Transcript ASC Survey Process - Kansas Hospital Association

www.kdheks.gov
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
BE COMPLIANT
BE SURVEY READY!
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
The Survey Process
in Hospitals/CAHs
March 6, 2012
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
KDHE Staff
Anita Hodge, RN, MA
State Survey Manager
Liza Ben Vaughn, RN
QI Coordinator
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Presentation Objectives
 Types of Hospital/CAH surveys
 Describe the survey process and tasks
 Survey Protocol
 Regulatory and Policy Reference
 Hospital/CAH Infection Control Worksheet
 Useful Contacts
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
HOT OFF THE PRESS!!
 February 17, 2012 S & C -12-17 Hospitals
 Requirements for Ordering Hospital Outpatient
Services
 Responsible for the care of the patient
 Licensed in, or holds a license recognized in the
jurisdiction where he/she sees the patient
 Acting within his/her scope of practice under State
law; and
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
HOT OFF THE PRESS cont.
 Authorized by the medical staff to order the
applicable outpatient services under a written
hospital policy that is approved by the governing
body. This includes both practitioners who are on
the hospital medical staff and who hold medical staff
privileges that include ordering the services, as well
as other practitioners who are not on the hospital
medical staff, but who satisfy the hospital’s policies
for ordering applicable outpatient services and for
referring patients for hospital outpatient services.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
HOT OFF THE PRESS cont.
 The hospitals medical staff policy for authorizing
practitioners to refer patients for outpatient services
must address how the hospital verifies that the
referring practitioner who is responsible for the
patient’s care is appropriately licensed and acting
within his/her scope of practice. The policy must
also make clear whether the policy applies to all
hospital outpatient services, or whether there are
specific services for which orders may only be
accepted from practitioners with medical staff
privileges.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Regulatory and Policy
Reference
 The Medicare Conditions of Participation for
hospitals are found at 42 CFR Part 482.
 Survey authority and compliance regulations can be
found at 42 CFR Part 488 Subpart A.
 Should an individual or entity (hospital) refuse to
allow immediate access upon reasonable request to
either a State Agency or CMS surveyor, the Office of
the Inspector General (OIG) may exclude the
hospital from participation in all Federal healthcare
programs in accordance with 42 CFR 1001.1301.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Regulatory and Policy
Reference continued . . . . . .
 The regulatory authority for the photocopying of




2012
records and information during the survey is found at
42 CFR 489.53(a)(13).
The CMS State Operations Manual (SOM) provides
CMS policy regarding survey and certification
activities.
Hospitals SOM Appendix A
Critical Access Hospitals SOM Appendix W
www.cms.hhs.gov/manuals/downloads/som107_App
endixtoc.pdf
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Surveyors
 In Kansas surveyors are all RN’s, in other states they
are dieticians, sanitarians etc.
 Surveyors cover the entire state of Kansas usually
working 4 days a week.
 Surveyors are trained and responsible for Hospital,
CAH, ASC, Hospice, Home Health, Rural Health
Clinics, Dialysis and OPPT surveys and complaint
investigations.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey types
 Initial Survey; licensure and certification
 Resurvey - approximately every 4 years
 ReVisit - Return survey if CoPs were out during the
resurvey.
 Complaints - IJ (2 days) or Non IJ Medium (45
days).
 EMTALA investigation
 Validation Survey (60 days after a JCAHO Survey)
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Complaint Survey
 JCAHO hospital complaints approved and directed
by CMS
 Other complaint survey approved and directed by
KDHE
 Two types of complaints IJ and non-IJ. IJ complaints
require a 2 day investigation response and non-IJ up
to 45 days for investigation.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Complaint Survey
 JCAHO hospital complaints approved and directed
by CMS
 Other complaint survey approved and directed by
KDHE
 Two types of complaints IJ and non-IJ. IJ complaints
require a 2 day investigation response and non-IJ up
to 45 days for investigation.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
~Hospital or CAH Survey~
 Hospitals are required to be in compliance
with the Federal requirements in the Medicare
Conditions of Participation (COP) in order to
receive Medicare/Medicaid payment.
 The goal of the survey process is to determine
if the hospital is in compliance with the COP
at 42 CFR Part 482. And if appropriate with
the PPS exclusionary criteria at 42 CFR 412
Subpart B.
 Swing Bed requirements at 42 CFR 482.66
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Hospital or CAH Survey~
 CAH are required to be in compliance with all the
requirements with 42 CFR 485 Subpart F.
