Post on 14-Dec-2015
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Fletcher Allen Health CareBurlington, VT
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Dawn LeBaron, Vice President for Hospital ServicesJack Conry, Director of Security, Safety, and ParkingLindsay Harbour, Safety Specialist
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Fletcher Allen Health Care
Three Main Campuses:
Medical Center Campus Fanny Allen Campus University Health Center (UHC) Campus 45+ Satellite Campuses
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Medical Center Campus
Largest Campus – hospital occupancy
Facility = 1.5 million SF
Surface Parking & Grounds = 1 million SF
Two Garages = 585,000 SF
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Fanny Allen Campus
2nd Largest Campus – hospital occupancy
Facility = 118,000 SF
Surface Parking & Grounds = 948,000 SF
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University Health Center Campus
Physician Offices – business occupancy
Facility = 250,000 SF
Surface Parking & Grounds = 273,000 SF
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Serving a population of one million: Level 1 Trauma Center 562 licensed beds, 458 staffed 2,183 births 50,419 inpatient and outpatient
admissions 60,356 emergency department visits 1,108,682 physician encounters
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2.4 million lab tests 1.44 million meals served 6,700 employees (including per diem & part-
time) 450 UVM Medical Group physicians (770 total
medical staff) 280 house staff (physicians in specialty training);
15 residency programs $8.7 million in charity care
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Today’s Discussion: Health care regulatory agencies CMS overview What lead to a full CMS survey at Fletcher Allen The CMS Life Safety tour and findings Life Safety hot spots EOC hot spots Fletcher Allen’s full Joint Commission Survey
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Regulatory Agencies
Fletcher Allen is reviewed by 30+ agencies.
Primary agencies are:
Joint Commission Centers for Medicare /Medicaid Services ( CMS) State / Local Licensing Agencies
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Fletcher Allen Health Care
FY11 (3 quarters)
10/1/10 – 6/30/11
27 Regulatory
“Site Visits”
AgencyName On-Site Visits
Division of Licensing and Protection 10
CMS 3
Food and Drug Administration 3
VOSHA 2
Joint Commission 2
American Association of Blood banks 1
American College of Surgeons Trauma 1
Division of Alcohol and Drug Abuse Program 1
Division of Mental Health 1
Environmental Protection Agency (EPA) 1
Homeland Security 1
Nuclear Regulatory Commission 1
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Division of Alcohol and Drug Abuse Program, 1
Division of Licensing and Protection, 10
Division of Mental Health, 1
Environmental Protection Agency (EPA), 1
Food and Drug Administration, 3
Homeland Security, 1
Joint Commission, 2
Nuclear Regulatory Commission, 1
VOSHA, 2
American Association of Bloodbanks, 1
American College of Surgeons Trauma, 1
CMS, 3
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Fletcher Allen Regulatory Site Visits:
Division of Licensing and Protection/ CMS (13) Complaint Allegation Surveys (10) Full Survey (1) Durable Medical Equipment (2)
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Other agencies (14) Joint Commission (2)
1 in response to CMS findings 1 Stroke Certification
Environmental Protection Agency (1) Nuclear Regulatory Commission (1) FDA (3) Department of Mental Health (1) American College of Surgeons (1) VOSHA (2) American Association of Bloodbanks (1) Homeland Security (1) Division of Alcohol and Drug Abuse (1)
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Regulatory Costs:
Year to Date = $177, 000 Includes: Escort, coordination of surveys,
survey interview sessions, development of POC and writing of plans.
Other costs: TJC follow up survey = $5,000
Total = $182,000
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Who is CMS?
A branch of the U.S. Department of Health and Human Services.
A federal agency that: administers the Medicare program and monitors the Medicaid programs offered by each
state. The United States is set up into sections of CMS
boards Vermont reports to the Boston section.
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What Triggers a CMS Survey?
Complaint Allegation
Self Report – Obligated to report: Allegations of abuse “Critical Incidents” in Mental Health (VT)
Validation Survey Within 60 days of TJC survey A quality check on TJC
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CMS Survey Results:
“Statement of Deficiencies”
No Findings Standard Level Finding Conditional Level Finding Immediate Jeopardy
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Standard Level Finding:
Typically do not require a response However if an organization is found to be out of compliance at
the condition level from a previous finding – they require response/ follow up survey
Condition Level Finding:
Requires a formal organizational response. It triggers:
A follow-up “focused survey” and A full CMS survey
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Immediate Jeopardy: Defined by CMS as:
“A crisis situation in which the health and safety of individuals are at risk (see §SOM 3010).”
It carries a threat of termination procedures if “conditions” are not resolved within 23 days.
The hospital can lose Medicare funding. Requires a formal response by organization It triggers:
A follow-up “focused survey” and A CMS “full survey” and A follow-up “Joint Commission” survey
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Monday, December 20, 2010 3 surveyors arrive unannounced
for a 3 day survey 4 complaint allegations, 1
involving the Cardiac Cath LabCath Lab complaint allegation involved patient complaint about consent (only physician can treat).
