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Basis and Scope: C-0800
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- Conditions that a hospital must meet to be designated as a CAH.
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|
Personnel: C-0804 |
- Staff that furnish services in a CAH must meet applicable requirements:
- Clinical Nurse Specialist: Is a registered nurse and is licensed to practice nursing in the
state where services are provided according to state nurse license law and regulation.
- Nurse Practitioner: Must be a registered professional nurse who is currently licensed to
practice in the state.
- Physician Assistant: Must meet the applicable state requirements governing the qualifications
for assistants to primary care physicians.
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| Compliance: C-0810 |
- Refer or report suspected violations to the appropriate federal, state, or local agency.
|
| Advanced Directives and Patient Rights: C-0812 |
- Does facility have policy and procedure regarding advance directives?
- Does the hospital provide written information to patients at the time of admission concerning
their rights under state law to make decisions concerning medical care?
- The notice must include a clear and precise statement of limitation if the CAH cannot implement
an advance directive on the basis of conscience.
- Provision of care is not conditioned, or other discrimination against a patient, on whether (or
not) the individual has an advance directive.
- CAH and staff compliance with federal, state, and local laws and regulations
- Staff must comply with their advance directives and are educated to policy and procedures.
- Provide advance directive information to the competent patient when admitted, including how to
file a complaint to the state survey and certification agency.
- Inpatients and Outpatients have the right to make advance directives, including psychiatric
advance directives.
- Advance directive applies to ED, observation, and same day surgery patient.
- Information on advance directives is provided to all inpatients.
- Mechanism to formulate or update their current advance directive.
- Have advance directives to designate a support person for person of exercising the visitation
rights.
- If patient is incapacitated, a durable power of attorney (DPOA) must be used to inform decisions
and consent for the patient.
- CAH must also seek the consent of the patient's representative when informed consent is required
for a care decision.
- Prominent documentation in MR of completing advance directive and copy in record.
- Provide community education regarding issues concerning advance directives and the hospital must
document its efforts (video and audible tapes acceptable)
- Patients have the right to refuse treatment.
- Must disclose if the hospital is a physician-owned hospital.
- Physician's must also disclose to patients who they refer.
- Disclose in writing if physician is not on premise 24 hours a day for emergencies. Sign
acknowledgment if the patient is admitted.
- A sign is posted conspicuously stating the hospital does not have a physician present in the
hospital 24-hours per day, 7 days a week and indicates how the hospital will meet the medical
needs of any patient with an emergency medical condition.
- Patients signed acknowledgment that they understand a physician may not be present during all
hours services are furnished to the patient.
|
| C-0814 |
- Patient care services are furnished in accordance with state and local laws and regulations.
- Ensure delegating as allowed by law.
- Ensure practicing according to scope of practice, such as NP, CNS, PA
|
| C-0818 |
- Staff are licensed, certified, or registered per federal, state and local laws.
- Review personnel files to be sure credentials, licensure, and training and education
requirements are up to date including contract personnel.
- Review policies and procedures regarding certifications, licensure, and registration. Ensure
personnel are in compliance with CAH policy.
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| C-0822 |
- If the CAH moves, its eligibility for continued CAH status must be reassessed in accordance with
485.610(b).
|
| C-0826 |
- Conduct an informal assessment of the CAHs rural status, following the procedures in section
2256A of the SOM.
|
| C-0832 |
- Renovation or expansion of a CAH existing building or addition of the building(s) on the
existing main campus of the CAH is not considered a relocation.
- Entirely new replacement facilities constructed on the same site as the existing CAH main
campus, are considered relocated facilities.
|
Agreements
C-0862 |
- Agreement (at least one) with a rural health network hospital and one acute care hospital
related to patient referral and transfer, communication, emergency, and non-emergency patient
transportation.
- What policy and procedure are related to communication system?
- How CAH communicates with other hospitals – do you keep a communication log?
- CAH has a way for communicating and sharing patient data with other network members when the
system is not in operation.
- Written agreement with local EMS.
- Need to provide transport between the two facilities.
- For additional information regarding status and location of the CAH C- 0822, C-0824, C-0826,
C-0830, C-0832, C-0834 (co-locations), C-0836, C- 0840
|
| C-0864 |
- Patient referrals and transfers. Provide for transport
|
| C-0866 |
- Policy and procedure related to communication system (recommended)
- How network shares patient data, electronic data, telemetry, medical records with them
- If no communications system in place; how does the CAH communicate and share patient data with
the tertiary facility?
- Staff training provided to operate the communication system
|
| C-0868 |
- Does the CAH have a written agreement with the local EMS service to provide transportation
between the CAH and the tertiary facility?
- How emergency and non-emergency transport is provided between them
|
| C-0870 |
- Agreement between CAH, one of its network hospitals if applicable, a QIO or equivalent entity,
or one other state approved entity for credentialing and quality assurance activities.
- The agreement must include MR reviews for the determination of quality and medical necessity of
care.
- Have policy and procedure to determine how information is obtained, used and how confidentiality
is maintained
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Agreements - Credentialing and Privileging (Telemedicine)
C-0872 |
- The board must ensure written agreement with the distant site hospital (DSH) or distant site
telemedicine entity (DSTE) is present
- The written agreement for telemedicine includes:
Distant site hospital participates in Medicare; hospital provides current list of practitioners,
including their privileges, each practitioner holds a license in the State where the CAH is
located, and CAH reviews the services provided by telemedicine and provides feedback to the
distant site hospital
- Telemedicine agreement: List of providers must be approved by the governing board and medical
staff.
- The agreement should include credentialing and privileging the telemedicine physicians and
practitioners by the distant site hospital
- Ensure documentation indicating the granted privileges to each telemedicine physician and
practitioner.
- Documentation indicates the governing body or responsible individual made the privileging
decision based on the privileging decisions of the distant site hospital.
- The Governing Board determines what category of practitioners are eligible for appointment to
the medical staff (MS)
- Board appoints with recommendation of the MS
- Board approves the MS bylaws and other MS rules and regulations.
- Make sure MS is accountable to the board for quality of care provided to the patients.
- Criteria is established and followed for selection of MS that is based on individual character,
competence, training, experience, and judgment
- Privileges are never based solely on certification, fellowship, or membership in a special body
or society
- Written agreement is present stating the distant-site hospital participates in Medicare and has
an independent obligation to comply with all Conditions of Participation.
- Evidence the CAH conducts the required review of the telemedicine services provided by the
telemedicine services provided by practitioners, including any associated adverse events and
complaints, and it provides the required feedback to the DSTE hospital.
|
| C-0874 |
- Provide a written agreement stating DSTE will provide services to ensure compliance with CoPs.
- List physicians/practitioners covered by agreement, includes privileges and licensure
information.
- Evidence that the CAH reviews the services provided by the telemedicine physicians and
practitioners, including any adverse events and complaints, and provides written feedback to the
distant-site telemedicine entity.
- Does the CAH verify that the telemedicine entity fulfills the terms of the agreement with
respect to its credentialing and privileging process and otherwise assures that services are
provided in a manner that enables the CAH to meet all applicable CAH requirements.
- Provide verification that the DSTE fulfills terms to C and P process to enable CAH to meet
applicable CAH requirements.
- CAH has documentation indicating that it granted privileges to each telemedicine physician and
practitioner (through medical staff granting privileges and approval by governing board)
- Is there documentation that indicates the CAHs governing body or responsible individual made the
privileging decision based on the privileging decisions of the distant site telemedicine entity?
|
Emergency Services
C-0880 |
- Provision of emergency services as a direct service of the CAH – includes provision of
services to both inpatients and outpatients. ND 33-07-01.1-25(1a)
- The ED cannot be a provider-based offsite location.
- Must comply with acceptable standards of practice.
- Need qualified medical director.
- Need to have policy and procedure regarding the care provided in the ED.
- Policies and procedures are developed and approved by the medical staff, including mid-level
practitioners.
- Policies current and revised based on QA activities.
- If no ED need policy/procedure governing the handling of emergencies ND
33-07-01.1-25(a2)
- Need policy /procedure for operation of ED in time of disaster ND
33-07-01.1-25(g-13)
- Under the direction of a qualified member of the medical staff; MS Bylaws define what
"qualified" means.
- Need triage procedures.
- Must have adequate equipment.
- Must determine the categories and numbers of staff needed in the ED (MD/DO, RN, ward clerks, PA,
NP, EMTs)
- The scope of diagnostic and /or therapeutic respiratory services offered by the CAH should be
defined in writing, and approved by the MS such as (intubation, breathing treatments, CT scans,
venous Doppler's, ultrasound etc.)
- Qualifications, education, training, of personnel authorized to perform respiratory care
services and if supervision is needed
- Must have written policies to address the following services:
- Equipment assembly and operation
- Safety practices, including infection control measures.
- Handling storage and dispensing of therapeutic gases.
- Cardiopulmonary resuscitation
- Procedures to follow in the advent of adverse reactions to treatments or interventions:
- Pulmonary function testing
- Therapeutic percussion and vibration
- Bronchopulmonary drainage
- Mechanical ventilator and oxygenation support
- Aerosol humidification, and therapeutic gas administration
- Administration of medications; and
- Procedures for obtaining and analyzing blood samples (arterial blood gases)
- Verify EMS are organized under the direction of a qualified member of the MS.
- ED staff education to include:
- Parenteral administration of electrolytes, fluids, blood, and blood components
- Care and management of injuries to extremities and central nervous system
- Prevention of contamination and cross infection and
- Provision of emergency respiratory services
- Review staffing schedule to determine that the number and type of staff available are
appropriate to the volumes and services provided.
- If blood gases or other laboratory tests are performed by respiratory services, verify current
CLIA certification.
|
ED Availability of 24-hours Emergency Services
C-0882 |
- Emergency services available on a 24-hour a day basis.
- Name all providers who work in ER and name the type of certification/training. Call schedule,
backup plan.
- Can PA's or NP's admit patients? Do they provide notification of admits?
- Emergency services available 24/7 and how CAH will ensure/verify
they are ND 33-07-01.1-25 (i)
- Qualified provider available to see patients within 30 min (rural) or 60 min (frontier) and how
CAH ensures patients are seen within the required time
- Process and timeframe and documentation for notifying provider and their arrival time.
