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Fletcher Allen Health Care Burlington, VT Is a CMS Survey in Your Future? Dawn LeBaron, Vice President for Hospital Services Jack Conry, Director of Security, Safety, and Parking Lindsay Harbour, Safety Specialist. Is a CMS Survey in Your Future?. Fletcher Allen Health Care

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Fletcher Allen Health Care

Burlington, VT

Is a CMS Survey in Your Future?

Dawn LeBaron, Vice President for Hospital Services

Jack Conry, Director of Security, Safety, and Parking

Lindsay Harbour, Safety Specialist

is a cms survey in your future
Is a CMS Survey in Your Future?

Fletcher Allen Health Care

Three Main Campuses:

  • Medical Center Campus
  • Fanny Allen Campus
  • University Health Center (UHC) Campus
  • 45+ Satellite Campuses
is a cms survey in your future3
Is a CMS Survey in Your Future?

Medical Center Campus

  • Largest Campus – hospital occupancy
  • Facility = 1.5 million SF
  • Surface Parking & Grounds = 1 million SF
  • Two Garages = 585,000 SF
is a cms survey in your future4
Is a CMS Survey in Your Future?

Fanny Allen Campus

  • 2nd Largest Campus – hospital occupancy
  • Facility = 118,000 SF
  • Surface Parking & Grounds = 948,000 SF
is a cms survey in your future5
Is a CMS Survey in Your Future?

University Health Center Campus

  • Physician Offices – business occupancy
  • Facility = 250,000 SF
  • Surface Parking & Grounds = 273,000 SF
is a cms survey in your future6
Is a CMS Survey in Your Future?

Serving a population of one million:

  • Level 1 Trauma Center
  • 562 licensed beds, 458 staffed
  • 2,183 births
  • 50,419 inpatient and outpatient admissions
  • 60,356 emergency department visits
  • 1,108,682 physician encounters
is a cms survey in your future7
Is a CMS Survey in Your Future?
  • 2.4 million lab tests
  • 1.44 million meals served
  • 6,700 employees (including per diem & part-time)
  • 450 UVM Medical Group physicians (770 total medical staff)
  • 280 house staff (physicians in specialty training); 15 residency programs
  • $8.7 million in charity care
is a cms survey in your future8
Is a CMS Survey in Your Future?

Today’s Discussion:

  • Health care regulatory agencies
  • CMS overview
  • What lead to a full CMS survey at Fletcher Allen
  • The CMS Life Safety tour and findings
  • Life Safety hot spots
  • EOC hot spots
  • Fletcher Allen’s full Joint Commission Survey
is a cms survey in your future9
Is a CMS Survey in Your Future?

Regulatory Agencies

Fletcher Allen is reviewed by 30+ agencies.

Primary agencies are:

  • Joint Commission
  • Centers for Medicare /Medicaid Services ( CMS)
  • State / Local Licensing Agencies
is a cms survey in your future10
Is a CMS Survey in Your Future?

Fletcher Allen Health Care

FY11 (3 quarters)

10/1/10 – 6/30/11

27 Regulatory

“Site Visits”

is a cms survey in your future12
Is a CMS Survey in Your Future?

Fletcher Allen Regulatory Site Visits:

  • Division of Licensing and Protection/ CMS (13)
    • Complaint Allegation Surveys (10)
    • Full Survey (1)
    • Durable Medical Equipment (2)
is a cms survey in your future13
Is a CMS Survey in Your Future?
  • Other agencies (14)
      • Joint Commission (2)
        • 1 in response to CMS findings
        • 1 Stroke Certification
      • Environmental Protection Agency (1)
      • Nuclear Regulatory Commission (1)
      • FDA (3)
      • Department of Mental Health (1)
      • American College of Surgeons (1)
      • VOSHA (2)
      • American Association of Bloodbanks (1)
      • Homeland Security (1)
      • Division of Alcohol and Drug Abuse (1)
is a cms survey in your future14
Is a CMS Survey in Your Future?

Regulatory Costs:

  • Year to Date = $177, 000
    • Includes: Escort, coordination of surveys, survey interview sessions, development of POC and writing of plans.
    • Other costs:
      • TJC follow up survey = $5,000
  • Total = $182,000
is a cms survey in your future16
Is a CMS Survey in Your Future?

Who is CMS?

  • A branch of the U.S. Department of Health and Human Services.
  • A federal agency that:
    • administers the Medicare program and
    • monitors the Medicaid programs offered by each state.
  • The United States is set up into sections of CMS boards
  • Vermont reports to the Boston section.
is a cms survey in your future17
Is a CMS Survey in Your Future?

What Triggers a CMS Survey?

