits,  Supply and provision of emergency medications stored in the kits must be consistent with standards of practice,  and appropriate for a specified age group or disease treatment,

193 Pharmacy  Pharmacy should be involved in the evaluation, use and monitoring of drug delivery systems (IV pumps, PCA)  Schedule Drugs and potential for error of administration devices,  Including automated drug- dispensing machines (Pyxis, Omnicell, Meditol et. al.),

194 Pharmacy  Medications must be prepared safely,  Safe preparation procedures could include;  Only the pharmacy compounds or admixes all sterile medications, intravenous admixtures, or other drugs except in emergencies or when not feasible (for example, when the product’s stability is short).  Staff uses safety materials and equipment while preparing hazardous medications.

195 Pharmacy Whenever medications are prepared, staff uses appropriate techniques to avoid contamination during medication preparation, which include, but are not limited, to the following:  Using clean or sterile technique as appropriate;  Maintaining clean, uncluttered, and functionally separate areas for product preparation to minimize the possibility of contamination;

196 Pharmacy  Using a laminar airflow hood or other appropriate environment while preparing any intravenous (IV) admixture in the pharmacy, any sterile product made from non-sterile ingredients, or any sterile product that will not be used with 24 hours; and  Visually inspecting the integrity of the medications.

197 Drug Storage 276  All drugs must be kept in a locked room or container,  If the container is mobile or readily portable, when not in use, it must be stored in a locked room, monitored location, or secured location that will ensure the security of the drugs,  Must be stored in a manner to prevent access by unauthorized individuals,

198 Drug Storage 276  Persons without legal access to drugs cannot have unmonitored access to drugs,  Cannot have keys to medication storage rooms, carts, cabinets, or containers (housekeepers, security),  Drug storage is a big issue with both CMS and the Joint Commission

199 Nursing Med Carts/Anesthesia Cart  When not in use, nursing medication carts, anesthesia carts, and other medication carts that contain drugs,  Must be locked or stored in a locked storage room,  If cart is in use and unlocked, someone with legal access to the drugs in the cart must be close by and directly monitoring the cart (276),

200 Outdated Drugs 276  Must have a pharmacy labeling, inspection, and inventory management system that ensures that outdated, mislabeled, or otherwise unusable drugs are not available for patient use,  Surveyor will make sure staff is familiar with medication P&P,  Need policy to ensure P&P are periodically reviewed,  Will look to see if access to concentrated solutions is restricted (KCL, NaCl greater than 0.9%),

201 Surveyor Procedure  Look for policy for the safeguarding, transferring and availability of keys to the locked storage area,  Inspect the pharmacy and where medications are stored,  Inspect patient-specific and floor stock medications to identify expired, mislabeled or unusable medications,  If the unit dose system is utilized, verify that each single unit dose package bears name and strength of the drug, lot and control number equivalent, and expiration date.

202 Surveyor 276  Review P&P to determine who is designated to remove drugs from the pharmacy or storage area,  Determine if the pharmacist routinely reviews the contents of the after-hours supply to determine if it is adequate to meet the after-hours needs of the CAH.  Interview the Pharmacy Director, pharmacist and pharmacy employees to determine their understanding of the controlled drug policies,

203 Reporting ADR and Errors 277  Procedures for reporting adverse drug reactions and errors in the administration of drugs,  Written P&P to require these be reported immediately to practitioner who ordered the drug,  Entry should be made in the MR,  Significant ADRs should be reported to the FDA in accordance with MedWatch program,

204 Reporting ADR and Errors 277  Important to flag new types of mistakes as they occur and create systems to prevent their recurrences (system analysis approach),  System should work through those mistakes and continually improve and refine things, based on what went wrong (example RCA),  See sample forms to use for RCA and FMEA,

205 Reporting ADR and Errors 277  Reduction of medication error and adverse reactions by effective reporting systems that proactively identify causative factors and are used to implement corrective actions to reduce or prevent reoccurrences (FMEA),  Need to develop definition of medication error that includes near misses,

206 High Risk Meds/Definition 277  System to minimize high risk medications (chemo, insulin, Heparin),  Need to have a policy on high alert drugs and what you do (double checks)  Such systems could include: checklists, dose limits, pre-printed orders, special packaging, special labeling, double- checks and written guidelines,

207 http://ismp.org/Tools/highalertmedication s.pdf

208 High Alert How to Guide IHI www.ihi.org/NR/rdonlyres/8B2475CD-56C7-4D9B-B359-801F3CC3A8D5/0/HighAlertMedicationsHowToGuide.doc

211 Medication Error is Defined as  Mention NCCMERP definition of medication error,  Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”

212 Medications Errors 277  Can’t just rely on just incident reports to identify medication errors and ADE,  Proactive includes observation of medication passes,  Concurrent and retrospective review of patient’s clinical records,  ADR surveillance team,

213 Medications Errors 277  Implementation of medication usage evaluations for high-alert drugs,  and identification of indicator drugs or “patient signals” that, when ordered, or noted automatically generate a drug regimen review for a potential ADE,  IHI calls them trigger drugs and has three tools for hospitals to reduce errors

214 Indicator Drugs (Trigger Drugs)  Monitor Digibind usage and develop protocol for appropriate use,  Monitor use of reversals agents such as Romazicon and Narcan to look for unreported cases of adverse events,  Narcan, antihistamines, Vitamin K,  IV glucose, glucagon,  Epinephrine, topical calamine,  Phentolamine, digibind, protamine, hyaluronidase,  Kayexalate, anti-emetics and anti-diarrheas,

217 Monitor Medication Errors 277  Must have method to measure the effectiveness of its reporting system,  And whether system is identifying as many med errors and ADE as would be expected by benchmark studies,  Need non-punitive reporting system or people will not report errors (many balance with Just Culture),  Pharmacist should be readily available by telephone or other means to discuss drug therapy, interactions, side effects, dosage etc,

218 Medication Alerts  The CAH should have a means to incorporate external alerts and/or recommendations from national associations and governmental agencies for review and facility policy and procedure revision consideration.  National associations could include Institute for Safe Medications Practice, National Coordination Council for Medication Error Reporting and Prevention, The Joint Commission (no longer called JCAHO), ISMP, IHI, USP, and ASHP etc.

219 Medication Alerts  Governmental agencies may include ;  Food and Drug Administration (FDA),  Med Watch Program, and  Agency for Health Care Research and Quality (AHRQ).

220 Websites  National Patient Safety Foundation at the AMA- www.ama-assn.org/med-sci/npsf/htm,  The Institute for Safe Medication Practices- www.ismp.org  U.S. Pharmocopiedia (USP) Convention, Inc.- www.usp.org  U.S. Food and Drug Administration MedWatch- www.fda.gov/medwatch  Institute for Healthcare Improvement- www.ihi.org,www.ihi.org  AHRQ- www.ahrq.gov,www.ahrq.gov  Sentinel event alerts at www.jointcommission.org,www.jointcommission.org

221 Additional Resources  American Pharmaceutical Association- www.aphanet.org  American Society of Heath-System Pharmacists- www.ashp.org  Enhancing Patient Safety and Errors in Healthcare- www.mederrors.com  National Coordinating Council for Medication Error Reporting and Prevention-www.nccmerp.org,  FDA's Recalls, Market Withdrawals and Safety Alerts Page: http://www.fda.gov/opacom/7alerts.html http://www.fda.gov/opacom/7alerts.html

222 Drug Orders/Returns 277  Pharmacy must ensure that drug orders are accurate and that medications are administered as ordered,  When medications are returned unused, the pharmacy should determine the reason the medication was not used (CMS calls this medication reconciliation and different from Joint Commission (TJC)),  Example: Did the patient refuse the medication, was there a clinical reason the medication was not used, was the medication not used due to error?

223 P&P to Minimize Med Errors 277 Policies should include: High-alert medications with dosing limits, administration guidelines, packaging, labeling and storage; Limiting the variety of medication- related devices and equipment. For example, limit the types of general- purpose infusion pumps to one or two; Availability of up-to-date medication information;

224 Required Drug Policies 277  Availability of pharmacy expertise such as having a pharmacist available on-call when pharmacy does not operate 24 hours a day,  Standardization of prescribing and communication practices,

225  These are drugs that should be avoided in patients who are over 65!  Updated in 2012  Includes drugs not to be used for certain diseases  High risk drugs include Indocin, Talwin, Tigan, Dalmane, Muscle relaxants (Robaxin, Somam Flexeril etc.), Elavil, Triavil, Equanil, Librium, Aldoment, Diabense, all barbituates except Pb, Demerol, Ticlid, Toradol, Norflex, Ismelin, Hylorel, Mellaril, Mineral oil, etc. Beers list of Inappropriate Meds

226  Heart failure- Norpace, high sodium drugs,  HTN-pseudoephedrine, diet pills,  Seizure- Clozaril, Thorazine, Navane, Mellaril,  Anticoagulants-ASA, Plavix, Persantine, Ticlid,  Categories for depression, Insomnia, Anorexia, Stress incontinence, syncope, etc. Beers list of Inappropriate Meds

228 Required Pharmacy P&P Standardization of prescribing and communication practices; Avoidance of certain abbreviations (TJC IM Chapter has nine, no longer NPSG); All elements of the order such as dose, strength, units (metric), route, frequency, and rate; Alert systems for look-alike and sound-alike drug names (now 2 times the number);

229 Set Item Abbreviation Potential Problem Preferred Term 1. U (for unit)Mistaken as zero, four or cc Write "unit " 2. IU (for International unit) Mistaken as IV (intravenous) or 10 (ten) Write "International unit " 3. 4. Q.D., Q.O.D. (Latin abbreviation for once daily and every other day) Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for "I". Write "daily" and "every other day TJC Do Not Use Abbreviations

230 LASA Drugs  Be sure to take action when a problem is noted,  Decide if you will take thru risk management, pharmacy, medical staff, or use the PI process  Look at your list on at least a yearly basis and update as necessary,  ISMP newsletters are a good source of information on current cases of look alike/sound alike drugs,

