Department of Health Licensing Survey

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Department of Health Licensing Survey

• Meeting the minimum standards

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Presented in cooperation with the Rural
Healthcare Quality Network

• Speaker
• Richard A. Bryan, BSN, RN, CCM
• Vice President, Healthcare Risk Management
• Arthur J. Gallagher Co. of Washington, Inc.

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Department of Health Licensing SurveyMeeting the
minimum standards

• Agenda
• Introduction
• Where the rules are located (WACs RCWs), Guide
  to Surveyors
• Hospital Survey Process High level review of
  the steps the surveyors take
• Top Ten Findings What they mean to you
• Who has the rock in their pocket Assessing
  who, within the organization, should be
  responsible for specific areas of survey
  readiness and preparation (it may not be the most
  obvious person if you really want to pass
• Wrap up and questions

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• It is the doctrine of war to not assume the
  enemy will not come, but rather to rely on ones
  readiness to meet him not to presume that he
  will not attack, but rather make ones self
  invincible.
• Sun Tzu, The Art of War

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RCW 70.41.030Standards and rules. The
department shall establish and adopt such minimum
standards and rules pertaining to the
construction, maintenance, and operation of
hospitals, and rescind, amend, or modify such
rules from time to time, as are necessary in the
public interest, and particularly for the
establishment and maintenance of standards of
hospitalization required for the safe and
adequate care and treatment of patients. To the
extent possible, the department shall endeavor to
make such minimum standards and rules consistent
in format and general content with the applicable
hospital survey standards of the joint commission
on the accreditation of health care
organizations. The department shall adopt
standards that are at least equal to recognized
applicable national standards pertaining to
medical gas piping systems. 1995 c 282 1
1989 c 175 127 1985 c 213 17 1971 ex.s. c
189 9 1955 c 267 3. NOTES Effective date
-- 1989 c 175 See note following RCW 34.05.010.
Savings -- Effective date -- 1985 c 213 See
notes following RCW 43.20.050
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RCW 70.41.130 Denial, suspension, revocation,
modification of license -- Procedure.

• The department is authorized to deny, suspend,
  revoke, or modify a license or provisional
  license in any case in which it finds that there
  has been a failure or refusal to comply with the
  requirements of this chapter or the standards or
  rules adopted under this chapter. RCW 43.70.115
  governs notice of a license denial, revocation,
  suspension, or modification and provides the
  right to an adjudicative proceeding.
• 1991 c 3 335 1989 c 175 128 1985 c 213
  22 1955 c 267 13.
• NOTES
• Effective date -- 1989 c 175 See note following
  RCW 34.05.010.
• Savings -- Effective date -- 1985 c 213 See
  notes following RCW 43.20.050.

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RCW 70.41.170Operating or maintaining
unlicensed hospital or unapproved tertiary health
service --

• Penalty. Any person operating or maintaining a
  hospital without a license under this chapter,
  or, after June 30, 1989, initiating a tertiary
  health service as defined in RCW 70.38.025(14)
  that is not approved under RCW 70.38.105 and
  70.38.115, shall be guilty of a misdemeanor, and
  each day of operation of an unlicensed hospital
  or unapproved tertiary health service, shall
  constitute a separate offense.
• 1989 1st ex.s. c 9 612 1955 c 267 17.
• NOTES
• Effective date -- Severability -- 1989 1st ex.s.
  c 9 See RCW 43.70.910 and 43.70.920.

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Chapter 246-320 WAC HOSPITAL LICENSING REGULATIONS

• Provides a framework for the Department of
  Health Surveyors to inspect hospitals. It also
  Provides hospitals with the rules!

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WAC 246-320-025   On-site licensing survey.

