Critical Access Hospitals

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Critical Access Hospitals

• CAH

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Introductions

• Background of program
• Reasons for mock surveys
• Planning for more than a year
• Background of participants
• Hospitals
• Mock Surveyors
• Background of presenter

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www.kdheks.gov
KDHE Vision - Healthy Kansans living in Safe
Sustainable Environments
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(No Transcript)
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Objectives
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Program Objectives

• Assist CAHs in meeting their goals of providing
  the best patient care with best practices
• Understanding the state and federal regulations
• Providing new eyes recognize problem areas
• Providing possible corrective action that has
  been successful in other hospitals
• Providing resources for assistance

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Mock Surveyor Objectives

• Understand the survey methods used by KDHE and
  CMS to survey CAHs
• Understand the difference between a CoP and a
  standard regulation
• Understand the content of the CAH CoPs including
  the use of interpretive guidelines procedures
  in Appendix W
• Be able to assist their CAH in meeting state and
  federal regulations improving patient care.

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Mock Survey Program

• One day of classroom 8 hours
• 4 days of on the job training Avg 30 hrs
• Reviewing
• Interviewing
• Observing
• Information Analysis, decision making and writing
  up the report Avg 6 hrs
• Exit interview Avg 2 hrs

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Mock Survey Process

• Pre-Entrance meeting
• Entrance conference
• Information gathering and investigation
• Observations, interviews and record reviews
• Daily conference with CEO
• Exit conference

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PROCEDURES

• Focus on actual potential patient outcomes
• Assess care services provided including
  appropriateness of care.
• Visit all care units, all campuses, outpatient
  areas, surgery, ED, X-ray rehabilitation areas.
• Observe actual care provided
• Check QA - has it been incorporated into each
  department?

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So What did we Find?
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• 61 Federal State regulatory concerns
• 48 Federal
• 5 State
• 6 Risk Management
• 2 EMTALA
• 55 Federal State regulatory concerns
• 42 Federal
• 7 State
• 6 Risk Management
• 32 Federal State regulatory concerns
• 23 Federal
• 5 State
• 1 Risk Management
• 3 EMTALA

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CoP 0150Compliance with State, Federal and
Local Laws and Regulations

• Credentialing files
• keeping up to date between times of credentialing

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CoP (C-0190 CFR 485.616)Agreements

• C195 CFR 485.616(b)
• Agreements for Credentialing
• and
• Quality Assurance

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COP - C0200 CFR 485.618Emergency
ServicesMeets the needs of its IPs OPs
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CoPC0210 CFR 485.620 Number of Beds
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Observation Patient Services

• IG require one person named to coordinate OP
  services

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Cop C0220 CFR 485.623Physical Plant
Environment

• C0222(1)Housekeeping preventative maintenance
  programs that ensure
• Essential mechanical, electrical, pt-care
  equipment is maintained in safe operating
  condition
• C0223(2)Proper routine storage prompt disposal
  of trash
• C0224(3)Drugs biologicals appropriately stored
• C0225(4)Premises are clean orderly

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Standard C0227 CFR 485.623(c)Emergency
ProceduresNon-medical emergencies

• Disaster Drills

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CoP CFR 485.627 Organizational Structure

• Governing Body/Responsible Individual
• The person responsible for the operation of the
  CAH
• (3) The person responsible for the medical
  direction

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Standard C0262 CFR 485.631(c)PA, NP CNS
Responsibilities
(1) Participate in development, execution
periodic review of the policies (2) Participate
with physician in periodic review of patient
records
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CoP C0270 CFR 485.635Provision of Services
Standard C0271 CFR 485.635(a) Patient
Care Policies
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C0280 CFR 485.635(a)(4) Policies reviewed
annually by the group of professional personnel
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1. Services are furnished in accordance with
   appropriate written policies consistent with
   state laws
2. A description of the services furnished directly
   those furnished through agreement or
   arrangement
3. Policies include the following
4. Emergency medical services
5. Guidelines for management of health problems
   including those that require consultation /or
   referral, maintenance of health records,
   procedures for periodic review evaluation of
   services furnished by the CAH
6. Rules for storage, handling, dispensation,
   administration of drugs biologicals. In
   accordance with accepted principles, current
   accurate records kept, outdated, mislabeled. Or
   otherwise unusable drugs are not available for pt
   use.

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Standard C0285 CFR 485.635(c)Services Provided
Through Agreements or Arrangements

• Must be well defined, but contracts not needed
  evidence that Gov Body is responsible for
  services.
• Revised as needed
• QA Gov Body assures services provided according
  to acceptable standards

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C0291 CFR 485.635(c)(3)CAH maintains a list of
all services furnished under arrangements or
agreements with nature and scope of services.
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Standard C0294 CFR 485.635(d)Nursing Services

• Ensure adequate training , orientation,
  supervision of all nursing staff and non-CAH
  nursing staff and that their clinical activities
  are evaluated and know the P Ps (a CAH-employed
  RN should conduct the supervision evaluation of
  the clinical activities of non-CAH staff.)