- CAH must maintain the types, quality and numbers of supplies, drugs and biologicals, blood and
blood products, and equipment.
|
Equipment, Supplies, and Medication Availability
C-0884
|
- Ensure that the required equipment, supplies, and medications are always readily available.
|
Drugs and Biologicals
C-0886
|
- How does the CAH ensure that staff knows where drugs and biological are kept, inventory
maintained, Drugs and biological replaced?
- Who is responsible for monitoring drugs and biologicals?
- Medications are locked and dated according to MIFU if opened.
- Monitor medication refrigerator temperatures, keep a log for temps to assure safe storage.
- Monitor crash cart medications. Checked and verify narcotic count. Replace when needed according
to policy.
|
Equipment and Supplies
C-0888
|
- The surveyor will interview ED staff to make sure knowledgeable including:
- Parental administration of electrolytes, fluids, blood, and blood components
- Care and management of injuries to extremities and central nervous system
- Prevention of contamination and cross infection
- Provision of emergency respiratory services
- How CAH provides the equipment and supplies needed and ensures they are readily available
- Equipment and supplies commonly used in life-saving procedures include:
- Airways, endotracheal tubes, Ambu bag/valve/mask, oxygen, tourniquets, immobilization
devices, nasogastric tubes, splints, IV therapy supplies, suction machine,
defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters.
- Make sure staff know where the equipment is located.
- Know how supplies are replaced and who is responsible for doing this and watch for expired
suture.
- Do you supply patients with medication at discharge? Process?
- Patient care equipment maintenance: how performed, schedule (defibrillator)
- What to do when equipment fails
- Is there emergency lighting and power?
- Who will examine sterilized equipment for expiration dates?
- Who will examine oxygen supply system to determine functional capabilities?
- Check the force of the vacuum (suction) equipment to see that it is in operating condition.
|
| (Provision of Services – Emergency Medical Services) |
- Current policies/procedures for every service/procedure given (MS approved)
ND 33-07-01.1-25(g)
- ED Policies and procedures revised at least biennially.
- Integration with the CAH-wide QA program
- Medical staff delineation of criteria for ED privileges
- How the ED will be staffed appropriately: types and numbers of professionals
- Policy/procedure for emotionally ill or under influence of drugs, alcohol, DOA
ND 33-07-01.1-25(g-4)
- Procedure for early transfer severely ill or injured ND 33-07-01.1-25(g-5)
- Procedure communication with police, health authorities and emergency vehicle operators
ND 33-07-01.1-25 (g-9)
- How will provide emergency RT services and scope of services (MS approved)
- Qualifications of RT service providers, including job title, licensure requirements, education,
training, experience they may perform without supervision.
- The scope of diagnostic and/or therapeutic respiratory services offered by the CAH should be
defined in writing, and approved by the MS (CT scans, venous Doppler's, U/S)
|
Blood and Blood Products
C-0890
|
- Policy/procedure or contract/agreement/arrangement for services for the procurement,
safekeeping, and transfusion of blood, including the availability of blood products needed for
emergency patients 24 hours a day (No requirement to store blood on site)
- The call schedule will be reviewed.
- Documentation of blood refrigerator temperatures and corrective action as needed.
- Can provide in emergency directly or through arrangement, in some cases more practical to
transport patient to where the blood is – availability of lab services – 24hr/d, 7d/week.
- Compatibility testing, if performed (CLIA Certified)
- If collecting blood must register with FDA
- Need agreement in writing re: provision of blood between CAH and testing lab.
- Ensure blood is properly stored to prevent deterioration.
- Refrigerator temps should be documented.
- If types and cross matches must have necessary equipment such as Sero-Fuge and heat block
- CAH may keep 4 units of O Negative blood on hand at all times.
- Release to give, signed by doctor, is needed since not cross matched
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Blood Storage
C-0892
|
- Need to be under the control and supervision of a pathologist or other qualified doctor.
- If blood banking is done under arrangement, the arrangement must
- Be approved by MS and administration – will look for agreement
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Personnel
C-0894
|
- Must have practitioner (physician, PA, NP, and CNS) with training in emergency care on call and
immediately available by telephone or radio contact and available within 30 minutes 24 hours a
day
- Specific training required for practitioners? (ACLS/ ATLS)
- Have policy/procedure in place to ensure MD/DO is available by phone ND
33-07-01.1-09 (Governing Body)
- RN can satisfy C-0207 temporarily if the CAH has ≤ 10 beds and frontier and approval given
in writing from State ** List of qualified nurses is available
- Will review call schedules and ask staff if they know who is on call.
- Will review documentation that PA, NP, CNS, or MD was on site within the allowable time frame
- Have a procedure where provider is available by phone or radio on 24-hour basis to receive
calls.
- RN with training and experience in emergency care can conduct specific medical screening exam.
RN must be on site and immediately available when a patient requests care and the nature of the
request must be within scope of practice for a RN and consistent with state law, medical staff
bylaws. If you have facilities that are considered "frontier/remote location" will need to add
more as to RNs.
|
| C-0898 |
- Coordination with emergency response systems/ambulance
- Ensure that procedures are in place for coordination with ERS to make available by telephone or
radio contact, on a 24-hours a day basis, a MD or DO to receive emergency calls and provide
medical direction in emergency situations
- Ensure there is a plan in place to demonstrate that procedures are followed and evaluated for
effectiveness
|
Bed Type/Observation
C-0902
|
- CAH maintains no more than 25 acute care beds at any one time (not including observation beds)
- Any of the 25 beds can be used to provide acute or swing bed, dependent on patient need
- Does not count if CAH has up to 10 bed rehab unit or behavioral health unit
- Do not count in 25 bed count exam or procedure tables, stretchers, Operating Room tables, ED
carts, 10 bed distinct rehab or behavioral health unit, newborn bassinets and isolettes for
well-baby boarders and post-anesthesia care unit (PACU) bed and inpatient beds in
Medicare-certified distinct part rehabilitation or psychiatric units
- Do not count OB beds if active labor, but do count birthing rooms where patient stays after
giving birth
- Hospice beds can be dedicated are also counted as part of the 25 beds
- Observation is not appropriate for: Substitute for inpatient admission, for continuous
monitoring, or medically stable patients who need diagnostic testing or outpatient procedure
(blood, chemo, dialysis), patients awaiting nursing home placement, for convenience to the
patient or family, for routine prep or recovery prior to or after diagnostic or surgical
services, as a routine stop between the ED and inpatient admission, no prescheduled observations
services or observation services begin and end with the order of the physician
- There is an order for observation services prior to start of the service; order is not
backdated
- Standing orders for observation services are not permitted or utilized
- Must provide documentation to show that observation bed is not an inpatient bed.
Need specific clinical criteria for observation services and it must be different inpatient criteria.
|
Length of Stay
C-0904
|
- Length of Stay – CAH provides acute inpatient care for a period that does not exceed, on an
annual average basis, 96 hours per patient (96-hour average LOS rule does not apply to hospice
patients)
- Calculate the CAH's LOS based on patient census data.
- Policy on observation beds to meet – they do not count observation beds in 25 bed count
now or in calculating average LOS.
- Two Midnight Rule – Need an order and need to document medical necessity
|
| C-0910 |
- Building and equipment maintenance part of the QA program, this applies to all campuses,
satellites, inpatient and outpatient locations
|
Construction
C-0912
|
- CAH is constructed, arranged, and maintained to ensure access to and safety of patients and
provides adequate space for the provision of direct services.
- There is adequate space for the scope of services required to be provided on-site.
- Buildings are maintained to ensure the safety and well-being of patients.
- Design of the facility assures staff can reach patients readily.
|
Environmental Services and Maintenance
C-0914
|
- Must have housekeeping and preventative maintenance programs: routine, preventive, handling
spills.
- There is a list of all facility and medical equipment including specific equipment information,
such as ID number, manufacturer, model number, serial number, location, department, etc.
- Policies, procedures, and programs are in place for all equipment, including frequency of
maintenance, following manufacturer-recommended maintenance activities and schedule.
- Equipment used for the first time is inspected and tested.
- Individual responsible for overseeing the equipment maintenance program and activities is
qualified
- All essential mechanical, electrical and patient-care equipment is maintained in safe operating
conditions (supplies and equipment must be maintained) and available when needed.
- Building maintenance program: routine, preventive, and inspections.
- Patient care equipment maintenance program: routine, preventive, storage
- How do you ensure your equipment is maintained properly (boilers, elevators, air compressors,
ventilators, X-ray equipment, IV pumps, kitchen freezer/refrigerator, laundry equipment)?
- Medical Gases stored securely.
- Have a policy and procedures which address the effectiveness of the CAHs alternative equipment
maintenance (AEM) program.
- AEM Program – demonstrates that CAH is performing risk-based assessments, preventative
maintenance, or establishing the AEM program.
- Maintain a written inventory of all medical equipment or a written inventory of selected
equipment categorized by risk assessment.
- Is critical equipment readily located?
- Identify in writing how to maintain, inspect, and test the medical equipment on the inventory.
Could a malfunction have been prevented? What steps are needed to prevent future malfunctions?
How determination is made whether or not the malfunction resulted from the use of an AEM
strategy
- How do staff report maintenance issues?
- What is the process for removal from service of equipment determined to be unsafe or no longer
suitable for its intended application?
- The use of performance data to determine if modification is in the AEM program procedures are
required
- CAH evaluates the safety and effectiveness of the AEM maintenance activities for equipment and
takes corrective actions when needed, actions are documented.
|
Disposal of Trash
C-0920
|
- Need policies for proper routine storage and prompt disposal of trash (includes biohazardous
waste)
- Must be disposed of in accordance with standards (EPA, OSHA, CDC, environmental and safety),
including radioactive materials.
|
Storage of Drugs
C-0922
|
- Drugs and biologicals: Ensure storage and locking (see also C-0886)
- Must be properly locked in the storage area; make sure drugs are not left out in open, in tube
system or on dumb waiter ledge.
- What process do you have in place to make sure drugs are stored according to manufacturer's
instructions for temp and light storage, labeling, etc.
|
Physical Environment
C-0924
|
- Premises clean and orderly and uncluttered with equipment not stored in corridors, spills not
left unattended, no peeling paint et al.
- Will look at walls, ceilings, and floors (no storage directly on floor), maintenance log.
- Chemicals Stored appropriately.