•    The purpose of this section is to provide
  annual on-site survey requirements in accordance
  with chapter 70.41 RCW.
• (1) The department will     (a) Conduct at
  least one on-site licensing survey each calendar
  year to determine compliance with the provisions
  in chapter 70.41 RCW and this chapter     (b)
  Notify the hospital in writing of state survey
  findings     (c) Contact the hospital to
  discuss the findings of an on-site licensing or
  joint commission on accreditation of health care
  organizations (JCAHO) survey when appropriate
  and     (d) Not conduct the annual on-site
  licensing survey when requested by a hospital
  accredited by JCAHO in accordance with
  subsections (2) and (3) of this section.

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Department of Health Licensing SurveyMeeting the
minimum standards

• There is a compelling reason for minimum
  standards!

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Department of Health Licensing SurveyMeeting the
minimum standards

• Our communities expect more from us!

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Department of Health Licensing Survey State
Operations Manual Survey Protocol
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Department of Health Licensing Survey

• Hospitals must comply!

Should an individual or entity (hospital) refuse
to allow immediate access upon reasonable request
to either a State Agency or CMS surveyor, the
Office of the Inspector General (OIG) may exclude
the hospital from participation in all Federal
healthcare programs in accordance with 42 CFR
1001.1301.
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Department of Health Licensing SurveySurvey
Process

• Team Arrives
• Entrance Conference
• On-Site Team Meeting
• Sample Selection
• Information Gathering/Investigations
• Survey Locations
• Observation
• Interviews
• Document Review
• Completion of Hospital/CAH Medicare Database
  Worksheet
• Team Discussion
• Determination of Severity of Deficiencies
• Exit conference
• Closure
• Post Survey Plan of Correction

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Department of Health Licensing Survey

• Arrival
• The entire survey team should enter the
  hospital together. Upon arrival, surveyors should
  present their identification. The team
  coordinator should announce to the Administrator,
  or whoever is in charge, that a survey is being
  conducted. If the Administrator (or person in
  charge) is not onsite or available (e.g., if the
  survey begins outside normal daytime
  Monday-Friday working hours), ask that they be
  notified that a survey is being conducted. Do not
  delay the survey because the Administrator or
  other hospital staff is/are not on site or
  available.

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Department of Health Licensing Survey Entrance
Conference

• The entrance conference sets the tone for the
  entire survey. Be prepared and courteous, and
  make requests, not demands. The entrance
  conference should be informative, concise, and
  brief it should not utilize a significant amount
  of time. Conduct the entrance conference with
  hospital administrative staff that is available
  at the time of entrance.

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Department of Health Licensing Survey Entrance
Conference

• During the entrance conference, the Team
  Coordinator will arrange with the hospital
  administrator, or available hospital
  administrative supervisory staff if he/she is
  unavailable to obtain the following
• - A location (e.g., conference room) where the
  team may meet privately during the survey
• - A telephone for team communications,
  preferably in the team meeting location
• - A list of current inpatients, providing each
  patients name, room number, diagnosis(es),
  admission date, age, attending physician, and
  other significant information as it applies to
  that patient.

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Department of Health Licensing Survey Entrance
Conference

• The team coordinator will explain to the
  hospital that in order to complete the survey
  within the allotted time it is important the
  survey team is given this information as soon as
  possible, and request that it be no later than 3
  hours after the request is made. SAs may develop
  a worksheet to give to the facility for obtaining
  this information
• - A list of department heads with their
  locations and telephone numbers
• - A copy of the facilitys organizational chart
  
• - The names and addresses of all off-site
  locations operating under the same provider
  number
• - The hospitals infection control plan
• - A list of employees
• - The medical staff bylaws and rules and
  regulations
• - A list of contracted services and
• - A copy of the facilitys floor plan,
  indicating the location of patient care and
  treatment areas

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Department of Health Licensing Survey
Information Gathering/Investigation

• General Objective
• The objective of this task is to determine the
  hospitals compliance with the Medicare CoP
  through observations, interviews, and document
  review.