  • Complaint Allegation
  • Self Report – Obligated to report:
    • Allegations of abuse
    • “Critical Incidents” in Mental Health (VT)
  • Validation Survey
    • Within 60 days of TJC survey
    • A quality check on TJC
is a cms survey in your future18
Is a CMS Survey in Your Future?

CMS Survey Results:

“Statement of Deficiencies”

  • No Findings
  • Standard Level Finding
  • Conditional Level Finding
  • Immediate Jeopardy
is a cms survey in your future19
Is a CMS Survey in Your Future?

Standard Level Finding:

  • Typically do not require a response
  • However if an organization is found to be out of compliance at the condition level from a previous finding – they require response/ follow up survey

Condition Level Finding:

  • Requires a formal organizational response.
  • It triggers:
    • A follow-up “focused survey” and
    • A full CMS survey
is a cms survey in your future20
Is a CMS Survey in Your Future?

Immediate Jeopardy:

  • Defined by CMS as:

“A crisis situation in which the health and safety of individuals are at risk (see §SOM 3010).”

  • It carries a threat of termination procedures if “conditions” are not resolved within 23 days.
  • The hospital can lose Medicare funding.
  • Requires a formal response by organization
  • It triggers:
    • A follow-up “focused survey” and
    • A CMS “full survey” and
    • A follow-up “Joint Commission” survey
is a cms survey in your future21
Is a CMS Survey in your Future?

So, what happened at Fletcher Allen?

is a cms survey in your future22
Monday, December 20, 2010

3 surveyors arrive unannounced for a 3 day survey

4 complaint allegations, 1 involving the Cardiac Cath Lab

Cath Lab complaint allegation involved patient complaint about consent (only physician can treat).

No EOC involvement at this point

Tuesday, January 11, 2011

2 surveyors arrive unannounced for a 2 day survey

Follow-up from the 12/20/10 survey

Focus of survey is Cardiac Cath Lab and EP (Electrophysiology) Service

Tuesday, January 11, 2011

End of the day tour of Cath Lab.

Debris and brown stains on the floor.

Cleaning process described.

Wednesday, January 12, 2011

7:30 am continuation of the Cath Lab tour from 1/11/11.

Room Cleaning – Trash emptied, but debris and stains still on floor.

Patient scheduled for 8:00 am

Is a CMS Survey in Your Future?
is a cms survey in your future23
Is a CMS Survey in Your Future?

Cath Lab Survey Results-1/13/11

Four “Condition Level” Findings:

      • Governance
      • Medical Staff
      • Infection Control
      • Patient Rights & Ethics
  • Plan for Correction (POC) due 2/8/11
  • Sparked a full unannounced CMS survey
is a cms survey in your future24
Is a CMS Survey in Your Future?

Statement of Deficiencies

&

Plan of Correction

  • Corrective action the hospital will being implementing
  • Plan for educating
  • Plan for monitoring

CMS Form 2567

is a cms survey in your future25
Is a CMS Survey in Your Future?

Wednesday, January 19, 2011

  • 3 surveyors arrive unannounced for a 3 day survey (complaint allegation)
  • Survey focused on the Emergency Department and EMTALA
  • EMTALA

Emergency Medical Treatment and Labor Act

      • Perform medical screening exam
      • Treat/ stabilize
is a cms survey in your future26
Is a CMS Survey in Your Future?

EMTALA Survey Results

Immediate Jeopardy!

  • Posting of Signs (489.20.q)
  • Medical Screening Exam (489.24.c)
  • Stabilizing Treatment (489.24.c.1-3)
  • Plan of Correction
  • Sparked a CMS focused survey
  • Sparked another CMS full survey!
  • Sparked a JC follow-up survey
is a cms survey in your future27
Tuesday, March 8, 2011

Full CMS Survey:

13 surveyors arrive unannounced for a 4 day full CMS full survey (includes 2 Life Safety Surveyors)

Originally sparked by December 2010 Cath Lab complaint allegation.

Full Survey offers CMS surveyors the opportunity to look at all self reports.

Thursday, March 10, 2011

1 TJC surveyor arrives unannounced for a 1 day survey

A follow-up survey to the EMTALA finding.

