1 Center for Medicare and Medicaid Services and Joint Commission Hospital Survey Process 2009.

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Center for Medicare and Center for Medicare and Medicaid Services andMedicaid Services and

Joint Commission HospitalJoint Commission HospitalSurvey ProcessSurvey Process

2009

2Surveys TypesSurveys Types

Complaint Investigations – GeneralComplaint Investigations - EMTALAFull Survey Medicare Recertification Survey - for non-accredited,

every 3-5 years (Deemed Status)Validation Survey - authorized by CMS 60 days

following the Accrediting Organization surveySurveys 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.pdfwww.cms.hhs.gov/manuals/downloads/som107ap_a_hosptials.pdf

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Documents requested at Documents requested at Entrance ConferenceEntrance Conference

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 Center for

Medicare and Medicaid Services (Medicare and Medicaid Services (CMS) Hospital/CAH Medicare Database Worksheet

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Is This How Your Patients Feel Is This How Your Patients Feel About Your Hospital?About Your Hospital?

They hate cleaning! They make the beds, they do the floors and six months later you have to start all over again.

5The Survey ProcessThe Survey Process

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

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Dietary Services discussed Dietary Services discussed with patientswith patients

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Conditions of ParticipationConditions of Participation for CAHfor CAH

Compliance with Hospital Requirements and applicable laws

Status and LocationAgreementsEmergency Services# of Beds & Length of StayPhysical Plant and

EnvironmentOrganizational StructureStaffing and Staff

Responsibilities

Provision of ServicesClinical RecordsSurgical ServicesPeriodic Evaluation &

Quality Assurance Review

Organ, Tissue and Eye Procurement

Special Requirements for CAH Providers of Long-Term Care Services (Swing beds)

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Conditions of Participation for Conditions of Participation for HospitalsHospitals

Compliance with Federal, State and Local Laws

Governing BodyPatients’ RightsQuality Assessment and

Performance ImprovementMedical StaffNursing ServicesMedical RecordsPharmaceutical ServicesRadiological ServicesLaboratory ServicesFood and Dietetic Services

Utilization ReviewPhysical Environment Infection ControlDischarge PlanningOrgan, tissue and Eye

ProcurementSurgical ServicesAnesthesia ServicesNuclear MedicineOutpatient ServicesEmergency ServicesRehabilitation ServicesRespiratory Services

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CFR 485.620(a)CFR 485.620(a)Number of BedsNumber of Beds

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 tablesStretchersOperating room tables and recovery room stretchersBeds in obstetric deliveryNewborn bassinets and isolettesStretchers in emergency departmentsBeds in Medicare certified distinct part rehabilitation

or psychiatric units

10Bed count Bed count continued …..continued …..

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

11Medicare Payments UpdatedMedicare Payments Updated

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Most common COP Most common COP out of compliance for theout of compliance for theHealth survey for a CAHHealth survey for a CAH

Condition at 485.641 Periodic Evaluation and

Quality Assurance Review

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CFR 485.641 CFR 485.641 Periodic Evaluation & QA ReviewPeriodic Evaluation & QA Review

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

14Navigating A HospitalNavigating A Hospital

15Annual Program EvaluationAnnual Program Evaluation

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

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Most common COPs out for the Most common COPs out for the Health Survey of a HospitalHealth Survey of a Hospital

Patient Rights Quality Assessment & Performance

Improvement (QAPI)Nursing Service

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Survey CompletionSurvey Completion

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)

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PoC RequirementsPoC Requirements

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

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2009 Standard: PC.03.05.052009 Standard: PC.03.05.052009 EP: 12009 EP: 1

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)

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2009 Standard: PC.03.05.05 2009 Standard: PC.03.05.05 2009 EP: 32009 EP: 3


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.


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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.


23Restraint Policy?Restraint Policy?

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Orders for restraint used to protect the physical safety of the nonviolent or non–self-destructive patient are renewed in accordance with hospital policy.

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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)


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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).

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2009 Standard: PC.03.05.092009 Standard: PC.03.05.092009 EP: 1 2009 EP: 1 continued….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).

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2009 Standard: 2009 Standard: PC.03.05.09 2009 EP: 2PC.03.05.09 2009 EP: 2


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.

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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.

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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.

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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

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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

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2009 Standard: PC.03.05.15 2009 Standard: PC.03.05.15 2009 EP: 1 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

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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)

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2009 Standard: PC.03.05.17 2009 Standard: PC.03.05.17 2009 EP: 3 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

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2009 Standard:PC.03.05.19 2009 Standard:PC.03.05.19 2009 EP: 22009 EP: 2

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.

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2008 Standard:PC.03.05.19 2008 Standard:PC.03.05.19 2008 EP: 32008 EP: 3


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

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2008 Standard: HR.01.01.01 2008 Standard: HR.01.01.01 2008 EP: 252008 EP: 25


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.

39Oversee Dietary ServicesOversee Dietary Services

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2008 Standard: HR.01.01.01 2008 Standard: HR.01.01.01 2008 EP: 262008 EP: 26


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.

41Utilization Review ChangesUtilization Review Changes

Utilization Review:

NO CHANGES

42Utilization Review Starts EarlyUtilization Review Starts Early

4343Hospital Compare BackgroundHospital Compare Background

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

4444Hospital Process of Care MeasuresHospital Process of Care Measures

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

45Getting Best Results?Getting Best Results?

4646

Display of Process of Care MeasuresDisplay of Process of Care Measures

4848

Display of Process of Care MeasuresDisplay of Process of Care Measures

4949Hospital Outcome MeasuresHospital Outcome Measures

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

5050

Hospital Outcome MeasuresHospital Outcome Measures

5151

Hospital Consumer Assessment and Hospital Consumer Assessment and Healthcare Systems (HCAPHS) SurveyHealthcare Systems (HCAPHS) Survey

Standardized survey instrument for measuring patients’ perspectives of hospital care. Reporting Criteria:

1.Voluntarily submitted by acute care and critical access hospitals

2.All payer types reported

Sample of Questions: 1.How often did nurses communicate well with patients?2.How often did patients receive help quickly from

hospital staff?3.How often did staff explain about medicines before

giving them to patients?4.How often was patients’ pain well controlled?5.How often were patients room and bathrooms cleaned?

5252

Display of HCAPHS SurveyDisplay of HCAPHS Survey

5353

Display of HCAPHS SurveyDisplay of HCAPHS Survey

5454MedicareMedicare Payment and Volume Data Payment and Volume Data

The data represents Medicare inpatient hospital payment information and the number of patients treated (volume) for a limited set of conditions and surgical procedures.

Reporting Criteria: 1. Submitted by acute care hospitals2. Medicare billing information

Measures: • Average Medicare Payment• Number of Patients Treated

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QuestionsQuestions

1 Center for Medicare and Medicaid Services and Joint Commission Hospital Survey Process 2009.

Documents

Transcript of 1 Center for Medicare and Medicaid Services and Joint Commission Hospital Survey Process 2009.