- No storage of combustibles with heating and electrical equipment.
|
Ventilation
C-0926
|
- There must be proper ventilation, lighting, and temperature control in all pharmaceutical,
patient care, and food preparation areas.
- OR Temps and Humidity maintained per AIA/AORN
|
Life Safety Code
C-0930
C-0932
|
- Life safety plan. Meet Life Safety Code of the National Fire Protection Association (2-hour fire
wall)
- Corridor doors and doors to rooms containing flammable/combustible matters have only positive
latching hardware, no roller latches.
- CMS waiver provided – when application resulted in unreasonable hardship and does not
adversely affect health and safety of patients
|
Fire Inspection
C-0934
|
- Maintain written evidence of regular inspection and approval by state and or local fire control
agencies
- Surveyor will examine copies of inspection and approval reports.
|
Alcohol-Based Hand Rub Dispensers
C-0936
|
- Alcohol-based hand rub dispensers are installed to protect against inappropriate access.
|
Sprinkler System
C-0938
|
- When sprinkler systems are down for more than 10 hours the building/portion affected are
evacuated or fire watch is instituted
|
Windows/Doors
C-0940
|
- Every sleeping room has an outside window/door
(Built after 2016) Height must not exceed 36 inches above floor.
|
Life Safety Code
C-0942
C-0944
|
- Waiver present – specific provisions of Life Safety Code resulted in unreasonable hardship
and no adverse effect to health/safety of patients.
- Applicable provisions and steps to meet the requirements of Health Care Facilities Code are met
unless waiver provided.
Refer to Appendix
Z of the SOM to cite the specific Emergency Preparedness E-tags.
|
Emergency Procedures
C-0950
|
- CMS Moved Emergency Preparedness final rules to Appendix
Z
- CMS
Emergency preparedness checklist
- Emergency preparedness plan developed, maintained, reviewed, and updated every 2 years and
includes:
- Documented, facility-based and community-based risk assessment utilizing an all-hazards
approach.
- Includes strategies to address emergency events per risk assessment.
- Addresses patient populations.
- Includes process for cooperation and collaboration with local, tribal, regional, state, and
federal emergency officials.
- Policies and procedures are in place and reviewed/updated every 2 years and include:
- Provisions for subsistence are needed for all.
- Tracking of staff and patients
- Safe evacuation from facility
- Means to shelter in place.
- System for medical documentation to maintain confidentiality.
- Use of volunteer or other emergency staff
- Arrangement with other CAH/providers to receive patients.
- A communication plan is developed and in place and reviewed every 2 years.
- Training and testing of the plan are completed every 2 years with supporting documentation along
with
- Annual exercises are conducted annually – full-scale and one additional exercise
- Emergency and standby power systems are in place.
- If part of an integrated health system – each facility is complying.
- Assure safety of patients in non-medical emergencies
- Staff trained in handling emergencies such as reporting and extinguishing of fires, evacuations,
et al. Validate training with in- service records.
- Report all fires to state officials.
- The surveyor will interview staff to make sure they know what to do in case of a fire, tornado,
blizzard.
- Consider policy and procedures related to workplace violence. Provide education to staff on work
place violence and reporting. Include in QAPI program.
- Ensure all personnel are trained to manage emergency procedures for non-medical emergencies.
Review staff training documents and in-service records to confirm training
- Emergency power and lighting – National Fire Protection Amendments (NFPA) 101, 2000
Edition and applicable Facilities, for emergency lighting and emergency power in ED and for
battery lamps or flashlights in other areas
- Must comply with the applicable provisions of the Life Safety Code
- Emergency fuel and water supplies, have a plan to provide care to inpatients and to other
persons who may come to the CAH in need of care (source of water is FEMA)
- Includes planning with local utility companies and others for the provision of emergency sources
of water and gas.
- Have a plan for prioritizing their use until adequate supplies are available.
- Policy and procedure addressing specific conditions (snowbound facility, spring flooding,
etc.) in comprehensive emergency preparedness plan
- Develop a comprehensive plan to ensure that the safety and wellbeing of patients are assured
during emergency situations.
- Coordinate with federal, state, and local emergency preparedness and health authorities to
identify likely risks for the area.
- Considerations when developing the comprehensive emergency plan.
- Differences needed for each location where the certified CAH operates,
- Special needs of patient populations treated at the CAH (e.g., patients with psychiatric
diagnosis, patients on special diets, newborns, etc.)
- Security of patients and walk in patients.
- Security of supplies from misappropriation
- Pharmaceuticals, food, other supplies, and equipment that may be needed during
emergency/disaster situations.
- Communication to external entities if telephones and computers are not operating or
become overloaded.
- Communication among staff within the CAH itself
- Qualifications and training needed by personnel, including healthcare staff, security
staff, and maintenance staff, to implement and carry out emergency procedures.
- Identification, availability, and notification of personnel that are needed to implement
and carry out the CAHs emergency plan.
- Identification of community resources, including lines of communication and names and
contact information for community emergency preparedness coordinators and responders.
- Provisions for gas, water, and electricity supply if access is shut off to the
community.
- Transfer or discharge patients to home or other healthcare settings.
- Methods to evaluate repairs needed and to ensure resources needed.
|
Governing Body
C-0962
|
- Must have only one governing body (or responsible individual) and this governing body (or
responsible individual) is responsible for the conduct of the CAH as an institution.
- Governing board responsibilities/bylaws – board approves MS bylaws.
- Policy/procedure that has governing body or individual that assumes legal responsibility for
implementing and monitoring. ND 33-07-01.1-09
- Board must determine what categories of practitioners are eligible for appointment and reappoint
to MS (NP, PA, Dentist, CRNA) and there is written criteria for staff appointments.
- Board is responsible for conduct of CAH and for quality of care to patients.
- Criteria for MS is based on individual character, competence, training, experience, and
judgment.
- The surveyor will look to see board or written documentation of person responsible for CAH
- Does Board have categories of practitioners for appointment to MS?
- Confirm that Board appoints all members to the MS.
- CEO, delegation of authority for daily operations, as applicable
- What evidence (e.g., minutes of board meetings) demonstrates that the governing body or the
individual who assumes responsibility for CAH operation is involved in the day-to-day operation
of the CAH and is fully responsible for its operations?
- Medical staff operates under current bylaws, rules and policies approved by governing body
(responsible individual).
|
Medical Direction
C-0964
C-0966 |
- Reporting changes in operating officials to the state.
- Reporting changes in ownership to the state.
- Reporting changes in medical director to state.
|
Staffing
C-0971
|
- CAH has professional staff that includes one or more physicians, and may include PA, NP, or
CNS
- Need to have organizational chart which shows names of all MD/DO and PA, NP, or CNS
- Surveyor will review work schedules
|
Supervision
C-0972
|
- Professional staff supervises all ancillary personnel.
|
Staff Coverage
C-0974
|
- Staffing policies (have sufficient staff to take care of patients and provide essential services
to CAH operation)
- Have staffing schedules and daily census records available for reviewing
|
Staff Availability
C-0976
|
- MD, DO, NP, PA, or CNS must be available at all times to furnish care.
- Must show practitioner is available and shows up when patient presents to the hospital
|
Nurse on Duty
C-0978
|
- RN, CNS, or LPN on duty whenever one or more inpatients
|
Physician Responibilites
C-0981
|
- MD/DO must provide medical directions and supervision of staff.
- The surveyor will want evidence that the doctor provides oversight and is available for
consultation.
- Have a policy that specifies a time frame for the maximum interval between inpatient reviews.
- How do you ensure that the doctor participates in the development of policies and procedures?
- Provide evidence that there is periodic review of patient records by the doctor.
|
| C-0982 |
- MD/DO participates in developing, executing and periodically reviewing policies.
- PA/NP need to participate in developing and reviewing written policies and procedures.
|
| C-0984 |
- MD/DO w/ advanced practitioners periodically review patient records, provide orders, and
provides med services to CAH patients (define "periodically").
|
Physician Supervision
C-0986
|
- Must have a doctor on staff and must perform medical oversight and must be present for
sufficient period (no longer says must be present at least once every two weeks).
- The surveyor will want evidence that the physician provided oversight and is available for
consultation or patient referral.
- Periodically reviews and signs all records of patients cared for by NP, CNS, or PA and MD/DO
signs records after review is completed.
- Select a sample of inpatient and outpatient records, including both open and closed records.
- For inpatient records of patients whose care is/was managed by a non-physician practitioner,
verify that:
- An MD/DO has reviewed and signed all records that were open at the time of the review,
and all inpatient records that were closed since the MD/DO's last review; and
- That review takes place within the timeframe specified by the CAH's policy. (Consider if
CAH has EHRs that can be reviewed and signed off remotely)
|
| C-0988 |
- Establish a protocol for contacting a physician (MD or DO is always available) for consultation,
assistance and/or patient referral through radio or telephone or electronic communication
(telemedicine)
- MD or DO must be present in the CAH for sufficient periods of time.
- Develop policy and procedure on minimum amount of time and frequency of MD/DO presence on-site
and document compliance.
- Must have list of on call physicians.
|
PA, NP, CNS
C-0991
|
- PA, NP, CNS, participate with an MD/DO in the review of their patients' health records.
- PA, NP, CNS, participate in the development, execution and periodic (at least once a year, see
C-1024) review of policies ND 33-07-01.1-15
- Policies must be UpToDate with state requirements for midlevel standard of practice
|
| C-0993 |
- Participate with MD/DO in periodic review of patient health records
|
| C-0995 |
- Provides services in accordance with CAH policies, when a physician is not available
|
Transfer of Patient
C-0997
|
- Arranges for, or refers patients to, needed services and assures records are maintained and
transferred as required.
- Must send the patient's medical records.
- Need transfer policy and should be consistent with EMTALA
|
Patient Admission
C-0998
C-0999 |
- Admitting privileges must be consistent with what state law allows.
- MD/DO notified when PA, NP, CNS admits a patient.
- If PA, NP, CNS admits, MD/DO is responsible for med or psych problems outside the scope of
practice of the admitting practitioner.
- MD/DO is responsible for and monitoring the care of each Medicare/Medicaid patient for all
medical problems during hospitalization.
- Periodic review of clinical privileges and performance by NP, CNS, PA
- Quality and appropriateness of diagnosis and treatment are evaluated.
