Center for Medicare and Medicaid Services and Joint Commission Hospital Survey Process

1. Center for Medicare and Medicaid Services andJoint Commission HospitalSurvey Process 2009

2. Complaint Investigations – General • Complaint Investigations - EMTALA • Full Survey • Medicare Recertification Survey - for non-accredited, every 3-5 years (Deemed Status) • Validation Survey - authorized by CMS 60 days following the Accrediting Organization survey • Surveys based on Conditions of Participation found at CFR 42.485 (CAH) and CFR 42.482 (Hospitals) • All surveys are unannounced www.cms.hhs.gov/manuals/downloads/som107ap_w_cah.pdf www.cms.hhs.gov/manuals/downloads/som107ap_a_hosptials.pdf Surveys Types

3. All inpatients with name, age, diagnoses, admission date, room number, and attending physician • 25 most frequent diagnoses & most frequent surgical procedures • Departments with manager or director’s name • Licensed employees and a copy of the nursing staffing policy • Credentialed medical staff and those with surgical privileges • Contracted services • Location of all patient care and treatment areas • Names/addresses of off-site locations operating under same provider number • Facility’s organizational chart • Infection Control Plan • Medical Staff bylaws and rules and regulations • Meeting Minutes of the Governing Body and Medical Staff • And any other information needed to complete the Center for Medicare and Medicaid Services (CMS) Hospital/CAH Medicare Database Worksheet Documents requested at Entrance Conference

4. They hate cleaning! They make the beds, they do the floors and six months later you have to start all over again. Is This How Your Patients Feel About Your Hospital?

5. Tour and inspect all patient care and treatment areas, pharmacy, dietary, medical records, off site areas, etc. • Conduct patient and staff interviews • Review: • At least 20-30 inpatient records • Outpatient, emergency department records depending on hospital type • Policies and procedures • Quality Assurance/Performance Improvement data • Governing Body, Medical Staff meeting minutes • Infection Control Plan, data and minutes The Survey Process

6. Dietary Services discussed with patients

7. Compliance with Hospital Requirements and applicable laws Status and Location Agreements Emergency Services # of Beds & Length of Stay Physical Plant and Environment Organizational Structure Staffing and Staff Responsibilities Provision of Services Clinical Records Surgical Services Periodic Evaluation & Quality Assurance Review Organ, Tissue and Eye Procurement Special Requirements for CAH Providers of Long-Term Care Services (Swing beds) Conditions of Participationfor CAH

8. Compliance with Federal, State and Local Laws Governing Body Patients’ Rights Quality Assessment and Performance Improvement Medical Staff Nursing Services Medical Records Pharmaceutical Services Radiological Services Laboratory Services Food and Dietetic Services Utilization Review Physical Environment Infection Control Discharge Planning Organ, tissue and Eye Procurement Surgical Services Anesthesia Services Nuclear Medicine Outpatient Services Emergency Services Rehabilitation Services Respiratory Services Conditions of Participation for Hospitals

9. All hospital –type beds located in the CAH will be counted to establish the 25 bed limit with the exception of the following: • Examination or procedure tables • Stretchers • Operating room tables and recovery room stretchers • Beds in obstetric delivery • Newborn bassinets and isolettes • Stretchers in emergency departments • Beds in Medicare certified distinct part rehabilitation or psychiatric units CFR 485.620(a)Number of Beds

10. Observation services are defined as services furnished by a CAH to evaluate an outpatient’s condition to determine the need for discharge or possible admission as an inpatient. (The maximum stay is 48 hours, medically necessary with a physician’s order) • Observation stays fall under Part B and require coinsurance. CAH must give written notice of non-coverage to the beneficiary prior to stay. • Beds used by patients on observation status, that conform to the hospital-type beds, will be counted as part of the maximum bed count. • Outpatient observation patient should not be commingled with inpatients Bed count continued …..

11. Medicare Payments Updated

12. Condition at 485.641 Periodic Evaluation and Quality Assurance Review Most common COP out of compliance for theHealth survey for a CAH

13. The CAH must ensure that specific periodic evaluation and quality assurance review requirements are met. • Annual Program Evaluation • Periodic Evaluation: • Services • Patient Records • Policies • Changes generated • Quality Assurance (QA) Review: • Quality of Patient Care • Medications & Infections • MD/DO Oversight • Contracted MD/DO Oversight • Performance Improvement • Documentation CFR 485.641 Periodic Evaluation & QA Review

