An Update: What's New and Problematic: Joint Commission Standards and CMS Regulations

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Tracer Tips For Staff• Have a plan: As soon as the surveyor and escort arrive on

the floor or unit, everyone knows the action plan. • Bad idea: Everyone abandons the nursing station to avoid

being interviewed. • Bad idea: Who is the charge nurse? The charge nurse is

Jane Doe, silence, pause, oh Jane isn’t on duty today. • Bad idea: Can I tell her what this is about?• Bad idea: Can you come back, we are so short staffed at

this hospital I can’t take the time. • Bad idea: We can do the tracer review where ever you

would like. I guess we can use this computer. • ID a quiet room, out of main traffic path to review the

medical record for the patient tracer

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GOOD IDEAS FOR TRACER INTERVIEW• Be enthusiastic about how good you are• Talk proudly about the excellent service and care you

provide• Offer data or other follow up to support compliance if

available for areas cited by surveyor• Have multiple staff (MD, pharmacist plus RN a BIG help)

participate in the unit interviews, one person can forget, get intimidated

• Know what your EMR will display based on userid. • Don’t think “what is the right answer” think about what

you do day after day. • Know where policies are kept & how to access them

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When They Are in Your Unit• Know where to find your policies & “fast facts” or

other tip tool • Have two people in the patient record, a second

person as back up looking for stuff• Offer policies, describe education, run policies

through your command center• Use your resources, you don’t need to memorize• Call on experts around you

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When They Leave Your Unit

• After the team leaves, find all “IOUs”• Find the missing stuff, if it exists• Find the order• Find the anesthesia record, the consent, etc• Copy it, highlight the part the surveyor couldn’t

find• Send to your command center• Make a copy to the surveyor room during special

issue resolution, escort should record this

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Role of the Escort/Note Taker

• Record the potential problems• Warn senior leadership of anticipated RFI’s• Get ahold of senior leaders STAT if situation is

significant, or surveyor mumbles anything about “immediate threat”.

• Be the expert in finding OR documentation in med/surg records.

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GOOD IDEAS FOR TRACER INTERVIEW• During tracers staff on MS units may be asked to

show documents including:– History and physical– Update to the H&P– Nursing assessment– Consults– Orders– Home medication list, reconciliation if inpatient– If surgical, pre anesthesia 1+2, time out,– Post procedure note with all elements– post anesthesia note.

• Train escorts and scribes where to find these.

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Tracer Tips For Staff• Before answering a question:

– Take a deep breath– Make sure you understand the question– Or ask “Could you please rephrase that question…”– Offer to provide the answer later in the day– Stop talking once you have answered– If your surveyor pauses after your answer, try to

seek acknowledgement that you have fully answered the question don’t just restart talking.

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Tracer Tips For Staff, cont.• Never, never “fix” a chart to avoid an RFI• Never “make up” answers to please the surveyor• Don’t be intimidated by surveyors, or by your own

management. • Do not argue with the surveyor• Take advantage of surveyor suggestions• Know what improvements in patient care came from

PI (performance improvement) activities• Don’t affirm the leading question…” this isn’t a very

good process, is it?”

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Focus on the Top 10 & NPSGs

• The 2013 standards have 1700 EPs that can be scored

• The Joint Commission does >90% of its scoring on about 25 standards/NPSGs

• Implement the top scored and all NPSGs• Spend you time and energy here!• If it’s a problem in 30% of the nations

hospital make sure it is solid at yours.

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HOT BUTTON TOPICS WITH TJC• Physical environment

– Air pressures and exchanges– Fire safety documentation EC.02.03.05– Temperature and humidity monitoring

• High level disinfection and sterilization• High reliability• Risk assessment• Clinical contracting

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THE USUAL SUSPECTS• The top 10 MFSS including:

– Hallway clutter– Dating and timing medical records/legibility– Medication storage and security

• Histories and physicals triple threat, PC, RC, MS

• Immediate post procedure notes• Anesthesia assessments

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THE ANNUAL PROBLEMS• Annual reports missing• Reference to pre 2009 standard numbers in annual

reports• Annual evaluations missing or glowing despite known

problems• Annual reports have no real performance measures• PFI deadlines missed• Failure to implement ILSM for PFI items• Failure to update ILSM policy to match standards

