Transcript CAHCOPS2015PART2of3 - Arkansas Hospital Association

Critical Access Hospital CoPs
Part 2 of 3
What every CAH needs to know about the
Conditions of Participation (CoPs)
Speaker
Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP
AD, BA, BSN, MSN, JD
President
Board Member
Emergency Medicine Patient
Safety Foundation
614 791-1468 (Call with
Questions, No emails)
[email protected]
2
2
new website at
www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf
3
Drugs and Biologicals 276
2015
Rules for the storage, handling,
dispensing, and administration of drugs
and biologicals,
Need to store drugs in accordance with
acceptable standards of practice,
Keep accurate records of the receipt
and disposition of all scheduled drugs,
And all outdated, mislabeled, or
otherwise unusable drugs are not
available for patient use,
4
Drugs and Biologicals 276
2015
Long section that pharmacy and nursing
need to read and rewritten in 2015
Must make sure are managed in manner that
is safe and appropriate
Must have an order for the medication
Must have written P&P to govern pharmacy
services
P&P must address storage, handling,
dispensing, and administration
Must follow acceptable standards of care
5
Drugs and Biologicals 276
2015
CAH rules and P&P must be consistent with
standards or guidelines for pharmaceutical
services and medication administration
Such as USP, ASHP, ISMP, Infusion Nurses
Society, IHI, and National Coordinating Council
The written P&P must also be consistent with
state and federal law
Others include:
 ASHP Foundation (American Society of Healthcare System
Pharmacist Foundation), American Nurses Association (ANA),
American Pharmacy Association (APA), APIC, CDC, etc
6
ISMP Institute for Safe Medication Practices
www.ismp.org
7
American Society of Health System
Pharmacists or ASHP
www.ashp.org/
8
Infusion Nurses Society INS
www.ins1.org
9
National Coordinating Council
www.nccmerp.org
10
11
USP U.S. Pharmacopeial
www.usp.org
12
Institute for Healthcare Improvement IHI
www.ihi.org
13
Drug Rules Must Include 276
2015
Rules (P&P) must identify qualification of
pharmacy director
 Person must make sure state laws are followed
including who can perform pharmacy services
 Including supervision of the pharmacy staff
 Must be able to identify standards used in
developing P&P
 Note can cite as reference in P&Ps
Storage including location of storage areas,
medication carts, and dispensing machines
14
Drug Rules Must Include 276
2015
Proper environmental conditions
 Follow manufacturer’s recommendation such as keep
refrigerated, room temperature, out of light, etc.
Security
 P&P must be consistent with state and federal law
as who can access pharmacy or drug storage
areas
– Housekeeping, security or maintenance are usually
not given unsupervised access
 If kept in private office then patients and visitors
are not allowed without supervision
15
Drug Rules Must Include 276
2015
Area restricted to personnel only are
generally considered secure
 Given flexibility in non-controlled drugs such as
don’t have to be locked up when setting up for a
procedure
 Example would be the OR
 Would lock up when area not staffed
Medication carts, anesthesia carts, epidural
carts and non-automated medication carts
with medications must be secure when not in
use
16
Medications in the OR ASA Position
www.asahq.org/For-Members/StandardsGuidelines-and-Statements.aspx
17
ASA Guidelines and Statements
http://asahq.org/For-Healthcare-Professionals/Standards-Guidelines-and-Statements.aspx
18
Recommendation on Medications in the OR
www.apsf.org/newsletters/html/2010/spring/01_conference.htm
19
Drugs Rules Must Include 276
2015
Must have P&P on security and monitoring of
all carts
 Whether locked or unlocked
 If unlocked staff must be close by and directly
monitoring the cart as when passing medications
Handling medications which includes mixing
or reconstituting according to mfg
recommendation
 Includes compounding or admixing of sterile IVs
or other drugs
20
Drugs Rules Must Include 276
2015
Only pharmacy can reconstitute, mix, or
compound a drug
 Except in an emergency
 Except if not feasible such as product’s stability
is short
Compounding used or dispensed must be
consistent with acceptable principles such as
those described in USP/NF chapter
 Which including adding an ingredient to a
commercial product
 Includes reconstitution of drug
21
Drugs and Biologicals 276
2015
Pharmacy must demonstrate how it assures
that all sterile and non-sterile compounded
preparations are pursuant to SOC
Minimal standards include compliance with
USP 797 and USP 795
 Include preparation, storing, and transporting
 Very detailed so staff need to read this section
 Can it meet low, medium or high risk levels?
All compounded forms must be sterile including
wound irrigation, eye drops and ointments,
injections, infusions, nasal inhalation, etc.
22
Blue Box Advisory USP 797
23
Drugs Rules Must Include 276
2015
Drug Quality and Security Act (DQSA) has
sections related to compounding
Outsourcing facilities who compound drugs
register and must comply with section 503B
of the FDCA and other requirements such as
the FDA’s current good manufacturing
practice (CGMP)
 Will be inspected by the FDA according to risk
based schedule
 Must meet certain other conditions including
reporting adverse drug events to the FDA
24
FDA’s Compounding Website
www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Pharmacy
Compounding/default.htm
25
Use a Company that is Registered
26
Drug Rules Must Include 276
2015
If CAH obtains compounded medications
from compounding pharmacy rather than a
manufacturer or a registered outsourcing
facility then must demonstrate that medicine
received have been prepared in accordance
with acceptable principles
 Contract with the vendor would want to ensure
CAH access to their quality data verifying their
compliance with USP standards
 Should document you obtain and review this
data
27
Drugs and Biologicals 276
2015
Dispensing medications
 Dispensed timely
 Follow all state laws
 Enough staff to provide accurate and timely
medication delivery
 System so medications orders get to
pharmacy promptly and available when
needed by the patient
Concerns or questions should be clarified
with prescriber before dispensing
28
Drugs and Biologicals 276
2015
Can use unit dose or floor stock system
 Automated dispensing cabinets are secure
option
Need P&P for who can access medications
after hours (night cabinet standard)
Suggest P&P on do not use abbreviations,
high alert drug list, safety recommendation
for high alert medications, quantities of
medications dispensed to minimize diversion,
limit overrides, return all meds in secure oneway return bin, etc.
