RURAL HEALTH HOSPITALS AND CRITICAL ACCESS HOSPITALS

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RURAL HEALTH HOSPITALS AND CRITICAL ACCESS
HOSPITALS

• Arizona Department of Health Services
• March 11, 2009

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Presentation Outline

• Top deficient practices in State Rules
• Top deficient practices in Critical Access
  Hospitals
• Swing Bed reminders

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State Deficiency Nursing Service

• Tag 353 - R9-10-208.C.15. RN Responsibility
• Tag 335 - R9-10-208.C.2.a. Acuity Plan
• Tag 333 - R9-10-208.C.1. Policies and
  Procedures Implemented

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State Deficiency - Nursing

• R9-10-208.C. A nurse executive shall require
  that
• R9-10-208.C.15. A registered nurse assesses,
  plans, directs, and evaluates nursing services
  provided to a patient
• This is the top deficient practice cited.

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RN Responsibility

• R9-10-208.C.15. NURSING SERVICES
• Feeding tube placement not assessed prior to the
  administration of the supplement, and feeding
  went into the patients lung.
• Scant urinary output identified, but not
  assessed not reported to oncoming shift. When
  the catheter was finally checked and replaced,
  the drainage was over 1300 cc.
• Failure to provide the services and care to
  prevent the development of pressure ulcers.
• Failure to assess patients in the ED per
  established protocols.
• RN administered an ordered medication that the pt
  had a known allergy to.

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State Deficiency - Nursing

• R9-10-208.C. A nurse executive shall require
  that
• R9-10-208.C.2. An acuity plan is established,
  documented, and implemented that includes
• R9-10-208.C.2.a. A method that establishes the
  types and numbers of nursing personnel that are
  required for each unit in the hospital

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State Deficiency - Nursing

• ACUITY
• Survey process
• To assess patient(s) and compare with staff
  nurses assessment.
• Review of your program and data to determine if
  staff are scheduled according to the skill mix.
• Review for variances and documentation related to
  the variance
• Examples
• Patients may be assessed, but there is no
  documentation of staffing adjustments to meet
  patient needs.
• The plan identifies RN and CNAs, not LPNs, and
  LPNs and CNAs are being utilized.

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State Deficiency - Nursing

• Acuity
• Will always be evaluated as part of the general
  survey process and will be included in any
  complaint investigation related to patient care
  services
• The acuity system established must meet the
  needs of the patient with the appropriate staff
  assigned to meet the needs

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State Deficiency Policies and Procedures

• R9-10-208.C. A nurse executive shall require
  that
• R9-10-208.C.1. Policies and procedures for
  nursing services are established, documented, and
  implemented

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Policy and Procedures

• Incident reports not documented per policy.
• Foley catheter inserted without a physician
  order.
• Observed the nursing staff are not using
  appropriate identification methods to identify
  patient prior to procedure/medication

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Policy and Procedure

• Linen changes not documented per facility policy.
• Daily hygiene not documented per the units
  standard of care.
• Orders not followed through according to the
  policy and procedure
• Vital Signs
• Now doses of Medications administered timely
• Consults not ordered

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State Deficiency Quality Management

• Tag 231 - R9-10-204.A.2. Program Established
• Tag 235 - R9-10-204.B.1.c. Evaluation of Data
• Tag 236 - R9-10-204.B.1.d. Action based on data

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State Deficiency - Quality

• R9-10-204.A. A governing authority shall require
  that an ongoing quality management program is
  established that
• R9-10-204.A.2. Evaluates the quality of hospital
  services and environmental services related to
  patient care, including contracted services.

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State Deficiency - Quality

• R9-10-204.B. An administrator shall require
  that
• R9-10-204.B.1. A plan is established,
  documented, and implemented for an ongoing
  quality management program that, at a minimum,
  includes
• R9-10-204.B.1.c. A method to evaluate the data
  collected to identify a concern about the
  delivery of hospital services

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State Deficiency - Quality

• R9-10-204.B. An administrator shall require
  that
• R9-10-204.B.1. A plan is established,
  documented, and implemented for an ongoing
  quality management program that, at a minimum,
  includes
• R9-10-204.B.1.d. A method to make changes or
  take action as a result of the identification of
  a concern about the delivery of hospital services