 If a CAH has a distinct part psychiatric unit and
rehabilitation unit and or swing beds those areas will
also be surveyed.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Introduction Hospital Survey
 Certification
determination is
accomplished through
surveyor
observations,
interviews, and
document and or
record reviews.
Our Vision is "healthy Kansans living in safe and sustainable
environments“, The state belongs to all of us-"Kansas Don't
Spoil It"
Survey Process Focus and
Team
 A hospital’s performance of patient-focused functions and




2012
processes and
Organizational functions and processes
Surveyors assess the hospital’s compliance with each
COP for all services, all areas and locations in which the
hospital receives reimbursement for services billed under
its provider number.
The size and composition of the team are bases on the
size of the facility based on the average daily census:
The number and type of services offered including
outpatient:
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Process
 Emphasis on OBSERVATION
- Hand Hygiene
- Healthcare providers should wear gloves
- Injection safety
- Pre-drawing medications
- Single-dose & multi-dose medications
- Sharps Disposal
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Process
* Emphasis on OBSERVATION
* Supplement with interview
- Staff
- Patients
- Physicians
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Focus and Team
 The number and location of off-site locations and
special care units:
 If the facility had a historical pattern of serious
deficiencies or complaints and
 If new surveyors are with the team as part of their
training.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Process
 Surveys generally occur during daytime working
hours but may occur at other times. This may
include weekends and times outside the normal
working hours.
 Surveyors modify the process in recognition of
patient activities and the staff available.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Process
 Hospital surveys are unannounced. The only
exception would be an initial licensure and an initial
certification survey.
 The survey assess compliance with Federal health,
safety, and quality standards that will assure the
patient/beneficiary receives safe, quality care and
services.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Tasks
 Task 1~Off-Site Survey Preparation
 Task 2~Entrance Activities
 Task 3~Information Gathering
 Task 4 Preliminary Decision Making and Analysis of
Findings
 Task 5 Exit Conference
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Off-Site Survey Preparation
 Objective of off-site preparation is to analyze
information about the hospital to identify areas of
potential concern and determine if any special
features which would require extra modules.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Information Reviewed Off-Site
 Information from provider file, ownership, type of
services, PPS, swing-bed, the number, type and
location of any off-site locations
 Previous survey results for patterns, number and
nature of deficiencies and number, frequency, and
types of complaint investigations and the findings.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Off-Site continued
 The dates of the most recent survey, along with
information from CMS and SA data bases.
 Waivers and variances, if they exist. Determine if
there are any applicable survey directives from the
SA or CMS RO
 Any additional information available (web sites,
media reports etc)
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Team Meeting
 Team coordinator makes preliminary assignments
 Reviews information with team
 Discusses information about the hospital
 Discusses the potential date and time of the exit
conference
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Team Resources
 Medicare Hospital COP and Interpretive Guidelines
~Appendix A
 Appendix Q~ Immediate Jeopardy
 Appendix V ~ Responsibilities in Emergency Cases
(EMTALA)
 Various worksheets
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Task 2 ~ Entrance
 Objective is to explain the survey process to the




2012
hospital and obtain the information needed to
conduct the survey.
Usually made with administrative staff
Explain the purpose and scope of the survey
Clarify that all hospital areas and locations,
departments, and patient care settings under the
provider number may be surveyed.
Interviews will be conducted privately with patients,
staff, and visitors unless requested.
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Entrance Forms
 Hospital/CAH Medicare Database Worksheet
 Entrance Conference Information sheet, the hospital
lists department heads or directors, status (full time,
part time, contract) availability during the survey.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Entrance Forms
 Identify services provided
 Number of beds, acute, LTC and swing beds
 Number of Active Medical Staff
 Number of Allied Health Professionals
 Attach a list of the above
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Requested Documents and
Reports
 Organizational Charts
 Map of the hospital with location of all
departments
 All service agreements and any network
agreements (communications systems, physician
coverage and referral, OPO transportation of
patients.