No EOC involvement at this point
Tuesday, January 11, 2011 2 surveyors arrive unannounced
for a 2 day survey Follow-up from the 12/20/10
survey Focus of survey is Cardiac Cath
Lab and EP (Electrophysiology) Service
Tuesday, January 11, 2011 End of the day tour of Cath Lab. Debris and brown stains on the
floor. Cleaning process described.
Wednesday, January 12, 2011 7:30 am continuation of the Cath
Lab tour from 1/11/11. Room Cleaning – Trash emptied,
but debris and stains still on floor. Patient scheduled for 8:00 am
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Cath Lab Survey Results-1/13/11
Four “Condition Level” Findings: Governance Medical Staff Infection Control Patient Rights & Ethics
Plan for Correction (POC) due 2/8/11
Sparked a full unannounced CMS survey
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Statement of Deficiencies&
Plan of Correction
Corrective action the hospital will being implementing
Plan for educating
Plan for monitoring
CMS Form 2567
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Wednesday, January 19, 2011
3 surveyors arrive unannounced for a 3 day survey (complaint allegation)
Survey focused on the Emergency Department and EMTALA
EMTALA Emergency Medical Treatment and Labor Act Perform medical screening exam Treat/ stabilize
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EMTALA Survey Results
Immediate Jeopardy!
Posting of Signs (489.20.q) Medical Screening Exam (489.24.c) Stabilizing Treatment (489.24.c.1-3)
Plan of Correction Sparked a CMS focused survey Sparked another CMS full survey! Sparked a JC follow-up survey
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Tuesday, March 8, 2011
Full CMS Survey:
13 surveyors arrive unannounced for a 4 day full CMS full survey (includes 2 Life Safety Surveyors)
Originally sparked by December 2010 Cath Lab complaint allegation.
Full Survey offers CMS surveyors the opportunity to look at all self reports.
Thursday, March 10, 2011
1 TJC surveyor arrives unannounced for a 1 day survey
A follow-up survey to the EMTALA finding.
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Surveyor 1 Surgical Services Medical Records Infection Control Nursing: SICUSurveyor 2 Discharge Planning UR Emergency Services Nursing: OB, NICU, Pedi ICUSurveyor 3 & 4 Rehab: Cost reporting Rehab Services Outpatient Services Nursing: McClure 6Surveyor 5 Psych Unit (with Surveyor 9) Psych Unit Complaints (2) Organ & Tissue ProcurementSurveyor 6 Compliance with local, state, federal laws Governing Body Emergency Services (with Surveyor 2) Medical Staff Nursing: Administrative Review
Surveyor 7 Pharmacy with 1 complaint Radiology Nuclear Nursing: MICU, Baird 6Surveyor 8 Laboratory Services Physical Environment Respiratory Services Nursing: Shepardson 6, Baird 4Surveyor 9 Psych Unit (with surveyor 5) Shepardson 3, Shepardson 6Surveyor 10 & 11 Anesthesia Services Patient Rights QAPISurveyor 12 (Life Safety) ½ of Medical Center Campus Fanny Allen Campus 4 Satellite CampusesSurveyor 13 (Life Safety) ½ of Medical Center Campus UHC Campus 2 Satellite Campuses
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Fletcher Allen’s Survey Plan:
CMS survey team assigned a large conference room as their home base.
Each CMS surveyor assigned a Fletcher Allen point of contact and escort.
Fletcher Allen home base established in close proximity to the CMS home base.
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CMS Full Survey:
An opportunity for surveyors to review all
“self reports”
Plastic wrist restraints Pepper spray
Immediate Jeopardy!
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Full Survey “Hot Spots”
Infection Prevention Dressing changes Sterile technique Toys in waiting rooms Cleaning of glucometersMedication Security Med carts locked Handling of medsEOC Refrigerator logs Hallway clutter Alarm responsePatient Confidentiality Use of WOW’s
Resuscitation Carts Checked per written policyMedical Records Were orders carried out Documentation of action takenPain Assessment Multidisciplinary assessment Documenting assessments Completion of care plans Assessment per policyRestraints Written order Documentation according to policyQuality & Safety Explain PI process and projects
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Environment of Care Issues:
Remember: 13 surveyors look at all of the EOC
Goose neck faucets on Psychiatric Unit Shower controls on Psychiatric Unit Loose handrails in hallways Emergency Lighting in “procedure
rooms” Security of the Operating Room Access signs for the Operating room Refrigerator temperature logs in
Dietary Temperature and humidity logs in CSR Cracked vinyl (tables and mattresses)
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CMS Life Safety Tour:
Two Life Safety surveyors – Both state fire marshals
Two Fletcher Allen escorts
Four Facilities Management/Safety escorts
Survey locations divided in two
Main hospital campus and two satellites
Fanny Allen campus and four satellites
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Life Safety ‘Hot Spots”
Fire stopping Door closers Fire doors close and latch Stairwell storage Door jambs with no doors Delayed egress signs Emergency lighting tests Obstructed pull stations GFCI outlets – 6’ from water Extension cords
Smoke Detectors spacing 36” from air supply
Power cord daisy chains Sprinkler heads in storage
closets Storage within 18” of sprinkler Electrical Panels
Labeling (including spares) Open spaces Broken latches
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CMS Home Base
13 Surveyor talking among themselves
Life Safety surveyor to Ambulatory Site surveyor:
“Did you know that they are doing surgery at their Plastic Surgery site without emergency lighting?”