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Quality Management

• Quality Management program is established that
  covers the services and programs offered by the
  hospital.
• Contracted services need to be integrated into
  the quality management program.
• Evaluation is occurring. This would mean that
  not only data is collected but the data is
  evaluate.
• Be sure the program established in writing is
  what is implemented
• Participation requirements
• Meeting commitments
• Reporting process
• Action based on the evaluation
• Re-evaluation of the action to determine if the
  action improved/corrected the patient care
  concern
• Program is ongoing
• Continuous Quality Management
• Once a year and/or once a quarter may not meet
  the needs of the facility

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State Deficiency Medical Staff

• R9-10-207.A. A governing authority shall
  require that
• R9-10-207.A.3. A medical staff member complies
  with medical staff bylaws and medical staff
  regulations

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Medical Staff

• Peer Review Conducted
• Orders written according to the bylaws
• Participation in hospital committees impacting
  patient care
• Pharmacy
• Dietary
• Infection Control
• Quality Management

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State Deficiency - Administration

• R9-10-203.A. A governing authority shall
• R9-10-203.A.9. Review and evaluate the
  effectiveness of the quality management program
  at least once every 12 months

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CMS Deficiency Tag 276 Patient Care Policies

• The policies include the following
• (iv) rules for the storage, handling,
  dispensation, and administration of drugs and
  biologicals. These rules must provide that there
  is a drug storage area that is administered in
  accordance with accepted professional principles,
  that current and accurate records are kept of the
  receipt and disposition of all scheduled drugs,
  and that outdated, mislabeled, or otherwise
  unusable drugs are not available for patient use.
• Most frequently cited CMS deficient practice

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CMS Deficiency Tag 241 - Governing Body or
Responsible Individual

• The CAH has a governing body or an individual
  that assumes full legal responsibility for
  determining, implementing, and monitoring
  policies governing the CAH's total operation and
  for ensuring that those policies are administered
  so as to provide quality health care in a safe
  environment.

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CMS Deficiency Tag 337 Quality Assurance

• The quality assurance program requires that all
  patient care services and other services
  affecting patient health and safety are evaluated.

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CMS Deficiency Tag 270 Provision of Services

• 485.635 Condition Level
• This will be cited due to non compliance to
  standard level deficiencies within this
  condition.
• Patient Care Policies
• Infection Control
• Med errors and Adverse Reactions
• Nutrition
• Radiology Services
• Laboratory Services
• Emergency Services
• Agreements
• Lab
• Physician
• Dietary
• Transfers
• Nursing Services
• RN Responsibilities
• Care Plans
• Drug Administration

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Swing Beds

• CFR 485.645
• A CAH must meet certain requirements in order to
  be granted an approval from CMS to provide
  post-hospital SNF care as specified in section
  409.30 of this chapter, and to be paid for
  SNF-level services, in accordance with paragraph
  (c) of this section.

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Swing Bed Eligibility

• A CAH must meet the following eligibility
  requirements
• (1) The facility has been certified as a CAH by
  CMS under 485.606(b) of this subpart and
• (2) The facility provides not more than 25
  inpatient beds. Any bed of a unit of the facility
  that is licensed as a distinct-part SNF at the
  time the facility applies to the State for
  designation as a CAH is not counted under
  paragraph (a) of this section.
• The facility must apply for swing beds with the
  Medicare Administrative Contractor (FI or MAC)
• The facility must meet the requirements
  identified under the Conditions of Participation
  or Swing Beds
• The patient cannot be admitted directly to a
  swing bed from a non acute care facility

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Compliance with SNF Requirements

• The CAH is substantially in compliance with the
  following SNF requirements contained in subpart B
  of part 483 of this chapter
• (1) Resident rights (483.10(b)(3) through
  (b)(6), (d), (e), (h),(i), (j)(1)(vii) and
  (viii), (1), and (m) of this chapter).
• (2) Admission, transfer, and discharge rights
  (483.12(a) of this chapter).
• (3) Resident behavior and facility practices
  (483.13 of this chapter).
• (4) Patient activities (483.15(f) of this
  chapter), except that the services may be
  directed either by a qualified professional
  meeting the requirements of 483.15(f)(2), or by
  an individual on the facility staff who is
  designated as the activities director and who
  serves in consultation with a therapeutic
  recreation specialist, occupational therapist, or
  other professional with experience or education
  in recreational therapy.
• (5) Social services (483.15(g) of this chapter).
  
