Download Critical Access Hospital Survey Process

Center for Medicare and
Medicaid Services and
Joint Commission Hospital
Survey Process
2009
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Complaint Investigations – General
Complaint Investigations - EMTALA
Full Survey
Medicare Recertification Survey - for non-accredited,
every 3-5 years (Deemed Status)
Validation Survey - authorized by CMS 60 days
following the Accrediting Organization survey
Surveys based on Conditions of Participation found at
CFR 42.485 (CAH) and CFR 42.482 (Hospitals)
All surveys are unannounced
www.cms.hhs.gov/manuals/downloads/som107ap_w_cah.pdf
www.cms.hhs.gov/manuals/downloads/som107ap_a_hosptials.pdf
Surveys Types
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All inpatients with name, age, diagnoses, admission date, room
number, and attending physician
25 most frequent diagnoses & most frequent surgical procedures
Departments with manager or director’s name
Licensed employees and a copy of the nursing staffing policy
Credentialed medical staff and those with surgical privileges
Contracted services
Location of all patient care and treatment areas
Names/addresses of off-site locations operating under same
provider number
Facility’s organizational chart
Infection Control Plan
Medical Staff bylaws and rules and regulations
Meeting Minutes of the Governing Body and Medical Staff
And any other information needed to complete the Center for
Medicare and Medicaid Services (CMS) Hospital/CAH Medicare
Database Worksheet
Documents requested at
Entrance Conference
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They hate cleaning! They make
the beds, they do the floors and
six months later you have to
start all over again.
Is This How Your Patients Feel
About Your Hospital?
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Tour and inspect all patient care and treatment
areas, pharmacy, dietary, medical records, off
site areas, etc.
Conduct patient and staff interviews
Review:
* At least 20-30 inpatient records
* Outpatient, emergency department records
depending on hospital type
* Policies and procedures
* Quality Assurance/Performance Improvement
data
* Governing Body, Medical Staff meeting
minutes
* Infection Control Plan, data and minutes
The Survey Process
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Dietary Services discussed
with patients
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Compliance with Hospital
Requirements and
applicable laws
Status and Location
Agreements
Emergency Services
# of Beds & Length of Stay
Physical Plant and
Environment
Organizational Structure
Staffing and Staff
Responsibilities
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Provision of Services
Clinical Records
Surgical Services
Periodic Evaluation &
Quality Assurance
Review
Organ, Tissue and Eye
Procurement
Special Requirements for
CAH Providers of LongTerm Care Services
(Swing beds)
Conditions of Participation
for CAH
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Compliance with Federal,
State and Local Laws
Governing Body
Patients’ Rights
Quality Assessment and
Performance Improvement
Medical Staff
Nursing Services
Medical Records
Pharmaceutical Services
Radiological Services
Laboratory Services
Food and Dietetic Services
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Utilization Review
Physical Environment
Infection Control
Discharge Planning
Organ, tissue and Eye
Procurement
Surgical Services
Anesthesia Services
Nuclear Medicine
Outpatient Services
Emergency Services
Rehabilitation Services
Respiratory Services
Conditions of Participation for
Hospitals
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All hospital –type beds located in the CAH will be
counted to establish the 25 bed limit with the
exception of the following:
Examination or procedure tables
Stretchers
Operating room tables and recovery room
stretchers
Beds in obstetric delivery
Newborn bassinets and isolettes
Stretchers in emergency departments
Beds in Medicare certified distinct part
rehabilitation or psychiatric units
CFR 485.620(a)
Number of Beds
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Observation services are defined as services
furnished by a CAH to evaluate an outpatient’s
condition to determine the need for discharge or
possible admission as an inpatient. (The maximum
stay is 48 hours, medically necessary with a
physician’s order)
 Observation stays fall under Part B and require
coinsurance. CAH must give written notice of noncoverage to the beneficiary prior to stay.
 Beds used by patients on observation status, that
conform to the hospital-type beds, will be counted as
part of the maximum bed count.
 Outpatient observation patient should not be
commingled with inpatients
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Bed count
continued …..
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Medicare Payments Updated
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Condition at 485.641
Periodic Evaluation and
Quality Assurance Review
Most common COP
out of compliance for the
Health survey for a CAH
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The CAH must ensure that specific periodic evaluation
and quality assurance review requirements are met.