231 LASA  TJC has MM standard on LASA  Policy need to includes precautions for LASA medications  It is a much bigger problem according to recent research so USP has database hospitals can check for LASA drugs  8 th Annual MedMaRX report issued in 2008 shows problems with 3,170 drug pair names which is doubled number since 2004

232 http://ismp.org/

234 Required Pharmacy Policies 277  Use of facility approved pre-printed order sheets whenever possible;  A voluntary, non-punitive, reporting system to monitor and report adverse drug events (including medication errors and adverse drug reactions);  The preparation, distribution, administration and proper disposal of hazardous medications;  Medication recalls;  Policies and procedures are reviewed and amended secondary to facility-generated reports of adverse drug events,

235 Non-Punitive Environment  Studies showed that if you have punitive environment errors will not be reported,  Most of serious errors are made by long term employee with unblemished records,  It was the system that actually lead to the error,  Change the environment or culture-called system analysis,  Important to have a non-punitive environment,  We need to move beyond the culture of blame so we can find out what errors are occurring,  Balance this with Just Culture,

236 Surveyor Procedure 277  What drug information is available at the nursing stations?  Will look at the pharmacy P&P, formulary and, if there is a pharmacy and therapeutic committee, the minutes of the committee meetings,  Are the above P&P present,  Review medical records to make sure medication errors are reported promptly,  Make sure generated sufficient number of medication errors,

237 Infection Control 278 A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel,  Must have an active surveillance program that includes specific measures for prevention,  Early detection, control, education, and investigation of infections and communicable diseases,  Remember the IC Worksheet  CMS gets $50 million grant in 2011 to enforce IC standards and in 2012 HHS gets a billion dollars and some hospitals report increased scrutiny

238 Infection Preventionist or IP

239 Infection Control 278  Must be a mechanism to evaluate the effectiveness of the program (IC plan) and to provide corrective action when necessary,  Program must include implementation of nationally recognized systems of infection control guidelines,  So what’s in your IC Plan?  Such as CDC, OSHA, and APIC, SHEA, AORN,  ** nosocomial infections are more recently referred to as Healthcare- associated infections (HAI),

244 Infection Control Websites  Association for Professionals in Infection Control and Epidemiology (APIC) infection control guidelines at www.apic.org,www.apic.org  Centers for Disease Control and Prevention- www.cdc.gov,  Occupational Health and Safety Administration (OSHA)- www.osha.gov,  The National Institute for Occupational Safety and Health NIOSH- www.cdc.gov/niosh/homepage.html, www.cdc.gov/niosh/homepage.html

245 Additional Resources  See the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 1  AORN in the Perioperative Standards and Recommended Practices has a chapter on sterilization and disinfection including many on steam sterilization  APIC is good source of information2  1 http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf  2 www.apic.org

248 Additional Resources  2011 CDC Guidelines for Prevention of Intravascular Catheter Related Infections,  CDC Guidelines for the Prevention of catheter-Induced Urinary Tract Infections, December 2009,  http://www.cdc.gov/hicpac/cauti/002_cauti_toc.h tml  AHRQ toolkit  http://www.ahrq.gov/qual/haiflyer.htm

CDC 2011 Intravascular Catheter Guidelines 249 http://www.cdc.gov/hicpac/BSI/B SI-guidelines-2011.html

Infection Control Video  HHS has published a training video that every nurse, physician, infection preventionist and healthcare staff should see  This includes risk managers  It is an interactive video  Called Partnering to Heal: Teaming Up Against Healthcare-Associated Infections  Go to http://www.hhs.gov/partneringtoheal  HHS wants to decrease HAI by 40% in 2013, want 1.8 million fewer injures and can save 60,000 lives 250

251 www.hhs.gov/ash/initiatives/hai/training/

CA-UTI Resources  Pa Patient Safety has toolkit to prevent CA- UTIs,  http://patientsafetyauthority.org/EducationalTool s/PatientSafetyTools/cauti/Pages/home.aspx  APIC guidelines to eliminate catheter- associated UTI  AORN article Jan 2010 on new scip measure regarding urinary catheter removal  at www.aorn.org/News/Managers/November2009Issue/Ca theter/ 252

CA-UTI Resources  IDSA as the “Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infections in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America  http://cid.oxfordjournals.org/content/50/5/625.full  Iowa Healthcare Collaborative toolkit  http://www.ihi.org/IHI/Programs/ImprovementM ap/PreventCatheterAssociatedUrinaryTractInfec tions.htm 253

254 Infection Control Policies 278  Definition of nosocomial infections (now called HAI) and communicable diseases;  Measures for identifying, investigating, and reporting nosocomial infections and communicable diseases;  Measures for assessing and identifying patients and health care workers, including personnel, contract staff (e.g., agency nurses, housekeeping staff), and volunteers, at risk for infections and communicable diseases;

255 Infection Control Policies 278  Methods for obtaining reports of infections and communicable diseases on inpatients and health care workers,  including all personnel, contract such as agency nurses, housekeeping staff, and volunteers, in a timely manner;

256 Infection Control Policies 278  Measures for the prevention of infections, especially infections caused by organisms that are antibiotic resistant or in other ways epidemiologically important; device-related infections (e.g., those associated with intravascular devices, ventilators, tube feeding, indwelling urinary catheters, surgical site infections; and those infections associated with trach care, respiratory therapy, burns, immunosuppressed patients, and other factors which compromise a patient's resistance to infection; (VAP bundle, central line bundle, SCIP,)

257 Infection Control Policies 278  Measures for prevention of communicable disease outbreaks, especially tuberculosis;  Provision of a safe environment consistent with nationally recognized infection control precautions, such as the current CDC recommendations for the identified infection and/or communicable disease;  Isolation procedures and requirements for infected or immunosuppressed patients;  Use and techniques for standard precautions;

258 Infection Control Policies 278  Education of patients, family members and caregivers about infections and communicable diseases;  Methods for monitoring and evaluating practices of asepsis;  Techniques for hand washing, respiratory protections, asepsis, sterilization, disinfection, food sanitation, housekeeping, fabric care, liquid and solid waste disposal, needle disposal, separation of clean from dirty, as well as other means for limiting the spread of contagion;

259 APIC Brochures  APIC has a number of educational brochures that hospitals can download and provide to staff and patient  Includes 10 tips to prevent the spread of infection and hand hygiene for patients and one for healthcare workers  Information to patients is on standard precautions (hand hygiene) and  Transmission precautions for patients with certain diseases (contact precautions )  1 www.apic.org/AM/Template.cfm?Section=Education_Resources&Template=/TaggedPag e/TaggedPageDisplay.cfm&TPLID=91&ContentID=8738

261 Infection Control Policies 278  Authority and indications for obtaining microbiological cultures from patients;  A requirement that disinfectants, antiseptics, and germicides be used in accordance with the manufacturers' instructions to avoid harming patients, particularly central nervous system effects on children;  Orientation of all new personnel to infections, communicable diseases, and to the infection control program;

262 Flash Sterilization (Immediate Use)

263 Infection Control Policies 278  Measures for the screening and evaluation of health care workers, including all staff, contract workers such as agency nurses, housekeeping staff, and volunteers, for communicable diseases, and for the evaluation of staff and volunteers exposed to patients with non-treated communicable diseases;  Employee health policies regarding infectious diseases and when infected or ill employees, including contract workers and volunteers, must not render patient care and/or must not report to work;

264 Infection Control Policies 278  A procedure for meeting the reporting requirements of the local health authority (such as the state department of health);  Policies and procedures developed in coordination with Federal, State, and local emergency preparedness and health authorities to address communicable disease threats and outbreaks,

265 Infection Control Log  Recommended that the infection control officer or officers maintain a log of all incidents related to infections and communicable disease,  Including those identified through employee health services,  Log is not limited to HAI,  Deleted by July 16, 2012 for FR for PPS hospitals but not from the CAH manual yet  All incidents of infection and communicable disease should be included in the log,  Log documents infections and communicable diseases of patients and all staff (patient care, non patient care, employees, contract staff and volunteers).

266 Role of Leaders in IC 278  CEO, MS, and DON must ensure there is hospital wide QA program,  And infection control training programs that address problems identified through the IC program,  Then revise the program,  Designate an infection control officer,  Person must be qualified and is responsible for IC functions and is responsible to implement the P&P developed by IC Committee,

267 Infection Preventionist Is responsible for (should include in job description);  Developing a system for identifying, investigating, reporting, and preventing the spread of infections and communicable diseases among patients and personnel, including contract staff and volunteers;  Identifying, investigating and reporting infections and outbreaks of communicable diseases among patients and personnel, including contract staff and volunteers, especially those occurring in clusters;

268 Infection Control Preventionist  Preventing and controlling the spread of infections and communicable diseases among patients and staff;  Cooperating with CAH-wide orientation and in-service education programs;  Cooperating with other departments and services in the performance of quality assurance activities; and  Cooperating with disease control activities of the local health authority.

269 www.cdc.gov/nhsn/mdro_cdad.htm l

273 Dietary 279  If the CAH furnishes inpatient services,  Procedures must be in place that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practice,  A CAH is not required to prepare meals itself.  Can obtain meals under contract,  Infection control issues in dietary hit hard

274 Dietary 279  Food and dietetic services must be organized,  Directed and staffed in such a manner to ensure that the nutritional needs of the patients are met in accordance with practitioners’ orders,  And recognized dietary practices,

275 Dietary Policies 279  Availability of a diet manual and therapeutic diet menus to meet patients’ nutritional needs,  Frequency of meals served,  System for diet ordering and patient tray delivery,  Accommodation of non-routine occurrences such as enteral nutrition (tube feeding), total parenteral nutrition, peripheral parenteral nutrition, change in diet orders, early/late trays, nutritional supplements, etc.,

276 Dietary Policies 279  Integration of the food and dietetic service into the PI and Infection Control programs;  Guidelines for acceptable hygiene practices of food service personnel; and  Guidelines for kitchen sanitation.

