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State Survey for Licensure of Hospitals

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  1. State Survey for Licensure of Hospitals George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems Summer 2004

  2. State Board of Health 12 VAC 5-410 Rules and Regulations for the Licensure of Hospitals in Virginia Center for Quality Health Care Services and Consumer Protection Virginia Department of Health Richmond, Virginia

  3. Governing Body • Administrator/president • Asst.. Administrator/ Vice President • Governing body by-laws • Date of last revision • Documentation of lines of authority for operation of hospital • Organizational chart • Board meeting minutes review • Frequency of meetings

  4. Results of Other Surveys • Last JCAHO survey • Last CAP survey • State fire Marshall Inspection • Sprinkler system compliance status • OSHA • New services since last survey: • Construction projects:

  5. Administrative Policies for Review • Licensure/certification verification policy • Organ donation • Moderate sedation policy • Restraint policy • Incident reporting policy

  6. Contracted Services • List of contracted services • Review two contracts in-depth • Review of a Service Contract may include: • Scope of service • Quality Assurance Responsibilities • Participation in Performance Improvement Projects • Supervision of personnel

  7. Medical Staff • President medical staff: • Total medical staff number: • Active: • Courtesy/consult: • Medical staff status: • Dentists/oral surgeon • Podiatrists • Allied health professionals practicing (e.g. certified registered nurse anesthetists and physician assistants)

  8. Medical Staff – Bylaws, Rules & Regulations • Medical staff organization (diagram if available) departmental/department of the whole • Medical staff appointment criteria • Initial appointment • provisional period • Transition procedure from provisional to active status • Reappointment frequency • Board certification requirements • Temporary privileges/locum tenens

  9. Medical Staff – Bylaws, Rules & Regulations(continued) • Allied health appointment criteria • Reappointment frequency • Medical records • Time frame for completion • H & P time frames (medical & surgical) • H & P for admissions of podiatrists and dentists • Verbal orders - 24 hours

  10. Completeness of Credentialing Process • Current license • Data Bank Query - (within 12 months of appointment . or re-appointment) • Q.A. Review documentation • Board certification status • Documentation of other hospital queries when applicable • Initial appointment. -Verification of credentials/ character • Delineation of clinical privileges/approval signature • Hospital Governing Board approval

  11. Infection Control • Meeting with Infection control officer and medical director • Review Infection control plan • Surveillance • Hospital-wide • Focused/targeted • Inpatient • Outpatient • Nosocomial infection rates

  12. Infection Control • Reported outbreaks • Isolation categories • Negative pressure rooms (whole house) • TB control • Respirators used - length of use • Number of confirmed cases last year • Number of PPD conversions • Policy for PPD testing - who & how often

  13. Infection Control • Method of monitoring compliance • Education programs • Orientation/annual/ongoing • Hand washing • Small blood spill policy • Location of spill kits if used • Products used

  14. Infection Control • Infection control committee • Frequency of meetings • Meeting minutes • Approval areas • Biomedical waste disposal • Linen procedures • Sterilization equipment & procedures • Housekeeping chemicals

  15. Quality Management • Meeting with Quality management director • Organization Performance Written Plan • Organizational reporting structure (diagram) • Hospital tracking system. • Clinical/critical pathways • Medical staff reviews, Reporting for re-credentialing • Quality council and QI Teams • Committee meetings: frequency, minutes

  16. Fire and Safety • Meet Fire and safety safety officer • Review fire plan • Fire drills (one per shift per quarter) • Who participated • What procedures practiced • What areas were involved • Performance evaluation • Corrective actions if indicated

  17. Fire and Safety • Construction drills (two per shift per quarter) • Interview employees re: Fire plan (at least 3) • Safety committee • Frequency of meetings • Review of committee meeting minutes • Committee safety surveys of departments • Frequency, Who participates • Scope of survey/checklist used

  18. Electrical Equipment Checks • Initial use check - policy - how documented • Hospital owned equipment • Privately owned equipment • Patient use • Personnel use • Hospital bed preventive maintenance • Frequency • How documented

  19. Biomedical Equipment Checks • Biomedical equipment checks • By whom • List of frequency categories • How tracked and documented • Emergency generator log • Number of emergency generators • Frequency of testing • Log of testing and actual use

  20. Disaster and Mass Casualty • Meet the chairman of the disaster plan • Review written plan - Last revision • Documented rehearsals twice a year • Dates of drills • Drills evaluated with corrective actions • Documentation of drills kept 2 years

  21. Emergency Services • Meet emergency department manger • Emergency dept. Medical director must be Board Certified • Number of rooms • Number of patients seen last year average • Number of patients seen/day • Average transfers/month • Average number of patients that leave Against Medical Advice (AMA)/month

  22. Emergency Department Staffing • Nursing • RN on duty all shifts • Physicians • Physician on-call duty roster - posted • Obstetric - newborn roster of physicians with clinical privileges

  23. Continuing Education • Written plan for unit specific continuing education • Documentation of education activities for last year • Plans for current year • Required personnel competencies and skills • Required frequency of validation • Checklist of content • Certifications, ACLS, PALS, Other

  24. Medication Administration • PYXIS SUR-MED Other • Refrigerated medications • Secure • Thermometer • Irrigation solutions • policy for use • Timed/dated

  25. Medication Administration • Buffered Xylocaine use • policy for mixing • Multiple dose vials • policy for use • Single dose vials • Compliance with one use poison control center used • Telephone number posted

  26. Other Checks • EMTALA (The Emergency Medical Treatment and Active Labor Act ) signage posted in waiting room triage • Triage protocols/Triage privacy • Crash carts • Number of cart: Adult and Pediatric • Documented shift checks • Who checks carts for outdates • How documented

