Critical Access Hospital Survey Process

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Critical Access Hospital Survey Process

• March 18, 2009

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Types Surveys

• Complaint Investigations
• EMTALA Complaint Investigations
• Full Survey
• Medicare Recertification Survey every 3-5 years
• Validation Survey authorized by CMS 60 days
  following the Accrediting Organization survey
• All surveys are unannounced
• Surveys based on Conditions of Participation
  found at CFR 42.485
• www.cms.hhs.gov/manuals/downloads/som107ap_w_cah.p
  df

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Documents requested at Entrance Conference

• List of inpatients with name, room number,
  diagnosis(es), admission date, age, and attending
  physician
• List of departments with manager or directors
  name
• A copy of the facilitys organizational chart
• The CAHs infection control plan
• A list of employees and a list of credentialed
  medical staff members
• Staffing documents to determine adequate and
  per facilities' acuity policy
• Maintenance records to determine if equipment is
  periodically examined
• The Medical Staff bylaws and rules and
  regulations
• A list of contracted services
• The location of all patient care and treatment
  areas
• The names and addresses of all off-site locations
  operating under the same CCN number
• The survey team will ask for other information to
  complete the CMS Hospital/CAH Medicare Database
  Worksheet

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Survey Process

• Tour and inspect all patient care areas and
  treatment areas
• Tour pharmacy, dietary, medical records, off site
  locations, etc.
• Review at least 20 inpatient records and some
  outpatient/ emergency department records
• Conduct patient and staff interviews
• Review policies and procedures
• Review Quality Assurance/Performance Improvement
  data

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Conditions of Participation for CAH

• Compliance with Other Laws
• Status and Location
• Compliance with Hospital Requirements
• Agreements
• Emergency Services
• Number of Beds and Length of Stay
• Physical Plant and Environment
• Organizational Structure
• Staffing and Staff Responsibilities
• Provision of Services
• Clinical Records
• Surgical Services
• Periodic Evaluation and Quality Assurance Review
• Organ, Tissue and Eye Procurement
• Special Requirements for CAH Providers of
  Long-Term Care Services (Swing beds)

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CFR 485.620(a)Number of Beds

• All hospital type beds located in the CAH will
  be counted to establish the 25 bed limit with the
  exception of the following
• Examination or procedure tables
• Stretchers
• Operating room tables and recovery room
  stretchers
• Beds in obstetric delivery
• Newborn bassinets and isolettes
• Stretchers in emergency departments
• Beds in Medicare certified distinct part
  rehabilitation or psychiatric units
• Observation beds
• Note dedicated beds to a hospice under
  arrangement count a part of the 25 beds but do
  not contribute to the 96 hour annual average
  length of stay.

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Observation Beds

• Observation beds are not included in the 25 bed
  maximum, nor in the calculation of the average
  annual acute care patient length of stay.
• Observation care is well-defined set of specific,
  clinically appropriate services of short-term
  treatment, assessment and reassessment to
  determine the need for discharge or possible
  admission as an inpatient. (maximum stay is 48
  hours, medically necessary with a physicians
  order)
• Observation stays fall under Part B and require
  coinsurance. The CAH must give written notice of
  noncoverage to the beneficiary prior to stay.
• Standing orders for observation services is not
  acceptable, not to be used for patients awaiting
  nursing placement, for routine prep or recovery
  for diagnostic or surgical services
• Observation services Begin and End with an order
• CAH must be able to document that it has specific
  clinical criteria for admission and discharge for
  observation services for all payor types.

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Distinct Part Units

• May have a maximum of 10 psychiatric Distinct
  Part Unit (DPU) inpatient beds
• May have a maximum of 10 rehabilitation DPU
  inpatient beds.
• These beds are held to the Hospital Conditions of
  Participation under Appendix A and the PPS
  payment requirements
• Rehab DPU must provide services directly no
  contractual

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Swing Beds 42 CFR Part 485.645

• The patient swings from receiving acute-care
  services and reimbursement to receiving skilled
  nursing (SNF) services and reimbursement.
• The patient need not change location in the
  facility
• There is no length of stay restrictions
• Medicare reimbursement requires a 3-day
  qualifying stay prior to admission to a swing-bed
• The swing-bed care is regulated by both the CAH
  requirements and the swing-bed requirements
• Swing-beds services may not be provided in CAH
  distinct part units.Survey findings for
  swing-bed deficiencies will be on a separate Form
  CMS 2567

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Medicare Beneficiaries Notices

• 42 CFR 405.1205 (b) requires CAHs to provide each
  Medicare beneficiary who is an inpatient a
  standardized notice, the Important Message from
  Medicare (IM) within two days of their admission
  and be signed and dated by the patient.
• 42 CFR 405.1205 (b) (3) requires CAHS to provide
  the IM to beneficiaries a copy of the signed IM
  as far as possible in advance of discharge but
  not more that two calendars before discharge.
• If the date of the signed IM is delivered falls
  within 2 calendar days of discharge, no
  additional copy is given.