• Guiding Principles
• Focus attention on actual and potential patient
  outcomes, as well as required processes.
• Assess the care and services provided, including
  the appropriateness of the care and services
  within the context of the regulations.
• Visit patient care settings, including inpatient
  units, outpatient clinics, anesthetizing
  locations, emergency departments, imaging,
  rehabilitation, remote locations, satellites,
  etc.
• Observe the actual provision of care and services
  to patients and the effects of that care, in
  order to assess whether the care provided meets
  the needs of the individual patient.
• Use the interpretive guidelines and other
  published CMS policy statements to guide the
  survey.
• Use Appendix Q for guidance if Immediate Jeopardy
  is suspected.

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Department of Health Licensing SurveyInformation
Gathering/Investigation

• The objective of this task is to determine the
  hospitals compliance with the Medicare CoP
  through observations, interviews, and document
  review.
• Focus attention on actual and potential patient
  outcomes, as well as required processes.
• Assess the care and services provided, including
  the appropriateness of the care and services
  within the context of the regulations.
• Visit patient care settings, including inpatient
  units, outpatient clinics, anesthetizing
  locations, emergency departments, imaging,
  rehabilitation, remote locations, satellites,
  etc.
• Observe the actual provision of care and services
  to patients and the effects of that care, in
  order to assess whether the care provided meets
  the needs of the individual patient.

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Department of Health Licensing SurveySurvey
Locations

• For hospitals with either no or a small number
  of off-campus provider-based locations, survey
  all departments, services, and locations that
  bill for services under the hospitals provider
  number and are considered part of the hospital.

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Department of Health Licensing SurveyPatient
Sample Size and Selection

• Review the patient list provided by the hospital
  and select patients who represent a cross-section
  of the patient population and the services
  provided
• Minimum of 30 inpatient records. For small
  general hospitals (this reduction does not apply
  to surgical or other specialty hospitals) with an
  average daily census of 20 patients or less, the
  sample should not be fewer than 20 inpatient
  records, provided that number of records is
  adequate to determine compliance.
• To conduct an initial survey of a hospital there
  must be enough inpatients currently in the
  hospital and patient records (open and closed)
  for surveyors to determine whether the hospital
  can demonstrate compliance with all the
  applicable CoP.

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Department of Health Licensing SurveyPatient
Review

• A comprehensive review of care and services
  received by each patient in the sample should be
  part of the hospital survey. A comprehensive
  review includes observations of care/services
  provided to the patient, patient and/or family
  interview(s), staff interview(s), and medical
  record review.

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Department of Health Licensing SurveyObservations

• Surveyors are encouraged to make observations,
  complete interviews, and review records and
  policies/procedures by stationing themselves as
  physically close to patient care as possible.
• When conducting observations, particular
  attention should be given to the following
• - Patient care, including treatments and
  therapies in all patient care settings
• - Staff member activities, equipment,
  documentation, building structure, sounds and
  smells
• - People, care, activities, processes,
  documentation, policies, equipment, etc., that
  are present that should not be present, as well
  as, those that are not present that should be
  present
• - Integration of all services, such that the
  facility is functioning as one integrated whole
• - Whether quality assessment and performance
  improvement (QAPI) is a facility- wide activity,
  incorporating every service and activity of the
  provider and whether every facility department
  and activity reports to, and receives reports
  from, the facilitys central organized body
  managing the facility-wide QAPI program and
  Storage, security and confidentiality of medical
  records.-

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Department of Health Licensing SurveyInterviews

• Interviews provide a method to collect
  information, and to verify and validate
  information obtained through observations.
  Informal interviews should be conducted
  throughout the duration of the survey
• Staff interviews should gather information about
  the staffs knowledge of the patients needs,
  plan of care, and progress toward goals. Problems
  or concerns identified during a patient or family
  interview should be addressed in the staff
  interview in order to validate the patients
  perception, or to gather additional information.
• Patient interviews should include questions
  specific to the patients condition, reason for
  hospital admission, quality of care received, and
  the patients knowledge of their plan of care. For
  instance, a surgical patient should be questioned
  about the process for preparation for surgery,
  the patients knowledge of and consent for the
  procedure, pre-operative patient teaching,
  post-operative patient goals and discharge plan.