Immediate Jeopardy!
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90 Life Safety Findings: GFCI outlets (22) Smoke detector/air handler (8) Power strips interconnected (7) Electrical panel labeling (5) Smoke detector spacing (4)
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90 Life Safety Findings (continued): Penetrations/fire stopping (4) Sprinkler head needed (4) Door self closer needed (4) Fire door does not close and latch (3)
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90 Life Safety Findings (continued): Electrical panel, open spaces (3) Extension cords (3) Electrical panel, broken latch (2) Stairwell storage (2) Kitchen hoods needed for frying (3)
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90 Life Safety Findings (continued): Emergency light malfunction (1) Emergency light needed in
generator room (1) Pull station blocked (1) Store room door removed (1) Pre-action valve in stairwell (1) Dirty smoke detector (1) Storage 18” of sprinkler (1) Strobe light blocked (1) Outlet cover broken (1) Cabinet on power cord (1)
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90 Life Safety Findings (continued): Suspended light blocking sprinkler (1) Breaker lock missing (1) Delayed egress sign (1) Delayed egress not approved (1) Fire proofing spray on metal beam (1) Cooking staff knowledge of fire
suppression system (1) Wires above ceiling not supported (1) Emergency light malfunction (1)
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CMS Lessons Learned:
It doesn’t matter how old the building. It is still held to current standards.
Know your “procedure rooms”.
Alert others in advance about the route of the tour.
In most cases, arguing gains nothing.
Surveyors take pictures and share with other surveyors.
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Joint Commission Survey
Joint Commission Full Survey
Monday, August 15, 2011
Seven (7) surveyors including one (1) Life Safety Engineer
Full five (5) day survey
Two (2) day Life Safety survey
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Joint Commission Survey
Environment of Care & Emergency Management Session:
Documents provided upon arrival: EOC Committee Meeting Minutes Management Plans Emergency Operation Plan Annual Program Evaluations Hazard Vulnerability Analysis Inventory of Assets and Resources
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Joint Commission Survey
EOC & EM Issues:
EM.02.02.13 (EP2) – Not documented in the medical staff bylaws who may grant disaster privileges.
EC.02.06.01 (EP1) – Clean utility room with storage stacked too high to the ceiling. Hazardous to staff.
EC.02.02.01 (EP5) – Unlocked soiled utility room with hazardous items accessible to children (used AA batteries and bottles of cleaning solution).
IC.02.02.01 (EP3) – Expired surgical gloves, biogel gloves, and tampons.
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Joint Commission Survey
LD.04.01.01 (EP3) – Exposed pipes under sinks in handicapped bathrooms (ADA violation).
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Joint Commission Survey
Life Safety Survey:
Day One:
Documentation Review
Day Two:
Building Tour
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Joint Commission Survey
TJC Life Safety Survey:Fletcher Allen Issues
EC.02.03.05 (EP6) – Documentation that electric fire pumps were run weekly for 10 minutes.
EC.02.03.05 (EP10) – No documentation for the quarterly inspection of water supply connections.
EC.02.03.05 (EP19) – No inventory of fans to ensure that all air handling units shut down properly.
EC.02.05.07 (EP4) – 42 days between generator tests one month of the year.
EC.02.05.07 (EP6) – 42 days between automatic transfer switch test one month of the year.
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Joint Commission Survey
TJC Life Safety Survey:Fletcher Allen Issues (continued)
EC.02.05.07 (EP7) – No documentation that emergency generator was operated for 4 continuous hours at least every 36 months.
EC.02.05.07 (EP8) – No documentation that emergency generator was operated at 30% nameplate rating for 4 continuous hours at least every 36 months.
LS.01.02.01 (EP3) – Written ILSM risk assessments not completed for each SOC Plan for Improvement.
LS.02.01.10 (EP5) – Fire door did not close and latch with vertical gap greater than 1/8”.
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Joint Commission Survey
TJC Life Safety Survey:|
Issues continued:
LS.02.01.01 (EP6) – Fire door with kick plate larger than 16”.
LS.02.01.20 (EP13) – Hallway clutter (medication carts and soiled linen hampers).
LS.02.01.35 (EP4) – Conduit and HVAC duct resting on sprinkler pipes.
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Joint Commission Survey
Joint Commission Lessons Learned:
Documentation – Get it to the surveyors early.
Binders – Develop binders for documents the surveys are likely to request.
Have a plan for replacing organizational “experts”, if they are “on vacation”.
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Fletcher Allen Contact Information:
Dawn LeBaron, Vice President for Hospital Services 802-847-2805 Dawn.lebaron@vtmednet.org
Lindsay Harbour, Safety Specialist 802-847-2284 Lindsay.harbour@vtmednet.org
Jack Conry, Director of Security, Safety, and Parking 802-847-2812 Jack.conry@vtmednet.org