 Staffing schedules for the last month for ED, OP
and nursing units
 On call schedules for the past 3 months for MD
and other staff (lab, x-ray etc)
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Requested Documents and
Reports continued
 List of current patients, room number, diagnosis,
admission date, age, and physician (nursing
rounding reports, etc)
 List of deaths in the last 3 months, include diagnosis
 Committee Meeting minutes for
Infection control, Pharmacy, QAPI,
Governing Body, Medical Staff, and Nursing
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Documents and Reports
 Hospital board and Medical Staff bylaws, rules
and regulations
 Hospital Policy and procedure manuals with the
following P and P flagged (if computerized
provide access)
Infection Control
Pharmacy
ED
Surgical Department
Dietary
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Policies and Procedures
Nursing,blood administration, staffing plan,
planned education, fetal tissue, etc
Medical Records
Outpatient and or Clinic
Patient Rights
Patient transfer
Distinct Part Psych or Rehab
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Document and Reports cont…
 Logs from the emergency room, OB, OR,
Outpatient, and any others for the past 12
months
 Hospital’s HR policy for employee health
 The hospital’s current approved QAPI plan
 Annual Program Evaluation
 Surveyors will choose physician and mid-level
practitioners for credentialing review
 Surveyors will choose staff for evidence of
appropriate licensure, certification and or
registration.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Surveyors will need
 A location where the team may meet privately
 A telephone and phone numbers for key staff
 Access to a copy machine
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Task 3 Information Gathering
 The objective is to determine the Hospital’s
compliance with the Medicare COP’s through
observation, interview, and document review
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey
 Surveyors will visit patient care settings,
including inpatient, outpatient, anesthetizing
locations, ED, imaging, rehabilitation, laboratory,
laundry, dietary,remote locations, satellites, etc.
 Surveyors will observe actual care, medication
administration and other services to patients and
the effects of that care.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Record Review
 Surveyors review the sampled patient’s medical
record.
 Physician orders
 Use of verbal or telephone orders
 Assessments
 Plan of Care
 Patient response to care and services
 Medication Regime
 Ancillary Services
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Observations
 Surveyors observe staff member activities,
equipment, documentation, building structure,
sounds and smells.
 Integration of all services
 QAPI is a facility wide activity incorporating every
service and activity
 Storage, security and confidentiality of medical
records.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Interviews
 Interviews provide a method to collect information,
and to verify and validate information obtained
through observation or record review.
 Interviews determine what additional observations,
interview and record reviews are necessary.
 Interviews are conducted privately with patients, staff
or family members.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Staff Interview
 Gather information about the staff’s knowledge of the
patient’s needs, plan of care and progress towards
goals. Problems or concerns identified during a
patient or family interview will be addressed in staff
interview to validate the patient’s perception, or to
gather additional information.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Information Gathering
 Goal to maintain an ongoing dialog with
hospital staff throughout the survey process.
 Informal conferences may be held to inform
the hospital of survey findings. This allows
staff the opportunity to present additional
information.
 The surveyor role is non-consultative but
information may be provided upon request.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Sample Size
 A selection of patients who represent a crosssection of the patient population and services.
 The sample size is based on the hospital’s
average daily census. The sample will be at
least 10 percent of the average but not less than
30.
 An average daily census of 20 requires at least a
sample of 20.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Pre-Operative Area
 Focal Points
- Patient ID, site marking
- Medication administration
- Medical records
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
SURGICAL ATTIRE
AORN 2011 Perioperative Standards & Recommended Practices
All individuals who enter the semi restricted and restricted areas of the surgical
suite should wear freshly laundered surgical attire intended for use only within
the surgical suite.
1. Clean, freshly laundered surgical attire should be donned in a designated
dressing area of the Hospital. If scrubs are worn into the Hospital from outside,
they should be changed before entering semi restricted or restricted areas.
2. Home laundering of surgical attire is not recommended. AORN does not
support the practice of home laundering of surgical attire. AORN has always
recommended that surgical attire be laundered by a facility or industrial
laundry.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
SURGICAL ATTIRE
 There had been much discussion about "surgical masks."
 AORN 2011 at Vl.b. it states "A fresh, clean surgical mask should be worn
for every procedure. The mask should be replaced and discarded
whenever it becomes wet or soiled.
 AORN 2011 at Vl.b.1. it states "Masks should not be worn hanging down
from the neck. The filter portion of a surgical mask harbors bacteria
collected from the nasopharyngeal airway. The contaminated mask
may cross-contaminate the surgical attire top."
 AORN 2011 at Vl.c. states, "Surgical masks should be discarded after
each procedure."
 AORN 2011 at Vl.d. states, "Only one surgical mask should be worn at a
time.“
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
SURGICAL ATTIRE
AORN 2011 Perioperative Standards & Recommended Practices
3.Surgical personnel should cover head and facial hair, including sideburns
and necklines, when in the semi-restricted and restricted areas of the
surgical suite.
4. All individuals entering restricted areas of the OR Suite should wear a mask
when open sterile items and equipment are present.