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Common deficiencies cited

• Physical Plant Environment/Life Safety From Fire
• 485.635 (d) (3) Nursing Services-Drug
  Administration
• 485.635 (a)(3)(iv) Policies Drug Management
• 485.635 (a)(3)(vii) Policies- Nutrition
• 485.635 (a)(3)(vi) Policies- Infection Control
• 485.635 (a)(1) Patient Care Policies
• 485.635 (a)(4)(i) Records System
• 485.635 (b)(1) Quality Assurance

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485.635 (d) (3)

• All drugs, biologicals, and intravenous
  medications must be administered by or under the
  supervision of a registered nurse, a doctor of
  medicine or osteopathy, or where permitted by
  State law, a physician assistant, in accordance
  with written and signed orders, accepted
  standards of practice, and Federal and State laws.

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485.635 (a)(3)(iv)

• The policies includes rules for the storage,
  handling, dispensation, and administration of
  drugs and biologicals. These rules must provide
  that there is a drug storage area that is
  administered in accordance with accepted
  professional principles, that current and
  accurate records are kept of the receipt and
  disposition of all scheduled drugs, and that
  outdated, mislabeled, or otherwise unusable drugs
  are not available for patient use.

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485.635 (a)(3)(vii)

• The policies include, if the CAH furnishes
  inpatient services, procedures that ensure that
  the nutritional needs of inpatients are met in
  accordance with the recognized dietary practices
  and the orders of the practitioner responsible
  for the care of the patients, and the requirement
  of 485.25 (i) is met with respect to inpatients
  receiving post-hospital SNF care.

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485.635 (3)(vi)

• The policies include a system for identifying
  reporting, investigating and controlling
  infections and communicable diseases of patients
  and personnel.

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485.635 (a)(1)

• The CAHs health care services are furnished in
  accordance with appropriate written policies that
  are consistent with applicable State law.

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485.635 (a)(4)(i)

• For each patient receiving health care services,
  the CAH maintains a record that includes, as
  applicable, 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, and a brief summary of the episode,
  disposition, and instructions to the patient.

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485.635 (b)(1)

• The quality assurance program requires that all
  patient care services and other services
  affecting patient health and safety are evaluated.

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Annual Program Evaluation

• The evaluation is done at least once a year.
• Includes review of the utilization of CAH
  services
• A representative sample review of both active and
  closed clinical records (not less than 10 percent
  of both active and closed patient records and
  both inpatient and outpatient)
• A review of CAHs health care policies
• Review the data and determine if actions were
  required
• Has an effective QA program
• QA reviews all patient care services
• QA reviews Medication therapy and nosocomial
  infections
• MD /DO evaluate care provided by NP, CNS or PA
• Quality review of the diagnosis and treatment at
  the CAH by another hospital that is a member of
  the network, QIO or equivalent or other qualified
  entity identified in the State rural health care
  plan
• CAH considers the findings and or recommendations
  of the QIO and takes corrective action if
  necessary
• CAH takes appropriate remedial action to address
  deficiencies found in QA program

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Survey Completion

• Deficiencies found, facility will receive CMS
  form 2567 within 10 working days and the facility
  must return the 2567 with a plan of correction
  (PoC) within 10 calendar days.
• Findings are sent to Center for Medicare and
  Medicaid Services (CMS)

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PoC Requirements

• The procedure for implementing the plan of
  correction (PoC) for each deficiency cited
• The title of the individual responsible for
  implementing and monitoring the PoC
• Evidence has been incorporated into QA/PI to
  prevent recurrence
• Supporting documentation as evidence of
  correction
• Procedures for monitoring and tracking to ensure
  the PoC is effective
• A completion dare for each deficiency cited
• Date and signature of the authorized
  representative on the bottom of page one of the
  original Statement of Deficiencies and Plan of
  Correction Form

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Questions

• Contact information
• Karen Senger, RN, B.S.N.
• 217-782-7412
• karen.senger_at_illinois.gov

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