29
30
Do Not Use Abbreviations ISMP
31
TJC’s Do Not Use Abbreviation List
32
ISMP List of High Alert Medications
www.ismp.org
33
Drugs and Biologicals 276
2015
Administer meds by qualified staff in
accordance with state law
 So in one state LPN can not push certain IV
medications
 Must follow acceptable standards of practice for
medication administration
Follow record keeping for receipt and
disposition of scheduled drugs
 DEA has five from schedule I to V substances
 Schedule IV includes certain narcotics so must
track them
34
Drugs and Biologicals 276
2015
Want locked storage of scheduled drugs when
not in use
Keep accurate counts to show use
Reconcile any discrepancies in the counts
Ensure outdated, mislabeled, or unusable
medication is not used
Must have pharmacy labeling, inspection, and
inventory management
Do not use past the BUD or beyond use date
 P&P to determine BUD date if not marked
35
Drugs and Biologicals 276
2015
Each individual drug must be labeled with
name, strength of drug, lot and control number
and expiration date
If multidose vial open must have expiration
date of 28 days until otherwise specified by
the manufacturer
Must have system to report ADEs and
medication errors
Pharmacy needs to assess to see if problems
in pharmacy caused or contribute to these
36
Drugs and Biologicals 276
2015
Surveyor is to ask nursing if medications
dispensed in a timely manner
If late medications surveyor is to investigate
Surveyor is to ask what professional
pharmacy principles pharmacy is using
Surveyor to make sure drugs are secure
Will verify only pharmacist or authorized
person compounds, labels, and dispenses
 Some state laws state can not be done by
pharmacy tech
37
Survey Procedure276
2015
Surveyor to make sure has a process to
follow up on ADE and medication errors
Surveyor to determine if CAH obtains
compounded drugs from external source that
is not FDA registered then does it evaluate
and monitor adherence to safe principles
Will ask for example of when BUD had to be
determined for a compounded sterile
medication based on P&P
Long survey procedure for this tag number
38
Reporting ADR and Errors 277 2015
 Standard: Procedures for reporting
adverse drug reactions (ADR) and
medication errors
Staff must report these
 Take care of patient and report for
QAPI
Need a definition for both
 CMS mention National Coordinating
Definition of Medication Error (NCCMER)
 Mentions ASHP definition of adverse event
39
Definition of Medication Error
40
Definition of Adverse Drug Event ADR
41
Reporting ADR and Errors 277 2015
ADR and medication errors that reach the
patient must be reported to the practitioner
The report must be made immediately if it
causes harm to the patient such as a phone
call
 If harm is not known then must report immediately
 If no harm then can inform practitioner in the
morning
Documentation of the error and notification of
the practitioner must be made in the MR
42
Reporting ADR and Errors 277 2015
Must educate staff on medication errors and
ADEs to facilitate reporting
 Must include reporting of near misses
 Must educate how and whom they are to be
reported
 For example, on a medication incident report
which is sent to pharmacy, nursing and then into
the QAPI program
To help assess vulnerabilities and implement
reoccurrences
 Can do RCA, FMEA, or QAPI review
43
Reporting ADR and Errors 277 2015
Encourages a non-punitive approach that
focuses on system issues
Can’t just rely on incident reports
Must take other steps to identify errors and
ADRs
 Trigger drug analysis, observe medication
passes, concurrent and retrospective reviews,
medication usage evaluations for high alert
drugs etc.
Encourage reporting to FDA MedWatch
Program and ISMP
44
Non-Punitive Environment
Studies showed that if you have punitive
environment errors will not be reported,
Most of serious errors are made by long term
employee with unblemished records,
It was the system that actually lead to the error,
Change the environment or culture-called
system analysis,
Important to have a non-punitive environment,
We need to move beyond the culture of blame so
we can find out what errors are occurring,
Balance this with Just Culture,
45
Indicator Drugs (Trigger Drugs)
Monitor Digibind usage and develop protocol for
appropriate use,
Monitor use of reversals agents such as
Romazicon and Narcan to look for unreported
cases of adverse events,
Narcan, antihistamines, Vitamin K,
IV glucose, glucagon,
Epinephrine, topical calamine,
Phentolamine, digibind, protamine,
hyaluronidase,
Kayexalate, anti-emetics and anti-diarrheas,
46
47
48
FDA MedWatch Form
49
ISMP Medication Error Reporting Program
www.ismp.org
50
List of High Alert Medications
51
High Alert How to Guide IHI
www.ihi.org/NR/rdonlyres/8B2475CD-56C7-4D9B-B359-801F3CC3A8D5/0/HighAlertMedicationsHowToGuide.doc
52
53
54
Survey Procedure 277 2015
Will make sure nursing staff knows what to do
if there is a medication error (ME) or ADE
 Will ask nursing to provide an example of what
they would do if ME or ADE
Surveyor will review records of ME and ADE
to make sure immediately reported and
documented in the medical record
Will ensure hospital has system for reporting
into QAPI
Will make sure staff trained in reporting
expectations
55
Medication Resources
National Patient Safety Foundation at
www.npsf.org
Governmental agencies may include;
 Food and Drug Administration (FDA)
at www.fda.gov
 Med Watch Program at
www.fda.gov/medwatch
 Agency for Health Care Research
and Quality (AHRQ) at www.ahrq.gov
56
Websites
The Institute for Safe Medication
Practices- www.ismp.org
U.S. Pharmacopoeia (USP)
www.usp.org
Institute for Healthcare Improvementwww.ihi.org,
AHRQ- www.ahrq.gov,
Sentinel event alerts at
www.jointcommission.org,
57
Additional Resources
 American Pharmaceutical Associationwww.aphanet.org
 American Society of Heath-System Pharmacistswww.ashp.org
 Enhancing Patient Safety and Errors in Healthcarewww.mederrors.com
 National Coordinating Council for Medication Error
Reporting and Prevention-www.nccmerp.org,
 FDA's Recalls, Market Withdrawals and Safety
Alerts Page:
http://www.fda.gov/opacom/7alerts.html
58
Infection Control 278 2015
Standard: Need a system for identifying,
reporting, investigating and controlling
infections and communicable diseases of
patients and personnel
 Must be facility wide
 Provides definitions of infectious diseases and
communicable disease that hospital can put in
its P&P
 HAI or healthcare-associated infection is one
that patient develops while in the hospital or
other healthcare facility
59
CMS Infection Control Worksheet
Final infection control worksheet issued
November 26, 2014
Not being used at this time for CAH
However, highly recommend CAH take a
look at the infection control worksheet
 Great tool to help understand how to comply with
the infection control standards
 Available free off the CMS survey memo website
 Also one published on discharge planning and
QAPI
60
Final Worksheet Infection Control
www.cms.gov/SurveyCertificationG
enInfo/PMSR/list.asp#TopOfPage
61
Infection Control 278
2015
CDC found 1 in 25 hospital patients has a
HAI
 This is 772,000 every year
75,000 patients will die from HAI every year
Must have sanitary environment
 No dried blood on side rails or floor
Need infection preventionist who is qualified
by education and experience
APIC has competency document
62
Infection Preventionist or IP
63
APIC Competency Infection Prevention
www.ajicjournal.org/article/S0196-6553(12)00165-4/fulltext
64
65
Infection Control 278
2015
Must follow nationally recognized infection
control practices or guidelines
Examples include: CDC, APIC, SHEA, AORN
and OSHA
 CDC is Center for Disease Control
 AORN is the Association for periOperative
Nurses
 APIC is the Association for Professionals in
Infection Control and Epidemiology
 SHEA is the Society for Healthcare Epidemiology
of America
66
APIC Website
www.apic.org
67
SHEA Website
/www.shea-online.org
68
AORN
www.aorn.org
69
AORN Guidelines for Perioperative Practice
70
OSHA Website
www.osha.go
v
71
OSHA Worker Safety in Hospitals
72
CDC Website
www.cdc.gov/
73
4 Challenges in Infection Control
CMS said there are four special
challenges in infection control (just four?)