 Annual Program Evaluation
 Periodic Evaluation:
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Services
Patient Records
Policies
Changes generated
 Quality Assurance (QA) Review:
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Quality of Patient Care
Medications & Infections
MD/DO Oversight
Contracted MD/DO Oversight
Performance Improvement
Documentation
CFR 485.641
Periodic Evaluation & QA Review
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Navigating A Hospital
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The evaluation is done at least once a year. Includes:
 Review of the utilization of CAH services
 Review of representative sample of clinical records (not less than
10% of active and closed, inpatient and outpatient records)
 Review of health care policies
 Review of data and actions taken
 Effectiveness of Quality Assurance program to include:
 Review of all patient care services, medication therapy and
nosocomial infections
 MD/DO evaluate care provided by NP, CNS or PA
 Quality review by another hospital that is a member of the
network, QIO or equivalent or other qualified entity identified
in the State rural health care plan of diagnoses and treatment
at the CAH
 Consideration of the findings/recommendations of the QIO
and corrective action taken if necessary
 Appropriate remedial action taken by CAH to address
deficiencies found in QA program
Annual Program Evaluation
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Patient Rights
 Quality Assessment & Performance
Improvement (QAPI)
 Nursing Service
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Most common COPs out for the
Health Survey of a Hospital
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If deficiencies are found, the facility will
receive CMS form 2567 within 10 working
days
 The facility must return the 2567 with a
plan of correction (PoC) within 10
calendar days
 Findings are sent to Center for Medicare
and Medicaid Services (CMS)
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Survey Completion
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Planned action to correct the deficiency and
expected completion date
Be specific and realistic in stating exactly how
the deficiency was or will be corrected
Monitoring procedures to ensure that the plan of
correction is effective
Title of the person responsible for
implementation of the plan of correction
The PoC must be signed and dated by the
administrator or other authorized official
PoC Requirements
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For hospitals that use Joint Commission accreditation
for deemed status purposes:
A physician or other authorized licensed
independent practitioner primarily responsible for
the patient’s ongoing care orders the use of
restraint or seclusion in accordance with hospital
policy and law and regulation.
Note: The definition of physician is the same as that used by
CMS (refer to the Glossary)
2009 Standard: PC.03.05.05
2009 EP: 1
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For hospitals that use Joint Commission accreditation
for deemed status purposes:
The attending physician is consulted as soon as
possible, in accordance with hospital policy, if he
or she did not order the restraint or seclusion.
Note: The definition of physician is the same as that used by
CMS (refer to the Glossary)
2009 Standard: PC.03.05.05
2009 EP: 3
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For hospitals that use Joint Commission accreditation
for deemed status purposes:
Unless state law is more restrictive, every 24 hours, a
physician or other authorized licensed independent
practitioner primarily responsible for the patient’s
ongoing care sees and evaluates the patient before
writing a new order for restraint or seclusion used for
the management of violent or self-destructive behavior
that jeopardizes the immediate physical safety of the
patient, staff, or others in accordance with hospital
policy and law and regulation.
Note: The definition of physician is the same as that used
by CMS (refer to the Glossary)
2009 Standard: PC.03.05.05
2009 EP: 5
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Restraint Policy?
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For hospitals that use Joint Commission
accreditation for deemed status purposes:
Orders for restraint used to protect the physical
safety of the nonviolent or non–selfdestructive patient are renewed in accordance
with hospital policy.
2009 Standard: PC.03.05.05
2009 EP: 6
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For hospitals that use Joint Commission
accreditation for deemed status purposes:
Physicians or other licensed independent
practitioners or staff who have been trained in
accordance with 42 CFR 482.13(f) monitor the
condition of patients in restraint or seclusion.
(See also PC.03.05.17, EP 3)
Note: The definition of physician is the same as that used
by CMS (refer to the Glossary)
2009 Standard: PC.03.05.07
2009 EP: 1
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Time frames for assessing and monitoring patients in restraint or
seclusion
Note 1: The definition of restraint per 42 CFR 482.13(e)(1)(i)(A–C) is as
follows: 42 CFR 482.13(e)(1) Definitions. (i) A restraint is— (A) Any
manual method, physical or mechanical device, material, or
equipment that immobilizes or reduces the ability of a patient to move
his or her arms, legs, body, or head freely; or 42 CFR
482.13(e)(1)(i)(B) (A restraint is— ) A drug or medication when it is
used as a restriction to manage the patient's behavior or restrict the
patient's freedom of movement and is not a standard treatment or
dosage for the patient's condition. 42 CFR 482.13(e)(1)(i)(C) A
restraint does not include devices, such as orthopedically prescribed
devices, surgical dressings or bandages, protective helmets, or other
methods that involve the physical holding of a patient for the purpose
of conducting routine physical examinations or tests, or to protect the
patient from falling out of bed, or to permit the patient to participate
in activities without the risk of physical harm (does not include
physical escort).