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MORE ANNUAL PROBLEMS• Missing the new stuff, failure to realize that surveyors

are trained on “that which is new”. • Failure to take advantage of the planning year, CAUTI,

ED Flow and boarders• Missed annual education or competency

requirements– CAUTI– CLBSI– SSI

– Waived testing

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MOST FREQUENT SUSTAINABILITY FAILURES

• Failure to critically evaluate standards compliance– The data looks good, but the review was

very superficial• There is a Med Rec form in the chart =

compliance• There is a history and physical form in the chart• There is an immediate post procedure note• There is a pre-anesthesia assessment• Hand hygiene compliance was 100%

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LEARN FROM THE MISTAKES OF OTHERS

• Sentinel events have been a great teaching tool in that hospitals can learn about the common problems and root causes in other hospitals and develop prevention strategies.

• The most frequently scored standards present another teaching opportunity. – If 30% or more of hospitals are getting hit,

shouldn’t we prepare too?

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The Top 10 Most Frequently Cited TJC Hospital Standards First Half 2013

1. Medical Record EntriesRC.01.01.01 EP 6, EP 11, EP 19 55%– Information needed to justify the

patient’s care, treatment, and services missing

– Entries are not dated, timed, signed– Illegible hand writing

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The Top 10 Most Frequently Cited

2. Maintaining the Path of Egress LS.02.01.20 EP 13, 16-22 54%– Corridors are not free of clutter– Rules don’t apply to crash carts and

isolation carts in use– Suites are not designated where clutter

rules don’t apply– Clinicians remember the 30 minute rule!

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Top 103. High Level Disinfection

IC.02.02.01 EP 1, EP 2, EP 4 47%– High level disinfection and sterilization problems– Usually a CMS Condition Level Finding– Cidex or other test strips not dated, poor

documentation of quality controls– Poor low level disinfection – Ø contact time– Poor storage of equipment, devices, and supplies

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DISINFECTION• Has the ICP identified and evaluated every

location that performs HLD?• Have the same forms and processes been

standardized throughout the organization?• Is compliance consistent in every

department that performs HLD?• Do we teach or label surface disinfectants

to make it easy for staff to know contact time?

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Top 1010.Manage risks with utility systems

EC.02.05.01 46%– New to the top 10 in 2012, higher now in 2013,

scored in the ORs & procedure areas– Pos/Neg air pressure relationships wrong– Air exchanges, correct # per hour– Filtration problems

• Surveyors can use Tissue Test• Improper system design, or• Lack of inspection, testing, maintenance or

performance problems– Staff don’t know what the requirement is and

can’t help to support it

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AIR PRESSURE

• Do we have vendor/staff documentation at least twice a year?– If any defects in the report do we have evidence

of corrective action and retest?• Do staff in the work unit understand the pressure

requirements?– Do staff in the work unit do any testing like a

tissue test?• Do administrative rounds demonstrate that doors

that must be closed, are closed?

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Top 10

5. Maintain building features to prevent effects of fire, smoke LS.02.01.10 45%– Usually fire doors not latching– Fire barrier penetrations– Doors undercut, gaps, rated

• Do you have an inventory for checking periodically like a BMP? Do you have data?

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Top 106. Maintenance of Fire Safety Equipment

EC.02.03.05 EPs 1- 25 44%– Inspection, testing and maintenance of each

piece of fire safety device (smoke detector, fire pull station, magnetic door release)

– Often a problem with poor organization and ability to find evidence

– Often a double hit against leadership

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Top 107. Maintain building features to protect against

fire and smoke LS.02.01.30 43%– Smoke barrier penetrations, hazardous

areas not protected– Gaps under doors

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Top 108. Maintain fire extinguishing features

LS.02.01.35 35% – Sprinkler or fire extinguishment

issues– Hanging things from sprinkler pipe,– 18 inch rule, sprinkler head broken

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Top 109. Safe, functional environment

EC.02.06.01 EP 1, EP 13 36%– Safe, functional area, a catch all standard

for ripped mattresses or stained ceiling tiles– Maintain ventilation, temperature and

humidity• Door held open by air pressure, hot/cold calls,

humidity >60%RF

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ADMINISRATIVE ROUNDS

• Is furniture in good repair, no rips or tears?• Are ceiling tiles free of water damage and

stains?• Is OR, sterile storage, central supply

temperature and humidity being monitored and found compliant?