 Challenge 1: Multidrug-Resistant
Organisms
 Challenge 2: Infection Control in
Ambulatory Care
 Challenge 3: Communicable Disease
Outbreaks
 Challenge 4: Bioterrorism
/ 40
74
Multidrug-Resistant Organisms
Multidrug-resistant organisms (MDROs) are
resistant to one or more antimicrobial agents
 Treatment is more difficult
 These bad bugs are more dangerous such as C-diff,
VRE, MRSA, CRE (E. coli, Enterobacter, Klebsiella) etc.
 National priority
Have systems in place to identify early and
prevent transmission of these organisms.
 The CDC has a special publication on
“Management of Multidrug-Resistant Organisms in
Healthcare Settings, 2006”1
1http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
/ 40
75
CDC Module on C-Diff
76
Multidrug-Resistant Organisms
Multidrug-resistant organisms (MDROs) are
resistant to one or more antimicrobial agents
 Treatment is more difficult
 These bad bugs are more dangerous
Have systems in place to identify and
prevent transmission of these organisms.
The CDC has a special publication on
“Management of Multidrug-Resistant
Organisms in Healthcare Settings, 2006”1
1http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
/ 40
77
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline20
06.pdf
78
APIC C-Diff Guide
www.apic.org/ProfessionalPractice/Implementation-guides
79
SHEA C-Diff Guidelines
www.sheaonline.org/GuidelinesResources/Guidelines/Guid
eline/ArticleId/11/Clinical-Practice-Guidelines-forClostridium-difficile-Infection-in-Adults-2010.aspx
80
AHRQ Toolkit on KPC 2014
AHRQ has a free toolkit for hospitals to help
control and prevent Klebsiella pneumoniae
carbapenemase (KPC)
 Called the Carbapenem-Resistant
Enterobacteriaceae (CRE) Control and
Prevention Toolkit
 This is a highly dangerous, antibiotic-resistant
germ
Will help hospitals implement the CDC
guidelines and is 56 page toolkit
 available at www.ahrq.gov/cretoolkit
81
82
Free Toolkit for Hospitals
83
CDC National Healthcare Safety Network
www.cdc.gov/nhsn/
84
www.cdc.gov/nhsn/training/
85
www.cdc.gov/hicpac/pdf/guidel
ines/bsi-guidelines-2011.pdf
86
87
Infection Control Ambulatory Care
Infection control in ambulatory care
presents special problems
 Patients remain in common areas such as the
lobby and ED waiting areas
 Patients are turned around quickly with minimal
cleaning
 Infectious patients may not be recognized
immediately
 Immuno-compromised patients can receive
treatment in rooms with other patients who
pose a risk of infection
/ 40
88
Infection Control Ambulatory Care
 Place in room and don’t leave in lobby if can be
contagious and implement cough etiquette protocol
 Guidelines have been developed by the CDC’s
Healthcare Infection Control Practices Advisory
Committee (HICPAC) hwww.cdc.gov/hicpac/pubs.html
 Infection control plan for ambulatory care
 Norovirus gastroenteritis outbreaks
 Guidelines for Disinfection and Sterilization in Healthcare
Facilities
 Guidelines for Isolation Precautions
 CDC Intravascular guidelines
 MRDO and Influenza Vaccination of Healthcare Personnel
/ 40
89
Infection Control Ambulatory Care
CDC’s Guidelines (continued)
 Guidance on Public Reporting of HAI 2005
 Guidelines for Preventing Healthcare Associated
Pneumonia 2004
 Guidelines for Environmental Infection Control in
Healthcare Facilities 2003, 2002 Hand hygiene
guidelines, Prevention of Surgical Site Infections
and more
 HICPAC is a federal advisory committee made up
of 14 external IC experts who provide guidance and
advice to the CDC and HHS
– Members from APIC, SHEA, AORN, CMS, FDA etc.