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Department of Health Licensing SurveyDocument
Review

• Document review focuses on a facilitys
  compliance with the CoP.
• Patients clinical records, to validate
  information gained during the interviews, as well
  as for evidence of advanced directives, discharge
  planning instructions, and patient teaching. This
  review will provide a broad picture of the
  patients care. Plans of care and discharge plans
  should be initiated immediately upon admission,
  and be modified as patient care needs change.
• Closed medical records may be used to determine
  past practice, and the scope or frequency of a
  deficient practice. Closed records should also be
  reviewed to provide information about services
  that are not being provided by the hospital at
  the time of the survey
• Personnel files to determine if staff members
  have the appropriate educational requirements,
  have had the necessary training required, and are
  licensed, if it is required
• Credential files to determine if the facility
  complies with CMS requirements and State law, as
  well as, follows its own written policies for
  medical staff privileges and credentialing

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Department of Health Licensing SurveyDocument
Review

• Maintenance records to determine if equipment is
  periodically examined and to determine if it is
  in good working order and if environmental
  requirements have been met
• Staffing documents to determine if adequate
  numbers of staff are provided according to the
  number and acuity of patients
• Contracts, if applicable, to determine if patient
  care, governing body, QAPI, and other CoP
  requirements are included and
• Policy and procedure manuals. When reviewing
  policy and procedure manuals, verify with the
  person in charge of an area that the policy and
  procedure manuals are current

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Department of Health Licensing SurveyCompletion
of Medicare Database Worksheet

• Arrange an interview with a member of the
  administrative staff to update and clarify
  information from the provider file. The
  Hospital/CAH Medicare Database Worksheet will be
  used to collect information about the hospitals
  services, locations, and staffing by Medicare
  surveyors during hospital surveys. The worksheet
  will be completed by the surveyors using
  observation, staff interviews, and document
  review. The worksheet will not be given to
  hospital staff to complete. The worksheet is used
  to collect information that will later be entered
  into the Medicare database. During the interview
  clarify any inconsistencies from prior
  information or information gathered during the
  survey.

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Department of Health Licensing SurveyTeam
Discussion Meeting

• The teams preliminary decision-making and
  analysis of findings assist it in preparing the
  exit conference report. Based on the teams
  decisions, additional activities may need to be
  initiated.
• At this meeting, the surveyors will share their
  findings, evaluate the evidence, and make team
  decisions regarding compliance with each
  requirement. Proceed sequentially through the
  requirements for each condition appropriate to
  the facility as they appear in regulation. For
  any issues of noncompliance, the team needs to
  reach a consensus. Decisions about deficiencies
  are to be team decisions, with each member having
  input.

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Department of Health Licensing SurveyDetermining
the Severity of Deficiencies

• The regulations at 42 CFR 488.26 state, The
  decision as to whether there is compliance with a
  particular requirement, condition of
  participation, or condition for coverage, depends
  upon the manner and degree to which the provider
  or supplier satisfies the various standards
  within each condition. When noncompliance with a
  condition of participation is noted, the
  determination of whether a lack of compliance is
  at the Standard or Condition level depends upon
  the nature (how severe, how dangerous, how
  critical, etc.) and extent (how prevalent, how
  many, how pervasive, how often, etc.) of the lack
  of compliance. The cited level of the
  noncompliance is determined by the
  interrelationship between the nature and extent
  of the noncompliance.