- Review completed by MD/DO, can be via contract, by network member hospital, QIO, entity in State
rural health plan.
- Telemedicine – can be reviewed by distant site hospital or entity
|
Patient Care Policies
C-1006 |
- Services provided as stated in written policy and consistent with state law (QA)
ND 33-07-01.1-17
|
| C-1008 |
- Maintain documentation of the policy and procedures committee activity. Must reflect any changes
made.
- P&P committee must review existing and new P&Ps at least biennially.
- Final decision on P&Ps is made by the board.
- If the P&P recommendations by the advisory group are rejected, then the board must include
in the record and the rational for the change
|
| C-1010 |
- Policy/procedure on scope of services provided by CAH directly or through agreement/contract
- Include statements like "taking complete medical histories, providing complete physical
examinations, laboratory tests including" (with a list of tests provided)
- Include arrangements made with Hospital X to provide the following services with list of
specialized diagnostic and lab testing
|
| C-1012 |
- Policies for emergency care services show how CAH would meet all its emergency services
requirements.
- How the CAH provides 24-hour emergency care to its patients?
- What equipment, supplies, medications, blood, and blood products are maintained onsite, and
which are readily available for treating emergency cases by agreement at other facilities?
- What types of personnel are available to provide emergency services and what are their required
onsite response times?
- How the CAH coordinates with local emergency response systems?
|
Guidelines for Medical Management
C-1014 |
- Conditions, signs, or developments requiring consultation and/or patient referral (to MD,
others)
- Guideline on maintaining medical record – health care record policies.
- Periodic review and evaluation of services
- Need to policy to include the scope of medical acts which may be done by PA, NP, CNS
- Indicate what medical procedures the PA or NP can do.
- Guidelines need to describe the medical conditions, signs or development that require
consultation
|
Drugs and Biologicals
C-1016 |
- Must identify the qualifications for and designate an individual who has overall responsibility
for the CAH's pharmacy services, including development of the rules governing pharmacy services.
- Policy and procedure must identify qualification of pharmacy director; including who can perform
pharmacy services, supervision of pharmacy staff and identify standards used in developing
policy and procedures (can cite as a reference)
Storage of drugs and biologicals, including the location of storage areas, medication cars, and
dispensing machines
- Must have rules for drug storage, handling, dispensation and administration of drugs and
biologicals area in accordance with accepted professional practices
(C-0886, C-0922)
- Drugs stored according to manufacturer's directions and state and federal law.
- Drugs stored in locked room or container.
Proper environmental conditions
- CAH rules and policy and procedures must be consistent with standards or guidelines for
pharmaceutical services and medication administration, such as USP, ASHP, ISMP, Infusion Nurses
Society, IHI and National Coordinating Council and consistent with state and federal law.
- Proper environmental conditions; follow manufacturer's recommendation. Such as keep
refrigerated, room temperature, out of light etc.
Security
- Consistent with state and federal law to address who is authorized access to the pharmacy or
drug storage area.
- Must have policies and procedures consistent with state and federal law of who has access and
keys to drug and storage areas. (Housekeeping, security, or maintenance usually not given
unsupervised access). Area restricted to personnel only are generally considered secure.
- Given flexibility in non-controlled drugs such as do not have to be locked up when setting up
for a procedure (OR would lock up when area not staffed)
- Medication carts, anesthesia carts, epidural carts and non-automated medication carts with
medications must be secure when not in use.
- Policies and procedures are expected to address the security and monitoring of carts, locked, or
unlocked, containing drugs and biologicals in all patient care areas.
Handling drugs and biologicals
- Handling medications that include mixing or reconstituting according to manufacture
recommendation. Includes compounding or admixing of sterile IVs or other drugs.
Compounding
- Compounding used or dispensed must be consistent with acceptable principles such as those
described in USP/NF chapter.
- Must be administered in accordance with accepted professional principles.
- Must be able to demonstrate how all sterile and non-sterile compounded preparations dispensed
and/or administered.
- Must be able to provide evidence that standard operating procedures for compounding, if
performed in-house, and for quality oversight of compounding, regardless of source, are
consistent with accepted professional principles.
- Included is compliance with USP 797 and USP 795 (preparation, storing, and transporting)
- All compounded forms must be sterile including wound irrigation, eye drops and ointments,
injections, infusions, nasal inhalation, etc.
- Only pharmacy can reconstitute, mix, or compound a drug
Use of outside compounders (outsourcing facilities)
- Outsourcing facilities who compound drugs register and must comply with section 503B of the FDCA
and other requirements such as the FDA's current good manufacturing practice (CGMP)
- Must meet certain other conditions including reporting adverse drug events to the FDA.
- If CAH obtains compounded medications from compounding pharmacy rather than a manufacturer or a
registered outsourcing facility, then must demonstrate that medicine received have been prepared
in accordance with acceptable principles.
- Contract with the vendor would want to ensure CAH access to their quality data verifying their
compliance with USP standards.
- Should document you obtain and review this data.
Dispensing drugs and biologicals
- Dispensing medications, dispensed timely, follow all state laws.
- Enough staff to provide accurate and timely medication delivery.
- System so medications orders get to pharmacy promptly and are available when needed by the
patient; (automated dispensing units outside the pharmacy, night cabinets, contracted services
after hours via tele pharmacy contracting, on-call pharmacists, etc.)
- Can use unit dose or floor stock system; Automated dispensing cabinets are secure option.
- Need policy and procedures for who can access medications after hours (night cabinet standard)
- Suggest policy and procedure on do not use abbreviations, high alert drug list, safety
recommendation for high alert medications, quantities of medications dispensed to minimize
diversion, limit overrides, return all meds in secure one-way return bin, etc.
Administration of drugs and biologicals to patients
- Must comply with applicable state law that governs the qualifications, certification, or
licensure of staff who administer drugs and biologicals and must adhere to accepted standards of
practice for medication administration.
Record keeping for the receipt and disposition of all scheduled drugs.
- Current, accurate records of receipt and disposition of scheduled drugs; a policy covers
control
of distribution, use and disposition from entry to disposition; can readily identify
loss/diversion; records available.
- Pharmacy records detail flow of drugs from entry to disposition
- Pharmacy maintains control over drugs in all locations, including floor stock.
- Maintaining records related to requisitioning and dispensing drugs.
- Want locked storage of scheduled drugs when not in use; keep accurate counts to show use;
Reconcile any discrepancies in the counts.
Ensuring that outdated, mislabeled, or otherwise unusable drugs are not used for patient
care.
- Ensure drugs are dispensed only by licensed pharmacist.
- Must have pharmacy labeling, inspection, and inventory management.
- Need to make sure no outdated drugs or mislabeled drugs. Each individual drug must be labeled
with name, strength of drug, lot and control number and expiration date, including "beyond use
date" as applicable.
- If multidose vial is opened, must have expiration date of 28 days on the label unless otherwise
specified by the manufacturer.
- Only pharmacists or pharmacy-supervised staff compound, label and dispense drugs.
- Surveyor to make sure drugs are secure.
- How do you make sure no outdated drugs or mislabeled drugs?
Assessing adverse drug reactions and medication administration errors
- The surveyor will ask nursing if medications were dispensed in a timely manner.
- The surveyor will ask what professional pharmacy principles pharmacy is using.
- Must have a system for staff to report adverse drug reactions and medication administration
errors
- Pharmacy services are expected to assess all such reports to determine if problems or errors in
pharmacy services caused or contributed to the adverse reaction or medication administration
error.
- If a contracted service, how on-premises supervision is accomplished.
- If a contracted service, MS approves the contract.
- Pharmacist job description includes development, supervision, and coordination of all pharmacy
services activities.
- Pharmacists and pharmacy technicians perform only those duties within the scope of their
license/education.
- Pharmaceutical services can be provided as direct services or through an agreement.
- Does not require continuous on-premises supervision at the CAH's pharmacy
- May be accomplished through regularly scheduled visits, and/or telemedicine in accordance with
law and regulation and accepted professional principles.
- A single pharmacist must be responsible for the overall administration of the pharmacy.
- The pharmacist must be responsible for developing, supervising, coordinating all the activities
of the CAH wide pharmacy services and be knowledgeable about CAH pharmacy practice and
management.
- Pharmacy must have sufficient staff in types, numbers, and training to provide quality services,
including 24-hour, 7-day emergency coverage.
- Need to have enough staff to provide accurate and timely medication delivery, ensure accurate
and safe medication administration.
- Emergency kit with adequate contents – not outdated
|
Reporting Adverse Drug Reaction and Error
C-1018 |
- Procedures for reporting adverse drug reactions and errors (ADEs) in the administration of drugs
is voluntary, non-punitive; include definitions.
- ADR and medication errors that reach the patient must be reported to the practitioner.
- Staff must report ADR and errors; the report must be made immediately if it causes harm to the
patient such as a phone call; if harm is not known then they must report immediately, if no harm
then can inform practitioner in the morning.
- Documentation of the error and notification of the practitioner must be made in the MR.
- Must educate staff on medication errors and ADEs to facilitate reporting.
- Must include reporting of near misses
- Must educate how and whom they are to be reported.
- Consider taking other steps to identify errors and ADRs; can't just rely on incident reports;
trigger drug analysis, observe medication passes, concurrent and retrospective reviews,
medication usage evaluations for high alert drugs etc.
- Nursing staff should know what to do if there is a medication error (ME) or ADE
- Process for reporting administration errors, adverse reactions, and drug incompatibilities
immediately to the attending physician
- Process for review and amendment of policy/procedures following reports of adverse events.
- Process for reporting serious adverse drug reactions to the federal MedWatch program.
- QA/PI activities for errors/reactions include identifying potential corrective actions and are
implemented, if appropriate
- Consider non-punitive reporting system or people will not report errors (may balance with Just
Culture)
- Pharmacist should be readily available by telephone or other means to discuss drug therapy,
interactions, side effects, dosage etc.
- Know how drug information will be available at the nursing stations.
- Pharmacy policy and procedure, formulary; have a pharmacy and therapeutic committee, record
minutes of the committee meetings. Policies should include:
- High alert medications with dosing limits, administration guidelines, packaging,
labeling and storage.
- Limiting the variety of medication related devices and equipment
- Availability of up-to-date medication information
- Availability of pharmacy expertise such as having a pharmacist available on call when pharmacy
does not operate 24 hours a day.