Is a CMS Survey in Your Future?
is a cms survey in your future28
Surveyor 1

Surgical Services

Medical Records

Infection Control

Nursing: SICU

Surveyor 2

Discharge Planning

UR

Emergency Services

Nursing: OB, NICU, Pedi ICU

Surveyor 3 & 4

Rehab: Cost reporting

Rehab Services

Outpatient Services

Nursing: McClure 6

Surveyor 5

Psych Unit (with Surveyor 9)

Psych Unit Complaints (2)

Organ & Tissue Procurement

Surveyor 6

Compliance with local, state, federal laws

Governing Body

Emergency Services (with Surveyor 2)

Medical Staff

Nursing: Administrative Review

Surveyor 7

Pharmacy with 1 complaint

Radiology

Nuclear

Nursing: MICU, Baird 6

Surveyor 8

Laboratory Services

Physical Environment

Respiratory Services

Nursing: Shepardson 6, Baird 4

Surveyor 9

Psych Unit (with surveyor 5)

Shepardson 3, Shepardson 6

Surveyor 10 & 11

Anesthesia Services

Patient Rights

QAPI

Surveyor 12 (Life Safety)

½ of Medical Center Campus

Fanny Allen Campus

4 Satellite Campuses

Surveyor 13 (Life Safety)

½ of Medical Center Campus

UHC Campus

2 Satellite Campuses

Is a CMS Survey in Your Future?
is a cms survey in your future29
Is a CMS Survey in Your Future?

Fletcher Allen’s Survey Plan:

  • CMS survey team assigned a large conference room as their home base.
  • Each CMS surveyor assigned a Fletcher Allen point of contact and escort.
  • Fletcher Allen home base established in close proximity to the CMS home base.
is a cms survey in your future30
Is a CMS Survey in Your Future?

CMS Full Survey:

An opportunity for surveyors to review all

“self reports”

  • Plastic wrist restraints
  • Pepper spray
  • Immediate Jeopardy!
is a cms survey in your future31
Full Survey “Hot Spots”

Infection Prevention

Dressing changes

Sterile technique

Toys in waiting rooms

Cleaning of glucometers

Medication Security

Med carts locked

Handling of meds

EOC

Refrigerator logs

Hallway clutter

Alarm response

Patient Confidentiality

Use of WOW’s

Resuscitation Carts

Checked per written policy

Medical Records

Were orders carried out

Documentation of action taken

Pain Assessment

Multidisciplinary assessment

Documenting assessments

Completion of care plans

Assessment per policy

Restraints

Written order

Documentation according to policy

Quality & Safety

Explain PI process and projects

Is a CMS Survey in Your Future?
is a cms survey in your future32
Is a CMS Survey in Your Future?

Environment of Care Issues:

Remember: 13 surveyors look at all of the EOC

  • Goose neck faucets on Psychiatric Unit
  • Shower controls on Psychiatric Unit
  • Loose handrails in hallways
  • Emergency Lighting in “procedure rooms”
  • Security of the Operating Room
  • Access signs for the Operating room
  • Refrigerator temperature logs in Dietary
  • Temperature and humidity logs in CSR
  • Cracked vinyl (tables and mattresses)
is a cms survey in your future36
Is a CMS Survey in Your Future?

CMS Life Safety Tour:

  • Two Life Safety surveyors – Both state fire marshals
  • Two Fletcher Allen escorts
  • Four Facilities Management/Safety escorts
  • Survey locations divided in two
  • Main hospital campus and two satellites
  • Fanny Allen campus and four satellites
is a cms survey in your future37
Life Safety ‘Hot Spots”

Fire stopping

Door closers

Fire doors close and latch

Stairwell storage

Door jambs with no doors

Delayed egress signs

Emergency lighting tests

Obstructed pull stations

GFCI outlets – 6’ from water

Extension cords

Smoke Detectors

spacing

36” from air supply

Power cord daisy chains

Sprinkler heads in storage closets

Storage within 18” of sprinkler

Electrical Panels

Labeling (including spares)

Open spaces

Broken latches

Is a CMS Survey in Your Future?
is a cms survey in your future38
Is a CMS Survey in Your Future?

CMS Home Base

  • 13 Surveyor talking among themselves
  • Life Safety surveyor to Ambulatory Site surveyor:

“Did you know that they are doing surgery at their Plastic Surgery site without emergency lighting?”

  • Immediate Jeopardy!
is a cms survey in your future39
Is a CMS Survey in Your Future?

90 Life Safety Findings:

  • GFCI outlets (22)
  • Smoke detector/air handler (8)
  • Power strips interconnected (7)
  • Electrical panel labeling (5)
  • Smoke detector spacing (4)
is a cms survey in your future40
Is a CMS Survey in Your Future?

90 Life Safety Findings (continued):

  • Penetrations/fire stopping (4)
  • Sprinkler head needed (4)
  • Door self closer needed (4)
  • Fire door does not close and latch (3)
is a cms survey in your future41
Is a CMS Survey in Your Future?

90 Life Safety Findings (continued):

  • Electrical panel, open spaces (3)
  • Extension cords (3)
  • Electrical panel, broken latch (2)
  • Stairwell storage (2)
  • Kitchen hoods needed for frying (3)
is a cms survey in your future42
Is a CMS Survey in Your Future?

