State Survey

1
State Survey for Licensure of Hospitals
George Mason University College of Nursing and
Health Science Regulatory Requirements for Health
Systems Summer 2004
2
State Board of Health
12 VAC 5-410 Rules and Regulations for the
Licensure of Hospitals in Virginia
Center for Quality Health Care Services and
Consumer Protection Virginia Department of
Health Richmond, Virginia
3
Governing Body

• Administrator/president
• Asst.. Administrator/ Vice President
• Governing body by-laws
• Date of last revision
• Documentation of lines of authority for operation
  of hospital
• Organizational chart
• Board meeting minutes review
• Frequency of meetings

4
Results of Other Surveys

• Last JCAHO survey
• Last CAP survey
• State fire Marshall Inspection
• Sprinkler system compliance status
• OSHA
• New services since last survey
• Construction projects

5
Administrative Policies for Review

• Licensure/certification verification policy
• Organ donation
• Moderate sedation policy
• Restraint policy
• Incident reporting policy

6
Contracted Services

• List of contracted services
• Review two contracts in-depth
• Review of a Service Contract may include
• Scope of service
• Quality Assurance Responsibilities
• Participation in Performance Improvement Projects
• Supervision of personnel

7
Medical Staff

• President medical staff
• Total medical staff number
• Active
• Courtesy/consult
• Medical staff status
• Dentists/oral surgeon
• Podiatrists
• Allied health professionals practicing (e.g.
  certified registered nurse anesthetists and
  physician assistants)

8
Medical Staff Bylaws, Rules Regulations

• Medical staff organization (diagram if available)
  departmental/department of the whole
• Medical staff appointment criteria
• Initial appointment
• provisional period
• Transition procedure from provisional to active
  status
• Reappointment frequency
• Board certification requirements
• Temporary privileges/locum tenens

9
Medical Staff Bylaws, Rules Regulations
(continued)

• Allied health appointment criteria
• Reappointment frequency
• Medical records
• Time frame for completion
• H P time frames (medical surgical)
• H P for admissions of podiatrists and dentists
• Verbal orders - 24 hours

10
Completeness of Credentialing Process

• Current license
• Data Bank Query - (within 12 months of
  appointment . or re-appointment)
• Q.A. Review documentation
• Board certification status
• Documentation of other hospital queries when
  applicable
• Initial appointment. -Verification of
  credentials/ character
• Delineation of clinical privileges/approval
  signature
• Hospital Governing Board approval

11
Infection Control

• Meeting with Infection control officer and
  medical director
• Review Infection control plan
• Surveillance
• Hospital-wide
• Focused/targeted
• Inpatient
• Outpatient
• Nosocomial infection rates

12
Infection Control

• Reported outbreaks
• Isolation categories
• Negative pressure rooms (whole house)
• TB control
• Respirators used - length of use
• Number of confirmed cases last year
• Number of PPD conversions
• Policy for PPD testing - who how often

13
Infection Control

• Method of monitoring compliance
• Education programs
• Orientation/annual/ongoing
• Hand washing
• Small blood spill policy
• Location of spill kits if used
• Products used

14
Infection Control

• Infection control committee
• Frequency of meetings
• Meeting minutes
• Approval areas
• Biomedical waste disposal
• Linen procedures
• Sterilization equipment procedures
• Housekeeping chemicals

15
Quality Management

• Meeting with Quality management director
• Organization Performance Written Plan
• Organizational reporting structure (diagram)
• Hospital tracking system.
• Clinical/critical pathways
• Medical staff reviews, Reporting for
  re-credentialing
• Quality council and QI Teams
• Committee meetings frequency, minutes

16
Fire and Safety

• Meet Fire and safety safety officer
• Review fire plan
• Fire drills (one per shift per quarter)
• Who participated
• What procedures practiced
• What areas were involved
• Performance evaluation
• Corrective actions if indicated

17
Fire and Safety

• Construction drills (two per shift per quarter)
• Interview employees re Fire plan (at least 3)
• Safety committee
• Frequency of meetings
• Review of committee meeting minutes
• Committee safety surveys of departments
• Frequency, Who participates
• Scope of survey/checklist used

18
Electrical Equipment Checks

• Initial use check - policy - how documented
• Hospital owned equipment
• Privately owned equipment
• Patient use
• Personnel use
• Hospital bed preventive maintenance
• Frequency
• How documented