- Standardization of prescribing and communication practices
- Beers Criteria Medication list of inappropriate medications; drugs that should be avoided in
patients who are over 65, includes drugs not to be used for certain diseases; American Geriatric Society Beers
List (informational purposes only)
- Who has access to the pharmacy? ONLY pharmacy supervisors, pharmacist, pharmacy techs should
have access to the pharmacy.
- Who has access to the pharmacy after hours? (Should only be one designated supervisory RN per
shift)
- What is the process for removal of medications from the pharmacy in the absence of the
pharmacist? (Should only take the amount needed immediately, must have documentation of patient
name, room number, name of drug, strength, amount, date, time, signature)
- Written policy/procedure to require ADE be reported immediately to practitioner who ordered the
drug.
- Method to measure effectiveness of the reporting system/benchmark.
- Proactively identify potential and actual ADEs: includes direct medication pass observe, MR
review, ADR surveillance team, medication use evaluation for high-alert drugs; or noted
automatically generate a drug regimen review. Review for specified drugs/patient (sole reliance
on incident reports does not meet the intent of this element)
- Availability of up-to-date medication use information, resources
- Availability of pharmacy expertise 24/7
- Investigation of cause for return of unused medications to pharmacy
- High-alert meds with dosing limits, etc.
- Policy limiting the variety of medication-related devices and equipment.
- Alert system for "look alike" and "sound alike" drugs.
- Policy standardization of prescribing and medication communication practices
- The DO NOT USE abbreviations list.
- Requirements for "complete" orders
- Use of pre-printed orders whenever possible
- How CAH incorporates external alerts/recommendations re: medication use safety
- Preparation, distribution, administration, and proper disposal of hazardous medications
- Handling of medication recalls
|
Dietary
C-1020
C-1022 |
- USDA
Dietary Guidelines for Americans
- Therapeutic Diet Manual available to all staff and approved by Medical Staff
- If the CAH furnishes inpatient services, procedures must be in place that ensure that the
nutritional needs of inpatients are met in accordance with recognized dietary practice.
- All diets are ordered by a practitioner responsible for patient OR qualified dietitian or
nutrition professional authorized by medical staff and per state law.
- Dietary P&Ps are reviewed biennially by group of professional personnel and updated as
necessary by the CAH.
|
Patient Services
C-1024 |
- Annual review of direct care diagnostic and therapeutic services and supplies policies
- Must provide diagnostic and therapeutic services as those provided in doctor's office or at
entry of healthcare organization like an outpatient department or ED – provide directly
or under contract.
- Must have supplies as that typically found in an ambulatory healthcare setting and a physician/s
office.
- Must provide adequate services, equipment, staff, and facilities adequate to provide the
outpatient services.
CAHs have flexibility to arrange for contracted services CMS removed the language requiring
directly provided services in the areas of general diagnostic, therapeutic services, radiology
services, laboratory services, and emergency procedures.
- CMS expects CAHs to provide timely diagnosis and treatment of patients and expects general
diagnostic and therapeutic, laboratory, radiology, and emergency services to be offered on-site
|
| C-1026 |
- CAH furnishes acute care inpatient services.
- Average LOS is 96 hours.
- Must certify that Medicare patients may be expected to be discharged or admitted to a hospital
within 96 hours.
- CAH is not required to maintain a minimum average daily census of patients receiving inpatient
acute care services or maintain a minimum number of beds that are to be used for inpatient
services.
- Wii review if admits are <8% of ED visits.
- Verify that the CAH is furnishing acute care inpatient services by reviewing data on the number
of patients admitted over the prior year.
- Review a sample of records of the patients the CAH transferred and determine if transfers were
appropriate.
|
Lab Services
C-1028 |
- Lab Policies: basic services provided directly or through a contractual agreement with a
certified laboratory; all procedures for tests performed whether available as routine and stat
basis; cultures taken.
- Must provide emergency laboratory services 24 hours/ 7 days a week.
- Basic lab services to include, urine dipstick, hemoglobin or hematocrit, blood glucose, stool
for occult blood, pregnancy tests, primary culturing for transmittal
ND 33-07-01.1-22.
- Scope and complexity; lab services must be provided directly at the CAH campus by CAH staff to
facilitate immediate diagnosis and treatment of patient. The CAH must have a current/valid CLIA
certificate or Certificate of Waiver for all tests performed and appropriate to the level of
services performed: 24/7
- Written description of tests available for emergency testing; list approved by MS.
- Reference labs
- Policy and procedure for collection, preservation, transport, receipt and reporting of tissue
specimens
- Quality control
- Policy to make sure all lab tests are recorded in the MR.
- Staff supervision, qualifications, orientation, training competencies
- Infection control standards
- How ED care is available to patients experiencing adverse reactions.
|
Radiology Services
C-1030 |
- Supervision of the department by a credentialed member of the MS
- Designation of staff qualified to operate equipment pieces of radiological equipment and/or
administering patient procedures and approved by medical staff.
- Review their personnel folders to determine if they meet the qualifications for tasks they
perform, as established in the CAH's policies and consistent with state law.
- Written policy, consistent with state law on personnel to operate radiology equipment and do
procedures ND 33-07-01.1-23.
- Radiology Administration Policies: provided as a direct service; available 24/7; scope and
complexity of services, approved by MS and governing body/CEO; if interpretation of imaging
internally or contracted; acceptable standards of practice; meeting patient and staff safety
standards
- Can offer a minimal set or more complex according to needs of the patients; interpretation
however can be contracted out.
- Diagnostic, therapeutic, and nuclear medicine must be provided in accordance with acceptable
standards of practice and must meet professionally approved standards for safety.
- Scope or what you do has to be in writing and approved by MS and board and by standards
recommended by nationally recognized professions such as the AMA and ACR
- Periodic inspection of equipment and process for timely corrective action when needed.
- Identification of which tests a radiologist must interpret, approved by MS.
- Only privileged providers order tests
- A Radiologist or physician must sign (or electronically sign) all reports
ND 33-07-01.1-23.
- Emergency radiation hazards, incidents, response and reporting, and procedures
- X-ray machine and/or portable X-ray machine have a technique chart posted and radiation
protection shielding.
- Policy and procedures on adequate radiation shielding for patients, personnel and facilities
which includes shielding built into physical plant, types of personal protective shielding to
use and under what circumstances, types of containers to be used for radioactive materials and
clear signage identifying hazardous radiation area.
- Policy: labeling all radioactive materials, including waste; transportation between locations
within CAH, control access to radioactive materials and provide testing of equipment for hazards
- Periodic checking of staff regularly exposed to radiation for the level of radiation exposure,
via exposure meters or badge tests.
- Need copies of all reports and printouts, written policy and ensure integrity of
authentication.
- File storage, security, retrieval, HIPAA
- Staff are trained on all policies and procedures, including radiation safety
|
Emergency Procedures
C-1032 |
- Emergency Procedures: see C-1026
- Must provide medical emergency services as a first response to common life-threatening injuries
and acute illness.
- Emergency Services can be done directly or by contracted services
|
Contractual Agreements
C-1034 |
- Agreements with one or more Medicare participating providers/suppliers for care; (exception,
distant-site providers/entities). See C-0872 and C-0874
- Governing body assesses the quality of care provided under these agreements, etc.
- Describe routine procedures for obtaining outside lab tests.
- CAH's QA plan must access those services provided under arrangement, identify quality and
performance problems, implement appropriate corrective or improvement activities, and ensure the
monitoring and sustainability of those corrective or improvement activities.
|
Contracted Services
C-1036
|
- Must have agreement or arrangement with one or more providers or suppliers participating under
Medicare to provide service to patients.
- Must have at least one MD or DO on its staff who is responsible.
- If agreement(s) are not in writing, CAH can provide evidence referred patients are accepted and
treated.
- Need policy and procedures for referring patients it discharges those who need additional
care.
|
Diagnostic Services
C-1038
|
- Lab or diagnostic services that are not available at the CAH – have an agreement with 1
or more providers, be sure referred patients are accepted and treated.
- Need to make sure basic lab services are available to ensure an immediate diagnosis and
treatment.
- Contracted lab must have CLIA certification.
- Need policies and procedures for additional/specialized lab services covering collection
preservation, transportation, receipt, and reporting of tissue specimen results.
|
Food and Dietary Services
C-1040
|
- Agreement for food, nutritional services not provided directly by the CAH is available.
|
Contracted Services
C-1042
|
- Keep a list of all contracted/agreement services is maintained, current, AND CONTAINS ALL
REQUIRED INFORMATION:
- Services being offered
- Entity providing service
- Services offered onsite or offsite
- When services are available
|
| C-1044 |
- Must include services offered, individual or entity that is providing it, and whether on or
off-site.
- Must include if any limit on the volume or frequency of the services provided.
- Update list each time services added or removed.
- The individual principally responsible for the CAH's operations is responsible for agreements
and oversight of those services
- All agreements require the contractor to provide services in compliance with CoPs
- CEO demonstrates how they have an oversight of all contracted services
- Provide specific examples of how CEO assures services comply with the CoP.
|
Nursing
C-1046
|
- Services under the direction of an RN ND 33-07-01.1-16
- Must designate an individual who is responsible for nursing services, including development of
policies and procedures for nursing services and ongoing review analysis of quality of nursing
care.
- Nursing services must meet the needs of all patients.
- How unit(s) adequately staffed and supervised.
- All agency nurses must be oriented and supervised.
- Will review nursing care plans, medical records, accident and investigate reports, staff
schedules and policies/procedures.
- Orientation includes units, emergency preparation, nursing policy/procedure, safety
policy/procedure, including agency nurses.
- Must have RN, LPN, or CNS on duty whenever the CAH has one or more patients.
- Must ensure appropriate staffing for outpatient nursing services.
- Must have enough supervisory and non-supervisory personnel to meet patient needs.
- RN must provide nursing care to each patient or make assignments.
- How RN provides or assigns qualified care giver for each patient, including swing bed and SNF
patients
- Ensure all nursing personnel assigned to provide nursing care have the appropriate education,
experience, licensure, competence, and specialized qualifications
|
| C-1048 |
- How RN must supervise, and evaluations evaluate the nursing care for each patient
- How does the CAH ensure that staffing schedules correlate to the number and acuity of patients,
including swing-bed patients.
|
All Drugs, Biologicals, and IV Medications
C-1049
|
- All drugs, biological and IV meds, must be administered by or under supervision of a RN, MD, DO,
or PA – in accordance with written and signed orders, accepted standards of practice,
federal and state laws.