90 Life Safety Findings (continued):

  • Emergency light malfunction (1)
  • Emergency light needed in generator room (1)
  • Pull station blocked (1)
  • Store room door removed (1)
  • Pre-action valve in stairwell (1)
  • Dirty smoke detector (1)
  • Storage 18” of sprinkler (1)
  • Strobe light blocked (1)
  • Outlet cover broken (1)
  • Cabinet on power cord (1)
is a cms survey in your future43
Is a CMS Survey in Your Future?

90 Life Safety Findings (continued):

  • Suspended light blocking sprinkler (1)
  • Breaker lock missing (1)
  • Delayed egress sign (1)
  • Delayed egress not approved (1)
  • Fire proofing spray on metal beam (1)
  • Cooking staff knowledge of fire suppression system (1)
  • Wires above ceiling not supported (1)
  • Emergency light malfunction (1)
is a cms survey in your future45
Is a CMS Survey in Your Future?

CMS Lessons Learned:

  • It doesn’t matter how old the building. It is still held to current standards.
  • Know your “procedure rooms”.
  • Alert others in advance about the route of the tour.
  • In most cases, arguing gains nothing.
  • Surveyors take pictures and share with other surveyors.
joint commission survey
Joint Commission Survey

Joint Commission Full Survey

  • Monday, August 15, 2011
  • Seven (7) surveyors including one (1) Life Safety Engineer
  • Full five (5) day survey
  • Two (2) day Life Safety survey
joint commission survey47
Joint Commission Survey

Environment of Care & Emergency Management Session:

Documents provided upon arrival:

  • EOC Committee Meeting Minutes
  • Management Plans
  • Emergency Operation Plan
  • Annual Program Evaluations
  • Hazard Vulnerability Analysis
  • Inventory of Assets and Resources
joint commission survey48
Joint Commission Survey

EOC & EM Issues:

  • EM.02.02.13 (EP2) – Not documented in the medical staff bylaws who may grant disaster privileges.
  • EC.02.06.01 (EP1) – Clean utility room with storage stacked too high to the ceiling. Hazardous to staff.
  • EC.02.02.01 (EP5) – Unlocked soiled utility room with hazardous items accessible to children (used AA batteries and bottles of cleaning solution).
  • IC.02.02.01 (EP3) – Expired surgical gloves, biogel gloves, and tampons.
joint commission survey49
Joint Commission Survey
  • LD.04.01.01 (EP3) – Exposed pipes under sinks in handicapped bathrooms (ADA violation).
joint commission survey50
Joint Commission Survey

Life Safety Survey:

Day One:

Documentation Review

Day Two:

Building Tour

joint commission survey51
Joint Commission Survey

TJC Life Safety Survey:

Fletcher Allen Issues

  • EC.02.03.05 (EP6) – Documentation that electric fire pumps were run weekly for 10 minutes.
  • EC.02.03.05 (EP10) – No documentation for the quarterly inspection of water supply connections.
  • EC.02.03.05 (EP19) – No inventory of fans to ensure that all air handling units shut down properly.
  • EC.02.05.07 (EP4) – 42 days between generator tests one month of the year.
  • EC.02.05.07 (EP6) – 42 days between automatic transfer switch test one month of the year.
joint commission survey52
Joint Commission Survey

TJC Life Safety Survey:

Fletcher Allen Issues (continued)

  • EC.02.05.07 (EP7) – No documentation that emergency generator was operated for 4 continuous hours at least every 36 months.
  • EC.02.05.07 (EP8) – No documentation that emergency generator was operated at 30% nameplate rating for 4 continuous hours at least every 36 months.
  • LS.01.02.01 (EP3) – Written ILSM risk assessments not completed for each SOC Plan for Improvement.
  • LS.02.01.10 (EP5) – Fire door did not close and latch with vertical gap greater than 1/8”.
joint commission survey53
Joint Commission Survey

TJC Life Safety Survey:|Issues continued:

  • LS.02.01.01 (EP6) – Fire door with kick plate larger than 16”.
  • LS.02.01.20 (EP13) – Hallway clutter (medication carts and soiled linen hampers).
  • LS.02.01.35 (EP4) – Conduit and HVAC duct resting on sprinkler pipes.
joint commission survey54
Joint Commission Survey

Joint Commission Lessons Learned:

  • Documentation – Get it to the surveyors early.
  • Binders – Develop binders for documents the surveys are likely to request.
  • Have a plan for replacing organizational “experts”, if they are “on vacation”.
is a cms survey in your future56
Is a CMS Survey in Your Future?

Fletcher Allen Contact Information:

Dawn LeBaron, Vice President for Hospital Services

Lindsay Harbour, Safety Specialist

Jack Conry, Director of Security, Safety, and Parking

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