19
Biomedical Equipment Checks

• Biomedical equipment checks
• By whom
• List of frequency categories
• How tracked and documented
• Emergency generator log
• Number of emergency generators
• Frequency of testing
• Log of testing and actual use

20
Disaster and Mass Casualty

• Meet the chairman of the disaster plan
• Review written plan - Last revision
• Documented rehearsals twice a year
• Dates of drills
• Drills evaluated with corrective actions
• Documentation of drills kept 2 years

21
Emergency Services

• Meet emergency department manger
• Emergency dept. Medical director must be Board
  Certified
• Number of rooms
• Number of patients seen last year average
• Number of patients seen/day
• Average transfers/month
• Average number of patients that leave Against
  Medical Advice (AMA)/month

22
Emergency Department Staffing

• Nursing
• RN on duty all shifts
• Physicians
• Physician on-call duty roster - posted
• Obstetric - newborn roster of physicians with
  clinical privileges

23
Continuing Education

• Written plan for unit specific continuing
  education
• Documentation of education activities for last
  year
• Plans for current year
• Required personnel competencies and skills
• Required frequency of validation
• Checklist of content
• Certifications, ACLS, PALS, Other

24
Medication Administration

• PYXIS SUR-MED Other
• Refrigerated medications
• Secure
• Thermometer
• Irrigation solutions
• policy for use
• Timed/dated

25
Medication Administration

• Buffered Xylocaine use
• policy for mixing
• Multiple dose vials
• policy for use
• Single dose vials
• Compliance with one use poison control center
  used
• Telephone number posted

26
Other Checks

• EMTALA (The Emergency Medical Treatment and
  Active Labor Act ) signage posted in waiting room
  triage
• Triage protocols/Triage privacy
• Crash carts
• Number of cart Adult and Pediatric
• Documented shift checks
• Who checks carts for outdates
• How documented

27
Other Checks

• Toxicology reference materials
• Master file of MSDS sheets
• where kept if not in E.D.
• 24 hour availability
• HAZMAT facilities

28
Nursing Medical/Surgical Units

• Medication system used
• Pyxis Sur-Med Med carts other
• Policy for multi-dose vials/irrigation solutions
• Refrigerated medications
• Temperature monitoring
• Sharps container compliance
• Blood glucose machines

29
Nursing Medical/Surgical Units

• Documented quality controls crash cart with
  defibrillator
• Documented daily checks
• Who checks outdates-how documented linen storage
• Clean/soiled equipment storage
• Clean/soiled
• Stretcher/Wheel chair cleaning schedule
• Who is responsible for cleaning

30
Nursing Medical/Surgical Units

• Hallways must be totally clear for fire egress
• Clinical resource information
• Current pharmaceutical manual
• Infection control manual
• Clinical pathway information-if applicable
• MSDS sheets
• Fire plan and disaster plan

31
Nursing Medical/Surgical Units

• Unoccupied room check Call bell
• Wall oxygen and suction outlets
• Electrical biomedical equipment checked
• Emergency electrical plugs identified
• Sharps box/gloves
• Negative pressure rooms
• Current isolation
• Respirator storage (if applicable)

32
Nursing Medical/Surgical Units

• Restraint use
• Observation of patient
• Chart review for orders and documentation
• Clean/dirty utility rooms
• Hazardous waste storage/disposal
• Dirty linen storage
• Kitchen/nourishment room
• Ice machine, Refrigerator/ Temp and Contents
  monitoring

33
Nursing Medical/Surgical Units

• Housekeeping
• Janitor's closet
• Chemical storage
• Housekeeping cart
• No food or drink
• Parking/storage

34
Critical Care Unit

• Number of beds
• Nursing /manager medical director
• Unit designed and equipped for special function
• Crash carts/emergency equipment
• Documentation of checks
• Medication system
• Pyxis Sur-Med other
• Stock drugs - who monitors for outdates
• Refrigerated medications - temperature monitoring

35
Critical Care Unit

• Blood glucose machine
• Documented quality controls
• Nursing assessment/documentation
• Use of critical pathways
• Other care planning used
• Critical care nursing assessment tool used

36
Critical Care Unit

• Staffing
• Staffing policy,Staffing schedules
• last 3 months/with census
• Categories of personnel assigned to unit
• RN LPN Aide/Tech Respiratory therapist
  
• Continuing education
• Written plan for unit specific continuing
  education
• Documentation of plans and activities

