An Update: What's New and Problematic: Joint Commission Standards and CMS Regulations

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An Update What's New and Problematic Joint
Commission Standards and CMS Regulations
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Tracer Tips For Staff

• Have a plan As soon as the surveyor and escort
  arrive on the floor or unit, everyone knows the
  action plan.
• Bad idea Everyone abandons the nursing station
  to avoid being interviewed.
• Bad idea Who is the charge nurse? The charge
  nurse is Jane Doe, silence, pause, oh Jane isnt
  on duty today.
• Bad idea Can I tell her what this is about?
• Bad idea Can you come back, we are so short
  staffed at this hospital I cant take the time.
• Bad idea We can do the tracer review where ever
  you would like. I guess we can use this computer.
  
• ID a quiet room, out of main traffic path to
  review the medical record for the patient tracer

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GOOD IDEAS FOR TRACER INTERVIEW

• Be enthusiastic about how good you are
• Talk proudly about the excellent service and care
  you provide
• Offer data or other follow up to support
  compliance if available for areas cited by
  surveyor
• Have multiple staff (MD, pharmacist plus RN a BIG
  help) participate in the unit interviews, one
  person can forget, get intimidated
• Know what your EMR will display based on userid.
• Dont think what is the right answer think
  about what you do day after day.
• Know where policies are kept how to access them

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When They Are in Your Unit

• Know where to find your policies fast facts
  or other tip tool
• Have two people in the patient record, a second
  person as back up looking for stuff
• Offer policies, describe education, run policies
  through your command center
• Use your resources, you dont need to memorize
• Call on experts around you

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When They Leave Your Unit

• After the team leaves, find all IOUs
• Find the missing stuff, if it exists
• Find the order
• Find the anesthesia record, the consent, etc
• Copy it, highlight the part the surveyor couldnt
  find
• Send to your command center
• Make a copy to the surveyor room during special
  issue resolution, escort should record this

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Role of the Escort/Note Taker

• Record the potential problems
• Warn senior leadership of anticipated RFIs
• Get ahold of senior leaders STAT if situation is
  significant, or surveyor mumbles anything about
  immediate threat.
• Be the expert in finding OR documentation in
  med/surg records.

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GOOD IDEAS FOR TRACER INTERVIEW

• During tracers staff on MS units may be asked to
  show documents including
• History and physical
• Update to the HP
• Nursing assessment
• Consults
• Orders
• Home medication list, reconciliation if inpatient
• If surgical, pre anesthesia 12, time out,
• Post procedure note with all elements
• post anesthesia note.
• Train escorts and scribes where to find these.

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Tracer Tips For Staff

• Before answering a question
• Take a deep breath
• Make sure you understand the question
• Or ask Could you please rephrase that question
• Offer to provide the answer later in the day
• Stop talking once you have answered
• If your surveyor pauses after your answer, try to
  seek acknowledgement that you have fully answered
  the question dont just restart talking.

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Tracer Tips For Staff, cont.

• Never, never fix a chart to avoid an RFI
• Never make up answers to please the surveyor
• Dont be intimidated by surveyors, or by your own
  management.
• Do not argue with the surveyor
• Take advantage of surveyor suggestions
• Know what improvements in patient care came from
  PI (performance improvement) activities
• Dont affirm the leading question this isnt a
  very good process, is it?

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Focus on the Top 10 NPSGs

• The 2013 standards have 1700 EPs that can be
  scored
• The Joint Commission does gt90 of its scoring on
  about 25 standards/NPSGs
• Implement the top scored and all NPSGs
• Spend you time and energy here!
• If its a problem in 30 of the nations hospital
  make sure it is solid at yours.

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HOT BUTTON TOPICS WITH TJC

• Physical environment
• Air pressures and exchanges
• Fire safety documentation EC.02.03.05
• Temperature and humidity monitoring
• High level disinfection and sterilization
• High reliability
• Risk assessment
• Clinical contracting

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THE USUAL SUSPECTS

• The top 10 MFSS including
• Hallway clutter
• Dating and timing medical records/legibility
• Medication storage and security
• Histories and physicals triple threat, PC, RC, MS
• Immediate post procedure notes
• Anesthesia assessments

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THE ANNUAL PROBLEMS

• Annual reports missing
• Reference to pre 2009 standard numbers in annual
  reports
• Annual evaluations missing or glowing despite
  known problems
• Annual reports have no real performance measures
• PFI deadlines missed
• Failure to implement ILSM for PFI items
• Failure to update ILSM policy to match standards

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MORE ANNUAL PROBLEMS

• Missing the new stuff, failure to realize that
  surveyors are trained on that which is new.
• Failure to take advantage of the planning year,
  CAUTI, ED Flow and boarders
• Missed annual education or competency
  requirements
• CAUTI
• CLBSI
• SSI
• Waived testing

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MOST FREQUENT SUSTAINABILITY FAILURES

• Failure to critically evaluate standards
  compliance
• The data looks good, but the review was very
  superficial
• There is a Med Rec form in the chart compliance
• There is a history and physical form in the chart
• There is an immediate post procedure note
• There is a pre-anesthesia assessment
• Hand hygiene compliance was 100

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LEARN FROM THE MISTAKES OF OTHERS

• Sentinel events have been a great teaching tool
  in that hospitals can learn about the common
  problems and root causes in other hospitals and
  develop prevention strategies.
• The most frequently scored standards present
  another teaching opportunity.
• If 30 or more of hospitals are getting hit,
  shouldnt we prepare too?