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Top 1010.Safe medication storage

MM.03.01.01 EPs 2, 3, 6, 7, 8 33%– Unsafe/secure storage of medication– Refrigerator temperature not sustained/monitored– Meds unsecured – not locked or under constant

surveillance– Access by non-licensed is not approved by policy– Terminated employee ADM access is not cut off– Medroom doors all have the same combination and

have never been changed. – Improperly labeled including Ø beyond-use date– Expired or damaged are not removed

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Lessons Learned from Recent TJC Surveys

Not the top ten, but very frequently scored issues

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Label All Medications(NPSG.03.04.01)

Label all meds on and off the sterile field.• All products, including sterile water/saline,

disinfectants in a basin must be labeled.• The safety goal includes bedside procedures

as well as IR, cath lab, out patient• Its an A element of performance

Prelabeling??? OK if your policy permits it

RANGE ORDERS, THERAPEUTIC DUPLICATION AND PRNS

• TJC does not prohibit range orders but it is virtually impossible to do it correctly and consistently without order specifications.

• If two therapeutic agents in the same class are prescribed, there must be specifications when to give drug 1, when to give drug 2

• PRN’s must have an indication for use

Medication Orders

• Preprocedure medications/IVs and testing nurse-initiated protocols are now permitted– Caveats: (create a policy) “Standing Orders”

• Must be approved by the medical staff, nursing (to affirm the practice is within the scope of license) and pharmacy (with respect to medications)

• Must be based on nationally recognized and evidence based guidelines and recommendations

• Include regular PI review to look for problems or improvement opportunities

• Date, time, and authenticate per state regulation

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CPOE and the Pre-OP/Post-OP Order• CPOE signing of post-operative anesthesia or surgical

orders pre-operatively now requires a risk assessment and policy to avoid a finding

• Got away with it on paper; could fudge or omit the time and not be noticed

• CPOE captures the time, so an easy observation• The LIP must either pend or plan the orders and log back

in and sign/ release/initiate the orders post-OP, OR • Sign orders pre-OP and justify via risk assessment and

policy having the RN reassess the patient and release/initiate the order based on the very nature of conditional/PRN orders

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CPOE Pre/Post-Op Orders

• Physicians and staff seek ways to expedite patient flow by writing post procedure orders before the procedure starts (sometimes hours, days, weeks). This is noble!

• EHR/CPOE systems allow organizations to build standard order sets or pre-printed orders to reduce/eliminate redundant work and expedite care. Also noble!

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CPOE Pre/Post-Op Orders• The organization must decide whether it will allowing

practitioners to write post-procedure orders prior to the procedure; if yes, then…

• Construct a risk assessment and policy that defends a process where conditional orders (i.e., if this, then that/PRN orders) may be entered/written ahead of time by the LIP and then allow licensed/competent PACU RN to review the order post-OP AND match the order to the assessed needs of the patient

• The RN then initiates or activates the order or consults with the ordering LIP if patient condition warrants/changes

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Sterile Processing Tour

• Attire: donned at the hospital, changed daily• Red line – no one enters without proper attire• No artificial nails, nail polish, jewelry, watches• Head AND facial hair covered at all times• In Decontamination: liquid-resistant garb, heavy-

duty gloves, eye protections• Follow manufacturers IFU• Temp and humidity monitor and actions• Competency assessment

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Reduce Risk of Infection

• Surveyors will observe staff as they process dirty equipment

• Surveyors will check manufacturer instructions for use (IFU) for three things: the device/instrument, the sterilizer itself, and the packaging (i.e., blue wrap or flash pan.)

• Check your policy, check staff understand and follow both. Create a recipe book or OneSource

• Will observe proper use of PPE

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SPD Facility

• Easily cleaned walls, floors and ceiling• Daily housekeeping• No exposed pipes, etc. that collect dust• Maintain neg/pos pressure by keeping doors and

windows closed; test pressures monthly• Sinks available for hand washing• Eye wash within 10 second travel time; single action

lever, tepid water temperature to allow 15 minute flush time

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HVAC Temperature, Humidity, Storage

• Monitor and record daily• Temp 68-73 in clean area of department• Temp 60-65 in decontamination • Humidity 20-60% in work areas• Proper # of Air Exchanges (>10, 2 fresh)• Pos/Neg pressure relationships• Humidity not > than 70% in sterile storage• 18 inch, 6 inch, 2 inch, solid lower shelf