5. All personnel entering the semi-restricted and restricted areas of the surgical
suite should confine or remove all jewelry and watches.
6. Fingernails should be kept short, clean, natural and healthy. Artificial nails
should not be worn.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Operating Room
 Focal Points:
- Time out for patient and site ID
- Medication Administration
- Patient preparation – e.g., alcohol-based
skin prep
- Surgical Attire
All individuals who enter the semi restricted
and restricted areas of the surgical suite should wear
freshly laundered surgical attire intended for use only
within the surgical suite.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Operating Room
 Surgical Attire continued . . . .
- Don’t wear scrubs from home into the surgical
suite.
 - Don’t let physicians from other hospitals come
into your surgical suites with the same scrubs on
they worn at another hospital to perform a surgery.

2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Operating Room
 Focal Points:
- Physical environment
* Design
* Equipment
- Sterilization/high-level disinfection
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Infection Control
 a Yankauer Suctioning Catheter Tip should not be
open and ready for use until needed.
 Many manufacturers state on the packaging the
"Yankauer Suction Catheter Tip is a sterile, singleuse suction tool . . . . "
 Although the upper airways (oropharynx and
nasopharynx) are not sterile, sterile technique is
recommended for all suctioning to avoid
introducing pathogens into the airways.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Survey Process
 Emphasis on OBSERVATION
- Hand Hygiene
- Healthcare providers should wear gloves
- Injection safety
- Pre-drawing medications
- Single-dose & multi-dose medications
- Sharps Disposal
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Hand Hygiene
 AORN 2011
 Hand washing should be performed:
- Upon arrival at the health care facility
- Before and after every patient contact
- Before putting gloves on and after removing
gloves or other personal protective equipment.
- Any time there is a possibility that there has been
contact with blood or other potentially infectious
materials or surfaces.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Hand Hygiene
 Hand washing should be performed
- Before and after eating
- Before and after using the restroom
- Before leaving the health care facility
- When hands are visibly soiled
* Hand washing remains one of the most important
measures in maintaining patient and health care
personnel safety.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Glucometers
 Glucose Testing Fingerstick Devices
- A new single-use, auto-disabling lancing device is used
for each patient
- Lancing penlet devices should NOT be used for
multiple patients - CLEANING
- Glucometer is not used on more than one patient
unless manufacturer’s instructions indicate this is
permissible
- Glucometer is cleaned and disinfected after every use.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Task 4 Preliminary Decision
Making and Analysis of Findings
 Surveyors consider findings from the survey and
make preliminary recommendations.
 Surveyors share findings, evaluate the evidence and
make team decisions regarding compliance with
each requirement.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Task 5 Exit Conference
 The general objective is to inform hospital staff of
the team’s preliminary findings.
 The team coordinator is responsible for
organization of the presentation of the exit.
 It is CMS’s general policy to conduct an exit
conference. However there are some situations
that justify refusal to continue or conduct an exit
conference.
Examples include: if the provider is represented
by counsel; anytime the provider creates a
hostile environment etc.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Recording the Exit Conference
 Audio tapes are permitted if the hospital provides
two tapes and two tape recorders, recording the
meeting simultaneously.
 Video taping is not allowed by KDHE
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Exit Conference
 The hospital determines which staff will attend
the conference. KDHE recommends 5 staff but
the TC may allow more.
 The identity of individual patient or staff members
are not to be revealed in discussing surveyor
findings.
 The hospital may have the opportunity to present
new information after the exit conference for
consideration after the survey.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Findings
 Surveyors are instructed to avoid referring to
data tag numbers.
 Findings of non-compliance are presented.
 Surveyors are instructed to avoid generalized
comments “overall the hospital looks good”.
 If IJ was identified surveyors will explain the IJ
and the significance and need for immediate
correction.
 Surveyors will discuss all findings.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2567 Form
 The hospital will receive a statement of
deficiencies within 10 days. Kansas emails the
2567 form to the hospital.
 The Form CMS 2567 is a document disclosed to
the public about the hospital’s deficiencies and
what is done to remedy them. The form is made
public no later than 90 calendar days following
completion of the survey. It documents specific
deficiencies cited, the hospitals plans for
correction and timeframes.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2567 Form
 A written plan of correction must be submitted to
KDHE within 10 calendar days following receipt of
the 2567.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Plan of Correction
 Corrective action taken for each individual
affected by the deficient practice, including any
system changes made.
 The position of the person who will monitor the
corrective actions and the frequency of the
monitoring.
 Dates each corrective action will be completed.