37
Critical Care Unit

• Required personnel competencies and skills.
• Frequency of re-qualification
• Documentation/checklist
• ACLS
• Certifications of personnel

38
Nursing Service

• Chief Nurse Executive
• Director of nursing
• Organizational Chart
• Staffing
• Acuity/system used
• Procedure used for verification of current
  licensure

39
Nursing Service

• Required training/continuing education.
• Blood glucose monitoring
• Active participation in conscious sedation
• Policies
• Administration of blood and blood products
• Restraint
• Moderate sedation

40
Employee Health

• Hepatitis B vaccine
• Policy
• Who is eligible
• Tuberculin testing (PPD - x-ray)
• Policy
• Methods used
• Conversions/follow up

41
Obstetric Services

• Administrative manager
• Nurse manager
• Postpartum, LD, Newborn services
• Medical director
• Board Certified or Board Eligible
• Appointment by Governing Body
• Responsibilities in writing
• Joint Committee - Ob Newborn services

42
Obstetric Services

• Joint conference committee meeting, Minutes.
• Services management plan
• Protocol for pregnant women who present in labor
• Copy at each nurses station
• Policies procedures
• Identification of high risk patients
• Anesthesia personnel available on site within 30
  min.

43
Obstetric Services

• Policies procedures
• Ob physician accessible within 10 min during
  oxytocic administration
• Criteria for use of Labor Delivery Rooms/Labor,
  Delivery, Recovery, and Postpartum Rooms
• Gynecologic patients - definition - if cared for
  on Ob
• Infection control.
• Written criteria for isolation or segregation for
  mothers and infants

44
Obstetric Services

• Physician availability
• Ob physician - 30 min. On-call
• Accessible - 10 min during oxytocic admin-
• On-call duty schedule posted at each Ob nurses
  station
• Roster of Ob Neoborn services physicians with
  privileges at each nurses station

45
Obstetric Services

• Staffing schedules (available for last 3 months)
  1.
• Ratios
• Post Partum 16-8
• Mother/baby 14
• Ld 11-2
• Post op recovery 12
• Policies for use of personnel from other hospital
  Areas

46
Obstetric Services

• Education training
• Written plan for unit specific continuing
  education with documentation of activities for
  last year and current year
• Training for identification of substance abuse in
  women infants
• Required competencies skills
• Frequency of validation
• Certifications, CPR - Adult - Neonatal

47
Obstetric Services

• Discharge planning
• Policy and Procedure/substance abusing post
  Partum women
• Appropriate referrals
• Include father and/or family members
• Documented in Medical Record
• Family planning information given to patient
• Documented
• Discharge teaching documentation

48
Obstetric Services

• Control plan
• Control station
• Visibility of unit
• Bracelet system used
• Cameras
• Medication system
• Pyxis Sur-Med Med cart other
• Refrigerated medication - temp monitoring
• Sharps containers

49
Obstetric Services

• Crash cart/defibrillator
• Daily monitoring with documentation
• Documentation of outdate monitoring
• Unit design
• Separate and distinct unit
• Soiled workroom janitor's closet - exclusive
  use by Ob
• Patient bath facilities with showers
  
• Staff clothing change areas

50
Newborn Services

• Nurse Manager
• Medical director
• Qualified for highest level of newborn services
  offered
• Appointed by governing body
• Responsibilities in writing
• Conduct joint conference with Ob Physicians
  quarterly
• Participation in Performance Improvement
  Initiatives

51
Newborn Services

• Written medical protocols
• To include management of medical conditions
  offered
• Consultation - stabilization - transfer
• Copy in nursery
• Approved by governing body
• Hospital to have written collaborative agreements
  with other hospitals providing higher levels of
  care

52
Newborn Services

• Newborn physician coverage
• On-call - on-site - 30 minutes
• On-call duty schedule - posted - each nurses
  station
• Roster of newborn services physicians with
  clinical privileges at each nurses station in
  newborn unit.
• Policies procedures
• Care of eyes, skin cord, Formula use
• Assessment with Apgar Scores

53
Newborn Services

• Breast milk use storage
• Education training
• Written plan for unit specific continuing
  education with documentation of activities for
  last year and current year
• Training for identification of substance abuse
  women infants

54
Newborn Services

• Required competencies skills
• Frequency of validation
• Certifications, CPR - Adult - Neonatal
• Staffing
• Ratios - according to level of care offered
• General - intermediate - specialty -
  sub-specialty
• LPN - student nurses - nurse aides - require
  direct supervision of a registered nurse in
  newborn services