/ 40
90
APIC Resources Ambulatory Care
91
CDC Norovirus Guidelines
www.cdc.gov/hicpac/norovirus/002_no
rovirus-toc.html
92
CDC HICPAC
93
Preventing Infections in the Outpatient Unit
CDC has a guide and checklist for
preventing infections in the outpatient setting
 The Guide to Infection Prevention for
Outpatient Settings: Minimum
Expectations for Safe Care and
 The Infection Prevention Checklist for
Outpatient Settings; Minimum
Expectations for Safe Care
 Free off the website at www.cdc.gov/hai/settings/outpatient/outpatientsettings.html?source=govdelivery
94
CDC Guide Infection Control Outpatients
www.cdc.gov/HAI/settings/outpatient/outpatient-careguidelines.html
95
Communicable Disease Outbreaks
Community-wide outbreaks of
communicable diseases present many
of the same types of issues as hospital
infection disease threats
 Such as measles, SARS, or the flu
 Understand the epidemiology
 Know how it is transmitted and the clinical
course of the disease in order to manage
the outbreak
/ 40
96
Communicable Disease Outbreaks
There are at a minimum four things that
must be addressed:
 Preventing transmission among patients,
healthcare personnel, and visitors
 Identifying persons who may be infected and
exposed
 Providing treatment or prophylaxis to large
numbers of people
 Logistical issues (staff, medical supplies,
resupply, continued operations, and capacity)
/ 40
97
98
Cover Your Cough Posters
www.cdc.gov/flu/protect/covercough.htm
99
Bioterrorism
 Hospitals should be well versed in emergency
preparedness, including bioterrorism
 The response will be different based on the agent
 Work with state and local agencies to develop a plan
 There is a long list of bioterrorism agents
 Anthrax, arenaviruses, botulism, brucellosis,
cholera, Ebola virus hemorrhagic fever, E. coli,
Lassa fever, plague, ricin toxin, salmonella, and
cryptosporidium
For a comprehensive list go to website1
1http://www.emergency.cdc.gov/agent/agentlist.asp
/ 40
100
CDC Emergency Preparedness
www.bt.cdc.go
v
101
CDC Emergency Preparedness
www.bt.cdc.gov/bioterrorism/index.asp
102
Bio-defense Solutions by the Army
www.usamriid.army.mil
103
104
Infection Control 278
2015
Surveillance and corrective actions
 Need active surveillance program
 Surveillance includes detection, data collection,
analysis, monitoring and evaluation
 Must have facility wide surveillance to monitor
infections and communicable diseases in the CAH
 Must be consistent with recognized surveillance
activities like the CDC National Healthcare Safety
Net (NHSN)
 Must address interventions to address issues
identified
105
Infection Control
 NHSN replaces the CDCs National Nosocomial
Infection Surveillance system (NNIS)
 Was considered the gold standard for tracking HAI
for more than 30 years
 Designed to help hospitals better manage episodes
of HAI such as MRSA and VRE
 Used by the VA hospitals
 Hospitals report central line infections in ICUs and
NICUs and certain CaUTI
Enroll on-line for HAI surveillance and many
other resources1
1http://www.cdc.gov/ncidod/dhqp/nhsn.html
/ 40
106
CDC National Healthcare Safety Network
www.cdc.gov/nhsn/
107
www.cdc.gov/nhsn/training/
108
Infection Control 278
2015
Sanitary environment
 Needed to avoid transmission of infection and
communicable diseases
 This includes all CAH units and off site locations
 Need to monitor housekeeping
 Must monitor maintenance including repair,
renovation, and construction activity
 Must monitor food storage, preparation, serving and dish
rooms, refrigerators, ice machines, air handlers,
autoclave rooms, venting systems, inpatient rooms,
treatment areas, labs, waste handling, surgical areas,
supply storage, equipment cleaning, etc.
109
Infection Control 278
2015
Mitigation of risks
 Need P&P to mitigate risks associated with HAI
 Must implement IC techniques and standard
precautions
 Must include but not be limited to:
 Hand hygiene, cough etiquette, use of contact,
droplet, and airborne precautions
– See Infection Control Worksheet
 Use of PPE such as gloves, masks, and gowns
 Safe work practices to prevent bloodborne
pathogen
110
Standard Precautions CDC
www.cdc.gov/hicpac/2007IP/2007ip_part3.html
111
PPE Section in IC Worksheet
112
OSHA Bloodborne Pathogen Standard
www.osha.gov/SLTC/bloodbornepathogens/index.htm
113
OSHA Blood borne Pathogen Standard
Must implement UNIVERSAL PRECAUTIONS
to prevent contact with blood such as:
 Hand washing (see CDC hand hygiene document at
www.cdc.gov or WHO 2009 hand hygiene)
 No recapping needles
 Sharp containers in close proximity to use
 Not eating or drinking in work station
 No apply lip balm in work areas, if reasonable likelihood
of occupational exposure)
 Not handling contact lens in work area
 Must wash your hands after gloves removed
IP Tools
www.infectionpreventiontools.com/
115
Isolation Contact Precautions
116
Safe Medication
278
2015
Safe medication preparation and
administration includes:
 Prepare injectables in designated clean
medication area not adjacent to contaminated
areas
– Such as medication room
 Proper hand hygiene before handling
medications
 Always disinfect a rubber septum with alcohol
before piercing it
– 15 second and let dry
117
Safe Medication
278
2015
Safe medication preparation and
administration includes:
 Always using aseptic technique when preparing
and administering injections
 Never entering a vial or IV with a used syringe or
needle
 Never administering medications from the same
syringe to more than one patient, even if the
needle is changed
 Single dose vials can be used on only one patient
– Unless prepared in pharmacy under USP 797 guidelines
118
10 CDC Safe Injection Practices Standards
www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
119
Safe Injection Practices and Sharps
Safety in IC Worksheet
120
Safe Medication
278
2015
Safe medication preparation and
administration includes:
 IV bags can be used on one patient
 If multi-dose vial try and use for one patient only
and do not take into patient room
 Mark multi-dose vial expires in 28 days unless
sooner by manufacturer
 Wear a mask when placing a catheter or
injecting into epidural, spinal or subdural area
– Like ED physician doing LP or anesthesiologist who
puts in epidural for pain relief
121
Wear a Mask Epidural Spinal or LP
www.cdc.gov/injectionsafety/SpinalInjection-Meningitis.html
122
123
124
Safe Medication
278
2015
Safe medication preparation and
administration includes:
 Never use same finger stick device for more
than one patient
 Never use insulin pens on more than one
patient and CMS issues memo on this
 Avoid sharing glucose meters
 If must be done then clean after every use as
recommended by manufacturer
 P&P to make sure reusable patient care
equipment is cleaned and reprocessed
125
CMS Memo on Insulin Pens
CMS issues memo on insulin pens on May
18, 2012
 Insulin pens are intended to be used on one
patient only
 CMS notes that some healthcare providers are
not aware of this
 Insulin pens were used on more than one
patient which is like sharing needles
 Every patient must have their own insulin pen
 Insulin pens must be marked with the patient’s
name
126
Insulin Pens
www.cms.gov/Medicare/Provider-EnrollmentandCertification/SurveyCertificationGenInfo/Polic
y-and-Memos-to-States-and-Regions.html
127
CDC Reminder on Insulin Pens
www.cdc.gov/injectionsafety/clinical-reminders/insulinpens.html
128
Insulin Pen Posters and Brochures
www.oneandonlycampaign.org
/content/insulin-pen-safety
129
CMS Memo on Safe Injection Practices
June 15, 2012 CMS issues a 7 page memo
on safe injection practices
 Discusses the safe use of single dose
medication to prevent healthcare associated
infections (HAI)
 Notes new exception which is important
especially in medications shortages
 General rule is that single dose vial (SDV)can only be
used on one patient
 Will allow SDV to be used on multiple patients if prepared
by pharmacist under laminar hood following USP 797
guidelines
130
Single Dose Memo
131
Fingerstick Devices
132
Fingerstick Devices
 Anyone performing fingerstick
procedures should ensure
that a device is not used on
more than one patient
 Use auto-disabling single-use
disposable fingerstick devices
 Pen like devices should not
be used on multiple patients
due to difficulty with cleaning
and disinfection (one patient
use)
133
Safe Injection Practices Memo
www.empsf.org
134
CDC One and Only Campaign
http://oneandonlycampaign.org/
135
Not All Vials Are Created Equal
136
http://ascquality.org/advancing_asc_quality.cfm
137
Safe Medication
278
2015
Safe medication preparation and
administration includes:
 Must train staff on infection control P&P
 Expected to provide role specific education on:
– Proper hand hygiene, standard and
transmission-based precautions, asepsis,
sterilization, disinfection, food sanitation,
housekeeping, linen care, medical and
infectious waste disposal, injection safety,
separation of clean from dirty, as well as other
means for limiting the spread of infections
138
Infection Control Video
HHS has published a training video that
every nurse, physician, infection
preventionist and healthcare staff should see
This includes risk managers
It is an interactive video
Called Partnering to Heal: Teaming Up
Against Healthcare-Associated Infections
Go to http://www.hhs.gov/partneringtoheal
139
Watch this Video on Preventing
HAI
www.hhs.gov/ash/initiatives/hai/training/
140
Watch Award Winning Video
Safe Injection Practices - How to Do It Right
www.youtube.com/watch?v=6D0stMoz80k&feature=youtu.b
141
CDC Guidelines on Hand Hygiene
142
143
CDC Poster Clean Hands Save
Lives!