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Relative Humidity to 20%• CMS finally agreed to lower the minimum

acceptable humidity level from 30% to 20%• Requires an “internal” waiver• You need not submit a waiver request to

CMS or TJC, but simply discuss at a committee of record (e.g., EOC, IC, OR Operations, etc.) and conclude and memorialize in minutes that you have adopted the 20% minimum acceptable

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EYE WASH STATIONS• Bottles are red flags• Bottles are only good for blood, body fluid,

minor irritant splashes• Corrosives must have plumbed eyewash or

equivalent• Staff must be able to find MSDS• Staff must be able to correctly operate eyewash• ANSI recommends weekly testing• Water must be tepid

H&P and Update • An H&P is done no more than 30 days prior to admission

or within 24 hours of admission. • If the H&P is done anytime in the 30 days prior to

admission you must update it within 24 hours of admission, or prior to an invasive procedure on the day of the procedure, whichever comes first.– Must document: the patient was examined, and

the H&P was reviewed, changes___ or no changes. – In EMR – use a SmartText: e.g., .no changes

or .changes

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HISTORY AND PHYSICAL

• MS.03.01.01, EP 6, A,D – “The organized medical staff specifies the minimal content of medical histories and physicals, which may vary by setting, level of care, tx and services”.

• Problem: a long form, short form or “ad hoc” form is spotted which doesn’t meet your requirements

• CMS now prohibits anything but a “comprehensive H&P” for ASC; Hospitals?

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HISTORY AND PHYSICAL

• EP 7, A – “The medical staff monitors the quality of H+P’s”.

• Surveyors score failure to obtain within 24 hours of admission or prior to surgery, then look for actions taken by MEC to improve.

• If quality data indicates that indeed sometimes there are performance gaps, what do the minutes show for actions?

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Sample H&P Bylaw LanguageA medical history and physical examination be completed and documented for each patient by a hospital practitioner with appropriate privileges no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration.

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Document Operative & High Risk Procedures (RC.02.01.03)

H&P in record before procedure (EP 3) Post op/post procedure report is written or

dictated before transfer to next level (EP 5) (Unless a post op/post procedure note is

entered immediately [see EP 7], if so, report may be written or dictated per policy)

The post operative/procedure report includes: name of LIPs, procedure name and description, findings, EBL, specimens, post op diagnosis (EP 6 - Top Scorer)

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Document Operative & High Risk Procedures (RC.02.01.03)

No premature Post-OP notes!!! Medical record includes the LIP release order or

approved DC criteria (EP 9) Medical record includes the use of DC criteria/pt

readiness (EP10)

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Informed Consent• Physician responsibility• Risk of not receiving treatment• Paper form needs date and time for all signatures• CMS requires patient to sign, date, time

• May need to have them re-initial, date, time on day of surgery• Form may include potential use of blood• Process includes discussion of likelihood of desired outcome• Anesthesia consent is usually in anesthesia record• Sedation consent is on presedation assessment• RN confirms patient understanding, advocate

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PREANESTHESIA ASSESSMENT

• PC.03.01.03– EP 1: Presedation/anesthesia assessment

required for any type of anesthesia including moderate

– EP 8: Immediate reassessment just prior to induction

• Not optional, always a 2 step process• Know where these 2 assessments are documented

CMS/TJC Anesthesia 1/11 Changes• Post-Anesthesia assessment must occur (and

be documented) within 48 hours of recovery.• No premature Post-Anesthesia Evals!!!• May be based on data collected by a nurse (as

in the case of SDS where discharge is by RN using criteria approved by the medical staff.)

• No requirement for an LIP post-sedation assessment.

• All entries to medical record are dated/timed

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Elements of Post Anesthesia Eval

• Remember required elements should conform to current standards of anesthesia care including respiratory function, rate, airway patency and O2 sat, CV function including pulse and BP, mental status, temp, pain, N+V, post-operative hydration.

Laryngoscope Blades• Clean and (at least) high level disinfect them per

manufacturer instructions for use• Store in manner that prevents recontamination• One blade per Zip-Lock bag if HLD, or • Peel pouch if steam• Consistent practice throughout the hospital

• Look everywhere!!!• Testing light source?

– Hand hygiene and/or use gloves– Place back into Zip-lock bag or peal pouch– Battery expiration dates!