55
General Level Nursery

• Nurse manager
• Medical director
• If not Board Certified or Board eligible, a
  Pediatrician-written agreement with Board
  certified or board eligible Pediatrician for 24
  hr. Consult by phone
• If no 24 hour basis Neonatologist on staff at the
  hospital, there must be a written agreement with
  another hospital for 24 hr telephone consult with
  a Board certified or Board eligible Neonatologist

56
General Level Nursery

• Hospital written collaborative Agreements
  providing higher levels of care
• Staffing Ratios
• Newly born/close observation 14
• Routine care 18
• Mother/baby care 14

57
General Level Nursery

• Identification control
• Bracelet system
• Two Bracelets on infant
• One on mother
• Bassinet/incubator ID card
• Policy for transport

58
General Level Nursery Design Criteria

• No more than 16 bassinets/nursery
• Special care area required for close observation.
  
• If 16 beds or less - require 2 nurseries - 8 beds
  each for cohorting
• Minimum of 24 sq.. Ft. floor area.Three ft.
  between bassinets
• 25 more bassinets than Ob beds.Multiple births
• One electrical outlet for each bassinet
• One incubator for every 10 bassinets

59
Intermediate Level Nursery Staffing

• Nurse manager
• Medical director, Board Certified or Board
  Eligible Pediatrician
• If no 24 hour basis Neonatologist on staff, the
  hospital, must have written agreement with
  another hospital for 24 hr telephone consult with
  a Board Certified Or Board Eligible Neonatologist
  
• Hospital written collaborative agreements with
  other hospitals providing higher levels of care
• Routine care 14 All personnel neonatal CPR
  trained

60
Intermediate Level Nursery Design Criteria

• No more than 16 bassinets/nursery
• 50 sq.. Ft. Floor area - 4 ft. Between bassinets
  and five feet wide aisles - (if renovated after
  8/10/95)
• Eight electrical outlets/infant station _ checked
  monthly
• Two oxygen outlets/infant station
• Two pressed air outlets/infant station
• Two suction outlets/infant station
• Portable x-ray machine outlet/nursery

61
Specialty Level Nursery Staffing

• Nurse manager. Advance training for high risk
  neonates
• Medical directorBd. Cert or bd. Elig.
  Neonatologist
• Hospital written collaborative agreements with
  other hospitals providing higher level of care.
  May have more than one.
• Nursing Ratios Routine care 13. All personnel
  must be neonatal CPR trained
• Education requirement for RNs Advanced training
  and experience in management of neonatal
  specialized care and ventilation care

62
Specialty Level Nursery Design Criteria

• No more than 16 bassinets/nursery
• 80 sq.. Ft. Floor area - 6 ft. Between bassinets
  and eight feet wide aisles - (if renovated after
  8/10/95)
• Twelve electrical outlets/Infant station checked
  monthly
• Two oxygen outlets/Infant station
• Two compressed air outlets/Infant station
• Two suction outlets/infant station
• Portable x-ray machine outlet/nursery

63
Sub-Specialty Level Nursery Staffing

• Neonatal clinical specialist
• Medical director Bd. Cert or Bd. Elig.
  Neonatologist
• Nursing Ratios
• Sub-specialty care 12
• Multi-system support care 11
• Education requirements for RNs
• Advanced training and experience in Management of
  high risk neonates, Unstable neonates and
  Multisystem problems

64
Sub-Specialty Level Nursery Design Criteria

• No more than 16 bassinets/Nursery
• 80 sq.. Ft. Floor area - 6 ft. Between bassinets
  and eight feet wide aisles - (if renovated after
  8/10/95)
• Twelve electrical outlets/infant station -
  checked monthly
• Two oxygen outlets/infant station
• Two compressed air outlets/infant station
• Two suction outlets/infant station
• Portable x-ray machine outlet/nursery

65
Surgical Services

• Nurse manager
• Operating room register
• Computerized
• Roster of surgical privileges
• Current medical staff
• Temporary locum tenens
• Non employee pass and scrubs
• Manufacturer's reps visitors
• Safety policies and procedures posted or check
  sheet on chart for hp- informed consent - pre op
  diagnosis

66
Surgical Services

• Medication system used Pyxis Sure-Med
  Other
• Crash cart for OR
• Where located, Documented checks daily
• Medication outdate checks, how documented?
• Linen and hazardous waste disposal procedure
• Equipment storage
• Education
• Written plan for surgical unit specific
  continuing education documented activities for
  last year current year
• Certifications