www.cdc.gov/h1n1flu/pd
f/handwashing.pdf
144
This is Your Hand Unwashed Johns
Hopkins
www.hopkinsmedicine.org/heic/docs/HH_hand_unwashed.pdf
145
Safe Medication
278
2015
Safe medication preparation and
administration includes:
 Must monitor compliance with all P&P and
IC program requirements
 Must do a program evaluation and make
revisions when indicated
 Need to provide education to patients and
visitors about precautions to prevent
infections
– CDC and APIC have many free resources
146
APIC Brochures
APIC has a number of educational
brochures that hospitals can download
and provide to staff and patient 1
Includes 10 tips to prevent the spread
of infection and hand hygiene for
patients and one for healthcare workers
Information to patients is on standard
precautions (hand hygiene) and
transmission precautions for patients
with certain diseases (contact
precautions)

1www.apic.org/AM/Template.cfm?Section=Education_Resources&Template=/TaggedPage/TaggedPa
geDisplay.cfm&TPLID=91&ContentID=8738
147
148
Survey Procedure 278
Surveyor to make sure there is a qualified IP
CAH must show how program follows
national guidelines and standards
 Recommend citing sources in P&P
Will look to make sure hospital is sanitary
and hospital performs active surveillance
Will make sure staff follow standard
precautions and have IC education
Will make sure medications are prepared
safely
149
Risk Assessment Tools from IP
Tools
www.infectionpreventiontools.com/home
150
Risk Assessment Tools
151
Risk Assessment Tools
152
Dietary 279
2015
Standard: If the CAH furnishes inpatient
services, including swing bed patients
Procedures must be in place that ensure that
the nutritional needs of inpatients are met in
accordance with recognized dietary practice
And the orders of a practitioner
 A CAH is not required to prepare meals
itself.
Can obtain meals under contract,
Infection control issues in dietary hit hard
153
Dietary Services 279
2015
Must be staffed to ensure that the nutritional
needs of the patients are met
Must have a qualified director
 Based on education, experience, specialized
training and license, certified, or registered if
required by the state
If swing beds must comply with following:
 Make sure resident maintains acceptable
parameters of nutritional status such as body
weight and proteins
 Receives a therapeutic diet
154
Dietary Services 279
2015
 Must follow recognized dietary practices
 For example, the IOM’s Food and Nutrition Board’s
DRI or Dietary Reference Intake 4 reference values
 RDA or the recommended dietary allowance is
average dietary intake of a nutrition sufficient of
healthy people
 Adequate Intake (AI) for a nutrient is similar to the
ESADDI and is only determine when an RDA cannot
be determined
– Estimated Safe and Adequate Daily Intake (ESADDI)
– AI is based on observed intakes of the nutrient by a group of
healthy persons
155
Dietary Services 279
2015
IOM’s Food and Nutrition Board’s DRI or
Dietary Reference Intake 4 reference values
(continued)
 Tolerable Upper Intake Level (UL) is highest
daily intake of a nutrient that is likely to pose
no risks of toxicity for most people
– As the UL increase, risk increases
 Estimated Average Requirement (EAR) is the
amount of the nutrient that is estimated to
meet the requirement of half of the health
people
156
IOM DRI or Dietary Reference Intake
http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-nutrient-reports
157
158
Dietary Guidelines for Americans
159
Interactive DRI Tool and Tables
160
Dietary Services 279
2015
Therapeutic diets may help meet the
patient’s nutritional needs
Patients must be assessed to determine if
they need a therapeutic diet for other
nutritional deficiencies
 Include in patient’s care plan
 Include the need to monitor intake
 Include if need daily weights, I&O, or lab
values
161
Nutritional Assessment Includes
Patient May Need Comprehensive
Assessment if:
 Medical or surgical conditions or physical status
interferes with their ability to digest or absorb
nutrients
 Patient has S&S indicating risk for malnutrition
– Anorexia, bulimia, electrolyte imbalance,
dysphagia, ESRD or certain medications
 Patient medical condition adversely affected by
intake and so need a special diet
– CHF, renal disease, diabetes, etc.
162
Dietary 279
2015
Patient May Need Comprehensive
Assessment if (continued):
Patient receiving artificial nutrition
 Tube feeding, TPN, or peripheral parenteral
nutrition
Need an order for diets, including therapeutic
diet, from practitioner responsible for care
Dietician or qualified nutritional specialist can
be C&P to order diet as consistent with state
law requirement
163
Survey Procedure 279 2015
Surveyor will verify dietician is qualified
Will ask how CAH uses DRIs in its menus to
meet the nutritional needs of patients
Will identify to make sure patients were
screened and assessed
Will make sure all diets are ordered
Will make sure dietary intake and nutritional
status are being monitored as appropriate
and swing beds patients aren’t losing weight
and maintaining protein level
164
Patient Services 280
2015
 Standard: Must provide diagnostic and therapeutic
services as those provided in doctor’s office or at
entry of healthcare organization like an outpatient
department or ED,
 Changed from Direct Services to Patient Services
 Can provide directly or under contract
 Must have supplies as that typically found in an
ambulatory healthcare setting and a physician’s
office
 These services include medical history, physical
examination, specimen collection, assessment of
health status, and treatment for a variety of medical
conditions.