277 Dietary Compliance 279  Must be in compliance with Federal and State licensure requirements for food,  And dietary personnel as well as food service standards, laws and regulations.  Must have qualified director of food and dietetic services  Employed or contracted  Must be delegated this responsibility by Board and MS,

278 Dietary Policies Required 279  Safety practices for food handling;  Emergency food supplies;  Orientation, work assignments, supervision of work and personnel performance;  Menu planning, purchasing of foods and supplies, and retention of essential records such as cost, menus, personnel, training records, QA reports, etc.; and  Dietary service PI program

279 Qualified Dietician The dietitian’s responsibilities include (put in job description), but are not limited to:  Approving patient menus and nutritional supplements;  Patient, family, and caretaker dietary counseling;  Performing and documenting nutritional assessments and evaluating patient tolerance to therapeutic diets when appropriate;

280 Dietician’s Job Description  Collaborating with other services (e.g., medical staff, nursing services, pharmacy service, social work service, etc.) to meet the nutritional needs of the patients; and  Maintaining pertinent patient data necessary to recommend, prescribe, or modify therapeutic diets as needed to meet the nutritional needs of the patients.  Need a physician’s order for the therapeutic diet  If consulted make sure verbal order from doctor or doctor write the order

281 Dietary  Must have dietary support staff,  HR file should document their competency,  Must follow recognized dietary practices,  Must follow national standards such as current Recommended Dietary Allowances (RDA) or the Dietary Reference Intake (DRI) of the Food and Nutrition Board of the National Research Council.  **IOM recommended dropped name of RDA in favor of DRI or dietary reference intakes,  ** “Dietary Guidelines for Americans 2011” published- www.dietaryguidelines.gov

283 Dietary  Menus must be nutritionally balanced,  Must meet needs of patients,  Screening criteria should be developed to identify patients at nutritional risk (usually done as part of nursing admission assessment),  Is identified as an altered nutritional status, a nutritional assessment should be performed,

284 Nutritional Assessment includes; All patients requiring artificial nutrition by any means (i.e., enteral nutrition (tube feeding), total parenteral nutrition, or peripheral parenteral nutrition);  Patients whose medical condition, surgical intervention, or physical status interferes with their ability to ingest, digest or absorb nutrients;

285 Nutritional Assessment  Patients whose diagnosis or presenting signs/symptoms indicates a compromised nutritional status (e.g., anorexia nervosa, bulimia, electrolyte imbalances, dysphagia, malabsorption, end stage organ diseases, etc.); and  Patients whose medical condition can be adversely affected by their nutritional intake (e.g., diabetes, congestive heart failure, patients taking certain medications, renal diseases, etc.).

286 Therapeutic Diets  Therapeutic diets must be prescribed by practitioner in writing by the practitioner responsible for patient’s care,  Documented in the MR including information about the patient’s tolerance,  Evaluate for nutritional adequacy,  Manual must be available for nursing, FS, and medical staff,  Dieticians can only make recommendations and can’t order,

287 Patient Care Policies 280  The P&Ps must be reviewed at least once a year,  Reviewed by group of professional personnel,  Make sure P&P are consistent with the standard of care  Cite the authority in the reference section at the end of the policy such as the AORN Perioperative Standards and Recommended Practices or ASPAN

288 Patient Services 281 6-7-2013  Must provide basic services as those provided in doctor’s office or at entry of healthcare organization like an outpatient department and ED,  Changed from Direct Services to Patient Services  Can provide directly or under contract  Must provide diagnostic and therapeutic services and have supplies as that typically found in an ambulatory healthcare setting and a physician’s office  These services include medical history, physical examination, specimen collection, assessment of health status, and treatment for a variety of medical conditions.

289 Outpatient Department 281  Must provide adequate services, equipment, staff, and facilities adequate to provide the outpatient services,  Must follow acceptable standards of practices such as ACR, AMA, ACOS, etc.,  OP Dept must be integrated with inpatient services such as MR, lab, radiology, anesthesia or other diagnostic services,  CAH physician or non-physician practitioner must be available to treat patients at the CAH when such outpatient services are provided  For those outpatient services that fall only within the scope of practice of a physician or non-physician practitioner

Tag 281 Many Changes Patient Services 290

291 Rehab Services DELETED  If rehab is provided, must have appropriate equipment and adequate staff,  Scope of what is offered must be in writing and approved by MS,  Need person to direct department who must be qualified and supervise supportive personnel,  MS have to define in writing the competencies and qualifications of the director,  Director must have annual evaluation,

292 Rehab Treatment Plan DELETED  Initiate plan of treatment based on evaluation and assessment with input from family and with order and include short and long term goals,  Must document changes in the treatment plan,  Person must be within scope of practice they are performing,  Surveyor will review medical records to patient later admitted that OP information has been included,

293 Lab Services 282 6-7-2013  Must provide basic lab services to include,  Urine dipstick or tablet including urine ketones,  Hemoglobin or hematocrit,  Blood glucose,  Stool for occult blood,  Pregnancy tests,  Primary culturing for transmittal to certified lab,  Will need written policy to make sure all labs tests are recorded in the MR,  July 16, 2012 where lab and radiology dept do not have to be a direct service anymore

294 Lab 282  Must have these basic lab services,  Must provide emergency services 24 hours/7 days a week,  Must have current CLIA certificate and if contracted out make sure they have a CLIA certificate  Scope of services and complexity must be adequate to meet the needs of the patients,  Can be employed or contract services,  Patient lab results are medical records and must comply with the MR chapter  Must have written P&P for collecting, preserving, transport, receipt if tissue specimen results,

Lab 282 Revised 6-7-2013 295

296 Radiology Services 283 6-7-2013  Radiology services must be provided by qualified staff,  Can be provided as a direct service or through a contract,  And do not expose patients or staff to radiation hazards,  Must have services to meet the needs of its patients at all times,

297 Radiology Services 283  Can offer minimal set or more complex, according to needs of the patients including nuclear medicine,  Hospital has flexibility to decide the types and complexities of radiologic services offered  Interpretation can be contracted out  Diagnostic, therapeutic, and nuclear medicine, must be provided in accordance with acceptable standards of practice and must meet professionally approved standards for safety

298 Radiology Services 283  Scope or what you do has to be in P&Ps approved by board or responsible party,  Must be consistent with state law  If telemedicine is used must comply with telemedicine standards  And by standards recommended by nationally recognized professions such as the AMA, Radiology Society of North America, Alliance for Radiation Safety in Pediatric Imaging, ACC, American College of Neurology, ACP, and ACR,  Example would be the ACR 2013 MRI safety standards and 2013 contrast manual

Radiology Services 283  P&P on adequate radiation shielding for patients, personnel and facilities which includes:  Shielding built into the physical plant  Types of personal protective shielding to use and under what circumstances  Types of containers to be used for radioactive materials  Clear signage identifying hazardous radiation area 299

300 Radiology Policies Required  Labeling of all radioactive materials, including waste with clear identification of the material  Transportation of radioactive materials between locations within the CAH;  Security of radioactive materials, including determining who may have access to radioactive materials and controlling access to radioactive materials;  Periodic testing of equipment for radiation hazards;

301 Radiology Policies  Periodic checking of staff regularly exposed to radiation for the level of radiation exposure, via exposure meters or badge tests  Storage of radio nuclides and radio pharmaceuticals as well as radioactive waste; and  Disposal of radio nuclides, unused radio pharmaceuticals, and radioactive waste,  To ensure periodic inspections of equipment,  Make sure problems are corrected in timely manner and have evidence of inspections and corrective actions

302 Radiology Policies 283 6-7-2013  There must be written policies developed and approved by the medical staff to designate which radiological tests must be interpreted by a radiologist,  MR chapter standards apply  Make sure patient shielding aprons are maintained properly and inspected  Surveyor will review equipment maintenance reports (PM)  Make sure staff know P&Ps

303 Radiology Policies 283  Supervision must include that all files, scans, and images are kept in a secure place and are retrievable,  Written policy, consistent with state law on which personnel can operate radiology equipment and do procedures,  Need copies of all reports and printouts,  Written policy to ensure integrity of authentication,  See tag 283 for required signage on hazardous radiation areas and more

Tag 283 Blue Box Advisory 304

305 Emergency Procedures 284 6-7-13  Must provide medical emergency services as a first response to common life threatening injuries and acute illness,  Emergency services can done directly or through contracted services  Individuals providing the services must to be able to recognize a patient need for emergency care  Must provide initial interventions, treatment, and stabilization of any patient who requires emergency services

Agreements 285 7-15-2011 306

Agreements 285  CAH has to have agreements with one or more providers or suppliers participating under Medicare to furnish services to patients  CMS made an exception since distant- site telemedicine entity (DSTE) is not required to be a Medicare provider  Agreements such as for obtaining outside lab tests 307

308 Contracted Services 286  Must have agreement or arrangement with one or more providers or supplies participating under Medicare to provide services to patients,  Need to describe routine procedures such as for obtaining outside lab tests,  Governing body is responsible for these services provided,  These must be evaluated thru PI and board must take action if problems occur,

309 Contracted Services 286-289  CAH must have agreements with 1 or more facilities to provide care to inpatients,  Arrangement with 1 or more doctors to provide care,  If labs provide additional diagnosis and clinical lab services must be in compliance with CLIA and lab will be surveyed separately for compliance,  Arrangements for food and inpatient nutritional needs to be meet,

310 Contracted Services  Surveyor will review medical records of patients transferred to make sure,  Transfer patients were accepted,  Patients referred for lab or dx tests had the tests performed,  Need to keep list of all services provided under contract or agreement,

311 Nursing Care 294  Nursing service must met the needs of patients,  Nursing service must be well organized service of CAH,  Must be under direction of a RN,  Nursing staff must be trained and oriented,  Adequately supervised,  Nursing personnel must know P&Ps,  CAH RN must conduct the supervision and evaluation of each non-CAH nursing staff,

312 Nursing Care 294  Surveyor is to observe nursing care in progress,  To determine if staffing is adequate,  Will look at nursing care plans, medical records, accident and investigative reports, staff schedules, and P&P,  Will review the method for orientation and needs to include nursing P&P, emergency procedures, CAH and unit, and safety P&P,

313 RN 295  RN must provide the care for each patient or assign care to other personnel,  Including SNF and swing be patients,  Care must be provided in accordance with patient needs,  RN must make all patient care assignments,  Assignments must take into consideration complexity of patient’s care,  Will look at written staffing plans,  Staff must be competent,  Make sure if temporary nurses used they are oriented and supervised,

314 RN Supervising Care 296  A RN must supervise and evaluate the nursing care for each patient (or if state law allows a PA),  Includes SNF level is a swing bed,  Must evaluate the patient’s needs,  Make sure nurses are licensed,  Will make sure staff have yearly evaluations,

315 Drugs and IVs 297  All drugs and IVs are administered under the supervision of RN or MD, (or a PA if allowed by state law),  Make sure all orders are signed off,  Be sure there is signature and date and TIME  Orders must be written with the acceptable standard of care,

316 Drugs and IVs  Drugs must be administered and prepared in accordance with the standard of care,  Will review medication record to make sure consistent with doctor’s orders,  Observe nurse pass meds and determine if policies followed,  How do you monitor drugs and IVs for PI?