• (6)Comprehensive assessment, comprehensive care
  plan, and discharge planning (483.20(b), (k),
  and (l) of this chapter, except that the CAH is
  not required to use the resident assessment
  instrument (RAI) specified by the State that is
  required under 483.20(b), or to comply with the
  requirements for frequency, scope, and number of
  assessments prescribed in 413.343(b) of this
  chapter).
• (7) Specialized rehabilitative services (483.45
  of this chapter).
• (8) Dental services (483.55 of this chapter).
• (9) Nutrition (483.25(i) of this chapter).

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CMS Deficiency Tag 395 Comprehensive Care
Plans

• The facility must develop a comprehensive care
  plan for each resident that includes measurable
  objectives and timetables to meet a resident's
  medical, nursing, mental and psychosocial needs
  that are identified in the comprehensive
  assessment.
• The care plan must describe the services that are
  to be furnished to attain or maintain the
  resident's highest practicable physical, mental,
  and psychosocial well-being as required under
  483.25 and any services that would otherwise be
  required under 483.25 but are not provided due
  to the resident's exercise of rights under
  483.10, including the right to refuse treatment
  under 483.10(b)(4).

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CMS Deficiency Tag 385 Patient Activities

• A facility must care for its residents in a
  manner and in an environment that promotes
  maintenance or enhancement of each resident's
  quality of life. The facility must provide for
  an ongoing program of activities designed to
  meet, in accordance with the comprehensive
  assessment, the interests and the physical,
  mental, and psychosocial well-being of each
  resident.
• The activities program must be directed by a
  qualified professional who is a qualified
  therapeutic recreation specialist or an
  activities professional who--
• o Is licensed or registered, if applicable, by
  the State in which practicing and
• o Is eligible for certification as a therapeutic
  recreation specialist or as an activities
  professional by a recognized accrediting body on
  or after October 1, 1990 or
• o Has 2 years of experience in a social or
  recreational program within the last 5 years, 1
  of which was full-time in a patient activities
  program in a health care setting or
• o Is a qualified occupational therapist or
  occupational therapy assistant or
• o Has completed a training course approved by the
  State.

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State Deficiency Tag 361 Residents Rights

• The resident has a right to a dignified
  existence, self-determination, and communication
  with and access to persons and services inside
  and outside the facility. A facility must
  protect and promote the rights of each resident,
  including the right to be fully informed in
  language that he or she can understand of his or
  her total health status, including but not
  limited to, his or her medical condition.

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CMS Deficiency Tag 381 - Restraints

• The resident has the right to be free from any
  physical or chemical restraints imposed for
  purposes of discipline or convenience, and not
  required to treat the resident's medical symptoms.

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CMS Deficiency Tag 388 Resident Assessment

• The facility must conduct initially and
  periodically a comprehensive, accurate,
  standardized, reproducible assessment of each
  resident's functional capacity.
• A facility must make a comprehensive assessment
  of a resident's needs. The assessment must
  include at least the following
• Identification and demographic information
• Customary routine
• Cognitive patterns
• Communication
• 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 potential

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CMS Deficiency Tag 400 - Nutrition

• Based on a resident's comprehensive assessment,
  the facility must ensure that a resident
  maintains acceptable parameters of nutritional
  status, such as body weight and protein levels,
  unless the resident's clinical condition
  demonstrates that this is not possible.

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Survey Publication

• Web Site www.az.carecheck.com
• All Statement of Deficiencies posted 30 days
  after the SOD is sent to the facility
• Medicare
• State
• Web Site www.azdhs
• Licensing Enforcement Hospitals
• All enforcement action is posted immediately
  after the finalization of the agreement between
  the department and the provider

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State Enforcement

• This is increasing over the past year
• Repeated Deficient practices
• Failure to provide care according to policy and
  procedure and/or Standard of Care that leads to
  an adverse outcome or high potential risk to a
  patient
• Adverse outcomes
• Infections
• Decubitus Development or progression of a wound
• Falls with injury
• Failure of nursing assessments leading to outcome