CedarsSinai Medical Center

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Cedars-SinaiMedical Center

• Department of Health and Human ServicesCenters
  for Medicare and Medicaid ServicesSurvey of
  Comprehensive Transplant CenterKimberly Alva,
  BSN, MSN, ACNP-BCLiver Transplant Nurse
  Practitioner

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Cedars-Sinai CMS Survey Experience
Number of Surveyors from DHHS 2 Nurses 1
Transplant Coordinator Number of Surveyors from
CMS 1 Nurse 1 Administrator
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Timeline of Survey

• DHHS surveyors at Cedars for 11 days
• Transplant Coordinator present for 5 days only
• CMS Surveyors present for 5 days only

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Survey Process

• Surveyors determined to survey by program
• Sequence of survey
• Heart Transplant
• Lung Transplant
• Liver Transplant
• Kidney and Pancreas Transplant
• Pediatric Kidney Transplant
• Duration approximately 2 days per program

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Survey Process

• For each of the programs the following were
  requested by the surveyors
• Patient Lists of all transplant patients
  currently admitted
• UNOS waitlist
• Patients removed from waitlist for reasons other
  than death or transplantation
• Delisting information from UNOS for transplanted
  patients
• UNOS Tiedi list

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Survey Process

• From list provided surveyors randomly picked
  patients
• Service Line Manager, Director of Nursing
  Services and Transplant Coordinator accompanied
  surveyor throughout the survey
• Met with the CTC Medical Director
• Surveyors asked to meet and interview key staff
  members Surgeons and Transplant Physicians
• Followed team during rounds
• Interviewed patients and reviewed medical record
• Met and interviewed team members

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Survey Process

• Randomly picked employee files
• Reviewed Competencies
• Extensive time devoted to Transplant
  Coordinators training and documentation in
  employee file
• Focus on reporting of SAE
• Data Coordinator present during survey to assist
  surveyors in navigating Electronic Medical Record
  and UNOS inquiries

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• What have you heard that you can apply tomorrow?