317 Verbal Orders 297  All orders must be legible, dated, TIMED, and authenticated (signed) by the practitioner responsible for care,  Includes VERBAL ORDERS,  Ordering practitioner signs off the verbal order and it must include a date and time,  VO must be used infrequently or for convenience and limited to urgent situations,

318 Verbal Order Policy Should Include :  Describe limitations or prohibitions on use of verbal orders;  List the elements required for inclusion in a complete verbal order;  Describe situations in which verbal orders may be used;  List and define the individuals who may send and receive verbal orders; and  Provide guidelines for clear and effective communication of verbal orders.

319 Culture of Questioning 297  CAHs should promote a culture in which it is acceptable, and strongly encouraged, for staff to question prescribers when there are any questions or disagreements about verbal orders,  Questions about verbal orders should be resolved prior to the preparation, or dispensing, or administration of the medication,

320 Complete Order  Verbal medication orders must include:  Name of patient; Age and weight of patient, when appropriate; date and time of the order; drug name; dosage form (e.g., tablets, capsules, inhalants), exact strength or concentration; dose, frequency, and route; quantity and/or duration; purpose or indication; specific instructions for use; and name of prescriber.

321 Medication Passes 297  Surveyor will select a patient, review their medication orders, review documentation of medications given, and observe nurse pass drugs,  Will look at P&P, approved by MS, as to who can pass meds and that P&Ps are followed,  Will look to see if id band checked or the nurse calls the patient by name,  Will check PI to see if administration of drugs is regularly monitored,  Will ask nurses if they permitted to take telephone orders,

322 Verbal Orders 297 A verbal order must be signed off as soon as possible which would be the earlier of the following:  The next time the prescribing practitioner provides care to the patient, assesses the patient, or documents information in the patient’s medical record, or  The prescribing practitioner signs or initials the verbal order within time frames consistent with Federal and State law and CAH policy

323 Verbal Orders 297  Must repeat back VO to prescriber,  All verbal orders must immediately be commenced to writing and signed by the person receiving the order,  VO must be documented in the medical record,  Covering physician can sign the VO for his or her partner,  PA or NP can not co-sign MD/DO order,  Must include above information in your policy on verbal orders!

CMS Visitation Sept 7, 2011 324 www.cms.gov/SurveyCertificationGenI nfo/PMSR/list.asp#TopOfPage

Visitation 1000 (Starts after Tag 297)  Must have P&P and process on visitation  Including any reasonable restrictions or limitations  Discusses 2004 JAMA article encouraging open visitation in the ICU  Includes inpatients and outpatients  Discusses role of support person for both  Patient may want support person present during pre-op preparation or post-op recovery 325

Reasonable Restrictions 1000  Infection control issues  Can interfere with the care of other patients  Court order restricting contact  Disruptive or threatening behavior  Room mate needs rest or privacy  Substance abuse treatment plan  Patient undergoing care interventions  Restriction for children under certain age 326

Visitation 1000  Need to train staff on the P&P  Need to determine role staff will play in controlling visitor access  Surveyor will verify you have a P&P  Will review policy to determine if restrictions  Is there documentation staff is trained?  Will make sure staff are aware of P&P on visitation and can describe the policy for the surveyor 327

Visitation 1001  Must inform each patient or their support person, when appropriate, of their visitation rights  Must include notifying patient of any restrictions  Patient gets to decide who their visitors are  Can not discriminate against same sex domestic partners, friend, family member etc.  The patient gets to decide 328

Visitation 1001  Support person does not have to be the same person as the DPOA  Support person can be friend, family member or other individual who supports the patient during their stay  TJC calls it a patient advocate  Support person can exercise patient’s visitation rights on their behalf if patient unable to do so 329

TJC Help Prevent Errors in Your Care 330 www.jointcommission.org/speak_up_help_prevent_errors_in_your_care/

Visitation 1001  Hospital must accept patient’s designation of an individual as a support person  Either orally or in writing  Suggest you get it in writing from the patient  When patient is incapacitated and no advance directives on file then must accept individual who tells you they are the support person  Must allow person to exercise and give them notice of patients rights and exercise visitation rights 331

Visitation 1001  Hospital expected to accept this unless two individuals claim to be the support person then can ask for documentation  This includes same sex partners, friends, or family members  Need policy on how to resolve this issue  Any refusal to be treated as the support person must be documented in the medical record along with specific reason for the refusal 332

Visitation 1001  Patient can withdraw consent and change their mind  Must document in the medical record that the notice was given  Surveyor is to look at the standard notice of visitation rights  Will review medical records to make sure documented  Will ask staff what is a support person and what it means 333

Visitation 1002  Must have written P&P  Must not restrict visitors based on race, color, sex, gender identify, sexual orientation etc.  In other words, if a unit is restricted to two visitors every hour the patient gets to pick their visitors not the hospital  Suggest develop culturally competent training programs 334

335 Nursing Care Plan 298  Nursing care plan must be developed and kept current on all inpatients,  Starts on admission and includes discharge planning,  Nursing care plans should include all pertinent information and is based on assessment,  Must be kept as part of the medical record,  Plan must describe goals, discharge planning, physiological and psychosocial factors,

337 Part 3

338 Speaker  Sue Dill Calloway RN, Esq.  CPHRM, CCMSCP  AD, BA, BSN, MSN, JD  President  Board Member Emergency Medicine Patient Safety Foundation www.empsf.org  614 791-1468  sdill1@columbus.rr.com 338

339 Medical Records 300 Must maintain clinical medical records system in accordance with P&Ps,  Must have a system of patient records, ways to identify the author and protect security of MR,  Must be sure MR are not lost, stolen, or altered or reproduced in authorized manner,  Limit access to only those authorized persons,  Note HIPAA law changes effective September 23, 2013

340 Medical Records 300  Must have current list of authenticates signatures (like signature cards),  And computer codes and signature stamps,  Must be adequately protected and authorized by governing body,  Must cross reference inpatients and outpatients,  If transfer to swing bed can use one MR but need divider,

341 Medical Record Both inpatient and swing bed must have MR;  Admission, discharge orders, progress notes, nursing notes, graphics, laboratory support documents, any other pertinent documents, and discharge summaries,  Must retain MR and file them,

342 Medical Records 300  Must have system to be able to pull any old MR within past 6 years,  24 hours a day and 7 days a week,  Inpatient or outpatient,  Surveyor will verify there is a MR for every patient,  Will look to be stored in place protected from damage, flood, fire, theft, etc.,  Must protect confidentiality of MR,  MR must be adequately staffed,

343 Medical Records 302  Must be legible, complete, accurate, readily accessible and systematically organized,  To ensure accurate and complete documentation of all orders, test results, evaluations, treatments, interventions, care provided and the patient’s response to those treatments, interventions and care.  Must have director of MR that has been appointed by governing board (303),

344 Medical Records 303 MR must contain:  Identification and social data,  Evidence of properly executed informed consent forms,  Pertinent medical history,  Assessment of the health status and health care needs of the patient,  Brief summary of the episode, disposition, and instructions to the patient;

345 Informed Consent 304  Include evidence of properly executed informed consent forms for any procedures or surgical procedures,  Specified by the medical staff,  Or by Federal or State law, if applicable, that require written patient consent,  Informed consent means the patient or patient representative is given the information, explanations, consequences, and options needed in order to consent to a procedure or treatment.  See also tag 320,

346 Consider List of Procedures Procedure Name Requires Informed Consent  Ablations Yes  Amniocentesis Yes  Angiogram Yes  Angiography Yes  Angioplasties Yes  Arthrogram Yes  Arterial Line insertion (performed alone) Yes  Aspiration Cyst (simple/minor) No

347 Consider List of Procedures  Aspiration Cyst (complex) Yes  Blood Administration Yes  Blood Patch Yes  Bone Marrow Aspiration Yes  Bone Marrow Biopsy Yes  Bronchoscopy Yes  Capsule Endoscopy Yes  Catherizations, Cardiac & vascular Yes  Cardioversion Yes

348 Informed Consent 304  A properly executed consent form contains at least the following:  Name of patient, and when appropriate, patient’s legal guardian;  Name of CAH;  Name of procedure(s);  Name of practitioner(s) performing the procedures(s);  Signature of patient or legal guardian;

349 Consent Form Must Include  Date and time consent is obtained;  Statement that procedure was explained to patient or guardian;  Signature of professional person witnessing the consent;  Name/signature of person who explained the procedure to the patient or guardian.

