Critical Access Hospitals. CAH. Introductions. Background of program Reasons for mock surveys Planning for more than a year Background of participants Hospitals Mock Surveyors Background of presenter. www.kdheks.gov. KDHE Vision - Healthy Kansans living in Safe Sustainable Environments.
Background of participants
KDHE Vision - Healthy Kansans living in Safe Sustainable Environments
Understand the survey methods used by KDHE and CMS to survey CAHs
Understand the difference between a CoP and a standard regulation
Understand the content of the CAH CoPs including the use of interpretive guidelines & procedures in Appendix W
Be able to assist their CAH in meeting state and federal regulations & improving patient care.
Focus on actual & potential patient outcomes
Assess care & services provided including appropriateness of care.
Visit all care units, all campuses, outpatient areas, surgery, ED, X-ray & rehabilitation areas.
Observe actual care provided
Check QA - has it been incorporated into each department?
keeping up to date between times of credentialing
C195 CFR 485.616(b)
Agreements for Credentialing
(1) Participate in development, execution & periodic review of the policies
(2) Participate with physician in periodic review of patient records
*Standard C0271 CFR 485.635(a) Patient Care Policies
Services are furnished in accordance with appropriate written policies consistent with state laws
Must be well defined, but contracts not needed – evidence that Gov Body is responsible for services.
Revised as needed
QA – Gov Body assures services provided according to acceptable standards
C0291 CFR 485.635(c)(3)CAH maintains a list of all services furnished under arrangements or agreements with nature and scope of services.
Ensure adequate training , orientation, supervision of all nursing staff and non-CAH nursing staff and that their clinical activities are evaluated and know the P & Ps (a CAH-employed RN should conduct the supervision & evaluation of the clinical activities of non-CAH staff.)
Legible, complete, accurate, readily accessible, organized
Confidentiality of record information and provides safeguards against loss, destruction, or unauthorized use.
Standard C0331 CFR 485.641(a) Periodic evaluation – all services at least annually
C0332 - # of patients served & volume of services
C0333 - Review of active & closed records
C0334 - Health care policies – reviewed as part of QA program
C0335 – The utilization of services was appropriate, established policies were followed & changes were made as needed
Provide ongoing program of activities designed to meet, according to comprehensive assessment, the interests & physical, mental, & psychosocial well-being of each resident.
The CAH must assist residents in obtaining routine and 24 hr emergency dental care
KAR 28-34-10a(c) Meds requiring refrigeration must be stored in refrigerators dedicated to drug storage only
KAR 28-34-10a(d) P&T committee must meet at least quarterly with med staff, nursing & Pharmacist
KAR 28-34-17b Must have a policy that determines the circumstances which require the presence of an assistant during surgery and determine whether the assistant should be a physician or nonprofessional personnel
Headed by qualified RN
Staffed by qualified person when occupied
Sufficient equipment to carry our intensive care
Intensive care or coronary care committee of the medical staff
Policies & procedures
Expired sterile supplies
P & P reviewed at least every 2 years
Personnel files for each staff member which include education, training, experience, periodic work evaluations
Health records-initial health exam upon employment, appropriate to duties of the employee, including x-ray or TB skin testing. Subsequent medical exams or health assessments per facility policy
First Do No Harm
To Error is Human-view errors as opportunities for improvement
You will not minimize occurrences unless you know all the facts.
In order to know all of the facts you must look at the process as well as the individual.
KAR 28-52-4 (b)
Prevention of harm to patients is achievable but is not a static condition. It is a never ending process that requires strong leadership commitment at all levels of the organization
It was an opportunity to learn the standards and different ways they can be met or violated. Knowing about a rule is one thing but truly understanding why the rule exists and sometimes the many ways it can be applied. It takes someone with knowledge to connect the dots
The sharing/networking of information and resources both with the facility and the other mock surveyors has been invaluable
We now have 18 CAHs with a mock surveyor to lead their hospitals in improving patient care
Those 18 surveyors and their hospitals have approved the plan of these 18 teaming up with 2 per hospital and completing a mock survey at 9 more CAHs.
That could total as many as 27 CAHs with an increase of knowledge of the regulations and ways to improve patient care
Support/resources needed for mock surveyors
Assignment by KHA for the 18 trained mock surveyors to survey other CAHs (9 total CAHs) – this needs to be completed ASAP