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Department of Health Licensing SurveyDetermining
the Severity of Deficiencies

• A deficiency at the Condition level may be due to
  noncompliance with requirements in a single
  standard or several standards within the
  condition, or with requirements of noncompliance
  with a single part (tag) representing a severe or
  critical health or safety breach. Even a
  seemingly small breach in critical actions or at
  critical times can kill or severely injure a
  patient, and represents a critical or severe
  health or safety threat.
• A deficiency is at the Standard level when there
  is noncompliance with any single requirement or
  several requirements within a particular standard
  that are not of such character as to
  substantially limit a facilitys capacity to
  furnish adequate care, or which would not
  jeopardize or adversely affect the health or
  safety of patients if the deficient practice
  recurred.

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Department of Health Licensing SurveyDetermining
the Severity of Deficiencies

• When a deficient practice (noncompliance) is
  determined to have taken place prior to the
  survey and the hospital states that it has
  corrected the deficient practice/issue
  (noncompliance), issues for the survey team to
  consider would include
• Is the corrective action superficial or
  inadequate, or is the corrective action adequate
  and systemic?
• Has the hospital implemented the corrective
  intervention(s) or action(s)?
• Has the hospital taken a QAPI approach to the
  corrective action to ensure monitoring, tracking
  and sustainability?
• The survey team uses their judgment to determine
  if any action(s) taken by the hospital prior to
  the survey is sufficient to correct the
  noncompliance and to prevent the deficient
  practice from continuing or recurring. If the
  deficient practice is corrected prior to the
  survey, do not cite noncompliance. However, if
  the noncompliance with any requirements is noted
  during the survey, even when the hospital
  corrects the noncompliance during the survey,
  cite noncompliance. All noted noncompliance must
  be cited even when corrected on site during the
  survey.

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Department of Health Licensing SurveyExit
Conference

• The general objective of this task is to inform
  the facility staff of the teams preliminary
  findings.
• It is CMS general policy to conduct an exit
  conference at the conclusion of each survey.
  However, there are some situations that justify
  refusal to continue or to conduct an exit
  conference. For example
• If the provider is represented by counsel (all
  participants in the exit conference should
  identify themselves), surveyors may refuse to
  conduct the conference if the lawyer tries to
  turn it into an evidentiary hearing or
• Any time the provider creates an environment that
  is hostile, intimidating, or inconsistent with
  the informal and preliminary nature of an exit
  conference, surveyors may refuse to conduct or
  continue the conference. Under such
  circumstances, it is suggested that the team
  coordinator stop the exit conference and call the
  State agency for further direction.

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Department of Health Licensing SurveyExit
Conference Sequence

• Introductory Remarks
• Ground Rules
• Presentation of Findings
• Closure

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Department of Health Licensing SurveyPost Survey
Plan of Correction

• Regulations at 42 CFR 488.28(a) allow
  certification of providers with deficiencies at
  the Standard or Condition level only if the
  facility has submitted an acceptable plan of
  Correction POC for achieving compliance within
  a reasonable period of time acceptable to the
  Secretary. Failure to submit a POC may result in
  termination of the provider agreement as
  authorized by 42 CFR 488.28(a) and
  489.53(a)(1). After a POC is submitted, the
  surveying entity makes the determination of the
  appropriateness of the POC.

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Department of Health Licensing SurveyTop Ten
Findings
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Department of Health Licensing SurveyTop Ten
Findings

• Inpatient - Individual Plan of Care, Initial
  Assessment Reassessment
• WAC 246-320-345
• Citations reflect a failure by hospitals to
• Establish a plan of care based on the patient
  assessment
• Reassess the patient periodically to determine if
  the initial needs/problems were resolved or
  continued or
• Reassess periodically to identify new patient
  problems needing different interventions
  according to a revised plan
• Individualize patient plans of care when the
  patient has very obvious special needs outside a
  standard plan of care that may have been based on
  a single medical diagnosis, or single procedure.