165
Outpatient Department 280 2015
 Must provide adequate services, equipment, staff,
and facilities adequate to provide the outpatient
services,
 Must follow acceptable standards of practices such
as ACR, AMA, ACOS, etc.,
 OP Dept must be integrated with inpatient services
such as MR, lab, radiology, anesthesia or other
diagnostic services,
 CAH physician or non-physician practitioner must
be available to treat patients at the CAH when such
outpatient services are provided
 For those outpatient services that fall only within the scope of
practice of a physician or non-physician practitioner
166
Patient Services 281 2015
Standard: The CAH furnishes acute care
inpatient services
 Average LOS is 96 hours
 CAH provide less complicated inpatient services
to meet the LOS requirement
 Will look at data to make sure patients who need
inpatient care are admitted
 Must certify that Medicare patients may be
expected to be discharged or admitted to a
hospital within 96 hours
 Does not believe in best interest to transfer a
167
patient that can be cared for locally
Patient Services 281 2015
CMS notes that CAH may have seasonal
variations
CAH is not required to maintain a minimum
average daily census of inpatients
Nor are they required to maintain a minimum
number of inpatient beds
 Will look at volume of ED and outpatient
services, number of certified beds and
dedicated observation beds, average annual
occupancy, average inpatient beds quarterly
and annually, % of ED patients admitted, etc.
168
Patient Services 281 2015
Wants to be sure not an excess number of
observation beds
Wants to be sure not transferring patients
from the ED to another hospital when the
CAH could care for them
 Data shows about ½ the number of patients who
visit a rural hospital are admitted then in a nonrural hospital (8.3 % vs. 16%)
If admits 8% of its ED patients annually CAH
is compliant with inpatient services and
surveyors do not need to investigate further
169
Lab Services 282
2015
Must provide basic lab services to include,
 Urine dipstick or tablet including urine ketones,
 Hemoglobin or hematocrit,
 Blood glucose,
 Stool for occult blood,
 Pregnancy tests,
 Primary culturing for transmittal to certified lab,
Will need written policy to make sure all labs tests
are recorded in the MR,
Lab and radiology dept do not have to be a direct
service
170
Lab 282
Must have these basic lab services,
Must provide emergency services 24 hours/7 days
a week,
Must have current CLIA certificate and if contracted out
make sure they have a CLIA certificate
Scope of services and complexity must be adequate to meet
the needs of the patients,
Can be employed or contract services,
Patient lab results are medical records and must comply with
the MR chapter
Must have written P&P for collecting, preserving,
transport, receipt if tissue specimen results,
171
Radiology Services
283 2015
Radiology services must be
provided by qualified staff,
 Can be provided as a direct
service or through a contract,
And do not expose patients
or staff to radiation hazards,
Must have services to meet
the needs of its patients at all
times,
172
Radiology Services
283
Can offer minimal set or more complex,
according to needs of the patients including
nuclear medicine,
Hospital has flexibility to decide the types
and complexities of radiologic services
offered
 Interpretation can be contracted out
 Diagnostic, therapeutic, and nuclear medicine,
must be provided in accordance with acceptable
standards of practice and must meet
professionally approved standards for safety
173
Radiology Services
283
 Scope or what you do has to be in P&Ps approved
by board or responsible party,
 Must be consistent with state law
 If telemedicine is used must comply with
telemedicine standards
 And by standards recommended by nationally
recognized professions such as the AMA, Radiology
Society of North America, Alliance for Radiation Safety in
Pediatric Imaging, ACC, American College of Neurology,
ACP, and ACR,
 Example would be the ACR 2013 MRI safety
standards and 2013 contrast manual
174
Radiology Services 283
P&P on adequate radiation shielding for
patients, personnel and facilities which
includes:
 Shielding built into the physical plant
 Types of personal protective shielding to use
and under what circumstances
 Types of containers to be used for radioactive
materials
 Clear signage identifying hazardous radiation
area
175
Radiology Policies Required
 Labeling of all radioactive materials,
including waste with clear identification of the
material
 Transportation of radioactive materials
between locations within the CAH;
 Security of radioactive materials, including
determining who may have access to
radioactive materials and controlling access
to radioactive materials;
 Periodic testing of equipment for radiation
hazards;
176
Radiology Policies
 Periodic checking of staff regularly exposed to
radiation for the level of radiation exposure, via
exposure meters or badge tests
 Storage of radio nuclides and radio
pharmaceuticals as well as radioactive waste;
and
 Disposal of radio nuclides, unused radio
pharmaceuticals, and radioactive waste,
 To ensure periodic inspections of equipment,

Make sure problems are corrected in timely manner
and have evidence of inspections and corrective
actions
177
Radiology Policies 283 6-7-2013
There must be written policies developed
and approved by the medical staff to
designate which radiological tests must be
interpreted by a radiologist,
MR chapter standards apply
Make sure patient shielding aprons are
maintained properly and inspected
Surveyor will review equipment
maintenance reports (PM)
Make sure staff know P&Ps
178
Radiology Policies
283
Supervision must include that all files, scans,
and images are kept in a secure place and
are retrievable,
Written policy, consistent with state law on
which personnel can operate radiology
equipment and do procedures,
Need copies of all reports and printouts,
Written policy to ensure integrity of
authentication,
 See tag 283 for required signage on
hazardous radiation areas and more
179
Tag 283 Blue Box Advisory
180
Emergency Procedures 284 2015
Must provide medical emergency services
as a first response to common life
threatening injuries and acute illness,
 Emergency services can be done directly or
through contracted services
 Individuals providing the services must to be
able to recognize a patient need for emergency
care
 Must provide medically appropropriate initial
interventions, treatment, and stabilization of any
patient who requires emergency services
181
Agreements 285
CAH has to have agreements with one or
more providers or suppliers participating
under Medicare to furnish services to
patients
CMS made an exception since distantsite telemedicine entity (DSTE) is not
required to be a Medicare provider
Agreements such as for obtaining outside
lab tests
182
Contracted Services 287 2015
Must have agreement or arrangement with
one or more providers or supplies
participating under Medicare to provide
services to patients
Arrangement or agreement with 1 or more
doctors to provide care
If referral agreement is not in writing then can
show that doctors are accepting patients
when referred (given appointments and seen)
Need P&P for referring patients it discharges
who need additional care
183
Lab & Diagnostic Services 288 2015
Lab or diagnostic services that are not
available at the CAH
 Want to have an agreement with 1 or more other
providers
 Want to be sure referred patients are accepted
and treated
Need to make sure basic lab services are
available to ensure an immediate diagnosis
and treatment
 Staff can provide or contracted services can
provide at the hospital
184
Contracted Services 286-289
Need to have agreement with a lab that can
provide additional or specialized lab tests
 CAH draws and sends tests out
 Required to have P&P on this
 If labs that provide additional diagnosis and
clinical lab services must be in compliance with
CLIA and lab will be surveyed separately for
compliance,
CAH needs evidence that the outside lab has
a CLIA certificate or waiver
Same is true of radiology services and if done
outside make sure CAH gets copy of report
185
Contracted Services Food 289 2015
CAH can provide food and other services to
meet inpatient’s nutritional needs
Or CAH can contract out this service
Must still make sure patient nutritional needs
are met
Dietary services must be provided as per the
P&P
Exception is grandfathered co-located CAH
but surveyor will assess it
186
Contracted Services 291 2015
Need to keep list of all services
provided under contract or agreement
 Must include service offered, individual or
entity that is providing it, and whether on or
off-site
 Must include if any limit on the volume of
frequency of the services provided
 Must include when the services are
available
 Update list each time services added or
removed
187
Contracted Services 292 2015
CEO is responsible for operation of all
patient services furnished in the CAH
 This includes those performed directly or by
contract
 Must take action to ensure this
It includes not only care provided directly to
patient but also services related to patient
care
 Housekeeping, instrument cleaning and
sterilization, laundry, pharmacy services, lab
188
Nursing Care 294
2015
Standard: Nursing service must met
the needs of patients
RN must provide nursing care to each
patient or assign
Nursing service must be well organized
Need chief nursing officer (CNO) who is
responsible for development of nursing P&P
 Staff must be aware of all P&P
 CNO responsible to supervise nursing staff
Must have ongoing review and analysis of
nursing care
189
Nursing Care 294
2015
All agency nurses must be oriented and
supervised
Surveyor will interview RN and ask how
nursing needs of patients are determined
How are staff assigned to provide care?