 The administrator or appropriate individual sign
and date the 2567 returned to KDHE within 10
days.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Plan of Correction
 The POC must meet the approval of
KDHE or in some cases CMS RO for it
to be acceptable.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
TOP “10” Hospital Citations
 Time frame 10/1/10 – 9/30/11
1. Tag A-0749 Infection Control Officer Responsibilities
2. Tag A-0700 Physical Environment
3. Tag A-0043 Governing Body
4. Tag A-0450 Medical Record Services
5. Tag A-0263 & A-0267 QAPI
6. Tag A-0083 Contracted Services
7. Tag A-0118, A-0132, A-0145 Patient Rights
8. Tag A-0154 Use of Restraints
9. Tag A-0396 Nursing Care Plan
10.Tag A-0490 Pharmacy Services
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0749 Infection Control Officer
Responsibilities
Arial
Must investigate, report and develop
an action plan as identified in the
hospital’s Infection Control Plan.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0700 Physical Environment

clud
Citations include a variety of
things from mold, LSC violations
which endanger patient and staff.
Areas and items in the hospital
that are not clean.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0043 Governing Body
Contracted services were not
included in QAPI, lack of oversight
with QA, failed to ensure staff
develop and implemented
effective Infection Control (IC)
practices. Failed to monitor
restraint policies and usage.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0450 Medical Record
Services
STD……sign, date and
time all entries by all
providers.
Secure storage of
medical records.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0263 & A-0267 QAPI



Restraint usage, contracted services
Medical records and care issues identified
during survey.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A0083 Contracted Services
All contracted services MUST be
monitored, included in QAPI,
have evidence of oversight from
the hospital to ensure all
contracted staff follow hospital
policies and training.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0118, A-0132, A-0145 Patient
Rights
Establish and follow a process for
prompt resolution of patient
grievances and MUST inform each
patient whom to contact .
Advanced Directive information.
Free from all forms of abuse or
harassment.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0154 Use of Restraints
Restraint or seclusion MAY only
be imposed to ensure the
immediate physical safety of the
patient and MUST be
discontinued at the earliest
possible time. All locations, all
patients not diagnosis driven but
based on individual
assessment.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0396 Nursing Care
Plan
Care plans individualized for restraint or
seclusion. NO standing orders for restraints.
Care Plans current for each patient based on
ongoing assessments.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
A-0490 Pharmacy
Services
Limit access to the pharmacy.
Secure storage of drugs and
biologicals in ALL areas of the
hospital. Crash carts, OR all
outpatient settings must meet
the regulations.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
TOP “10” CAH Citations
10/1/10 – 9/30/11
2012
1.
C-0307 Records Systems (STDs)
2.
C-0272, C-0276, C-0278 Patient Care Policies
3.
C-0334 Periodic Evaluation (Group of Professionals)
4.
C-0225 Maintenance
5.
C-0366 - C-0372 Swing Bed Patient Rights
6.
C-2400 & C-2407 EMTALA Stabilizing Treatment
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Top “10” CAH Citations cont .
7. C-0298 Nursing Services
8. C-0320 Surgical Services
9. C-0302 Records Systems
10. C-0241 Governing Body
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0307 STDs
ALL entries in the
medical record must
be timed, dated and
authenticated-to
identify the author.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0272, C-0276, C-0278
Patient Care Policies
Surveyors will review meeting minutes to
determine professional group composition and
ascertain the extent of the groups interaction.
Pharmaceutical services MUST be in accordance
with accepted professional standards for the rules
for storage, handling, management of outdated
drugs and biologicals, and dispensations and
administration of drugs and biologicals.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0272, C-0276, C-0278 Patient
Care Policies
Policies and implementation of a system for
identifying, reporting, investigating, and
controlling infections and communicable
diseases of patients and staff.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0334 Periodic Evaluation
(Group of Professionals)
Evidence the CAH’s health
care policies are evaluated,
reviewed and or revised as
part of the annual program
evaluation by the Group of
Professionals
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0225 Maintenance
Clean and orderly-means an uncluttered
physical environment where patients and
staff can function safely. No evidence of
peeling paint, floor obstructions, visible
water leaks, equipment and supplies are
stored.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0366 - C-0372
Swing Bed Patient Rights
Swing beds have numerous rights in ADDITION to all the
hospital rights. Ones frequently cited includeparticipates in planning care and treatment or changes in
care and treatment; married couples and rights about
work.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-2400 & C-2407 EMTALA
Stabilizing Treatment
C-2400
Must provide an appropriate MSE
Must provide stabilizing treatment
Must provide an appropriate transfer if
needed
No delay in exam or treatment
Must obtain a written informed refusal of
treatment
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-2400 & C-2407 EMTALA
Stabilizing Treatment
C-2407
Necessary stabilizing treatment for Emergency Medical
Conditions
42CFR 489.24(b) defines stabilized to mean:
“. . That no material deterioration of the condition is likely, within
reasonable medical probability, to result from or occur during the
transfer of the individual from a facility, or with respect to an
“emergency medical condition” as defined in this section under
paragraph (2) of that definition, that a woman has delivered the
child and the placenta.”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
What is an "emergency medical
condition"?