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Disposable ET Tube and Stylet

• Often found in/on an anesthesia cart ready for next case where the factory package is opened and stylet is inserted to save time in a STAT induction; package is not dated or timed with new expiration date/time.

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ET Tubes/Stylets• Video-assisted laryngoscope (e.g. GlideScope)

re-usable stylets must be sterilized and packaged per manufacturer instruction– Often found unwrapped on cart ready for re-use– Check the ED and non-OR anesthetizing locations

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Most surgical complications are avoidable

• Preventable surgical site infection through flawless timing of antibiotic prophylaxis

• Preventable surgical site infections and anesthesia-related complications through flawless prep technique and checklist use

• Wrong-patient, wrong-site operations avoided through supportive culture and checklist use– Data suggests we still have 6 events per day in the US

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Just Culture by David Marx

• Human Error– Inadvertent lapse, a mistake

• At-Risk Behavior– Maybe my way is safer/better/quicker?

• Reckless Behavior– Knowingly, willfully disregarding process

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February 2009

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AAO, OMIC, ASCRS, ASORN, and OOSS Ophthalmic Surgical Checklist Task Force

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TJC Pre-Procedure Verification (UP.01.01.01)

• A Process (involves patient when possible)• Uses a standardized list (paper, EMR or

poster – need not become part of record)– Documentation (e.g., H&P, consent, nursing

assessment, preanesthesia assessment)– Labeled radiology and lab tests– Any required blood products, implants,

devices, or special equipment

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TJC Site Marking(UP.01.02.01)

• Identify procedures that require marking– Laterality, or when there is more than one

possible location, gross spinal levels– Prior to procedure outside the room, patient

involved if possible– Marked by the LIP (for all intent and purposes)– Method is unambiguous and consistent– Written alternative process

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TJC Time Out (UP.01.03.01)

• The final verification process must be conducted in the location where the procedure will be done, just before starting the procedure

• All are actively involved, paying attention• Cath, Endo, ASC, IR, bedside, etc.• Compare two identifiers on the arm band (if

visible) against the medical record, OR select one of the following three options…

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Time Out and 2 identifiersThree Options

• Two team members confirm patient ID upon arrival in the procedure suite using two identifiers.

• One of the two team members remains with the patient during the entire pre-procedure process.

• During the final time out, this team member confirms patient ID. OR• Two team members ID patient upon arrival in procedure suite as previously

described. • Two patient identifiers are written on white board in procedure room and

confirmed by the two team members. • During final time out, the team confirms patient ID against information on white

board. OR• Place a patient ID on an exposed extremity – alternate wrist or either ankle. • Reference the two identifiers on this ID band during the final time out.

Pre-Procedure Verification

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Verification of patient, procedure, site at time of admission or entry

Relevant documents match to the correct patient, procedure and site:

H&P/progress note relevant to the intended procedure

H&P is updated if performed prior to day of procedure

Nursing assessment

Pre-anesthesia/sedation assessment performed

Completed informed consent form signed by Physician (LIP) and patient

Correctly labeled diagnostic and radiology test results

Required blood products, implants, devices and/or special equipment

SCIP Measures (Antibiotic, VTE, Beta Blockers, etc.)

Pre-Induction Pause

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Has the patient confirmed his/her identity, site, procedure and consent?

Is the procedure site marked (if applicable)?

Is the anesthesia machine and medication check complete?

Is pulse oximeter on and functioning?

Does the patient have a

Known allergy?

Difficult airway/aspiration risk (if yes, is difficult airway cart in room?)

Risk of >500ml blood loss (if yes, are 2 IVs/central access and fluids planned?)

Risk of hypothermia (if yes, fluid and forced air warmer is available)

Risk of malignant hyperthermia (if yes, discussed with staff)

Pre-Incision Timeout

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Have all new team members been introduced by name and role?

Are there any anticipated critical events (e.g., airway, blood, duration)?

Time Out

What is the patient’s name? Second identifier???

What procedure is planned and does it match the informed consent?

Does the site marking match the procedure/informed consent?

Is the patient positioned correctly?

Is any alcohol based prep fully evaporated? Is any ignition source secured?

Are relevant images and results properly labeled (match pt) and displayed?

Has antibiotic been started (less than 59 minutes before incision) and are needed irrigation fluids available?

Are anticipated blood products, implants, devices, & special equipment available?