  27. Other Checks • Toxicology reference materials • Master file of MSDS sheets • where kept if not in E.D. • 24 hour availability • HAZMAT facilities

  28. Nursing Medical/Surgical Units • Medication system used • Pyxis Sur-Med Med carts other • Policy for multi-dose vials/irrigation solutions • Refrigerated medications • Temperature monitoring • Sharps container compliance • Blood glucose machines

  29. Nursing Medical/Surgical Units • Documented quality controls crash cart with defibrillator • Documented daily checks • Who checks outdates-how documented linen storage • Clean/soiled equipment storage • Clean/soiled • Stretcher/Wheel chair cleaning schedule • Who is responsible for cleaning

  30. Nursing Medical/Surgical Units • Hallways must be totally clear for fire egress • Clinical resource information • Current pharmaceutical manual • Infection control manual • Clinical pathway information-if applicable • MSDS sheets • Fire plan and disaster plan

  31. Nursing Medical/Surgical Units • Unoccupied room check Call bell • Wall oxygen and suction outlets • Electrical & biomedical equipment checked • Emergency electrical plugs identified • Sharps box/gloves • Negative pressure rooms • Current isolation • Respirator storage (if applicable)

  32. Nursing Medical/Surgical Units • Restraint use • Observation of patient • Chart review for orders and documentation • Clean/dirty utility rooms • Hazardous waste storage/disposal • Dirty linen storage • Kitchen/nourishment room • Ice machine, Refrigerator/ Temp and Contents monitoring

  33. Nursing Medical/Surgical Units • Housekeeping • Janitor's closet • Chemical storage • Housekeeping cart • Nofood or drink • Parking/storage

  34. Critical Care Unit • Number of beds • Nursing /manager medical director: • Unit designed and equipped for special function • Crash carts/emergency equipment • Documentation of checks • Medication system: • Pyxis Sur-Med other • Stock drugs - who monitors for outdates • Refrigerated medications - temperature monitoring

  35. Critical Care Unit • Blood glucose machine: • Documented quality controls • Nursing assessment/documentation • Use of critical pathways • Other care planning used • Critical care nursing assessment tool used

  36. Critical Care Unit • Staffing: • Staffing policy,Staffing schedules • last 3 months/with census • Categories of personnel assigned to unit • RN LPN Aide/Tech Respiratory therapist • Continuing education • Written plan for unit specific continuing education • Documentation of plans and activities

  37. Critical Care Unit • Required personnel competencies and skills. • Frequency of re-qualification • Documentation/checklist • ACLS • Certifications of personnel

  38. Nursing Service • Chief Nurse Executive • Director of nursing: • Organizational Chart • Staffing: • Acuity/system used • Procedure used for verification of current licensure

  39. Nursing Service • Required training/continuing education. • Blood glucose monitoring • Active participation in conscious sedation • Policies • Administration of blood and blood products • Restraint • Moderate sedation

  40. Employee Health • Hepatitis B vaccine • Policy • Who is eligible • Tuberculin testing (PPD - x-ray) • Policy • Methods used • Conversions/follow up

  41. Obstetric Services • Administrative manager • Nurse manager: • Postpartum, L&D, Newborn services • Medical director • Board Certified or Board Eligible • Appointment by Governing Body • Responsibilities in writing • Joint Committee - Ob & Newbornservices

  42. Obstetric Services • Joint conference committee meeting, Minutes. • Services management plan • Protocol for pregnant women who present in labor • Copy at each nurses station • Policies & procedures • Identification of high risk patients • Anesthesia personnel available on site within 30 min.

  43. Obstetric Services • Policies & procedures • Ob physician accessible within 10 min during oxytocic administration • Criteria for use of Labor & Delivery Rooms/Labor, Delivery, Recovery, and Postpartum Rooms • Gynecologic patients - definition - if cared for on Ob • Infection control. • Written criteria for isolation or segregation for mothers and infants

  44. Obstetric Services • Physician availability: • Ob physician - 30 min. On-call • Accessible - 10 min during oxytocic admin- • On-call duty schedule posted at each Ob nurses station • Roster of Ob & Neoborn services physicians with privileges at each nurses station

  45. Obstetric Services • Staffing schedules: (available for last 3 months) 1. • Ratios: • Post Partum: 1:6-8 • Mother/baby: 1:4 • L&d: 1:1-2 • Post op recovery: 1:2 • Policies for use of personnel from other hospital Areas

  46. Obstetric Services • Education & training • Written plan for unit specific continuing education with documentation of activities for last year and current year • Training for identification of substance abuse in women & infants • Required competencies & skills • Frequency of validation • Certifications, CPR - Adult - Neonatal

  47. Obstetric Services • Discharge planning • Policy and Procedure/substance abusing post Partum women • Appropriate referrals • Include father and/or family members • Documented in Medical Record • Family planning information given to patient • Documented • Discharge teaching documentation

  48. Obstetric Services • Control plan • Control station • Visibility of unit • Bracelet system used • Cameras • Medication system • Pyxis Sur-Med Med cart other • Refrigerated medication - temp monitoring • Sharps containers

  49. Obstetric Services • Crash cart/defibrillator • Daily monitoring with documentation • Documentation of outdate monitoring • Unit design • Separate and distinct unit • Soiled workroom & janitor's closet - exclusive use by Ob • Patient bath facilities with showers • Staff clothing change areas

  50. Newborn Services • Nurse Manager • Medical director • Qualified for highest level of newborn services offered • Appointed by governing body • Responsibilities in writing • Conduct joint conference with Ob Physicians quarterly • Participation in Performance Improvement Initiatives