How are staff trained and oriented?
Will look at written staffing schedules to make
sure adhere to P&Ps
Will review personnel files to make sure
nurses are licensed
190
Nursing Care 294 2015
Must have RN, LPN, or CNS on duty
whenever the CAH has 1 or more patients
Must ensure appropriate staffing for outpatient
nursing services
Must have sufficient numbers of supervisory
and non-supervisory personnel to meet patient
needs
 Must be competent, educated, trained, oriented,
and licensed
 Need procedure for assigning and coordinating
nursing care
 RN make assignments
191
RN 295
 RN must provide the care for each patient or
assign care to other personnel,
 Including SNF and swing be patients,
 Care must be provided in accordance with patient
needs,
 RN must make all patient care assignments,
 Assignments must take into consideration
complexity of patient’s care,
 Will look at written staffing plans,
 Staff must be competent,
 Make sure if temporary nurses used they are
oriented and supervised,
192
RN Supervising Care
296 2015
A RN must supervise and evaluate
the nursing care for each patient (or if
state law allows a PA)
Includes SNF level is a swing bed
Must evaluate the care of each patient upon
admission including swing beds
Nursing care plans do not have to be
developed for outpatients
 But follow acceptable standards for medication
administration
193
Drugs and IVs
297
2015
Standard: All drugs and IVs are
administered under the supervision of
RN, MD/DO, or a PA if allowed by state
law
Need a signed order
 Be sure there is signature and date and
TIME on all orders
Orders must be written with the
acceptable standard of care
Must be consistent with both state and
federal laws
194
Drugs and IVs
297
2015
Drugs must be administered and prepared in
accordance with the standard of care
 Mentions NCCMERP, IHI, USP, ISMP, CDC,
and Infusion Nurses Society
 Discussed previously
P&P must specify who can administer meds
Need signed order by one authorized by P&P
Need P&P for verbal and standing orders
Need minimum content of medication orders
 Name, dose, route, frequency, etc.
195
196
Drugs and IVs
297
2015
Ensure compliance with acceptable practices
 Self administration of medications
 Training
 Basic safe practices
 Timing of medication
 IV medication
 Documentation
 Assessment of patients receiving
medications
197
Drugs and IVs
297
2015
Verbal and standing orders
 Practitioner must authenticate order ASAP
 Need P&P for both
 Standing orders must include how it is
developed, approved, monitored and
updated
 Must include when staff can initiate a
standing order
 Must include that standing order is signed off
 List of things that must be in the verbal order
198
Verbal Order P&P
199
Blue Box Advisory Verbal & Standing
200
Drugs and IVs
297
2015
Self administered meds
 Need an order
 Can include meds brought from home
 Must have P&P
Training
 Medication administration training and education
during orientation and CNE to include:
– Safe handling and preparation of drugs
– Knowledge of side effects, ADE, dose limits
– How to use equipment and need P&P
201
Drugs and IVs
297
2015
Basic safe practices
 Five rights
 Culture of safety where staff feel free to ask
questions
Timing of medications
 P&P specify time frames
 P&P must include those medications not eligible
for scheduled dosing times
– Such as stat, PRN, on call for surgery, loading dose
 Evaluation of timing policies
202
3 Time Frames for Administering
Medication
203
Timing of Medication P&P
 Time-critical scheduled medications (30
minute or 1 hour total window)
 These are ones in which an early or late
administration of greater than thirty minutes
might cause harm or have significant, negative
impact on the intended therapeutic or
pharmacological effect
 P&P must include whether these drugs are
always time critical
 Examples include: Antibiotic given within one
hour of incision time in the OR, fast acting
insulin with 15 minutes of lunch
204
Timing of Medication P&P
Non-time-critical scheduled medications
 Greater flexibility is given
 Medications scheduled more frequently than
daily but less than every 4 hours (such as bid
or tid) can be given 1 hour before or after for
window not to exceed 2 hours
 Medications given once daily, weekly, or
monthly may be given within 2 hours before
or after but can not exceed a total window of 4
hours (such as Allegra once a day)
205
Timing of Medication P&P
Missed or late administration of medications
 Policy must include what action to take if missed
or not given in permitted window of time
 Missed dose may be due from patient who is out
of the department, patient refusal, problems
related to medication being available or other
reasons
 Policy needs to include parameters of when nursing
staff are allowed to use their own judgment on the
rescheduling of late or missed dosed
 Missed or late doses must be reported to the
attending physician
206
Medication Assessment 297 2015
Assessment of Patients on Medications
Very concerned about patient having
respiratory depression or ADR from opioids
Must carefully monitor
May include respiratory status, BP, pulse ox
and ETCO2
Evaluate for confusion, agitation, unsteady
gait, itching, lethargy, etc.