67
Post Anesthesia Care Unit

• Nurse manager
• Medication system used
• Pyxis Sur-Med Other
• Documentation of narcotic use/waste
• Sharps boxes
• Small blood spill policy awareness
• linen storage Clean, Soiled

68
Post Anesthesia Care Unit

• Crash cart/defibrillator
• Documented daily checks
• Medication outdate checks - how documented
• Unit specific written continuing education plan
• annual activities
• May be combined with surgery

69
Anesthesia Service

• Chief of anesthesia
• Number of anesthesiologists number of CRNAs
• Contracted service?
• Medication system used
• Narcotic use and waste documentation
• Anesthesia carts
• Standardized-
• Who checks for outdated medications

70
Anesthesia Service

• Anesthesia policies
• Pre-anesthesia evaluation
• Done by a physician
• Review of pt's condition just prior to induction
• Both events recorded
• Post-anesthesia evaluation
• Inpatients - (within 24-36 hours)
• Outpatient - may be done by another physician
• Epidurals for pain management Where performed

71
Sterile Supply Service

• Physical barrier between contaminated work areas
  and clean work areas
  
• Cleaning, prep, sterilizing, aeration, storage
• Sterilizers/autoclaves
• New equipment approved by infection control
  committee
• Written procedures
• Approved by infection control committee
• a. Sterilizing and storage procedures
• b. Waste disposal
• Safety procedures/personnel/patients

72
Laundry Services

• Distinct areas for the separate storage and
  handling of clean and soiled linens
• Soiled areas - negative pressure
• Transport of clean linens
• Transported in containers exclusive for clean
  linen
• Stored in areas designated exclusively for this
  purpose

73
Respiratory Therapy Service

• Compliance with infection control policies
• Compliance with oxygen safety policies
• CLIA number if applicable
• Number of blood gas machines

74
Physical Therapy

• Number of physical therapists
• Number of occupational therapists
• Number of speech therapists
• Verification of current license for all
• License posted
• Whirlpool culture policy
• Frequency/review of culture results if done
• Debridement procedures done by pt

75
Physical Therapy

• Compliance with infection control policies
• Linen storage
• Thermometers for hydroculators thermometers for
  refrigerator
• Preventive maintenance for equipment

76
Pharmaceutical Services

• Pharmacy director/chief pharmacist
• Personnel
• Number of pharmacists Full time Part time
• Technicians
• current license posted
• Pharmacists
• Pharmacy
• Hours of operation
• Access to pharmacy after hours, Method of access

77
Pharmaceutical Services

• Number of satellite pharmacies
• Where located
• Medication systems used
• Pyxis Sur-Med Med carts
• Refrigerated medication monitoring
• Outdate monitoring
• Policy for multi-dose vial use
• Procedure for destruction of drugs
• Outdated, Narcotics, and Others

78
Pharmaceutical Services

• Procedure for reconciliation of In-house use of
  narcotics
• Anesthesia
• Other clinical areas
• Quality assurance
• Pharmacy Therapeutics Committee
• Adverse drug reaction reporting
• Definition, Average number/month, Number last
  year
• Formulary

79
Pharmaceutical Services

• Laminar hoods
• Horizontal
• Date of last certification
• Vertical
• Date of last certification
• Chemical bio-hazardous waste (chemotherapy)

80
Dietary Services

• Contracted service
• Food services manager
• Dietitian
• Number of dietitians
• Full time/part time/consultant
• Consultant reports with hours and activities
• Policies for patient consult
• Assessment/teaching documentation

81
Dietary Services

• Approved diet manual
• Frequency of approval
• Sanitation check
• Frequency,Last report
• Temperature monitoring policy
• Refrigerator/freezers
• Checksheet with temp guides/action taken
• Who reviews checksheet

82
Dietary Services

• Dish machine
• Final rinse temp.
• Who reviews temp. Log
• Over range hood cleaning
• Frequency -(directly over range)
• Exhaust ducts
• Inspected and/or cleaned 2x/year
• By whom

83
Dietary Services

• Dry storage
• 6 inches from floor
• 8 inches below sprinkler heads
• 36 inches circumference around sprinkler head
• Chemical/housekeeping storage - separate from
  food storage
• Covered dumpster fly control
• Employee interviews
• Fire plan and dietary fire extinguishing
  equipment