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Department of Health Licensing SurveyTop Ten
Findings

• Inpatient - Restraints 
• WAC 246-320-345(5)(g)
• The citations reflect a failure by hospitals to
  develop and implement complete policies for use
  of restraints or a failure to follow hospital
  policies for restraint. Specific examples
  include
• Failure to define restraint devices versus safety
  devices
• Failure to define a physical restraint versus a
  chemical restraint
• Failure to define use of restraints for
  medical/surgical reasons versus use of restraints
  for emergent behavioral/psychiatric reasons
• Failure to obtain appropriate orders for
  restraints
• Failure to document specific less restrictive
  interventions attempted
• Failure to document the reasons for the
  restraint

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Department of Health Licensing SurveyTop Ten
Findings

• Failure to document the actual restraint used
• Failure to periodically assess/reassess the
  patient to determine if restraints continue to be
  needed and/or if the patient physical needs and
  safety are met
• Failure to remove the restraint as soon as safely
  possible
• Failure to provide continuous face to face
  monitoring of patients in seclusion and
  restraint or
• Failure to provide and document annual training
  for staff caring for patients in restraints.

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Department of Health Licensing SurveyTop Ten
Findings

• In-Patient Blood Transfusions
• WAC 246-320-345(5)(o)
• Citations reflect failure by a hospital to
  follow established policies such as
• Failure to verify patient identify with two
  persons
• Failure to verify blood/blood product
  identification for the patient by two persons
• Failure to document the assessment of the patient
  pre and post administration of blood/blood
  products
• Failure to document initial, incremental and
  final vital signs
• Failure to document patient reaction/non reaction
  to transfusion or
• Failure to administer blood or blood product at
  the ordered infusion rate.

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Department of Health Licensing SurveyTop Ten
Findings

• HR - Qualified/Competent Staff
• WAC 246-320-165
• Failure to establish staff competency standards
  for specialized care areas or
• Failure to ensure that licensed, certified or
  registered staff practice only within their scope
  practice.
• Failure by a hospital to provide and document
  staff competency for specialized duties, such as
  
• - The registered nurse administering/monitoring
  conscious/ procedural sedation according to the
  January 2000 Nursing Commission Policy Statement
  for Registered Nurses Performing Procedural
  Sedation
• - Use of restraints and
• - Assessment and management of malignant
  hyperthermia.

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Department of Health Licensing SurveyTop Ten
Findings

• Pharmacy - Prepare, Dispense, Administration
• WAC 246-320-285
• Failure to have an organized and systematic
  pharmacy service under the direction of a
  hospital pharmacist
• Failure to have clear orders for medications
  which include parameters for dose, route,
  frequency and reasons for administration
• Failure to monitor medication effectiveness or
  therapeutic levels
• Failure to review and assure pharmacy approval of
  medication protocols, and/or pre-printed
  medication orders
• Failure to authenticate medication orders
  according to policy
• Failure to monitor for and remove outdated
  medications
• Failure to label medications in syringes and
• Failure to keep medications secure according to
  hospital policy.

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Department of Health Licensing SurveyTop Ten
Findings

• Air Pressure Relationships
• WAC 246-320-405 (9)(c)(ii)
• Hospital facility conditions that lead to these
  improper pressure relationships are
• Dampering air flow
• Closing/altering a doorway and
• Alterations/repairs to the ventilation system.

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Department of Health Licensing SurveyTop Ten
Findings

• Tamper Resistant Receptacles
• WAC 246-320-405 (9)(e)(ii)
• Tamper resistant receptacles are required in the
  following areas per the requirements of WAC
  246-320-405 (9)(e) (ii) and as noted in Table
  525-5
• Pediatric areas
• Alcoholism and Substance Abuse units
• Psychiatric units
• Exam rooms and
• Waiting areas.