14. Navigating A Hospital

15. The evaluation is done at least once a year. Includes: • Review of the utilization of CAH services • Review of representative sample of clinical records (not less than 10% of active and closed, inpatient and outpatient records) • Review of health care policies • Review of data and actions taken • Effectiveness of Quality Assurance program to include: • Review of all patient care services, medication therapy and nosocomial infections • MD/DO evaluate care provided by NP, CNS or PA • Quality review by another hospital that is a member of the network, QIO or equivalent or other qualified entity identified in the State rural health care plan of diagnoses and treatment at the CAH • Consideration of the findings/recommendations of the QIO and corrective action taken if necessary • Appropriate remedial action taken by CAH to address deficiencies found in QA program Annual Program Evaluation

16. Patient Rights • Quality Assessment & Performance Improvement (QAPI) • Nursing Service Most common COPs out for the Health Survey of a Hospital

17. If deficiencies are found, the facility will receive CMS form 2567 within 10 working days • The facility must return the 2567 with a plan of correction (PoC) within 10 calendar days • Findings are sent to Center for Medicare and Medicaid Services (CMS) Survey Completion

18. Planned action to correct the deficiency and expected completion date • Be specific and realistic in stating exactly how the deficiency was or will be corrected • Monitoring procedures to ensure that the plan of correction is effective • Title of the person responsible for implementation of the plan of correction • The PoC must be signed and dated by the administrator or other authorized official PoC Requirements

20. For hospitals that use Joint Commission accreditation for deemed status purposes: A physician or other authorized licensed independent practitioner primarily responsible for the patient’s ongoing care orders the use of restraint or seclusion in accordance with hospital policy and law and regulation. Note: The definition of physician is the same as that used by CMS (refer to the Glossary) 2009 Standard: PC.03.05.052009 EP: 1

21. For hospitals that use Joint Commission accreditation for deemed status purposes: The attending physician is consulted as soon as possible, in accordance with hospital policy, if he or she did not order the restraint or seclusion. Note: The definition of physician is the same as that used by CMS (refer to the Glossary) 2009 Standard: PC.03.05.05 2009 EP: 3

22. For hospitals that use Joint Commission accreditation for deemed status purposes: Unless state law is more restrictive, every 24 hours, a physician or other authorized licensed independent practitioner primarily responsible for the patient’s ongoing care sees and evaluates the patient before writing a new order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others in accordance with hospital policy and law and regulation. Note: The definition of physician is the same as that used by CMS (refer to the Glossary) 2009 Standard: PC.03.05.05 2009 EP: 5

23. Restraint Policy?

24. For hospitals that use Joint Commission accreditation for deemed status purposes: Orders for restraint used to protect the physical safety of the nonviolent or non–self-destructive patient are renewed in accordance with hospital policy. 2009 Standard: PC.03.05.05 2009 EP: 6

25. For hospitals that use Joint Commission accreditation for deemed status purposes: Physicians or other licensed independent practitioners or staff who have been trained in accordance with 42 CFR 482.13(f) monitor the condition of patients in restraint or seclusion. (See also PC.03.05.17, EP 3) Note: The definition of physician is the same as that used by CMS (refer to the Glossary) 2009 Standard: PC.03.05.07 2009 EP: 1

26. Time frames for assessing and monitoring patients in restraint or seclusion Note 1: The definition of restraint per 42 CFR 482.13(e)(1)(i)(A–C) is as follows: 42 CFR 482.13(e)(1) Definitions. (i) A restraint is— (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or 42 CFR 482.13(e)(1)(i)(B) (A restraint is— ) A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. 42 CFR 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (does not include physical escort). 2009 Standard: PC.03.05.092009 EP: 1

27. 2009 Standard: PC.03.05.092009 EP: 1 continued…. Time frames for assessing and monitoring patients in restraint or seclusion Note 2: The definition of seclusion per 42 CFR 482.13(e)(1)(ii) is as follows: Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may be used only for the management of violent or self-destructive behavior. Note 3: The definition of physician is the same as that used by CMS (refer to Glossary).

28. For hospitals that use Joint Commission accreditation for deemed status purposes: Physicians and other licensed independent practitioners authorized to order restraint or seclusion (through hospital policy in accordance with law and regulation) have a working knowledge of the hospital policy regarding the use of restraint and seclusion. 2009 Standard: PC.03.05.09 2009 EP: 2

29. A physician or other licensed independent practitioner responsible for the care of the patient evaluates the patient in-person within one hour of the initiation of restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others. A registered nurse or a physician assistant may conduct the in-person evaluation within one hour of the initiation of restraint or seclusion; this individual is trained in accordance with the requirements in PC.03.05.17, EP 3. Note 1: States may have statute or regulation requirements that are more restrictive than the requirements in this element of performance. 2009 Standard: PC.03.05.112009 EP: 1

