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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. KDHE Vision - Healthy Kansans living in Safe Sustainable Environments.

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Presentation Transcript
  • Background of program
    • Reasons for mock surveys
    • Planning for more than a year

Background of participants

    • Hospitals
    • Mock Surveyors
  • Background of presenter

KDHE Vision - Healthy Kansans living in Safe Sustainable Environments

program objectives
Program Objectives
  • Assist CAHs in meeting their goals of providing the best patient care with best practices
    • Understanding the state and federal regulations
    • Providing new eyes – recognize problem areas
    • Providing possible corrective action that has been successful in other hospitals
    • Providing resources for assistance
mock surveyor objectives
Mock Surveyor Objectives

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.

mock survey program
Mock Survey Program
  • One day of classroom – 8 hours
  • 4 days of on the job training – Avg 30 hrs
    • Reviewing
    • Interviewing
    • Observing
  • Information Analysis, decision making and writing up the report – Avg 6 hrs
  • Exit interview – Avg 2 hrs
mock survey process
Mock Survey Process
  • Pre-Entrance meeting
  • Entrance conference
  • Information gathering and investigation
    • Observations, interviews and record reviews
  • Daily conference with CEO
  • Exit conference

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?


61 Federal & State regulatory concerns

    • 48 Federal
    • 5 State
    • 6 Risk Management
    • 2 EMTALA
  • 55 Federal & State regulatory concerns
    • 42 Federal
    • 7 State
    • 6 Risk Management
  • 32 Federal & State regulatory concerns
    • 23 Federal
    • 5 State
    • 1 Risk Management
    • 3 EMTALA
cop 0150 compliance with state federal and local laws and regulations
CoP 0150Compliance with State, Federal and Local Laws and Regulations

Credentialing files

keeping up to date between times of credentialing

cop c 0190 cfr 485 616 agreements
CoP (C-0190 CFR 485.616)Agreements

C195 CFR 485.616(b)

Agreements for Credentialing


Quality Assurance

observation patient services
Observation Patient Services
  • IG require one person named to coordinate OP services
cop c0220 cfr 485 623 physical plant environment
Cop C0220 CFR 485.623Physical Plant & Environment
  • C0222(1)Housekeeping & preventative maintenance programs that ensure
      • Essential mechanical, electrical, & pt-care equipment is maintained in safe operating condition
  • C0223(2)Proper routine storage & prompt disposal of trash
  • C0224(3)Drugs & biologicals appropriately stored
  • C0225(4)Premises are clean & orderly
standard c0227 cfr 485 623 c emergency procedures non medical emergencies
Standard C0227 CFR 485.623(c)Emergency ProceduresNon-medical emergencies

Disaster Drills

cop cfr 485 627 organizational structure
CoP CFR 485.627 Organizational Structure
  • Governing Body/Responsible Individual
  • The person responsible for the operation of the CAH
  • (3) The person responsible for the medical direction
standard c0262 cfr 485 631 c pa np cns responsibilities
Standard C0262 CFR 485.631(c)PA, NP & CNS Responsibilities

(1) Participate in development, execution & periodic review of the policies

(2) Participate with physician in periodic review of patient records

cop c0270 cfr 485 635 provision of services
CoP C0270 CFR 485.635Provision of Services

*Standard C0271 CFR 485.635(a) Patient Care Policies


Services are furnished in accordance with appropriate written policies consistent with state laws

  • A description of the services furnished directly & those furnished through agreement or arrangement
  • Policies include the following:
    • Emergency medical services
    • Guidelines for management of health problems including those that require consultation &/or referral, maintenance of health records, procedures for periodic review & evaluation of services furnished by the CAH
    • Rules for storage, handling, dispensation, & administration of drugs & biologicals. In accordance with accepted principles, current & accurate records kept, & outdated, mislabeled. Or otherwise unusable drugs are not available for pt use.
standard c0285 cfr 485 635 c services provided through agreements or arrangements
Standard C0285 CFR 485.635(c)Services Provided Through Agreements or Arrangements

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.

standard c0294 cfr 485 635 d nursing services
Standard C0294 CFR 485.635(d)Nursing 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.)

cop c0300 cfr 485 638 clinical records
CoP C0300 CFR 485.638 Clinical Records

Legible, complete, accurate, readily accessible, organized

Confidentiality of record information and provides safeguards against loss, destruction, or unauthorized use.

standard c0322 cfr 485 639 b anesthesia risk evaluation
Standard C0322 CFR 485.639(b)Anesthesia Risk & Evaluation
  • Each pt must be evaluated for proper anesthesia recovery by a qualified staff
    • Include-cardiopulmonary status; level of consciousness; any follow-up care/observations; and any complications during recovery
cop c0330 cfr 485 641 periodic evaluation qa
CoP C0330 CFR 485.641Periodic Evaluation & QA

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

c0385 cfr 483 15 f rights activities
C0385 CFR 483.15(f) Rights Activities

Provide ongoing program of activities designed to meet, according to comprehensive assessment, the interests & physical, mental, & psychosocial well-being of each resident.

c0404 cfr 483 55 dental services
C0404 CFR 483. 55Dental Services

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

kar 28 34 18 ob newborn services
KAR 28-34-18 OB & Newborn Services
  • Must have continuous coverage by a qualified member of nursing staff with qualified RN immediately available
  • Safety of newborn
  • Nursery available
  • Policy for flow of staff - OB & other areas
  • Peri-Natal committee with appropriate medical staff & nursing
kar 28 34 28 c icu or ccu
KAR 28-34-28(c)ICU or CCU

Distinctly identifiable

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

kar 28 34 8a personnel
KAR 28-34-8aPersonnel

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

risk management

Risk Management

First Do No Harm

to error is human
To Error is Human

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.

investigation multiple issues providers
InvestigationMultiple Issues/Providers

KAR 28-52-4 (b)

  • Separate standard of care determinations shall be made for each involved provider and each clinical issue reasonably presented by the facts.

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

remarks from hospitals
Remarks from Hospitals
  • All three facilities felt it was a great success
  • – gave them insight into problem areas & ideas on how to improve QA/QI/PI to make it more valuable in improving care
    • Staff discussions with participants (they aren’t alone in their struggle to provide the best care possible)
    • Having a better understanding of the regulations and need to comply
    • It was great to hear about the things needing improvement and doing so without it being official
remarks from mock surveyors
Remarks from Mock Surveyors

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

what next
What Next

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