- Orders for drugs and biologicals, including verbal orders, are legible, timed, dated and
authenticated by practitioner (need signed order)
- Policy and procedure must specify who can administer meds.
- Policy that describes limitations or prohibitions on use of VO. Provide a mechanism to ensure
validity/authenticity of the prescribers. List elements to be included in verbal orders. List
and define the individuals who may send and receive VO and provide guidelines for clear and
effective communication of VO.
- Policies and procedures for verbal and standing orders.
- Practitioner must authenticate orders as soon as possible.
- Standing orders must include how it is developed, approved, monitored, and updated.
- Must include when staff can initiate a standing order.
- Must include that the standing order is signed off.
- List of things that must be in the verbal order.
- Establish protocols for clear and effective communication and verification of VO. CMS
expects nationally accepted read-back verification practice to be implemented for every
VO.
- Telephone and verbal orders must be used infrequently and limited to urgent situations.
- Policy on identification of patient prior to administration of drugs
- Medication passes – policy/procedure approved by MS as to who can pass medications.
- Need QA plan to see if administration of drugs is regularly monitored.
- CAH must ensure compliance with the following requirements concerning:
- Minimum content of medication orders:
- Name of patient
- Age and weight of patient- policy and procedure must address weight- based dosing.
- Date and time of the order
- Drug name
- Exact strength or concentration
- Dose, frequency, and route
- Dose calculation requirements, when applicable
- Quantity and/or duration when applicable
- Specific instructions for use
- Name of prescriber
- Policy self-administration of medications, if the CAH permits this, needs an order.
- Training; safe handling and preparation of drugs
- Basic safe practices; five rights
- Policy timing of medication administration; specify timeframes.
- Policies include what staff is to do when there are missed or late medications.
- Assessment/monitoring of patients receiving medications. Policy and procedure on how frequent to
monitor patient. Factors that put patients at greater risk for adverse events and respiratory
depression. Communicate in report and hand offs. High alert medications assess sedation level.
- Policies and procedures are in place regarding self-administered medications.
- Intravenous (IV) medications; Need correct choice of vascular access device to deliver blood and
medications. Policy and procedure to address which ones can be given IV and via what type of
access.
- Policy on monitoring patients receiving Opioids (respiratory and sedation levels)
- Documentation IV Blood Administration Procedures:
- Policy and procedure to include how frequent you monitor the patient and do vital signs.
- How to identify and treat and report an adverse transfusion reaction
- Two qualified persons, one who is administering the transfusion; document, verify correct blood
product, confirm correct patient
|
First Dose Rule
North Dakota 61-07-01-14
Pharmacist First Dose Review
|
- A hospital pharmacy must have a pharmacist review all medication order prior to the first dose
being administered to the patient. Policies and procedures must be put into place to ensure this
compliance. ND 61-07-01-14
- Either a pharmacist onsite or the use of hospital tele pharmacy services will be sufficient to
comply with the requirement ND 61-07-01-14
- All prescribers' medication orders (except in emergency situations) should be reviewed for
appropriateness by a pharmacist before first dose is dispensed.
- Therapeutic appropriateness of a patient's medication regimen
- Therapeutic duplication
- Appropriateness of the route and method of administration
- Medication-medication, medication-food, medication-laboratory test, and medication-disease
interactions
- Clinical and laboratory data to evaluate the efficacy of medication therapy to anticipate or
evaluate toxicity and adverse effects.
- Physical signs and clinical symptoms relevant to the patient's medication therapy.
- Preparation of sterile products in an appropriate environment, labeled by appropriately trained
and qualified personnel.
- Pharmacy should participate in CAH decisions about emergency medication kits i.e., stroke ER
toolkit.
- Supply and provision of emergency medication stored in the kits must be consistent with
standards of practice and appropriate for a specified age group or disease treatment.
- Pharmacy participation in evaluating, using and monitoring drug delivery systems, administration
devices, drug-dispensing machines.
- Medication preparation procedures.
- Using a laminar airflow hood or other appropriate environment while preparing any intravenous
(IV) admixture in the pharmacy, any sterile product made from non-sterile ingredients, or any
sterile product that will not be used within 24 hours; and visually inspecting the integrity of
the medications.
|
Nursing Care Plans
C-1050 |
- The nursing care plan started on admission and included discharge planning.
- The care plan must be kept current on all patients based on assessment and updated upon
reassessment or changes in patient condition.
- Plans must describe goals, discharge planning, physiological and psychosocial factors.
- Goals must be identified, measurable, and known to all appropriate personnel
ND 33-07-01.1-17
- Must be kept as part of medical record.
|
Rehabilitation Services
C-1052
|
- Rehab services are provided by qualified staff, including PT, OT, and speech language
pathology.
- Rehab is an optional service can be provided directly or through contracted services
- Must have an order, policy, and procedure, and be consistent with the (American PT Association,
American OT Association etc.)
- Must do a Plan of Care (POC) before treatment is started. Can be done by MD/DO, PA, NP, and CNS.
Can be done by PT, speech language pathologist or OT who is furnishing the service. Any change
in plan must be in accordance with provider's policy and procedure
- Organized integrated quality improvement, coordinated policies and procedures,
professional licenses ND 33-07-01.1-27
|
Visitation Rights
C-1054
C-1056
C-1058
|
- Includes inpatients and outpatients.
- Role of support person for both inpatient and outpatient
- Patient may want support person present during pre-op preparation or post-op
recovery.
Reasonable Restrictions
- Infection control issues
- Can interfere with the care of other patients.
- Court order restricting contact.
- Disruptive or threatening behavior
- A roommate needs rest or privacy.
- Substance abuse treatment plan
- Patients undergoing care interventions.
- Restriction for children under certain age
Visitation
- Policy regarding patient rights.
- Need to train staff on the policy and procedure.
- Patients must be informed of his or her visitation rights. Staff need to speak to how
notifications to patients are provided.
- Need to determine role staff will play in controlling visitor access and can describe the policy
for a surveyor.
- Surveyor will verify you have a policy and procedure.
- Written policy includes clear explanation of visitation restriction/limitations.
- Document that staff are trained.
- Inform each patient or their support person, when appropriate, of their visitation rights
- Include notifying patients or support person, of any restrictions.
- Patients get to decide who their visitors are.
- Cannot discriminate against same sex domestic partners, friend, family member etc. Treat all
individuals seeking to visit equally without preference.
- Cannot discriminate against race, national origin, religion, sex, gender identity, sexual
orientation, or disability.
- Support person does not have to be the same person as the durable power of attorney (DPOA)
- Support person can be friend, family member or other individual who supports the patient during
their stay (patient advocate)
- Support person can exercise patient's visitation rights on their behalf if patient unable to do
so.
- Hospitals must accept patient's designation of an individual or a support.
Person: 1. whether orally or in writing, 2. suggested to get in writing from patient
- When the patient is incapacitated and has no advance directives on file then must accept
individual who tells you they are the support person
- Hospitals are expected to accept this unless two individuals claim to be the support person then
can ask for documentation.
- This includes same sex partners, friends, or family members.
- Need a policy on how to resolve this issue.
- Any refusal to be treated as the support person must be documented in the medical record along
with specific reason for the refusal.
- Patients can withdraw consent and change their mind.
- Must document in the medical record that the notice was given.
- Educate staff on what a support person is and what it means.
|
Medical Records
C-1102 |
- Must maintain clinical medical records system in accordance with policy/procedures.
ND33-07-01.1-20
- MR policies review and revision periodically
- MR system ensures integrity of authentication and protects security of record entries.
- MR department staff qualified and can comply with state federal law ND
33-07-01.1-20
- Promptly completed in accordance with state, federal law. Have a current list of authenticates
signatures, computer codes and signature stamps. Protected and authorized by governing body,
cross reference inpatient and outpatients.
- Limit access to only those authorized people.
- What specific actions will constitute a security incident?
- How incidents will be documented, including what information should be contained in the
documentation.
- What incidents must be reported? How often and to whom? What information reports should
include?
- Must cross reference inpatients and outpatients.
- If transfer to swing bed can use one MR but need divider to show different level of care and
transition.
- Both inpatient and swing bed must have MR admission, discharge orders, progress notes, nursing
notes, graphics, laboratory support documents, any other pertinent documents, and discharge
summaries.
- Have a system that you can pull any old MR in the past 6 years, 24/7 for inpatient and
outpatient.
- Protect MR confidentiality and from damage, flood, fire, etc.
|
Accuracy
C-1104
|
- MR is legible, complete, accurate, readily accessible, systematically organized.
- Ensure accurate and complete documentation of all orders, test results, evaluation
|
| C-1106 |
- Designated member of professional staff responsible for maintaining/ensuring records.
|
Informed Consent
C-1110
|
- Verify what procedures or treatments require informed consent.
- MR-required elements – Identification and social data, informed consent forms for any procedures
or surgical procedures.
- What precautions are taken to ensure confidentiality and prevent unauthorized persons from
gaining access.
- MR retention period is 6 years and longer – Need system that can pull any old MR within this
time frame
- Informed Consent: Form should contain at least the following: name of patient, and when
appropriate, patient's legal guardian; name of CAH; Name of procedure(s); name of
practitioner(s) performing the procedures(s); signature of patient or legal guardian
- Consent form must include: Date and time consent is obtained; statement that procedure was
explained to patient or guardian; signature of professional person witnessing the consent;
name/signature of person who explained the procedure to the patient or guardian
- Discharge Summary – outcome CAH stay, disposition of patient, provisions for follow up care,
required for all hospital stays and prior to and after swing bed admit
- Discharge Summary – MD/DO may delegate to PA/NP if state allows it. Verification that MS has
specified which procedures or treatments need informed consent
- Surveyor will do review of closed and open MR at least 10% of avg daily census
|
H&P Requirements
C-1114
|
- All or part of H&P may be delegated to other practitioners MD/DO assumes responsibility and
sign.
- Bylaws require physical exam and reflect when H&P must be completed.
|
Response to Treatment
C-1116
|
- Important to describe the patient's response to treatment; all orders, reports on treatment and
medications, nursing notes, documentation of complications, other information used to monitor
the patients such as progress notes, lab tests, graphics
- Important to be sure MR are filed promptly and timely.