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Department of Health Licensing SurveyTop Ten
Findings

• Plant Cross Connections
• WAC 246-320-405 (9)(b)(iii)
• Whenever equipment is connected directly or
  indirectly to a potable water supply a backflow
  prevention device needs to be installed when or
  if
• The equipment contains or might contain a
  contaminated or contaminating water, liquid, gas
  or mixture
• The equipment has the potential to contaminate
  other equipment and or
• The equipment is connected to a non-potable water
  supply, sewer or drain.

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Department of Health Licensing SurveyTop Ten
Findings

• Examples of such equipment include
• Beverage carbonators
• Fluid disposal docking units
• Chemical feeders
• Food preparation sinks
• Commercial style laundry machines
• Hose bibs
• Dialysis units
• Ice machines
• Dish washers
• Pasteurizers
• Film developers
• Ultra-sonic washers

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Department of Health Licensing SurveyTop Ten
Findings

• Safety
• WAC 246-320-405(2)(a)
• Department of Health staff frequently identify
  the following unsafe conditions
• Unsecured gas cylinders
• Electrical receptacles in wet areas that are not
  protected by ground fault circuit interrupters
  (GFCI's)
• Lights over patient beds or in work areas that
  lack shields or shatterproof bulbs, unsecured
  windows
• Electrical panels in patient areas that are left
  unlocked and
• Plumbing and accessory fixtures installed in
  certain patient treatment areas that allow for
  self harm.

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Department of Health Licensing SurveyTop Ten
Findings

• Nutrition - Food Service
• WAC 246-320-305 (6)
• Department of Health staff have identified
  non-compliance with the Food Service Code for the
  following items of concern as well as others
• Food preparation sinks lacking indirect drains
• Potential cross-contamination of food products
• Improper food holding temperatures, both hot and
  cold and
• Improper dishwashing and sanitizing temperatures.

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Department of Health Licensing SurveyWho has the
rock in their pocket?

• Those facilities most successful during survey
  have assessed who within the organization should
  be responsible for specific areas of ongoing
  survey readiness and preparation.

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Department of Health Licensing Survey Who has
the rock in their pocket?
Finding the owner of the rock may be difficult.
Sometimes it may not be the most obvious
person. This if further compounded by siloing
within organizations.
H U M A N   R E S O U R C E S
F A C I L I T I E S
P A T I E N T   C A R E
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Department of Health Licensing Survey Who has
the rock in their pocket?
when individuals, groups, or divisionsout of
fearseek to make themselves vital to their
organizations and unconsciously or sometimes
deliberately try to protect their turf or reshape
their environment to gain as much control as
possible over what goes on. Bob Herbold

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Department of Health Licensing Survey Who has
the rock in their pocket?

• Assigning the most competent individual may
  require dealing with departmental silos or
  fiefdoms.
• Every department must understand that it is in
  the best interest of the facility to meet the
  minimum standards.

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Department of Health Licensing Survey Who has
the rock in their pocket?

• Real time examples
• Facilities In smaller facilities, the
  maintenance person that is so adept at keeping
  the place running may not be competent enough
  with the record keeping necessary to meet the
  minimum requirements of the Department of Health.
• Do you sacrifice day to day operations, or do
  you assign someone who is proficient in the paper
  requirements to work with them?
• In smaller facilities it may be someone from
  Upper Management.

54
Department of Health Licensing Survey Who has
the rock in their pocket?

• Other Examples?

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Department of Health Licensing SurveyWrap Up

• Survey is mandatory
• Facilities are surveyed to minimum standards
• Survey criteria is defined by CMS Conditions of
  Participation so tied to Federal
• Surveyors follow State Operations Manual that
  is 307 pages of specific instructions and
  guidance
• DOH has identified top ten most frequently
  written citations
• Senior management must engage in the process at
  all times, not just the week of survey
• DOH wants you to stay open.

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Department of Health Licensing Survey

• Questions?

Richard A.Bryan, BSN, RN, CCM Vice President,
Healthcare Risk Management Arthur J. Gallagher
Company of Washington 425-586-1057 Richard_bryan_at_a
jg.com