Overview of State Hospital Licensing Survey

Linda L. Foss PhD, RNExecutive Director Clinical Care FacilitiesOffice of Inspections and Investigations

Department of Health

Linda L. Foss

Executive Director

Clinical Care Facilities

• Survey Process• Regulatory Framework

Survey• Purpose of survey is determine

compliance with state licensing requirements

• State licensing requirements are minimum

What are we looking for?

Compliance

Survey Components • Observations

• Interviews

• Record review

Washington Administrative Code • Purpose and

Applicability• Licensing• Patient Care• Environment of Care

Management

• Design, Construction Review, and Approval of Plans

Hospital Responsibilities• Comply with RCW 70.41• Set up only the number of beds licensed • Notify with 2 business days of completion

accreditation survey • Notify in writing of accreditation decision

or status change in 30 days

Governance• Informing patient

of any unanticipated outcomes

• Establish and review governing authority policies

• Performance Plan• Organizational

Management• Reporting

Practitioners

Governance• Approve an

appoint medical staff

• Authenticated of orders by authorized practitioner

• Approve and Review Medical Staff bylaws

Criminal history, disclosure, and background inquiries

• Employee,• Contractor,• Volunteer, • Student

Access to• Children under 16 • Vulnerable adults• Developmentally

disable individuals

Patient Rights/Organizational Ethics

• Respect • Dignity• Confidentiality• Privacy• Complaint

resolution,

• Spiritual care• Communication• Free from abuse

and neglect

Patient Rights/Organizational Ethics • Involved in care • Right to refuse care• Advised of

unanticipated outcomes

• To be informed and agree with care

• Advanced directives• Request DNR• Right to donate

organs• Access protective

services

New Definitions • Victim of sexual assault" means a person

is alleged to have been sexually assaulted and who presents as a patient.

• Vulnerable Adult-includes hospitalized adults.

Leadership• Assessing patient and family satisfaction

of services• Posting Complaint Hotline• Provide patient with written billing

statements

Leadership • Provide for safe haven for abandoned

newborns • Provide of organization wide

performance improvement activities

Leadership• Assign a nurse at the executive level

• Establish hospital wide patient care services

Adverse Events Reporting • Process is now outlined in the WAC• Reported to Linda Furkay PhD, RN

Toll Free Hotline for Reporting Adverse Events

1-888-524-6257

Reportable Events • Failure or facility system malfunction such

as • Heating, ventilation, fire alarm• Water supply electrical• Information management

• Must Notify DOH-Office of Inspections and Investigation.

Notification • Who• Linda Foss • Phone 360-236-

2920• Fax number-

360-586-0123• linda.foss@doh.

wa.gov

• What• Type of event• Date of event

Management of Human Resources

• Job descriptions• Staff performance• Assure qualified staff• Supervision of staff• State licensure, certification, registration• TB screening

Education for staff • Orientation • Education

Blood borne pathogen exposure control HIV

Multi-drug resistant organisms

Qualified Staff

• License, registration certification

• Job description• Orientation• Performance

evaluation

• Supervision • Staff working within

scope of practice• Competency

Medical Staff Bylaws • Verification• Appointment• Reappointment• Delineated clinical

privileges

• Reporting practitioner

• Assessment of performance

Management of Information • Control access of patient information• Confidential, secure, and integrity • Medical record for every patient

Infection Control Program • Education• Policies• Patient care practices • Environmental management and

housekeeping functions

Improving Organizational Performance

• Hospital Wide • Periodically evaluated• Interdisciplinary • Includes one member of the board

Requirements for• Food and Nutrition

Services• Linen and Laundry

Services• Pharmaceutical

Services

• Laboratory, Imaging and other Diagnostic Services

• Safe Patient Handling

• Patient Care Services

Patient Care Units • Surgical • Anesthesia• Recovery Care• Obstetrical• Neonate and

Pediatrics• Critical or Intensive

Care

• Alcohol/Chemical Dependency

• Psychiatric• Long-Term• Emergency• Dialysis

Patient Care• Plan for Patient Care• Assessment of

Patient• Standards of Care

• Qualified Staff• Equipment

Patient Care• All patient access to safe and appropriate

care • Adopt and implement P&P for patient

care and nursing practice• Individuals conducting business in

hospital comply with P&P

Patient Care Services • Provide personnel, space, equipment,

reference materials, training• A registered nurse available for

consultation in the hospital at all times• Policies and procedures around care

process

Emergency Contraception • 24/7 emergency care to victims of sexual

assault• Provide medically and factually accurate

and unbiased written and oral information about emergency contraception

Safe Patient Handling• Develop a policy• Hazard assessment• Annual performance

evaluation of the program

• Annual staff training

• Procedures for hospital staff to follow

• Types of equipment

Management of Environment of Care• Manage environmental hazards and

risks, prevent accidents and injuries, and maintain safe conditions for patients, visitors, and staff.

Self-Assessment Tips.

Read the regulations

How are you meeting the regulations?

Where is the documentation that demonstrates

compliance?

Questions