- All MR must contain all lab reports, radiology reports, all vital signs and reports of treatment
include complications and hospital acquired infections, and all unfavorable reaction to drugs
|
Medical Record
C-1118
|
- Must maintain a record of each patient that includes dated signatures of the MD/DO or other
health care professional.
- Provider signatures are dated; time of entries documented.
- Entries in MR- only done by those specified in the MS Policy/procedure can write in the MR- need
date, time and authenticated.
- If rubber stamps are used, person must sign they will be the only one who uses it; must have
sanctions for improper use of stamp, computer key or code signature.
- Computer or other code signatures are authorized by governing body.
- List of codes is maintained using adequate safeguards.
- Policies and procedures are in place and provide appropriate sanctions for unauthorized/improper
use of computer codes.
- Have date and time when a verbal order is signed off.
|
| C-1120 |
- Confidentiality, safeguards against loss, destruction, or unauthorized use
- Access to information is limited to those who need to know.
- Safeguard MR, videos, audio
- Only authorized people can access MR contained in MR department.
- Precautions are taken to prevent physical/electronic altering, damage/deletion/destruction of
records or information in the record
|
| C-1122 |
- Written policy/procedure governs the use and removal of MR.
- Remember the federal HIPAA law on MR confidentiality and privacy and ARRA, HITECH, and breach
notification law.
- Written policy/procedure govern release of information in MR
|
| C-1124 |
- Patient's written consent required for release of MR information not required by law
|
| C-1126
|
- Ensure that records will be retained (i.e., through a written procedure) for at least 10 years
from date of last entry. ND 33-07-01.1-20.
- Medical records can be promptly retrieved.
|
| C-1140 |
- Performed in safe manner by qualified practitioners with current privileges granted by governing
body ND 33-07-01.1-29.
- Must follow standards of practice and recommendations by national recognized organizations (AMA,
ACOS, APIC, AORN)
- Appropriate equipment and types and numbers of personnel are present.
- Quality of outpatient surgical services must be consistent with inpatient.
- Scope of surgical services must be in writing and approved by MS.
- OR supervised by experienced staff members, address qualifications of supervisor of OR rooms in
policy and procedures and authorized by state law ND 33-07-01.1-29
- If LPN or scrub nurses are used, the RN supervision who is immediately available to physically
step in as needed.
- Written policies and procedures are in place, implemented and enforced and address:
- Aseptic surveillance and technique; scrub techniques
- Identification of infected and non-infected cases
- Housekeeping in OR – requirements/procedures between patients and terminal procedures.
- Pre-operative work-up requirements: pre-operative H&P
- Consents informed and releases.
- Clinical procedures
- Safety practices
- Patient identification procedures
- Scrub and circulating nurse duties.
- Personnel policies unique to OR
- Surgical counts in accordance with accepted standards of practice
- Scheduling of patients for surgery
- Resuscitation techniques
- DNR status
- Care of surgical specimens
- Malignant hypothermia
- Surgical procedure protocols (equipment, materials, supplies needed)
- Sterilization and disinfection procedures
- CAHs biomedical equipment program to include equipment monitoring, inspected, tested, and
maintained.
- Acceptable OR attire
- Handling infections and biomed waste
- Post-op care in accordance with acceptable standards of practice
- Must have adequate provisions for immediate post op care, in accordance with acceptable
standards of care (ASPAN)
- Complete H&P must be done in accordance with acceptable standards of practice.
- All or part of H&P may be delegated to other practitioners (PA, NP) if allowed by state law
and CAH. ND 33-07-01.1-29
- Surgeon must sign and assume full responsibility.
- H&P on chart prior to surgery
- Properly executed informed consent form is in the record and includes:
- Name of patient/legal guardian
- Name of CAH
- Name of Procedure
- Name of practitioner performing procedure/important aspects
- Signature of patient/legal guardian
- Date and time consent obtained.
- Statement procedure explained to patient/guardian.
- Signature of professional person witnessing consent
- Name/signature of person who explains procedure.
- Recovery room separate from CAH, access limited.
- Transfer requirements to and from recovery room
- The operating room register includes required information.
- Operative report
- OR organizational chart shows lines of authority and delegation within the department.
- On-call system
- Cardiac monitor, defibrillator, aspirator, suction equipment, and tracheotomy set.
- Equipment available for rapid and routine sterilization of OR materials, equipment monitored,
inspected, tested, and maintained by the CAHs biomedical equipment program.
- Sterilized materials are packaged, handled, labeled, and stored in a manner that ensures
sterility i.e., in a moisture and dust-controlled environment, Policy and procedure on
expiration dates.
|
Surgical Privilegs
C-1142 |
- Designation of qualified practitioners: surgery performed only by MD, DO, dentists, oral
surgeons, or Podiatrist when privileged to do so by governing body
- Surgical privileges are specified in writing must designate who are allowed to perform surgery,
need policy/procedures. Update privileges every 2 years
- MS appraisal procedure must evaluate each practitioner's training, education, experience and
demonstrated competence
- When Supervision required – MD/DO surgeon is in the same room working on same patient
- As established by the QI program, credentialing, adherence to hospital policy/procedures, and
laws
- There is a current list of surgeons with specific surgical privileges and list of surgeons
suspended /limited privileges
|
Anesthesia
C-1144
|
- Surgical risk assessment immediately before surgery by qualified practitioner
- Pre-anesthesia risk assessment immediately before surgery by qualified practitioner
- Anesthesia recovery evaluation before discharge by qualified practitioner
- Post anesthesia follow-up report must be written on all inpatients and outpatients prior to
discharge.
- Written by the individual who is qualified to administer the anesthesia.
- Must include at a minimum: cardiopulmonary status, LOC, follow-up care and/or observations and
any complications occurring during PACU.
|
Anesthesia Administration
C-1145
|
- Anesthesia service shall establish policies, procedures, rules, and regulations for the control,
storage, and safe use of combustible anesthetics, oxygen, and other medicinal gases in
accordance with national fire protection association standards; types of anesthesia to be
administered and procedures for each; personnel permitted to administer anesthesia; infection
control; safety regulations to be followed; and responsibility for regular inspection,
maintenance, and repair of anesthesia equipment and supplies. ND
33-07-01.1-32
- MS bylaws include criteria for determining anesthesia and other surgical care practitioners'
privileges.
|
Supervision
C-1147
|
- CRNA may administer under supervision of operating practitioners or anesthesiologist;
supervising practitioner must be immediately available to provide hands-on intervention when
needed.
|
Discharge
C-1149 |
- Policy in place to govern discharge procedures and instructions.
- Patients discharged in the company of a responsible adult unless exempted by doctor.
|
State Exemption
C-1150
|
- MD/DO supervision of CRNA can be exempted by the state.
|
Infection Prevention Program
C-1200
C-1204
C-1206
C-1208
C-1210
|
- Establish a written infection control plan – Aseptic techniques, universal precautions.
Inspect and clean air-intake sources, screens, and filters following manufacturer's recommendations
and hospital policy ND 33-07-01.1-14
- CAH has an active facility-wide program for surveillance, prevention and control of HAIs and
other infectious diseases and for the optimization of antibiotic use
through stewardship.
- Program addresses optimization of antibiotic use
- Must follow nationally recognized infection control practices or guidelines (CDC, APIC, SHEA,
AORN and OSHA)
- Infection prevention and control and antibiotic use issues are addressed in QAPI program.
- Infection Preventionist who is qualified by education and experience to be responsible for
(include in job description), for CAH Infection Control Program
- Infection Preventionist is appointed by the Board upon recommendations of medical staff and
nursing leadership.
- Program has policies and procedures documenting methods used for preventing and controlling
transmission of infections within and between healthcare settings.
- Sanitary Environment
- Program includes surveillance, prevention, and control of HAI.
- Program includes maintaining a clean and sanitary environment to avoid transmission of
infection.
- Program includes infection control issues identified by public health authorities.
- Infection prevention and control program reflects scope and complexity of service provided.
|
Leadership IC/Antibiotic Stewardship
C-1225, 1229,
C-1231, C-1235,
C-1237, C-1240,
C-1242,
C-1244, C-1246,
C-1248
|
- The governing body, or responsible individual, must ensure all the following: Systems are in
place and operational for the tracking of all infection surveillance, prevention and control,
and antibiotic use activities, in order to demonstrate the implementation, success, and
sustainability of such activities.
- All HAIs and other infectious diseases identified by the infection prevention and control
program as well as antibiotic use issues identified by the antibiotic stewardship program are
addressed in collaboration with the CAH's QAPI leadership.
The infection prevention and control professional(s) are responsible for:
- The development and implementation of facility-wide infection surveillance, prevention, and
control policies and procedures that adhere to nationally recognized guidelines.
- All documentation, written or electronic, of the infection prevention and control program and
its surveillance, prevention, and control activities(iii)
- Communication and collaboration with the CAH's QAPI program on infection prevention and control
issues.
- Competency-based training and education of CAH personnel and staff, including medical staff,
and, as applicable, personnel providing contracted services in the CAH, on the practical
applications of infection prevention and control guidelines, policies, and procedures.
- The prevention and control of HAIs, including auditing of adherence to infection prevention and
control policies and procedures by CAH personnel.
- Communication and collaboration with the antibiotic stewardship program
The leader(s) of the antibiotic stewardship program is responsible for:
- The development and implementation of a facility-wide antibiotic stewardship program, based on
nationally recognized guidelines, to monitor and improve the use of antibiotics.
- All documentation, written or electronic, of antibiotic stewardship program activities.
- Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well
as the CAH's infection prevention and control and QAPI programs, on antibiotic use issues.
- Competency-based training and education of CAH personnel and staff, including medical staff,
and, as applicable, personnel providing contracted services in the CAHs, on the practical
applications of antibiotic stewardship guidelines, policies, and procedures.
|
| C-1300
|
- A CHA-wide data-driven quality assessment and performance improvement program has been
developed, implemented, and maintained.
- There is evidence of the effectiveness of the QAPI program
|
| C-1302 |
- The complexity of the QAPI is appropriate to the CAH's size and services provided.
|
| C-1306 |
- The QAPI program is ongoing.
