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Hospital Regulatory Issues

Hospital Regulatory Issues. Bud Pate Director of West Coast Operations. Hospital Regulatory Considerations. State Department of Health / Licensing CMS Conditions of Participation Accreditation Rules. State DHS. The Bad News Regulations are incomplete, dated and inflexible The Good News

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Hospital Regulatory Issues

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  1. Hospital Regulatory Issues Bud PateDirector of West Coast Operations

  2. Hospital Regulatory Considerations • State Department of Health / Licensing • CMS Conditions of Participation • Accreditation Rules

  3. State DHS • The Bad News • Regulations are incomplete, dated and inflexible • The Good News • There’s a “get out of jail free” card: Title 22 sections 70741 and 70737

  4. 22 CCR 70741: Disaster and Mass Casualty Program • This section provides a mechanism for the planned and appropriate use of staff and space for the unusual situation • If appropriately written and implemented (with notification to DHS via 70737), the DMC / Emergency Preparedness plan allows the hospital to do what is necessary while maintaining continuous compliance with the regulations.

  5. Is Approval Necessary? • No, just notification. • 22 CCR 70737 • However, communication (and the approach to communication) should be excellent and ongoing • Refer to mass casualty program • Remember to notify CMS if: • Overflow into distinct part: e.g. SNF or Rehabilitation Unit. • Keep track of beginning and end

  6. Expectations for the Disaster and Mass Casualty Program • Best reference is JCAHO … post-Katrina update to standards • Incident Command • Define • Overflow locations • Separation of flow • Temporary / volunteer staffing

  7. JCAHO July 1, 200 • HR.1.35 Non-LIP Volunteers • MS.4.110 LIP Volunteer • EC.4.10 Drills

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