2009 Standard: PC.03.05.09
2009 EP: 1
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Time frames for assessing and monitoring patients in restraint
or seclusion
Note 2: The definition of seclusion per 42 CFR 482.13(e)(1)(ii) is
as follows:
Seclusion is the involuntary confinement of a patient alone in a
room or area from which the patient is physically prevented
from leaving. Seclusion may be used only for the management
of violent or self-destructive behavior.
Note 3: The definition of physician is the same as that used by
CMS (refer to Glossary).
2009 Standard: PC.03.05.09
2009 EP: 1 continued….
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For hospitals that use Joint Commission
accreditation for deemed status purposes:
Physicians and other licensed independent
practitioners authorized to order restraint or
seclusion (through hospital policy in accordance
with law and regulation) have a working
knowledge of the hospital policy regarding the
use of restraint and seclusion.
2009 Standard:
PC.03.05.09 2009 EP: 2
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A physician or other licensed independent practitioner
responsible for the care of the patient evaluates the
patient in-person within one hour of the initiation of
restraint or seclusion used for the management of
violent or self-destructive behavior that jeopardizes
the physical safety of the patient, staff, or others.
A registered nurse or a physician assistant may conduct
the in-person evaluation within one hour of the
initiation of restraint or seclusion; this individual is
trained in accordance with the requirements in
PC.03.05.17, EP 3.
Note 1: States may have statute or regulation requirements
that are more restrictive than the requirements in this
element of performance.
2009 Standard: PC.03.05.11
2009 EP: 1
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For hospitals that use Joint Commission accreditation
for deemed status purposes:
When the in-person evaluation (performed within
one hour of the initiation of restraint or seclusion)
is done by a trained registered nurse or trained
physician assistant, he or she consults with the
attending physician or other licensed independent
practitioner responsible for the care of the patient
as soon as possible after the evaluation, as
determined by hospital policy.
2009 Standard: PC.03.05.11
2009 EP: 2
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The in-person evaluation, conducted within one hour of
the initiation of restraint or seclusion for the
management of violent or self-destructive behavior
that jeopardizes the physical safety of the patient,
staff, or others, includes the following:
◦ - An evaluation of the patient's immediate
situation
◦ - The patient's reaction to the intervention
◦ - The patient's medical and behavioral condition
◦ - The need to continue or terminate the restraint
or seclusion
2009 Standard: PC.03.05.11
2009 EP: 3
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Documentation of restraint and seclusion includes:
 Any in-person medical and behavioral evaluation used
to manage violent or self-destructive behavior
 Description of the patient’s behavior and the
intervention used
 Any alternatives or other less restrictive interventions
attempted
 Patient’s condition/symptom(s) that warranted use of
restraint and seclusion
 Patient’s response to the intervention(s), including the
rationale for continued use of the intervention
 Individual patient assessments and reassessments
 Intervals for monitoring revisions to the plan of care
2009 Standard: PC.03.05.15
2009 EP: 1
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Documentation of restraint and seclusion includes:
 Patient’s behavior and staff concerns regarding safety
risks to the patient, staff, and others that
necessitated the use of restraint and seclusion
 Injuries to the patient or death associated with the
use of restraint and seclusion
 Identity of the physician or other licensed
independent practitioner who ordered the restraint
and seclusion
 Orders for restraint and seclusion
 Notification of the use of restraint and seclusion to
the attending physician
2009 Standard: PC.03.05.15
2009 EP: 1 continued…
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Based on the population served, staff education, training,
and demonstrated knowledge focus on the following:
- Strategies to identify staff and patient behaviors,
events, and environmental factors that may trigger
circumstances that require restraint or seclusion
- Use of nonphysical intervention skills
- Methods for choosing the least restrictive intervention
based on an assessment of the patient’s medical or
behavioral status or condition
- Safe application and use of all types of restraint or
seclusion used in the hospital, including training in
how to recognize and respond to signs of physical
and psychological distress (for example, positional
asphyxia)
2009 Standard: PC.03.05.17
2009 EP: 3
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Based on the population served, staff education, training,
and demonstrated knowledge focus on the following:
- Clinical identification of specific behavioral changes that
indicate that restraint or seclusion is no longer necessary
- Monitoring the physical and psychological well-being of the
patient who is restrained or secluded, including, but not
limited to, respiratory and circulatory status, skin integrity,
vital signs, and any special requirements specified by
hospital policy associated with the in-person evaluation
conducted within one hour of initiation of restraint or
seclusion
- Use of first-aid techniques and certification in the use of
cardiopulmonary resuscitation, including required periodic
recertification
2009 Standard: PC.03.05.17
2009 EP: 3 continued…
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The deaths addressed in PC.03.05.19, EP 1 are
reported to the Centers for Medicare & Medicaid
Services (CMS) by telephone no later than the close
of the next business day following knowledge of the
patient’s death.
