State Survey for Licensure of Hospitals

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