overview of state hospital licensing survey linda l. foss phd, rn executive director clinical care...

Overview of State Hospital Licensing Survey

Linda L. Foss PhD, RNExecutive Director Clinical Care FacilitiesOffice of Inspections and Investigations

Department of Health

Linda L. Foss

Executive Director

Clinical Care Facilities

• Survey Process• Regulatory Framework

Survey• Purpose of survey is determine

compliance with state licensing requirements

• State licensing requirements are minimum

What are we looking for?

Compliance

Survey Components • Observations

• Interviews

• Record review

Washington Administrative Code • Purpose and

Applicability• Licensing• Patient Care• Environment of Care

Management

• Design, Construction Review, and Approval of Plans

Hospital Responsibilities• Comply with RCW 70.41• Set up only the number of beds licensed • Notify with 2 business days of completion

accreditation survey • Notify in writing of accreditation decision

or status change in 30 days

Governance• Informing patient

of any unanticipated outcomes

• Establish and review governing authority policies

• Performance Plan• Organizational

Management• Reporting

Practitioners

Governance• Approve an

appoint medical staff

• Authenticated of orders by authorized practitioner

• Approve and Review Medical Staff bylaws

Criminal history, disclosure, and background inquiries

• Employee,• Contractor,• Volunteer, • Student

Access to• Children under 16 • Vulnerable adults• Developmentally

disable individuals

Patient Rights/Organizational Ethics

• Respect • Dignity• Confidentiality• Privacy• Complaint

resolution,

• Spiritual care• Communication• Free from abuse

and neglect

Patient Rights/Organizational Ethics • Involved in care • Right to refuse care• Advised of

unanticipated outcomes

• To be informed and agree with care

• Advanced directives• Request DNR• Right to donate

organs• Access protective

services

New Definitions • Victim of sexual assault" means a person

is alleged to have been sexually assaulted and who presents as a patient.

• Vulnerable Adult-includes hospitalized adults.

Leadership• Assessing patient and family satisfaction

of services• Posting Complaint Hotline• Provide patient with written billing

statements

Leadership • Provide for safe haven for abandoned

newborns • Provide of organization wide

performance improvement activities

Leadership• Assign a nurse at the executive level

• Establish hospital wide patient care services

Adverse Events Reporting • Process is now outlined in the WAC• Reported to Linda Furkay PhD, RN

Toll Free Hotline for Reporting Adverse Events

1-888-524-6257

Reportable Events • Failure or facility system malfunction such

as • Heating, ventilation, fire alarm• Water supply electrical• Information management

• Must Notify DOH-Office of Inspections and Investigation.

Notification • Who• Linda Foss • Phone 360-236-

2920• Fax number-

360-586-0123• linda.foss@doh.

wa.gov

• What• Type of event• Date of event

Management of Human Resources

• Job descriptions• Staff performance• Assure qualified staff• Supervision of staff• State licensure, certification, registration• TB screening

Education for staff • Orientation • Education

Blood borne pathogen exposure control HIV

Multi-drug resistant organisms

Qualified Staff

• License, registration certification

• Job description• Orientation• Performance

evaluation

• Supervision • Staff working within

scope of practice• Competency

Medical Staff Bylaws • Verification• Appointment• Reappointment• Delineated clinical

privileges

• Reporting practitioner

• Assessment of performance

Management of Information • Control access of patient information• Confidential, secure, and integrity • Medical record for every patient

Infection Control Program • Education• Policies• Patient care practices • Environmental management and

housekeeping functions

Improving Organizational Performance

• Hospital Wide • Periodically evaluated• Interdisciplinary • Includes one member of the board

Requirements for• Food and Nutrition

Services• Linen and Laundry

Services• Pharmaceutical

Services

• Laboratory, Imaging and other Diagnostic Services

• Safe Patient Handling

• Patient Care Services

Patient Care Units • Surgical • Anesthesia• Recovery Care• Obstetrical• Neonate and

Pediatrics• Critical or Intensive

Care

• Alcohol/Chemical Dependency

• Psychiatric• Long-Term• Emergency• Dialysis

Patient Care• Plan for Patient Care• Assessment of

Patient• Standards of Care

• Qualified Staff• Equipment

Patient Care• All patient access to safe and appropriate

care • Adopt and implement P&P for patient

care and nursing practice• Individuals conducting business in

hospital comply with P&P

Patient Care Services • Provide personnel, space, equipment,

reference materials, training• A registered nurse available for

consultation in the hospital at all times• Policies and procedures around care

process

Emergency Contraception • 24/7 emergency care to victims of sexual

assault• Provide medically and factually accurate

and unbiased written and oral information about emergency contraception

Safe Patient Handling• Develop a policy• Hazard assessment• Annual performance

evaluation of the program

• Annual staff training

• Procedures for hospital staff to follow

• Types of equipment

Management of Environment of Care• Manage environmental hazards and

risks, prevent accidents and injuries, and maintain safe conditions for patients, visitors, and staff.

Self-Assessment Tips.

Read the regulations

How are you meeting the regulations?

Where is the documentation that demonstrates

compliance?

Questions