- Involve all departments of the CAH and services (including those services furnished under
contract or arrangement.
|
| C-1309 |
- Use objective measures to evaluate its organizational processes, functions and services.
|
| C-1311 |
- Address outcome indicators related to improved health outcomes and the prevention and reduction
of medical errors, adverse events, CAH acquired conditions, and transitions of care, including
readmissions.
|
| C-1313 |
The CAH's governing body or responsible individual is:
- Ultimately responsible for the CAH's QAPI program.
|
C-1315
C-1319
C-1321 |
The CAH must:
- Focus on measures related to improved health outcomes that are shown to be predictive of desired
patient outcomes.
- Use the measures to analyze and track its performance.
- Set priorities for performance improvement, considering either high volume, high-risk services,
or problem prone areas.
|
| C-1325 |
- The program must incorporate quality indicator data including patient care data, and other
relevant data to achieve the goals of the QAPI program.
|
|
Quality Indicators |
| Healthcare Associated Infections (HAI) |
- All patient care services and other services affect patient health and safety.
- Evaluate the quality of care of allied staff (NP, PA, CNS) by doctor on MS or under contract.
- Does CAH evaluate nosocomial infections?
- Is there an infection control program established, meetings held, findings discussed, and
problems addressed?
- Does the CAH evaluate medication therapy?
|
| Peer Review |
- MD/DO evaluations of quality and appropriateness of PA, NP, or CNS. How is this documented for
the evaluation?
- How does the physician inform the CAH of any problems with the care provided by the advanced
practitioners?
- Are CRNA's evaluated by physicians with anesthesia experience/training?
|
| Quality Assurance |
- MD/DO care evaluated by hospital who is a member of the network; QIO or equivalent entity;
appropriate and qualified entity identified in the state rural health care plan.
- CAH have an arrangement for outside entity to review the appropriateness of the diagnosis and
treatment provided by each MD/DO providing services; This includes doctors providing
telemedicine services.
- Some CAHs may also prefer to conduct their own internal review in addition to the outside review
but not required
|
| Quality Assessment |
- Staff consider the findings and evaluations and recommendations of the evaluations and take
corrective action.
- Take steps to remedial action to address deficiencies found through quality assessment and
performance improvement.
- Identify who is responsible for implementing actions
|
| Deficiency |
- CAH takes appropriate remedial action to address deficiencies found thru QI Process.
- Who determines the appropriate remedial action and who is responsible for implementing the
remedial action?
- CAH documents the outcome of all remedial action
|
Discharge Planning
C-1400
|
- Must have an effective discharge planning process that focuses on the patients' goals and
treatment preferences.
|
Discharge Planning Process
C-1404 |
- Identify, at an early stage of hospitalization, patients likely to suffer adverse health
consequences
|
Discharge Planning Evaluation
C-1406
|
- Discharge planning evaluation must be timely to identify needs prior to discharge to avoid delay
in discharge.
|
Discharge Planning Evaluation
C-1408 |
- Identify post care services needed, such as hospice and home care.
|
Discharge Planning Evaluation
C-1410 |
- Discharge evaluation must include the patients' medical record for use in establishing an
appropriate discharge plan and this plan must be discussed with patient/family/caregiver.
|
Discharge Planning Evaluation
C-1412 |
- Upon the request of the patient's physician, the CAH must arrange for the development of the
discharge plan for the patient.
|
Discharge Planning Evaluation
C-1417 |
- Discharge plans must be developed or under the supervision of a RN, or social worker, or
qualified personnel.
|
Discharge Planning Evaluation
C-1420 |
- Discharge planning process must require regular re-evaluation.
|
Discharge Planning Evaluation
C-1422 |
- The discharge planning process must be assessed on a regular basis. Must include a review of a
representative number of discharge plans, including patients readmitted within 30 days.
|
Discharge Planning Evaluation
C-1425 |
- CAH must assist patients, families, or representatives in selecting a post care provider.
|
Discharge Planning Evaluation
C-1430 |
- CAH must discharge the patient, transfer or refer, and provide all necessary medical information
to the post care service or provider.
|
Organ Donation
C-1500 |
- Must have written policies/procedures that address organ procurement responsibilities
|
| C-1503 |
- Written agreement with OPO and OPO's responsibilities
- Survey and Certification 13-48-OPO CMS July 26, 2013, all hospitals have written agreements in
place with their OPO to notify them of an imminent death or of a death which has occurred. OPO
regulations at §486.322 (a) require that OPOs have a written agreement in place with 95 percent
of all participating Medicare and Medicaid hospitals and Critical Access Hospitals that have
both a ventilator and an operating room
Written agreement includes criteria for referral, definition of imminent death, timely notification
|
| C-1505 |
- Includes agreement with at least one tissue bank and at least one eye bank
|
| C-1507 |
- Ensures the family of each potential donor is informed of the option of donating- designated
requestor
|
| C-1509 |
- Encourages discretion, sensitivity to family
|
| C-1511 |
- Works with OPO in death records review to improve identification of potential donors
- This standard includes staff training on donation issues and their duties/roles – see the
interpretation guidelines for all required elements of staff training
|
Swing Bed
C-1600 |
- Requirements to be granted approval to provide post-CAH SNF level- of- care.
- Must be certified by CMS.
- 3-day rule only applies to Medicare patients
- No LOS restriction for CAH-SB patients
- No requirement to use MDS for patient access/care planning
|
Eligibility
C-1602
|
- Must be certified as a CAH.
- Have no more than 25 inpatient beds
- CAH has a Medicare provider agreement
|
Payment
C-1606 |
- Payment for inpatient rural primary care hospital and SNF-level of care services
|
SNF Services Rights
C-1608 |
- Resident rights – exercise of, notice of their rights to request, refuse.
- Right to be informed in advance of changes to the plan of care
- Right to choose attending physician.
- Right to retain and use personal possessions include furnishings and clothing as space
permits.
- Right to share room with spouse and both consent to arrangement
- Access to immediate family and friends and residents can change mind.
- Right to receive and send mail including means other than the post office.
- Must notify of any charges not covered by Medicare/Medicaid at time of admission and
periodically and if resident becomes eligible for Medicaid.
- Has right to personal privacy and confidentiality
- Right to receive written and telephone communication
- Right to secure medical records and to refuse release of records.
- Refer to Appendix
PP for the interpretive guidelines.
- Also refer to Appendix
PP for survey procedure on patient rights
- Appendix
PP is the interpretive guidelines for long-term care facilities
|
Admission, Transfer, Discharge
C-1610 |
- Admission, transfer, and discharge rights.
- Notice of transfer/Timing.
- Documentation in patient's medical record.
|
Freedom from Abuse/Neglect
C-1612 |
- Freedom from abuse, neglect, and exploitation
- CAH conducts proper investigation, completes reporting requirements, has written policies and
procedures that prevent abuse, neglect, and exploitation of patients.
- Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment,
including injuries of unknown source and misappropriation of resident property, are reported
immediately, but not later than 2 hours after the allegation is made, if the events that cause
the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if
the events that cause the allegation do not involve abuse and do not result in serious bodily
injury, to the administrator of the facility and to other officials (including to the State
Survey Agency and adult protective services where state law provides for jurisdiction in
long-term care facilities) in accordance with State law through established procedures.
|
Social Services
C-1616 |
- Medically related social services are provided to attain/maintain highest practicable physical,
mental, and psychosocial well-being of patient
|
Resident Assessment, Care Plan Discharge Summary
C-1620 |
- Comprehensive assessment, care plan and discharge planning, but no MDS/RAI
- Must Assessment if significant change (excludes re-admission if no significant change in
condition.)
- Assessment should include the following:
- Identification and demographic information
- Customary routine
- Cognitive patterns
- Communication and Vision
- Mood and behavior patterns
- Psychosocial well-being
- Physical functioning and structural problems
- Continence
- Disease diagnoses and health conditions
- Dental and nutritional status
- Skin condition
- Activity pursuit
- Medications
- Special treatments and procedures
- Discharge planning
- Documentation of summary information regarding the additional assessment performed by
completion on the MDS or Minimum Data Sheet
- Documentation of participation in assessment
- Must do direct observation and communicate with resident and licensed members on all
shifts.
- Must do a comprehensive care plan that include measurable objectives to meet patient's needs.
- Care plan to include:
- If patient refuses treatment
- Include any specialized services as result of the PASARR recommendations
(Preadmission Screening and Resident Review Process)
- Goals for admission and desired outcomes
- Preferences and potential for discharge- must document whether wants to return
to the community and document any referrals to local contact agencies and
include discharge plans.
- Care plan must be developed within 7 days after comprehensive assessment
done.
- Interdisciplinary team should develop objectives to attain highest level of functioning.
- Review and revise as necessary, such as after each assessment
- Services provided by staff who are culturally competent, qualified and who meet standards of
quality.
- Discharge Summary to include:
- Recapitulation of the resident's stay
- Includes diagnosis, course of illness and treatment, pertinent lab, X-rays, or consult
results.
- Final summary of the resident's status
- Medication reconciliation
- Care plan and discharge planning, refer to Appendix
PP of the SOM for interpretive guidelines and survey procedure
|
Rehabilitation
C-1622 |
- Specialized rehab services – provided directly or contracted, such as but not limited to
physical therapy, speech-language pathology, occupational therapy, respiratory therapy and
rehabilitative services for a mental disorder and intellectual disability or services of a
lesser intensity
- Facility must provide the required service
- May get from outside source.
- Need physician order
- Refer to Appendix
PP of the SOM for interpretive guidelines and survey procedure
|
Dental
C-1624 |
- Dental services – CAH assist residents in obtaining routine and 24-hour emergency dental care.
- May charge a Medicare resident for routine and emergency dental services.
- Must have a policy identifying when loss or damage to dentures is facility's responsibility so
may not charge a resident.
- Must refer residents within 3 days for lost or damaged dentures and document what they eat or
drink in the meantime.
- Refer to Appendix
PP of the State Operations Manual (SOM) for interpretive guidelines and survey procedure
|
Nutrition
C-1626 |
- Assisted nutrition and hydration. Includes nasogastric and gastrostomy tubes, both percutaneous
endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids
- Based on assessment, must make sure maintains usual body weight and electrolyte balance
- Is offered sufficient fluid intake.
- Refer to Appendix
PP of the SOM for interpretive guidelines and for survey
procedure
|