350 Medical Records 304  MR must contain information such as progress and nursing notes, medical hx., documentation, records, reports, recordings, test results, assessments etc. to : Justify admission; Describe the patient’s progress; and support the diagnosis; Describe the patient’s response to medications; and Describe the patient’s response to services such as interventions, care, treatments,

351 Medical Records  Must maintain confidentiality of records,  What precautions are taken to ensure confidentiality and prevent unauthorized persons from gaining access,  MR retention period is 6 years and longer if required by state (311),  When can records be removed ?  AHIMA has practice briefs that can be helpful to hospitals at www.ahima.org,

AHIMA Practice Briefs www.ahima.org 352

353 Discharge Summary 304 A discharge summary discusses:  The outcome of the CAH stay,  The disposition of the patient,  And provisions for follow-up care (any post appointments such as home health, hospice, assisted living, LTC, swing bed services,  Is required for all hospitals stays and prior to and after swing bed admission,

354 Discharge Summary 304  Admitting practitioner must do,  MD/DO may delegate writing the discharge summary to other qualified health care personnel such as nurse practitioners and physician assistants if state allows,  Surveyor will verify MS have specified which procedures or treatments need informed consent,  Surveyor will verify consent forms contain all the elements,  Will do review of closed and open MR-at least 10% of average daily census,

Discharge Summary 304  Recommendations to avoid unnecessary readmissions;  Make the appointment for the patient with the PCP before discharge  Dictate the discharge summary as soon as patient is discharge  Hospital has the responsibility to get the discharge summary or medical record information into the hands of the PCP before the first visit  Make appointment within 4 days after discharge 355

356 History and Physicals 305  All or part of H&P may be delegated to other practitioners if allowed by state law and CAH (see also tag 320),  However MD/DO assume full responsibility,  MD/DO must sign also,  Surveyor will look at bylaws to determine when H&P must be done,  Make sure H&P on chart before patient goes to surgery unless an emergency  Important issue with CMS and TJC

357 Response to Treatment 306  The following must describe the patient’s response to treatment;  All orders,  Reports of treatment and medications,  Nursing notes,  Documentation of complications,  Other information used to monitor the patients such as progress notes, lab tests, graphics,

358 Medical Records 306  Must make sure MR get filed promptly,  All MR must contain all lab reports,  Radiology reports,  All vital signs,  All reports of treatment include complications and hospital acquired infections,  All unfavorable reaction to drugs,

359 Entries in the MR 307  Only those specified in the MS P&P can write in the MR,  All entries must be DATED, TIMED, and authenticated (must sign off each order),  If rubber stamps used-person must sign they will be the only one who uses it,  Must have sanctions for improper use of stamp, computer key or code signature,  Must date and time when a verbal order is signed off,

360 Confidentiality of MR 308  Must maintain confidentiality of information,  Access to information limited to those who need to know,  Safeguard MR, videos, audio,  Will verify only authorized people can access MR contained in MR department (which many call Health Information Management),  Need to release only with written authorization of patient or authorized representative,

361 MR Policies 309  Need written P&P that govern the use and removal of MR,  To include the conditions of release of information,  Remember the federal HIPAA law on MR confidentiality and privacy and ARRA, HITECH, and breach notification law,  Written consent of patient required to release (310),

362 Retention of MR 311  Records are retained for at least 6 years from date of last entry,  And longer if required by State or federal law (OSHA, FDA, EPA),  or if the records may be needed in any pending proceeding,  Can be in hard copy, microfilm or computer memory banks,  AHIMA has practice brief on retention periods,

Retention & Destruction Updated 10/15/2013 363

Retention & Destruction 364

Federal and State Retention Periods 365

366 Surgical Procedures 320  Be performed in a safe manner,  By qualified practitioner with clinical privileges,  What does safe manner mean?  The equipment and supplies are sufficient so the type of surgery can be performed safely,  Surgery dept must be organized and staffed if you have one,

367 Surgical Procedures 2013 320  Standard: If a CAH provides surgical services it must be performed in a safe manner,  By qualified practitioner with clinical privileges,  What does safe manner mean?  The equipment and supplies are sufficient so the type of surgery can be performed safely,  Surgery dept must be organized and staffed if you have one,

Tag 320 Amended June 7, 2013 368

369 Surgical Services 320  Must follow state and federal laws,  Must follow standards of practice and recommendations by national recognized organizations (AMA, ACOS, APIC, AORN),  Quality of outpatient surgical services must be consistent with inpatient,  Scope of surgical services must be writing and approved by MS,  OR must be supervised by experienced staff member, address qualifications of supervisor of OR rooms in P&P,

370 Surgical Procedures 320  If LPN or OR tech used as scrub nurses then must be under RN who is immediately available to physically intervene,  There are also a number of policies and procedures that need to be in place.  AORN PeriOperative Standards and Recommended Practices have many resources to help meet CMS and TJC requirements  Must wear clean surgical attire that covers hair

371 Surgery Policies 320  Aseptic surveillance and practice, including scrub techniques  Identification of infected and non-infected cases  Housekeeping requirements/procedures  Patient care requirements  Preoperative work-up  Patient consents and releases  Clinical procedures  Safety practices  Patient identification procedures

372 Surgery Policies 320  Duties of scrub and circulating nurse,  Safety practices,  The requirement to conduct surgical counts in accordance with accepted standards of practice,  Scheduling of patients for surgery,  Personnel policies unique to the OR,  Resuscitative techniques,  DNR status,  Care of surgical specimens,  Malignant hyperthermia,

373 Surgery Policies 320  Appropriate protocols for all surgical procedures performed. These may be procedure-specific or general in nature and will include a list of equipment, materials, and supplies necessary to properly carry out job assignments.  Sterilization and disinfection procedures  Acceptable operating room attire  Handling infections and biomedical/medical waste

374 H&P 320  Complete H&P must be done in accordance with acceptable standards of practice,  All or part may be delegated to other practitioners (like PA or NP) if allowed by your state law and CAH,  Surgeon must sign and assumes full responsibility,

375 H&P 320  Need to have H&P on the chart PRIOR to surgery,  An exception is an emergency and then need brief admission note on chart,  Note should include at a minimum critical information about the patient’s condition including pulmonary status, cardiovascular status, BP, vital signs, etc.

376 Informed Consent 320  This includes all inpatient and outpatient,  Is informed of who will actually perform the surgery (no ghost surgery),  Must inform patient if practitioner other than the primary surgeon will perform important parts of the surgical procedure,  EVEN if it is under the primary surgeon’s supervision,

377 Informed Consent 320 Consent must include:  Name of patient or their legal guardian,  Name of hospital (CAH),  Name of specific procedure,  Name of person doing the procedure or important parts of the procedure other than primary surgeon,  Significant surgical tasks include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices and altering tissue,

378 Informed Consent 320  Nature and purpose of proposed treatment, Risks, consequences if no treatment is rendered, alternative procedures or treatments, probability that proposed procedure would be successful  Signature of patient or guardian,  Date and time consent obtained,  Statement that procedure explained to the patient or guardian,  Signature of professional person witnessing the consent (proposal to change to only witness and they are witness to signature only),  Name of person who explained procedure,

379 Informed Consent 320  Must disclose information to patient necessary to make a decision,  It is a process and not a form,  Authorization form signed by a patient who does not understand what he is signing is not informed consent,  Given in language patient can understand (interpreter and issue of health care literacy),

380 PACU 320  Must be adequate provisions for immediate post-op care,  Must be in accordance with acceptable standards of care (ASPAN),  Separate room with limited access,  P&P specify transfer requirements to and from PACU,  PACU assessment includes level of activity, respiration, BP, LOC, patient color (aldrete),  If no PACU close observation by RN in patient’s room,

381 OR Register 320  Register will include;  Patient’s name, id number,  Date of surgery,  Total time of surgery,  Name of surgeons, nursing personnel, anesthesiologist,  Type of anesthesia,  Operative findings, preop and post-op diagnosis, age of patient,

382 Operative Report Must Include 320  Name and id of patient,  Date and time of surgery,  Name of surgeons, assistants,  Pre-op and post-op dx,  Name of procedure,  Type of anesthesia,  Complications and description of techniques and tissue removed,  Grafts, tissue, devises implanted,  Name and description of significant surgical tasks done by others (see list-opening, closing, harvesting grafts,

383 Surveyor in OR 320  Will verify access to OR and PACU is limited,  That there is appropriate cleaning between surgical cases and appropriate terminal cleaning applied;  That operating room attire is suitable for the kind of surgical case performed,  That persons working in the operating suite must wear only clean surgical costumes,  AORN has a position statement on this

384 Surveyor in OR 320  That equipment is available for rapid and routine sterilization of OR materials,  that equipment is monitored, inspected, tested, and maintained by the CAH’S biomedical equipment program,  sterilized materials are packaged, handled, labeled, and stored in a manner that ensures sterility e.g., in a moisture and dust controlled environment,  P&P on expiration dates is followed,

385 Surveyor in OR 320  OR organizational chart show lines of authority and delegation within the dept,  Make sure have the following:  On-call system,  Cardiac monitor,  Resuscitator, Defibrillator, Aspirator (suction equipment),  Tracheotomy set (a cricothyroidotomy set is not a substitute),

386 Surgical Privileges 321  Must designate who are allowed to perform surgery,  Must conform to P&Ps,  must be within scope of practice laws,  Review the list of physician privileges to determine if current,  Surgical privileges updated every 2 years,  Are procedures performed by appropriate physicians,

387 Surgical Privileges 321  Surgery service must maintain roster specifying the surgical privilege,  Current list of surgeons suspended must also be retained,  MS bylaws must have criteria for determining privileges,  Surveyor will review written assessment of the practitioner's training, experience, health status, and performance.