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The date and time that the patient's death was
reported is documented in the patient's medical
record.
2009 Standard:PC.03.05.19
2009 EP: 2
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For hospitals that use Joint Commission accreditation
for deemed status purposes:
Staff document in the patient’s medical record the date
and time the patient death was reported to the Centers
for Medicare & Medicaid Services
This requirement was removed since it was already
covered in existing elements of performance or was
addressed in The Joint Commission survey process
2008 Standard:PC.03.05.19
2008 EP: 3
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For hospitals that use Joint Commission accreditation for
deemed status purposes:
The hospital designates an individual to direct dietary
services and oversee its daily management, whether
the services are provided by the hospital or through a
contracted service.
This individual is a full-time employee who is qualified by
experience and training
This requirement was removed since it was already
covered in existing elements of performance or was
addressed in The Joint Commission survey process.
2008 Standard: HR.01.01.01
2008 EP: 25
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Oversee Dietary Services
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For hospitals that use Joint Commission accreditation for
deemed status purposes:
The hospital has a dietitian on a full-time, part-time, or
consultant basis.
This requirement was removed since it was already
covered in existing elements of performance or was
addressed in The Joint Commission survey process.
2008 Standard: HR.01.01.01
2008 EP: 26
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Utilization Review:
 NO CHANGES
Utilization Review Changes
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Utilization Review Starts Early
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Provides information on how well hospitals in
different areas care for their adult patients with
certain medical conditions.
◦ Debuted on March 31, 2005 – 10 Quality
Measures
◦ Currently features 26 Measures
◦ New enhancements include Hospital Surveys
and Volume and Payment Data
Hospital Compare Background
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Measures how often hospitals provide recommended
care to get the best results for adult patients.
Reporting Criteria:
• Voluntarily submitted by acute care and critical
access hospitals
• All payer types reported
Process of Care Measures:
• Eight (8) measures related to heart attack care
• Four (4) measures related to heart failure care
• Six (7) measures related to pneumonia care
• Five (5) measures related to surgical infection
prevention
Hospital Process of Care Measures
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Getting Best Results?
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Display of Process of Care Measures
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Display of Process of Care Measures
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Predicts patient deaths for any cause within 30 days of
hospital admission for heart attack or heart failure,
whether the patients die while in the hospital or after
discharge.
Reporting Criteria:
• Voluntarily submitted by acute care hospitals
• Original (fee-for-service) Medicare payer
Outcome Measures:
• One (1) measure related to 30-day heart attack
mortality
• One (1) measure related to 30-day heart failure
mortality
Hospital Outcome Measures
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Hospital Outcome Measures
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Standardized survey instrument for measuring patients’
perspectives of hospital care.
Reporting Criteria:
1.Voluntarily submitted by acute care and critical access
hospitals
2.All payer types reported
Sample of Questions:
1.How often did nurses communicate well with patients?
2.How often did patients receive help quickly from
hospital staff?
3.How often did staff explain about medicines before
giving them to patients?
4.How often was patients’ pain well controlled?
5.How often were patients room and bathrooms cleaned?
Hospital Consumer Assessment and
Healthcare Systems (HCAPHS) Survey
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Display of HCAPHS Survey
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Display of HCAPHS Survey
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The data represents Medicare inpatient
hospital payment information and the number of
patients treated (volume) for a limited set of
conditions and surgical procedures.
Reporting Criteria:
1. Submitted by acute care hospitals
2. Medicare billing information
Measures:
• Average Medicare Payment
• Number of Patients Treated
Medicare Payment and Volume Data
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Questions
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