Are there any safety concerns: patient Hx, allergies, medications, position?

Intra/Post-Op Debrief/Huddle

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How shall I record the name of the procedure

Are the instrument, sponge and needle counts complete?

Have the specimens been correctly labeled and correct testing ordered?

What are the key concerns for recovery and management of this patient?

Any “went wells”?

Any “to improves”?

PRIMARY SOURCE VERIFICATION OF LICENSURE

• Only the state board website counts. May be print out or documented conversation

• Original licenses and photocopies are worthless for primary source verification

• Printout must have a date printed! • If you really do miss one and they are

unlicensed, you can get PDA

CLINICAL CONTRACTS• Patient care services that would otherwise be

performed by employees/practitioners of the hospital that are clinical in nature or would otherwise be performed by a professional.

• Laundry is not clinical, radiology technician is, sterile pharmacy compounding is, vendor night call radiologist is clinical

• TJC focuses on clinical contracts only• 3 required elements

– Contract contains performance measures– Someone evaluates performance– Medical staff has input in evaluating data

Sentinel Event Alerts• Program areas must be familiar with the

content and must have conducted an evaluation, gap analysis.

• Program areas must know what changes will be made and why other recommendations are not accepted.

• See opiate use, alarm fatigue, unintended foreign object and Jacob Cruezfeldt

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STANDARDS THAT BECOME MORE CHALLENGING WITH EMR

• “Find me the pre-anesthesia assessment”• “Show me the immediate reassessment just

prior to induction”• “Show me the immediate post procedure note”• “Show me the documentation of time out”• EMR will date and time these notes

automatically so audit and evaluate how your records look.

• Make sure staff can even find these documents

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EMR AND TIMING• Patient is being prepared for surgery in PAT.

– Physician documents H+P or update– Anesthesiologist does pre-anesthesia

assessment– Staff will document the pre-procedural

verification and final time out times.– One or more physicians may open, initiate or

document something on a post surgery page in the EMR….

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EMR AND TIMING• 6:30 am, patient arrives, IV started• H+P update 7 am• Pre-anesthesia assessment 7:15 am• Pre-procedure medication orders and IV by

anesthesia written at 7:30• Pre-procedural verification by staff 7:45• Time out 7:55• Anesthesia record case ends 10 am• Immediate post procedure note timed 7:30• Post procedure orders timed 7:30

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EMR AND TIMING

• If you want to start post procedure notes prior to the case filling out demographic, diagnostic information, make sure the note has a final time documented electronically or by author.

• If you want to write post procedure medication orders, there must be a process to pend, and un-pend them which includes physician authorization

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EMR Scavenger Hunt

1. Race and ethnicity2. Preferred language for healthcare communication

1. Evidence you provided it

3. Initial nursing assessment including:• Nutritional screen• Fall risk• Abuse screen• Skin risk assessment• Suicide risk assessment, if appropriate• Pain assessment

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EMR Scavenger Hunt4. History and physical5. Advance Directive – you asked and you tried to

obtain a copy6. Learning needs assessment7. Plan of care8. Pain assessment and reassessment - pick one

method and one location to document9. dietary consult report, if needed10. Discharge plan11. Patient education

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EMR Scavenger Hunt12. For Procedures and Surgeries:

• Informed consent with evidence of translator used if needed

• Pre-anesthesia assessment• Immediate pre-induction assessment• Pre procedure checklist• Timeout• Immediate post procedure note• Post anesthesia assessment

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EMR Scavenger Hunt13. Summary list for outpatient care14. Telephone order authentication15. Med reconciliation on admission & discharge16. PRN Medications have an indication for use17. Restraint orders, per your policy18. Restraint monitoring, per your policy19. Restraint included in the care plan20. Glucose reading and matching MAR dose administered21. RASS or Ramsey rating and matching sedation drip rate

or PTT and matching heparin drip adjustment

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What You Can Be Scored On

• The Elements of Performance/Standards• Situational rules in manual• The Frequently Asked Questions • Information found in Perspectives• Your own policies• *CMS Survey and Certification Letters*

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Clarification

• Evidence that the organization was compliant with the element of performance at the time of survey– We found it, here it is– We audited and are compliant 90% of the time

• Corrective actions do not count in your favor except for condition level findings

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MANAGING THE NON SURVEY YEARS

• Implement the new stuff as soon as published – Don’t wait!