388 Surgical Privileges 321  Surgical privileges are granted in accordance with the competence of each,  MS appraisal procedure must evaluate each practitioner’s training, education, experience, and competence,  As established by the QI program, credentialing, adherence to hospital P&P, and laws,

389 Surgical Privileges 321  Must specify for each practitioner that performs surgical tasks including MD, DO, dentists, oral surgeon, podiatrists,  RNFA, NP, surgical PA, surgical tech et. al.,  Must be based on compliance with what they are allowed to do under state law,  If task requires it to be under supervision of MD/DO this means supervising doctor is present in the same room working with the patient,

391 Pre-Anesthesia Assessment 322  Pre-anesthesia evaluation must be performed immediately prior to the surgery,  By qualified person to administer anesthetic to evaluate risk of anesthesia,  Must include; notation of risk of anesthesia, anesthesia, drug, and allergy history,  Potential anesthesia problems id,  Patient’s condition prior to induction,

392 Pre-anesthesia ASA Guideline  Preanesthesia Evaluation 1  Patient interview to assess Medical history, Anesthetic history, Medication history  Appropriate physical examination  Review of objective diagnostic data (e.g., laboratory, ECG, X-ray)  Assignment of ASA physical status  Formulation of the anesthetic plan and discussion of the risks and benefits of the plan with the patient or the patient’s legal representative  1 www.asahq.org/publicationsAndServices/standards/03.pdf

ASA Guidelines and Standards 393 http://asahq.org/For-Healthcare-Professionals/Standards- Guidelines-and-Statements.aspx

ETCO 2 for Moderate and Deep Sedation ASA 395 http://asahq.org/For-Healthcare-Professionals/Standards- Guidelines-and-Statements.aspx

ASA Practice Advisory Preanesthesia Evaluation 396 http://asahq.org/For-Members/Practice-Management/Practice- Parameters.aspx

ASA Standard on Preanesthesia Care 397 http://asahq.org/For-Healthcare-Professionals/Standards-Guidelines- and-Statements.aspx

399 Post Anesthesia Evaluation 321  Post-anesthesia follow-up report must be written on all inpatients and outpatients prior to discharge,  Written by the individual who is qualified to administer the anesthesia.  Must include at a minimum: Cardiopulmonary status, LOC, follow-up care and/or observations; and,  Any complications occurring during PACU.

400 Post Anesthesia ASA Guidelines  Patient evaluation on admission and discharge from the postanesthesia care unit  A time-based record of vital signs and level of consciousness  A time-based record of drugs administered, their dosage and route of administration  Type and amounts of intravenous fluids administered, including blood and blood products  Any unusual events including post-anesthesia or post procedural complications  Post-anesthesia visits

402 Anesthesia 323  CAH must designate who can administer anesthesia,  MS include criteria for determining privileges, In accordance with P&P and scope of practice and state law,  Only by anesthesiologist, MD/DO, CRNA, anesthesiology assistant, supervised trainee in education program, dentist, podiatrist,  State exemption process of MD supervision for CRNA,

403 Anesthesia 323  A CRNA may administer anesthesia when under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed,  An anesthesiologist’s assistant (AA) may administer anesthesia when under the supervision of an anesthesiologist who is immediately available if needed.

404 Immediately Available Means  Physically located within the OR or in the L&D unit;  and Is prepared to immediately conduct hands-on intervention if needed;  and Is not engaged in activities that could prevent the supervising practitioner from being able to immediately intervene and conduct hands-on interventions if needed

405 Discharge 325  All patients are discharged in the company of a responsible adult,  Any exceptions to this requirement must be made by the attending practitioner and documented in the medical record,  Surveyor will verify that the CAH has P&Ps in place to govern discharge procedures and instructions,

406 Quality Assessment 331  Must periodically review total program (will look at who is to do this),  At least once per year,  Include services provided and number of patients served,  look at volume of service (332),  Include at least 10% of charts- active and closed charts (333),

407 Quality Assessment 335  Review all P&Ps also (show evidence of how these are evaluated and reviewed),  Purpose of the evaluation is to determine whether the utilization of services was appropriate,  And whether the P&P we revised if needed,

408 Quality Assessment 336 An effective program includes;  Ongoing monitoring and data collection,  Problem prevention, id and analysis,  Identification of corrective actions,  Implementation of corrective actions,  Evaluation of corrective actions,  Measures to improve quality on a continuous basis,

409 Quality Assessment 336  QA program to evaluate appropriateness of diagnosis and treatment and in treatment outcomes,  Facility wide QA program (QI),  Can have QA by arrangement,  Surveyor will look at your QI PLAN, QI minutes,

410 Healthcare Associated Infections 337  Must evaluate nosocomial infections,  Must look at medication therapies,  Must evaluate the quality of care of LIPs (NP, PA, CNS) by doctor on MS or under contract,  Will look at how their performance is evaluated (339),  Quality of care and appropriateness of dx and tx by doctors must be reviewed by QIO (PRO), hospital that is member of network, or as identified in state rural health plan (340),

411 Quality Improvement 341  Staff consider the findings and evaluations and recommendations of the evaluations and take corrective actions,  Take steps to remedial action to address deficiencies found thru QI process,  Will look to see who is responsible for implementing actions,  Document the outcomes of all remedial actions (343)

340 Quality Assurance 7-15-2011 412

Quality Assurance 340  CAH have an arrangement for outside entity to review the appropriateness of the diagnosis and treatment provided by each MD/DO providing services  This includes doctors providing telemedicine services  Some CAHs may also prefer to conduct their own internal review in addition to the outside review but not required  Outside review may be done by hospital that is a member of the same rural health network as the CAH; a Medicare QIO 413

414 Organ, Tissue, and Eye 344  Hospital must have written P&P to address its organ procurement,  must have agreement with OPO,  Must timely notify OPO if death is imminent or has patient has died,  OPO to determine medical suitability for organ donation,  Defines what must be in your written agreement (definitions, criteria for referral, access to your death record information

OPO Agreements 415

416 Organ, Tissue, and Eye 345  Board must approve your organ procurement policy,  Must integrate into hospital’s QAPI program,  Surveyor will review written agreement with the OPO to make sure it has all the required information,  Check off the long list to ensure all elements are present (such as definition of imminent death, what is timely notification, allows them access to your death records etc.,

417 Imminent Death 345 Definition of imminent death might include a patient with severe, acute brain injury who:  Requires mechanical ventilation (due to brain injury);  Is in an ICU or ED; AND  Has clinical findings consistent with a Glascow Coma Score that is less than or equal to a mutually-agreed-upon threshold; or  MD/DOs are evaluating a diagnosis of brain death (within 1 hour) ; or  An MD/DO has ordered that life sustaining therapies be withdrawn, pursuant to the family’s decision (notify them before withdrawing life sustaining therapies),  Make sure your staff is aware of the P&P,

418 Tissue and Eye Bank 346  Need an agreement with at least one tissue and eye bank,  OPO is gatekeeper and notifies the tissue or eye bank chosen by the hospital,  OPO determines medical suitability,  Don’t need separate agreement with tissue bank if agreement with OPO to provide tissue and eye procurement,

419 Family Notification 347  Once OPO has selected a potential donor, person’s family must be informed of the donor’s family’s option,  OPO and hospital will decide how and by whom the family will be approached,

420 Organ Donation 347  Person to initiate request must be a designated requestor or organized representative of tissue or eye bank,  Designated requestor must have completed course approved by OPO,  Encourage discretion and sensitivity to the circumstances, views and beliefs of the families (348),  Surveyor will review complaint file for relevant complaints,

421 Organ Donation Training 349  Patient care staff must be trained on organ donation issues,  Training program at a minimum should include: consent process, importance of discretion, role of designated requestor, transplantation and donation, QI, and role of OPO,  Train all new employees, when change in P&P, and when problems identified in QAPI process,

422 Organ Donation 349  Hospital must cooperate with OPO to review death records to improve id of potential donors,  Surveyor will verify P&P that hospital works with OPO,  Maintain potential donors while necessary testing and placement of donated organs take place,  Must have P&P to maintain viability of organs,

423 Swing Beds LTC Services 350-408  Must meet following to provide post- hospital SNF care (350),  Must be certified by CMS,  SNF services must be in compliance with Subpart B of part 483,  Allows CAH to use beds interchangeable for either acute care or SNF level,  Swings from acute care reimbursement to SNF services and reimbursement,

424 Swing Beds  Must be discharge orders from acute care, progress notes and discharge summary and subsequent admission orders,  If patient does not change facilities can use same MR with chart separator,  Medicare requires 3 day qualifying stay in CAH prior to admission to swing bed,  3 day rule only applies to Medicare patients,

425 Swing Beds  No LOS restriction for swing bed,  No transfer agreement needed between CAH and nursing home,  CAH does not have to use the MDS form for recording patient assessment,  Swing bed patients receive SNF level of care and CAH is reimbursed for SNF level.

426 Swing Beds-Requirements  Resident rights,  Admission, transfer, and discharge rights,  Resident behavior and family practices (restraints),  Patient activities,  Social services, comprehensive assessment, dental services, and nutrition,

427 Eligibility 351  Must be certified as CAH,  Have no more than 25 beds,  Section on facilities participating as rural health care hospital (see 352),  Have to be in compliance with SNF requirements in subpart B of part 483, (residents rights, nutrition, dental, admission and discharge rights, patient activities, social services, comprehensive assessment etc.,

428 Resident Rights 361  Right to dignified existence,  Self determination,  Communicate and access to persons and services outside the facility,  Right to a copy of a notice of their rights,  In language they can understand,  Right to refuse treatment,

429 Resident Rights 361  Right to get access to their records within 24 hours (excluding weekends/holidays),  A right to buy a copy of their medical records with 2 working days notice,  Rights in writing about their conduct and responsibilities during their stay,  Facility must assure patient’s rights are followed,  Right to know what their rights are,

430 Resident Rights 361  Right to choose attending MD,  Right to share room with their spouse,  Participate in their plan of care,  Right to privacy and confidentiality,  Right to get mail and send mail unopened,  Right to personal property and visitors,  Work or not work,  Provide interpreters, sign language when needed,

431 Resident Rights 362  Right to refuse treatment,  Right to refuse to participate in experimental research,  A resident being considered for participation in experimental research must be fully informed of the nature of the experiment and understand the possible consequences of participating,  Will look to see if IRB has approved experimental treatment,  Right to make an advance directive,

432 Resident Rights 363  Inform each Medicaid patient that items and services that will be included and for which the resident will be charged and amount,  If M/M does not make payment for service, must notify the resident of what is not covered,  May charge for phone, TV, radio, personal clothing, confections, flowers, plants, private room unless isolation, social events, books etc.,  Must have P&P for advance directives, educate your staff on advance directives,  Must document in the MR if they have one,  Provide for community education on advance directives (can use videotapes and audiotapes),

433 Free Choice 364  Right to choose an attending MD/DO,  But doctor must fulfill given requirements such as the frequency of visits,  Facility has right to inform resident to seek another doctor,  Facility must help patient to find another physician,