30. For hospitals that use Joint Commission accreditation for deemed status purposes: When the in-person evaluation (performed within one hour of the initiation of restraint or seclusion) is done by a trained registered nurse or trained physician assistant, he or she consults with the attending physician or other licensed independent practitioner responsible for the care of the patient as soon as possible after the evaluation, as determined by hospital policy. 2009 Standard: PC.03.05.112009 EP: 2

31. The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others, includes the following: • - An evaluation of the patient's immediate situation • - The patient's reaction to the intervention • - The patient's medical and behavioral condition • - The need to continue or terminate the restraint or seclusion 2009 Standard: PC.03.05.11 2009 EP: 3

32. Documentation of restraint and seclusion includes: • Any in-person medical and behavioral evaluation used to manage violent or self-destructive behavior • Description of the patient’s behavior and the intervention used • Any alternatives or other less restrictive interventions attempted • Patient’s condition/symptom(s) that warranted use of restraint and seclusion • Patient’s response to the intervention(s), including the rationale for continued use of the intervention • Individual patient assessments and reassessments • Intervals for monitoring revisions to the plan of care 2009 Standard: PC.03.05.152009 EP: 1

33. 2009 Standard: PC.03.05.15 2009 EP: 1 continued… Documentation of restraint and seclusion includes: • Patient’s behavior and staff concerns regarding safety risks to the patient, staff, and others that necessitated the use of restraint and seclusion • Injuries to the patient or death associated with the use of restraint and seclusion • Identity of the physician or other licensed independent practitioner who ordered the restraint and seclusion • Orders for restraint and seclusion • Notification of the use of restraint and seclusion to the attending physician

34. Based on the population served, staff education, training, and demonstrated knowledge focus on the following: - Strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion - Use of nonphysical intervention skills - Methods for choosing the least restrictive intervention based on an assessment of the patient’s medical or behavioral status or condition - Safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia) 2009 Standard: PC.03.05.172009 EP: 3

35. 2009 Standard: PC.03.05.17 2009 EP: 3 continued… Based on the population served, staff education, training, and demonstrated knowledge focus on the following: - Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary - Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including, but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the in-person evaluation conducted within one hour of initiation of restraint or seclusion - Use of first-aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification

36. The deaths addressed in PC.03.05.19, EP 1 are reported to the Centers for Medicare & Medicaid Services (CMS) by telephone no later than the close of the next business day following knowledge of the patient’s death. • The date and time that the patient's death was reported is documented in the patient's medical record. 2009 Standard:PC.03.05.19 2009 EP: 2

37. For hospitals that use Joint Commission accreditation for deemed status purposes: Staff document in the patient’s medical record the date and time the patient death was reported to the Centers for Medicare & Medicaid Services This requirement was removed since it was already covered in existing elements of performance or was addressed in The Joint Commission survey process 2008 Standard:PC.03.05.19 2008 EP: 3

38. For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital designates an individual to direct dietary services and oversee its daily management, whether the services are provided by the hospital or through a contracted service. This individual is a full-time employee who is qualified by experience and training This requirement was removed since it was already covered in existing elements of performance or was addressed in The Joint Commission survey process. 2008 Standard: HR.01.01.01 2008 EP: 25

39. Oversee Dietary Services

40. For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a dietitian on a full-time, part-time, or consultant basis. This requirement was removed since it was already covered in existing elements of performance or was addressed in The Joint Commission survey process. 2008 Standard: HR.01.01.01 2008 EP: 26

41. Utilization Review: • NO CHANGES Utilization Review Changes

42. Utilization Review Starts Early

43. Provides information on how well hospitals in different areas care for their adult patients with certain medical conditions. • Debuted on March 31, 2005 – 10 Quality Measures • Currently features 26 Measures • New enhancements include Hospital Surveys and Volume and Payment Data Hospital Compare Background 43

44. Measures how often hospitals provide recommended care to get the best results for adult patients. Reporting Criteria: • Voluntarily submitted by acute care and critical access hospitals • All payer types reported Process of Care Measures: • Eight (8) measures related to heart attack care • Four (4) measures related to heart failure care • Six (7) measures related to pneumonia care • Five (5) measures related to surgical infection prevention Hospital Process of Care Measures 44

45. Getting Best Results?

46. Display of Process of Care Measures 46

47. 47

48. Display of Process of Care Measures 48

49. Predicts patient deaths for any cause within 30 days of hospital admission for heart attack or heart failure, whether the patients die while in the hospital or after discharge. Reporting Criteria: • Voluntarily submitted by acute care hospitals • Original (fee-for-service) Medicare payer Outcome Measures: • One (1) measure related to 30-day heart attack mortality • One (1) measure related to 30-day heart failure mortality Hospital Outcome Measures 49

50. Hospital Outcome Measures 50