PMDA PUBLIC POLICY UPDATE

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PMDA PUBLIC POLICY UPDATE

• Thomas Lawrence, MD
• David A. Nace, MD, MPH
• Co-Chairs, Public Policy Committee
• 10/26/07

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Objectives

• Outline recent DOH clarification on CRNP services
  in LTC
• As relates to Act 48 (CRNP Scope of Practice)
• Describe impact of Act 52 on LTC facilities
  (Healthcare Associated Infections)
• List key portions of Act 52
• Identify timeline for compliance

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CRNP Scope of Practice (Act 48)

• Passed in July
• Clarify questions on scope of practice for CRNPs
  in PA
• Formerly HB 1253
• www.legis.state.pa.us/cfdocs/legis/home/session.cf
  m

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Past DOH Position(Pre September 2007)

• 211.3 states
• A physicians oral and telephone orders shall be
  given
• Interpretation by DOH was only a physician could
  give oral or telephone orders

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CRNP Scope of Practice (Act 48)

• Order home health / hospice
• Order DME
• Issue oral orders to the extent permitted by the
  health care facility by-laws, rules,
  regulations, or administrative policies and
  guidelines
• Make PT and dietary referrals

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CRNP Scope of Practice (Act 48)

• Make respiratory and OT referrals
• Perform disability assessments
• Issue home bound schooling certificates
• Perform and sign initial assessment of methadone
  tx evaluations

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CRNP Scope of Practice (Act 48)

• Issue oral orders to the extent permitted by the
  health care facilitys by-laws, rules,
  regulations, or administrative policies and
  guidelines

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Current DOH Position(Post September 2007)

• DOH Clarification posted on message board
• Effective 9/13/07
• CRNP may now issue oral and telephone orders in
  PA LTC facilities

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State Regulation 211.7PA and CRNP

• Written policy
• how AHP used
• Responsibilities of supervising physician
• List at nursing stations
• Names of physician
• AHP and titles
• Licenses of MD and AHP available

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State Regulation 211.7PA and CRNP

• Definitions posted in prominent places
• Countersignature of AHPs documentation
• including notes, physical examinations, orders
• Within 7 days
• Original signature and date

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LTC FACILITY REGULATION CHECKLIST PA Code 211.7
USE OFADVANCE HEALTH CARE PRACTITIONERS
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Healthcare Associated Infections (Act 52)

• Health Care Facilities Act
• Signed into law July 2007
• Intent to reduce healthcare associated infections
  in PA healthcare facilities
• Includes nursing facilities
• Key agencies
• Patient Safety Authority
• Health Care Cost Containment Council
• DOH

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Definitions
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Healthcare Associated Infection (HCAI)

• A localized or systemic condition that results
• from an adverse reaction to the presence of an
• infectious agent or its toxins that
• Occurs in a patient in a health care setting
• Was not present or incubating at the time of
  admission, unless the infection was related to a
  previous admission to the same setting.
• If occurring in a hospital setting, meets the
  criteria for a specific infection site as defined
  by the CDC and its National Health Care Safety
  network (NHSN)

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Healthcare Facility

• A hospital or nursing home licensed or otherwise
  regulated to provide health care services under
  the laws of this commonwealth.

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Surveillance System

• On ongoing and comprehensive method of measuring
  health status, outcomes and related processes of
  care, analyzing data and providing information
  from data sources within a health care facility
  to assist in reducing HCAI

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Act 52 - 6 Key Components

• Comprehensive Infection Control Plan
• Active Surveillance System
• Electronic Reporting of HCAI
• Incentive Payments
• Surcharge
• Penalties

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Comprehensive Infection Control Plan

• 12/17/07 Plan Implemented
• 12/31/07 Plan Submitted to DOH
• 12/31/07 - Staff Notification of Plan
• Includes physicians

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Comprehensive Infection Control Plan

• Multi-disciplinary Committee (if applicable)
• Medical staff
• Administration
• Lab personnel
• Nursing staff
• Pharmacy staff
• Physical plant
• Patient Safety Officer
• Infection Control team
• Community member

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Comprehensive Infection Control Plan

• Effective measures for the
• Detection
• Prevention
• Control of HCAI

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Comprehensive Infection Control Plan

• Culture surveillance processes policies
• Not defined
• How does the facility perform review of
  surveillance data

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MDRO Surveillance CDC MMWR 2006
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Comprehensive Infection Control Plan

• System to ID and designate patients known to be
  colonized or infected with MRSA/MDRO
• Must culture
• all nursing home residents
• admitted to the hospital
• Procedures for identifying other high risk
  residents admitted to hospital

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Comprehensive Infection Control Plan

• Procedures protocols for staff with potential
  exposure to resident known to be colonized or
  infected
• When to culture or screen
• TB
• MRSA outbreaks
• Prophylaxis
• Flu
• Follow-up care
• Needlestick injuries

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Comprehensive Infection Control Plan

• Outreach process for notifying receiving health
  care facility or ASF of any patient known to be
  colonized or infected prior to transfer
• Hospital transfers
• Ambulance transport
• Surgical centers
• Other NFs

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Comprehensive Infection Control Plan

• Infection Control Protocol
• IC Precautions
• CDC Guidelines
• Intervention Protocols
• Evidence based standards
• Physical Plant Operations
• Appropriate Use of Antimicrobials
• Mandatory Education Programs for Staff
• Fiscal / Human Resource Requirements

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Comprehensive Infection Control Plan

• Process for Patient Safety Advisories
• Healthcare workers
• Medical staff
• Physical plant personnel

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Electronic Reporting

• All NF must electronically report HCAI to DOH and
  PSA
• Definitions TBD
• Format TBD
• Effective Date
• Pa Bulletin
• 4 months

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Quality Incentive Payment

• Jan 1, 2009 - Payments for 10 reduction in total
  HCAI in facility
• 2010 benchmarks for reduction
• Must be compliant for payment
• Funds as available

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Nursing Home Assessment

• July 1, 2008 surcharge on license fee
• Maximum aggregate 1 million
• Penalty for failure to pay 1000 / day
• Reimbursable cost
• DPW to make a pass through payment to the facility

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Penalties

• Failure to report HCAI
• Failure to develop, implement, or comply with a
  plan
• 1000 / day

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Timeline
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Resources

• Siegel JD, et al. 2007 Guidelines for isolation
  precautions Preventing transmission of
  infectious agents in healthcare settings, June
  2007 www.cdc.gov/ncidod/dhqp/pdf/isolationo2007.pd
  f
• Siegel JD, et al. 2006 Management of
  multidrug-resistant organisms in healthcare
  settings www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuidel
  ine2006.pdf
• Multidrug-Resistant Organisms in Non-Hospital
  Healthcare Settings (FAQ)
  www.cdc.gov/ncidod/dhqp/ar-multidrug
  FAQ.html

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