• Do internal mock tracers• Assume nothing, rely on data to self assess• Consider smart phone or tablet applications for

tracer teams to capture, photo, fix and track compliance. (iAuditor, AuditBee, Comply Flow Audit)

DESIGN FORMS FOR ENHANCED COMPLIANCE

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Consent Obtained

... Other text …

Signed: ____________ MD

... Other text … Consent obtained.

Signed: ____________ MD

... I have examined the patient, reviewed the findings of the history and physical and any changes are specified as follows: ______________________________.

Signed: ____________ MD

H and P Updated

... Other text …

Signed: ____________ MD

Pre-induction assessment conducted.

Identify natural components of the pre-anesthesia evaluation.

Send “Checklist” to All Unit Managers

• Each manager to print or pull punch list from their TJC folder, give location specific list to staff to review:– Medication room– Hallways and nurses station– Clean utility– Dirty utility

• Each list is specific to their area, check everything, initial, call in work orders

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Help Staff by Conducting Internal Tracers:

• Train staff on what to expect during the survey

• Ask yourself, ask your staff:– Do we do this?– Where is it written we do this?– How well, or how often do we do this?– Show me the evidence that we do this– Validate the “doing” with high risk and high

priority standards

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BEHAVIORAL HEALTH TOP 10

• #1 37% CTS.03.01.03 Treatment planning– Assessed needs, strengths and preferences– Goals of the individual served– Timing and updates match policy

BEHAVIORAL HEALTH TOP 10

• #2 23% HR.02.01.03 LIP assignment of clinical responsibilities– Similar to privileges and easier to implement in

behavioral health programs affiliated with hospitals

BEHAVIORAL HEALTH TOP 10

• #3 15% CTS.02.01.05 – physical health screening– Non 24 hour programs have a written process

on health screening to determine an individuals need for a medical history and physical exam.

BEHAVIORAL HEALTH TOP 10

• #4 HR.01.06.01 15% Competency assessment– Staff are deemed competent to perform

their duties– Competencies are updated in accordance

with organization policy and frequency

BEHAVIORAL HEALTH TOP 10

• #5 NPSG.15.01.01 15% - Suicide screening– Patients are screened for the risk of suicide

and the physical environment is assessed for hazards which are mitigated or removed.

BEHAVIORAL HEALTH TOP 10

• #6 EC.02.06.01 14% - The organization maintains a safe, functional environment– If you have patient safety hazards, suicide

hazards in the environment that have not been assessed and mitigated, you will be scored.

BEHAVIORAL HEALTH TOP 10

• #7 HR.01.02.05 13% Verification of staff qualifications– Licensure using primary source, education using

any source, health screening, criminal background check if required by law or policy.

BEHAVIORAL HEALTH TOP 10

• #8 MM.03.01.01 Storage of medication– Similar issues to what was discussed in

hospitals

BEHAVIORAL HEALTH TOP 10

• #9 CTS.04.03.33 13% The organization has a process for preparing, distributing food and nutrition processes. – Sanitary storage, temperature controlled,

special diets are accommodated, cultural preferences are honored, supervision of dining areas

BEHAVIORAL HEALTH TOP 10

• #10 CTS.02.01.11 13% Screening for nutritional status– Screen newcomers to identify those for

whom a nutritional assessment is appropriate

TOP 10 CMS FINDINGS 2013TAG DESCRIPTION

A 0159 -A 0208 PATIENT RIGHTS: RESTRAINT OR SECLUSION

A 0395 RN SUPERVISION OF NURSING CARE

A 0144 PATIENT RIGHTS: CARE IN SAFE SETTING

C & A 2400 ED COMPLIANCE WITH 489.24 (MEDICAL SCREEN, NURSING, TRANSFER, STABILIZE)

A 0115 PATIENT RIGHTS

A 0396 NURSING CARE PLAN

A 0404 & 0405 ADMINISTRATION OF DRUGS

A 0123 PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION

C-0294 & A-0385 NURSING SERVICES

A 0131 PATIENT RIGHTS: INFORMED CONSENT

A-0043 & C-0241 GOVERNING BODY

A 0450 MEDICAL RECORD SERVICES

A 0116 & 0117 PATIENT RIGHTS: NOTICE OF RIGHTS

Questions?

• John R. Rosing, MHA, FACHE• johnrosing@pattonhc.com• www.pattonhc.com