434 Consent 365  Right to be fully informed in advance about care and treatment,  Including any changes,  They have right to receive information in order to make healthcare decisions,  information should include medical condition, changes in condition, the benefits, reasonable risks of the recommended treatment, and reasonable alternatives,  Financial costs to treatment options must be disclosed in advance and in writing,

435 Privacy/Confidentiality 367  Right to personal privacy,  Right to confidentiality,  Privacy to written and telephone calls,  Right to privacy for visits in office, dining room, vacant chapel,  Privacy when using bathroom,  Staff should pull curtains, close doors,

436 Work 368  Resident has right to refuse to perform services for the facility,  Perform services if she wants (housekeeping, laundry, meal preparation),  Document need or desire to work in the plan of care,  Specify if services performed are paid or voluntary,  Rate must be at prevailing rate, laundry

437 Mail 369  Right to send and promptly receive mail that is unopened; and  Have access to stationery, postage, and writing implements at the resident’s own expense.  Deliver mail within 24 hours of delivery by us post office,

438 Access and Visitation 370  The resident has the right and the facility must provide immediate access to any resident by the following,  immediate family or other relatives of the resident,  others who are visiting with the consent of the resident.  Resident can withdrawal consent at any time,

439 Personal Property 371  Right to retain and use personal possessions,  Including some furnishings, and appropriate clothing, as space permits,  Unless to do so would infringe upon the rights or health and safety of other residents,  Surveyor will look to see if residents are encouraged to have and use personal items,

440 Married Couples 372  Resident has the right to share a room with his or her spouse,  When married residents live in the same facility,  And both spouses consent to the arrangement.  If there is a room available,

441 Admission, Transfers, Discharge  Transfer means outside of the facility,  Purpose to restrict transfer by facility-to prevent dumping of high care or difficult residents (373),  Only when initiated by the facility not the patient,  May not transfer or discharge a resident unless necessary to meet their welfare,  Appropriate because no longer needs the services provided (374),  Safety or health of individuals in facility is endangered,

442 Admission, Transfers, Discharge  Must document these in the medical record,  Must notify resident and family members and document reasons,  30 days notice with exceptions,endangerment to others, condition improved, urgent medical needs to be transferred,  Not a resident for 30 days,

443 Payment of Care 375  Resident has failed to pay for care after reasonable notice,  If eligible for Medicare after admission, may only charge allowable rate,  Must provide notice to the patient and document reason in MR (377),  Must be made within 30 days before resident is transferred, unless safety or health of individuals would be in danger,  Need to document accurate assessments to address resident’s needs,

444 Resident Behavior-Restraints  Right to be free from restraints (381),  Both physical and chemical,  Must do assessment and care planning,  Never used for discipline or convenience,  Need to have process of assessment and evaluation before restraints used,  Include in the plan of care,

445 Abuse 382  Right to be free from verbal, sexual, physical, and mental abuse,  Free from involuntary seclusion,  Defines each of these,  Must have written policies that prohibit neglect, and abuse and mistreatment,  include the definitions of each in your policy,  Will review any records of abuse,  Need P&P that prohibit mistreatment, neglect, and abuse and misappropriation of resident property,

446 Hiring of Employees 384  Not hire if found guilty of abusing, neglecting, or mistreating residents by a court of law,  Or entered into state NA registry for this,  Report any alleged violation involving neglect or abuse, or misappropriation of property to administrator and to other officials as required by state law,  Must investigate,  Should check all references,

447 Surveyor will look at…. 384 Was relevant documentation reviewed and preserved (e.g., dated dressing which was not changed when treatment recorded change)? Was the alleged victim examined promptly (if injury was suspected) and the finding documented in the report? What steps were taken to protect the alleged victim from further abuse (particularly where no suspect has been identified)?

448 Surveyor Will Look At What actions were taken as a result of the investigation? What corrective action was taken, including informing the nurse aide registry, State licensure authorities, and other agencies (e.g., LTC ombudsman; adult protective services; Medicaid fraud and abuse unit)?

449 Quality of Life  Must care for residents in way that promotes quality of life,  Have activities directed by qualified person,  Qualified occupational therapist,  Must provide social services to attain physical, mental and psychosocial well being,

450 Activities 385  Facility must provide for an ongoing program of activities designed the interests and the physical, mental, and psychosocial well-being of each resident.  Activities program by a qualified therapeutic recreation specialist or activity professional who is licensed or registered by state,  Or 2 yr experience on social or recreational program within the last 5 years, or  Is qualified OT or OT assistant,  Or had completed training by the state,

451 Activities 385  Surveyor will observe individual and group activity,  Long list of things under the survey procedures on this one,  What activities are planned,  Outcomes and responses,  Included in care plans based on resident’s assessment,  Adequate supplies,

452 Social Services 386  Facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident,  Need bachelor’s degree in social work or human services field (psychology, rehab counseling, etc.) and 1 year supervised social work experience in health care setting,

453 Social Services 386 Making arrangements for obtaining needed adaptive equipment, clothing, and personal items; Maintaining contact with family (with resident’s permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning; Assisting staff to inform residents and those they designate about the resident’s health status and health care choices; Making referrals and obtaining services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation);

454 Social Services 386 Assisting residents with financial and legal matters (e.g., applying for pensions, referrals to lawyers, referrals to funeral homes for preplanning arrangements); Discharge planning services (e.g., helping to place a resident on a waiting list for community congregate living, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities); Providing or arranging provision of needed counseling services;

455 Resident Assessments 388 Conduct initial and periodic and reproducible assessments of each resident’s functional capacity, and includes;  Identification and demographic information.  Customary routine.  Cognitive patterns.  Communication.  Vision.  Mood and behavior patterns.  Psychosocial well-being.

456 Resident Assessments 388  Physical functioning and structural problems.  Continence.  Disease diagnoses and health conditions.  Dental and nutritional status.  Skin condition.  Activity pursuit.  Medications

457 Resident Assessments 388  Special treatments and procedures.  Discharge potential.  Documentation of summary information regarding the additional assessment performed through the resident assessment protocols.  Documentation of participation in assessment.  Must do direct observation and communicate with resident and licensed members on all shifts,  Intent to do this to develop care plan,

458 Assessments  Assessment within 14 days after admission,  Assessment if significant change (390),  Excludes readmissions if no significant change in condition (389),  Very detailed information on what constitutes a significant change (394),  Must have a comprehensive care plan (395),  Care plan must include measurable objectives to met patient’s needs,

459 Care Plans 395  Interdisciplinary team should develop objectives to attain highest level of functioning,  Document if patient refuses something staff feel would help,  Care plan must be developed within 7 days after comprehensive assessment done,  Prepared by interdisciplinary team that includes doctor, RN with responsibility for resident, resident and family,  Review and revise as necessary,

460 Care Plan 395  Did an occupational therapist design needed adaptive equipment or a speech therapist provide techniques to improve swallowing ability?  Do the dietitian and the speech therapist determine, for example, the optimum textures and consistency for the resident’s food that provide both a nutritionally adequate diet and effectively use oropharyngeal capabilities of the resident,  Does staff make an effort to schedule care plan meetings at the best time of the day for residents and their families?

461 Service Provided 397  Services provided must meet the standard of care,  Make sure person providing care are qualified,  Are residents with acute conditions promptly hospitalized, as appropriate?  Are there errors in medication administration?  Make sure they follow the care plan (399),

462 Discharge Summary 399 Resident must have a discharge summary that includes;  Recapitulation of the resident’s stay,  Final summary of the resident’s status,  A post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment.

463 Nutrition 400 The facility must ensure that a resident;  Maintains acceptable parameters of nutritional status, such as body weight and protein levels,  unless the resident’s clinical condition demonstrates that this is not possible,  Unacceptable parameters include unplanned weight loss, peripheral edema, cachexia and laboratory tests indicating malnourishment (e.g., serum albumin levels).

464 Nutrition 401  Suggested parameters for evaluating significance of unplanned and undesired weight loss are:  See detailed information under 401, IntervalSignificant Loss Severe Loss 1 month5%Greater than 5% 3 months7.5%Greater than 7.5% 6 months10%Greater than 10%

465 Suggested Laboratory Values  Albumin >60 yr.: 3.4 - 4.8 g/dl (good for examining marginal protein depletion),  Plasma Transferrin >60 yr.:180 - 380 g/dl. (Rises with iron deficiency anemia. More persistent indicator of protein status.),  Hemoglobin 14-17 males and 12-15 females,  Hemocrit males 41-53, females 36-46,  K+ 3.5-5.0,  Mg+ 1.3-2.0,

466 Rehab Services 402  If specialized rehabilitative services such as, but not limited to,  physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and mental retardation, are required in the resident’s comprehensive plan of care,  Facility must provide the required service,

467 Rehab Services 402  Need physician order (403)  May get from outside source,  No fee can be charged a Medicaid recipient for specialized rehabilitative services because they are covered facility services.

468 Occupational Therapy 402  What did the facility do to decrease the amount of assistance needed to perform a task?  What did the facility do to decrease behavioral symptoms?  What did the facility do to improve gross and fine motor coordination?  What did the facility do to improve sensory awareness, visual-spatial awareness, and body integration?  What did the facility do to improve memory, problem solving, attention span, and the ability to recognize safety hazards?

469 Speech, Language Pathology  What did the facility do to improve auditory comprehension?  What did the facility do to improve speech production and expressive behavior?  What did the facility do to improve the functional abilities of residents with moderate to severe hearing loss who have received an audiology evaluation?  For the resident who cannot speak, did the facility assess for a communication board or an alternate means of communication?