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C0298 CFR 485.635(d)(4)Nursing Care Plan must be
developed current for each pt
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CoP C0300 CFR 485.638 Clinical Records

• Legible, complete, accurate, readily accessible,
  organized
• Confidentiality of record information and
  provides safeguards against loss, destruction, or
  unauthorized use.

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Standard C0322 CFR 485.639(b)Anesthesia Risk
Evaluation

• Each pt must be evaluated for proper anesthesia
  recovery by a qualified staff
• Include-cardiopulmonary status level of
  consciousness any follow-up care/observations
  and any complications during recovery

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CoP C0330 CFR 485.641Periodic Evaluation QA

• Standard C0331 CFR 485.641(a) Periodic
  evaluation all services at least annually
• C0332 - of patients served volume of services
• C0333 - Review of active closed records
• C0334 - Health care policies reviewed as part
  of QA program
• C0335 The utilization of services was
  appropriate, established policies were followed
  changes were made as needed

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HANDWASHINGMEDICAL ERRORSINFECTION CONTROL
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SWING BEDC0360 CFR 485.645(d)SNF Services
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C0385 CFR 483.15(f) Rights Activities

• Provide ongoing program of activities designed to
  meet, according to comprehensive assessment, the
  interests physical, mental, psychosocial
  well-being of each resident.

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C0404 CFR 483. 55Dental Services

• The CAH must assist residents in obtaining
  routine and 24 hr emergency dental care

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STATE REGULATIONS
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• KAR 28-34-10a(c) Meds requiring refrigeration
  must be stored in refrigerators dedicated to drug
  storage only
• KAR 28-34-10a(d) PT committee must meet at least
  quarterly with med staff, nursing Pharmacist
• KAR 28-34-17b Must have a policy that determines
  the circumstances which require the presence of
  an assistant during surgery and determine whether
  the assistant should be a physician or
  nonprofessional personnel

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KAR 28-34-18 OB Newborn Services

• Must have continuous coverage by a qualified
  member of nursing staff with qualified RN
  immediately available
• Safety of newborn
• Nursery available
• Policy for flow of staff - OB other areas
• Peri-Natal committee with appropriate medical
  staff nursing

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KAR 28-34-28(c)ICU or CCU

• Distinctly identifiable
• Headed by qualified RN
• Staffed by qualified person when occupied
• Sufficient equipment to carry our intensive care
• Intensive care or coronary care committee of the
  medical staff
• Policies procedures

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KAR 28-34-13Central Sterilizing Supply

• Expired sterile supplies

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KAR 28-34-8aPersonnel

• P P reviewed at least every 2 years
• Personnel files for each staff member which
  include education, training, experience, periodic
  work evaluations
• Health records-initial health exam upon
  employment, appropriate to duties of the
  employee, including x-ray or TB skin testing.
  Subsequent medical exams or health assessments
  per facility policy

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Risk Management

• First Do No Harm

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To Error is Human

• To Error is Human-view errors as opportunities
  for improvement
• You will not minimize occurrences unless you know
  all the facts.
• In order to know all of the facts you must look
  at the process as well as the individual.

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InvestigationMultiple Issues/Providers

• KAR 28-52-4 (b)
• Separate standard of care determinations shall be
  made for each involved provider and each clinical
  issue reasonably presented by the facts.

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Prevention of harm to patients is achievable but
is not a static condition. It is a never ending
process that requires strong leadership
commitment at all levels of the organization
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Remarks from Hospitals

• All three facilities felt it was a great success
• gave them insight into problem areas ideas
  on how to improve QA/QI/PI to make it
  more valuable in improving care
• Staff discussions with participants (they arent
  alone in their struggle to provide the best care
  possible)
• Having a better understanding of the regulations
  and need to comply
• It was great to hear about the things needing
  improvement and doing so without it being official

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Remarks from Mock Surveyors

• It was an opportunity to learn the standards and
  different ways they can be met or violated.
  Knowing about a rule is one thing but truly
  understanding why the rule exists and sometimes
  the many ways it can be applied. It takes
  someone with knowledge to connect the dots
• The sharing/networking of information and
  resources both with the facility and the other
  mock surveyors has been invaluable

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Accomplishments

• We now have 18 CAHs with a mock surveyor to lead
  their hospitals in improving patient care
• Those 18 surveyors and their hospitals have
  approved the plan of these 18 teaming up with 2
  per hospital and completing a mock survey at 9
  more CAHs.
• That could total as many as 27 CAHs with an
  increase of knowledge of the regulations and ways
  to improve patient care

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What Next

• Support/resources needed for mock surveyors
• Assignment by KHA for the 18 trained mock
  surveyors to survey other CAHs (9 total CAHs)
  this needs to be completed ASAP