Opioids are considered high risk
medications
207
ISMP List of High Alert
Medication
208
Medication Assessment 297 2015
Assessment of Patients on Medications
Factors that put patients at greater risk for
adverse events and respiratory depression
 Liver or kidney failure
 History of sleep apnea or snoring
 Age, thoracic or other surgical incisions
 History of smoking, pulmonary or cardiac disease
 First time medication use, receiving
benzodiazepines, antihistamines
 Asthma, Patient weight
209
Medication Assessment 297 2015
Need to communicate in report and hand
offs
High alert medications would want to assess
sedation level
Staff are expected to include patient reports
of their experience of medication’s effects
Educate the patient and family to notify
nurse if any difficulty breathing or ADEs
P&P must discuss manner and how frequent
to monitor patient
210
IV Medication & Blood 297 2015
Need correct choice of vascular access
devise to deliver blood and medications
Peripheral catheters, PICC, midlines, central
lines, implanted ports and other types of
devices
Need P&P to address which ones can be
given IV and via what type of access
Trace lines and tubes for correct connections
and prior to giving meds
Verify IV pump is properly programmed
211
IV Medication & Blood 297 2015
P&P expected to address:
 Monitoring for fluid and electrolyte imbalance
– Electrolyte imbalance can occur with IV meds
or blood
 Monitoring of patients receiving high alert
medication including opioids
– How often and what devices such as pulse ox
or ETCO2, and document pain level, VS,
respiratory status and sedation level
 Monitoring for over-sedation and respiratory
depression related to opioid in post-op patients
212
Pasero Opioid‐induced Sedation Scale
POSS
https://secure.tha.com/surveys/files/p
asero-opioid-induced-sedation-scaleposs.pdf
213
Richmond Agitation Sedation Scale
RASS
www.icudelirium.org/docs/RASS.pdf
214
Comparison of Sedation Scales
Medscape
www.medscape.com/vi
ewarticle/708387_3
215
ISMP Use a Standard Sedation
Scale
216
217
Blood Transfusions 297
2015
Confirm correct patient
Verify correct blood product
Standard calls for two qualified persons, one
who is administering the transfusion
 TJC NPSG allows one person hanging blood if use bar coding
Document monitoring
P&P include how frequent you monitor the
patient and do vital signs
How to identify and treat and report any
adverse transfusion reaction
218
Nursing Care Plan 298 2015
Must keep a current nursing care plan
(POC) for each inpatient
Starts upon admission and need to keep
current
 Includes planning for patient’s care while
in hospital
 Includes planning for transfer
Considers treatment goals, physiological
and psychosocial factors and discharge
planning
219
Nursing Care Plan 298 2015
POC develops appropriate nursing
interventions based on identified needs
Must be part of the permanent medical
record
Nursing can do it as part of the
interdisciplinary POC
Must still do a nursing POC
Surveyor will check to make sure POC
started soon after admission
 Will also make sure it is revised as necessary
220
Rehab Therapy 299
2015
Standard: Rehab services are provided by
qualified staff
 Included PT, OT, and speech-language pathology
 Rehab is an optional service
 Can be provided directly or through contracted
services
 Must have an order, P&P, and be consistent with
the SOC (American PT Association, American OT
Association etc.)
 Must follow the rehab plan of care requirements
and consistent with state law
221
Rehab Plan of Care (POC) Requirements
Must do POC before treatment is started
 Can be done by MD/DO, PA, NP, CNS,
 Can be done by PT, speech-language
pathologist, or OT who is furnishing the service
 The POC must
 Prescribe the type, amount, frequency, and
duration
 Must indicate the diagnosis and anticipated goal
 Any change in plan must be in accordance with
provider’s P&P
222
CMS Visitation Sept 7, 2011
www.cms.gov/SurveyCertificationGenI
nfo/PMSR/list.asp#TopOfPage
223
Visitation 1000 (Starts after Tag 297)
Must have P&P and process on visitation
 Including any reasonable restrictions or
limitations
Discusses 2004 JAMA article encouraging
open visitation in the ICU
Includes inpatients and outpatients
 Discusses role of support person for both
 Patient may want support person present
during pre-op preparation or post-op
recovery
224
Reasonable Restrictions 1000
Infection control issues
Can interfere with the care of other patients
Court order restricting contact
Disruptive or threatening behavior
Room mate needs rest or privacy
Substance abuse treatment plan
Patient undergoing care interventions
Restriction for children under certain age
225
Visitation 1000
Need to train staff on the P&P
Need to determine role staff will play in
controlling visitor access
Surveyor will verify you have a P&P
Will review policy to determine if restrictions
Is there documentation staff is trained?
Will make sure staff are aware of P&P on
visitation and can describe the policy for the
surveyor
226
Visitation 1001
Must inform each patient or their support
person, when appropriate, of their visitation
rights
Must include notifying patient of any
restrictions
Patient gets to decide who their visitors are
Can not discriminate against same sex
domestic partners, friend, family member
etc.
The patient gets to decide
227
Visitation 1001
Support person does not have to be the
same person as the DPOA
Support person can be friend, family
member or other individual who supports the
patient during their stay
 TJC calls it a patient advocate
Support person can exercise patient’s
visitation rights on their behalf if patient
unable to do so
228
TJC Help Prevent Errors in Your Care
www.jointcommission.org/speak_up_help_prevent_errors_in_your_care/
229
Visitation 1001
Hospital must accept patient’s designation of
an individual as a support person
 Either orally or in writing
 Suggest you get it in writing from the patient
When patient is incapacitated and no
advance directives on file then must accept
individual who tells you they are the support
person
 Must allow person to exercise and give them
notice of patients rights and exercise visitation
rights
230
Visitation 1001
Hospital expected to accept this unless two
individuals claim to be the support person
then can ask for documentation
 This includes same sex partners, friends, or
family members
 Need policy on how to resolve this issue
Any refusal to be treated as the support
person must be documented in the medical
record along with specific reason for the
refusal
231
Visitation 1001
Patient can withdraw consent and change
their mind
Must document in the medical record that
the notice was given
Surveyor is to look at the standard notice of
visitation rights
Will review medical records to make sure
documented
Will ask staff what is a support person and
what it means
232
Visitation 1002
Must have written P&P
Must not restrict visitors based on race,
color, sex, gender identify, sexual orientation
etc.
In other words, if a unit is restricted to two
visitors every hour the patient gets to pick
their visitors not the hospital
Suggest develop culturally competent
training programs
233
The End! Questions??
Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP
AD, BA, BSN, MSN, JD
President
Board Member
Emergency Medicine Patient
Safety Foundation
www.empsf.org
614 791-1468
[email protected]
234
234