470 Dental Services 404  The facility must assist residents in obtaining routine and 24-hour emergency dental care.  This requirement makes the facility directly responsible for the dental care needs of its residents.  The facility must ensure that a dentist is available for residents,  Make appt and arrange transportation (408),  Can’t charge Medicaid patients,  For Medicare and private pay can impose additional charge,

471 AHA Website on CAH  www.aha.org/memberRelations/cah.asp www.aha.org/memberRelations/cah.asp  Provides updates,  Directory of resources,  Federal legislation,  Growth of the program,  Grants,  State hospital association links,

472  Statement of Deficiencies and Plan of corrections,  Based on documentation of surveyor worksheet or notes and form CMS-2567,

475 The End  Are you up to the challenge??  See additional resources including patient safety resources,

476 Websites  Tools and Resources Rural Health Resource Center at http://www.ruralcenter.org/tasc/  American Association for Respiratory Care AARC- www.aarc.org,  American College of Surgeons ACS- www.facs.org,  American Nurses Association ANA- www.ana.org

477 Websites  Center for Disease Control CDC – www.cdc.gov,  Food and Drug Administration- www.fda.gov,  Association of periOperative Registered Nurses at AORN- www.aorn.org,  American Institute of Architects AIA- www.aia.org,  Occupational Safety and Health Administration OSHA – www.osha.gov,  National Institutes of Health NIH-www.nih.gov,

478 Websites  United States Dept of Agriculture USDA- www.usda.gov,  Emergency Nurses Association ENA- www.ena.org,  American College of Emergency Physicians ACEP- www.acep.org,  Joint Commission Joint Commission- www.JointCommission.org,  Centers for Medicare and Medicaid Services CMS- www.cms.hhs.gov,

479 Websites  American Association for Respiratory Care AARC- www.aarc.org,  American College of Surgeons ACS- www.facs.org,  American Nurses Association ANA- www.ana.org,  AHRQ is www.ahrq.gov,

480 Websites  American Hospital Association AHA- www.aha.org,  CMS Life Safety Code page - http://new.cms.hhs.gov/CFCsAndCoPs/07_ LSC.asp,  COPs available in word and PDR at http://www.access.gpo.gov/nara/cfr/waisidx _04/42cfr485_04.html,  American College of Radiology- www.acr.org,

481 Websites  Federal Emergency Management Agency (FEMA)- www.fema.gov,  Drug Enforcement Administration – www.dea.gov (copy of controlled substance act),  US Pharmacopeia- www.usp.org, (USP 797 book for sale),  Rural Assistance Center or RAC at http://www.raconline.org/ http://www.raconline.org/  CAH seminar Oct 2007 handouts at http://www.nrharural.org/conferences/sub/CAH. html

482 Websites  National Patient Safety Foundation at the AMA- www.ama-assn.org/med-sci/npsf/htm,  The Institute for Safe Medication Practices- www.ismp.org  U.S. Pharmacopeia (USP) Convention, Inc.- www.usp.org  U.S. Food and Drug Administration MedWatch- www.fda.gov/medwatch  Institute for Healthcare Improvement- www.ihi.org,  AHRQ at www.ahrq.gov,  Sentinel event alerts at www.jointcommission.org,

483 Websites  American Pharmaceutical Association- www.aphanet.org  American Society of Heath-System Pharmacists- www.ashp.org  Enhancing Patient Safety and Errors in Healthcare- www.mederrors.com  National Coordinating Council for Medication Error Reporting and Prevention-www.nccmerp.org,  FDA's Recalls, Market Withdrawals and Safety Alerts Page: http://www.fda.gov/opacom/7alerts.html

484 Infection Control Websites  Association for Professionals in Infection Control and Epidemiology (APIC) infection control guidelines at www.apic.org,  Centers for Disease Control and Prevention- www.cdc.gov,  Occupational Health and Safety Administration (OSHA) at www.osha.gov,  The National Institute for Occupational Safety and Health NIOSH at www.cdc.gov/niosh/homepage.html,  AORN at www.aorn.org,  Society for Healthcare Epidemiology of America (SHEA) at www.shea-online.org,

485 www.flexmonitoring.org/links.shtml

486 Helpful Websites

488 Federal Office of Rural Health Policy  Federal Office or Rural Health Policy Room 9A-55 5600 Fishers Lane Rockville, MD 20857 301 443-0835 301 443-2803 fax

489 Office of Rural Health Policy  Advises DHHS on matters affecting rural hospitals,  Has resources for CAH,  Furnishes selected articles,  Articles on rural issues on their web site  http://www.ruralhealth.hrsa.gov/index.htm

492 Physical Environment  How do you provide emergency power?  Can emergency generator provide power for emergency equipment and lighting,  Review maintenance records and policies of test runs and how often on emergency equipment,

493 Resources  AHRQ published patient safety primer in 2008 that is designed to help users to understand key concepts in patient safety at http://psnet.ahrq.gov/primerHome.aspx,  TeamSTEPPS is a teamwork system with tons of free resources on this at http://teamstepps.ahrq.gov/

494 AHRQ Website http://www.ahrq.gov/qual/

495 IHI Website www.ihi.org/ihi

496 SafetyLeaders.org Website

497 AHA Quality Center http://www.ahaqualitycenter.org/ahaqualitycenter/jsp/home.jsp

498 NCP VA National Safety for Patient Safety  Has multiple resources available at www.patientsafety.gov/bravo.htm  TIPS Newsletter - topics concerning patient safety,  NCPS Patient Safety Handbook developed by the National Center for Patient Safety,  Fall incident report by Morse Fall Scale and tools for falls,  Patient elopement tools,  Medication tips,

500 AHRQ  Medical Error and Patient Safety at http://www.ahrq.gov/qual/errorsix.htm, Web M&M, Mortality and Morbidity Monthly, at http://www.webmm.ahrq.gov/,  PSNet, AHRQ Patient Safety Network, http://psnet.ahrq.gov/, contains articles on medication errors and other patient safety issues that come out,  Are you signed up to get this? You can browse under medication errors/ADE topic.(866 articles)

502 ISMP  Institute for Safe Medication Practice is a rich source of information,  www.ismp.org, www.ismp.org  Has medication tools and resources,  Has high alert list, self assessment tools  Error prone abbreviation,  FDA MedWatch,  Confused drug name list, anticoagulant safety,  Sign up nurses for free newsletter via email called Nurse Advise-ERR at https://www.ismp.org/orderforms/adviseERRsubscri ption.asp

504 USP US Pharmacopeia  Good source of information and have the MEDMARX program,  Have drug error finder for LASA,  Revises heparin monograph at http://www.usp.org/hottopics/heparin.ht ml?hlc. http://www.usp.org/hottopics/heparin.ht ml?hlc  Has newletters at http://www.usp.org/aboutUSP/newslett er.html  Has USP email notices –monthly updates,  www.usp.org

506 Sign Up for FDA Alerts  Sign up to get safety alerts from FDA,  At http://www.fda.gov/opacom/7alerts.html  Example; Advil and ASA taken together- if heart patient takes ASA 81 mg for heart- ibuprofen can interfere with anti-platelet effect,  Take 30 minutes or longer,  Minimal risk with occasional use,  Lots of information on medications!  See also Drug Safety newsletter at http://www.fda.gov/cder/dsn/2008_winter/2008_wint er.pdf

508 FDA Patient Safety News 2008  Mixups between insulin U-100 and U-500 which occurred when selecting from computer screens,  Severe pain, muscle or joint pain, with osteoporosis drug with bisphosphate drugs such as Fosamax, Actonel, Boniva, and Reclast,  More patients die with luer misconnections,  Deaths from Fentanyl patches continue,  http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/index.cfm

510 IHI Institute for Healthcare Improvement  Excellent source of resources for patient safety and quality resources, toolkits, how to kits,  Prevent ADEs by implementing medication reconciliation,  Reduce harm from high alert medications,  Reduce MRSA infections,  Many resources related to medication issues, At www.ihi.org,

512 Leapfrog  Represents half a million Americans by corporations that purchase health insurance,  Rewards for improving safety and quality,  Aims CPOE, 27 procedures to preventing medical errors, high risk treatments, ICU staffing with intensivists  If 3 followed would prevent 907,600 medication errors, 65,341 lives and $41 billion dollars a year!  www.leapfroggroup.org

513 National Quality Forum  30 Safe Practices published in October, 2006,  34 Safe Practices Update 2009,  Includes CPOE, unit dose, anticoagulant therapy, culture of safety, standardize labeling and storage of medication, identification of high alert medications, medication reconciliation,  Chapter 6 was on Medication Management,

514 Culture SP 1 Information Management & Continuity of Care Medication Management Hospital Acquired Infections Condition- & Site-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Periop. MI Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy Asp. + VAP Prevention Central V. Cath BSI Prevention Sx Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Central Role Med Recon. Std. Med Labeling & Pkg High Alert Meds Unit Dose Medications Evidence- Based Ref. Culture CPOE Order Read-back Abbreviations Discharge System Critical Care Info. Labeling Studies Culture Meas., F.B., & Interv. Structures & Systems ID Mitigation Risk & Hazards Team Training & Team Interv. CHAPTER 1: Background  Summary, and Set of Safe Practices CHAPTERS 2-8 : Practices By Subject Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 7: Hospital-Acquired Infections Prevention of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Prevention Surgical Site Infection Prevention Hand Hygiene Influenza Prevention CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Prevention Perioperative Myocardial Infarct/Ischemia Prevention Pressure Ulcer Prevention DVT/VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure Consent & Disclosure CHAPTER 6: Medication Management Pharmacist Role Medication Reconciliation High-Alert Medications Standardized Medication Labeling & Packaging Unit-Dose Medications 2007 NQF Report

515 Pa Patient Safety Authority www.psa.state.pa.us/psa/site/default.asp

516 Federal Office of Rural Health Policy  Federal Office or Rural Health Policy Room 9A-55 5600 Fishers Lane Rockville, MD 20857 301 443-0835 301 443-2803 fax

517 Office of Rural Health Policy  Advises DHHS on matters affecting rural hospitals,  Has resources for CAH,  Furnishes selected articles,  Articles on rural issues on their web site  http://www.ruralhealth.hrsa.gov/index.htm

520 The End!  Sue Dill Calloway RN, Esq. CPHRM  AD, BA, BSN, MSN, JD  President  Chief Learning Officer Emergency Medicine Patient Safety Foundation www.empsf.org  614 791-1468  sdill1@columbus.rr.com 520

Critical Access Hospitals (CAH) What every CAH needs to know about the Conditions of Participation (CoPs)

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Critical Access Hospitals (CAH) What every CAH needs to know about the Conditions of Participation (CoPs)

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