"A medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical attention
could reasonably be expected to result in -placing the health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy,
serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part, or
"With respect to a pregnant woman who is having contractions -that there is inadequate time to effect a safe transfer to another hospital before
delivery, or
that the transfer may pose a threat to the health or safety of the woman or her
unborn child."
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0298 Nursing
Services
Nursing care plans should be kept current. Care
plan starts upon admission and includes patient
care in the CAH;
as well as discharge to meet post-CAH needs.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0320 Surgical Services
COP – Surgical Procedures MUST be performed in
a safe manner by qualified practitioners who are
privileged by the governing body. Applies to
any degree of surgical services. The scope of
Surgical Services MUST be defined in writing and
approved by the medical staff.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0302 Records
Systems
Medical records must be legible, complete,
accurately documented, readily accessible,
and systematically organized.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
C-0241 Governing Body
Standard for GB determining, implementing and
monitoring polices governing the CAH’s total
operation for ensuring policies are administered
to provide quality health care in a safe environment.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
What Should Be Done
Stay Informed!
 Attend industry association meetings and education
seminars
 Read relevant Journal articles
 Ask questions of your vendors and require
documentation
 Don’t accept the status quo!
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
HAI Policy Toolkit - CDC
 The Centers for Disease Control and Prevention
(CDC) and the Association of State and Territorial
Health Officials (ASTHO)
have released a new companion report to last
year’s HAI Policy Toolkit.
 To learn more about tools to enhance state HAI
prevention programs, visit:
http://www.cdc.gov/HAI/prevent/astho-policytoolkit.html
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Infection Control Practices
 Adhere to EVIDENCED BASED PRACTICES
 Progress toward elimination of HAI
 Encourage participation from all team players
(housekeepers, dietary aides, lab techs,
maintenance staff, visitors and family members, etc).
Commend staff for taking the extra steps to protect
patients and themselves.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Personnel-Related Activities
 Training in methods to prevent exposure to and
transmission of infections
- New Staff (all contracted staff are included)
- Regular Updates
Evaluating staff immunization status, per guidelines
selected or State law
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Personnel
 Kansas State Law
- 28-34-8a(f) Personnel health requirements. Upon
employment, all hospital personnel shall have a
medical examination which shall consist of
examinations appropriate to the duties of the
employee, including a chest X-ray or TB skin test.
Subsequent medical exams or health assessments
given periodically in accordance with hospital
policies.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Personnel continued . . . .
 Kansas State Law
 -28-34-8a(f)
 Each hospital shall develop policies and procedures
for control of communicable diseases, including
maintenance of immunization histories and the
provision of educational materials for patient care
staff.
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Helpful Resources
 Information Headquarters
www.Kdheks.gov/bhfr/index.
html
 www.cms.hhs.gov/
Centers for Medicare and
Medicaid Services
Our Vision is "healthy Kansans living in safe and sustainable environments“, The
state belongs to all of us-"Kansas Don't Spoil It"
Resources
 Disinfection and Sterilization
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disfecti
on_Nov_2008.pdf
• Environmental Cleaning
http://www.cdc.gov/ncidod/dhqp/gl_environinfection.ht
ml
• Hand Hygiene
http://www.cdc.gov/ncidod/dhqp/gl_handhygiene.html
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
Resources
 Isolation Precautions
http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
• Injection Safety
http://www.cdc.gov/ncidod/dhqp/injectionsaaafety.
html
• Glucometers
http://www.cdc.gov/hepatitis/Populations/Glucose
Monitoring.htm#section1
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
THANK YOU!
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
www.kdheks.gov
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”
KDHE
 Anita Hodge, State Survey Manager
[email protected]
 Liza Ben Vaughn, Quality Improvement
Coordinator [email protected]
2012
Our vision is 'healthy Kansans living in safe and sustainable environment'.
The state belongs to all of us - "Kansas Don't Spoil It”