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The Top 10 Most Frequently Cited TJC Hospital
Standards First Half 2013

• Medical Record Entries
• RC.01.01.01 EP 6, EP 11, EP 19 55
• Information needed to justify the patients care,
  treatment, and services missing
• Entries are not dated, timed, signed
• Illegible hand writing

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The Top 10 Most Frequently Cited

• Maintaining the Path of Egress
• LS.02.01.20 EP 13, 16-22 54
• Corridors are not free of clutter
• Rules dont apply to crash carts and isolation
  carts in use
• Suites are not designated where clutter rules
  dont apply
• Clinicians remember the 30 minute rule!

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Top 10

• High Level Disinfection
• IC.02.02.01 EP 1, EP 2, EP 4 47
• High level disinfection and sterilization
  problems
• Usually a CMS Condition Level Finding
• Cidex or other test strips not dated, poor
  documentation of quality controls
• Poor low level disinfection Ø contact time
• Poor storage of equipment, devices, and supplies

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DISINFECTION

• Has the ICP identified and evaluated every
  location that performs HLD?
• Have the same forms and processes been
  standardized throughout the organization?
• Is compliance consistent in every department that
  performs HLD?
• Do we teach or label surface disinfectants to
  make it easy for staff to know contact time?

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Top 10

• Manage risks with utility systems
• EC.02.05.01 46
• New to the top 10 in 2012, higher now in 2013,
  scored in the ORs procedure areas
• Pos/Neg air pressure relationships wrong
• Air exchanges, correct per hour
• Filtration problems
• Surveyors can use Tissue Test
• Improper system design, or
• Lack of inspection, testing, maintenance or
  performance problems
• Staff dont know what the requirement is and
  cant help to support it

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AIR PRESSURE

• Do we have vendor/staff documentation at least
  twice a year?
• If any defects in the report do we have evidence
  of corrective action and retest?
• Do staff in the work unit understand the pressure
  requirements?
• Do staff in the work unit do any testing like a
  tissue test?
• Do administrative rounds demonstrate that doors
  that must be closed, are closed?

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Top 10

• Maintain building features to prevent effects of
  fire, smoke
• LS.02.01.10 45
• Usually fire doors not latching
• Fire barrier penetrations
• Doors undercut, gaps, rated
• Do you have an inventory for checking
  periodically like a BMP? Do you have data?

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Top 10

• Maintenance of Fire Safety Equipment
• EC.02.03.05 EPs 1- 25 44
• Inspection, testing and maintenance of each piece
  of fire safety device (smoke detector, fire pull
  station, magnetic door release)
• Often a problem with poor organization and
  ability to find evidence
• Often a double hit against leadership

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Top 10

• Maintain building features to protect against
  fire and smoke
• LS.02.01.30 43
• Smoke barrier penetrations, hazardous areas not
  protected
• Gaps under doors

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Top 10

• Maintain fire extinguishing features
• LS.02.01.35 35
• Sprinkler or fire extinguishment issues
• Hanging things from sprinkler pipe,
• 18 inch rule, sprinkler head broken

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Top 10

• Safe, functional environment
• EC.02.06.01 EP 1, EP 13 36
• Safe, functional area, a catch all standard for
  ripped mattresses or stained ceiling tiles
• Maintain ventilation, temperature and humidity
• Door held open by air pressure, hot/cold calls,
  humidity gt60RF

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ADMINISRATIVE ROUNDS

• Is furniture in good repair, no rips or tears?
• Are ceiling tiles free of water damage and
  stains?
• Is OR, sterile storage, central supply
  temperature and humidity being monitored and
  found compliant?

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Top 10

• Safe medication storage
• MM.03.01.01 EPs 2, 3, 6, 7, 8 33
• Unsafe/secure storage of medication
• Refrigerator temperature not sustained/monitored
• Meds unsecured not locked or under constant
  surveillance
• Access by non-licensed is not approved by policy
• Terminated employee ADM access is not cut off
• Medroom doors all have the same combination and
  have never been changed.
• Improperly labeled including Ø beyond-use date
• Expired or damaged are not removed

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Lessons Learned from Recent TJC SurveysNot the
top ten, but very frequently scored issues
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Label All Medications(NPSG.03.04.01)

• Label all meds on and off the sterile field.
• All products, including sterile water/saline,
  disinfectants in a basin must be labeled.
• The safety goal includes bedside procedures as
  well as IR, cath lab, out patient
• Its an A element of performance
• Prelabeling??? OK if your policy permits it

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RANGE ORDERS, THERAPEUTIC DUPLICATION AND PRNS

• TJC does not prohibit range orders but it is
  virtually impossible to do it correctly and
  consistently without order specifications.
• If two therapeutic agents in the same class are
  prescribed, there must be specifications when to
  give drug 1, when to give drug 2
• PRNs must have an indication for use

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Medication Orders

• Preprocedure medications/IVs and testing
  nurse-initiated protocols are now permitted
• Caveats (create a policy) Standing Orders
• Must be approved by the medical staff, nursing
  (to affirm the practice is within the scope of
  license) and pharmacy (with respect to
  medications)
• Must be based on nationally recognized and
  evidence based guidelines and recommendations
• Include regular PI review to look for problems or
  improvement opportunities
• Date, time, and authenticate per state regulation

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CPOE and the Pre-OP/Post-OP Order

• CPOE signing of post-operative anesthesia or
  surgical orders pre-operatively now requires a
  risk assessment and policy to avoid a finding
• Got away with it on paper could fudge or omit
  the time and not be noticed
• CPOE captures the time, so an easy observation
• The LIP must either pend or plan the orders and
  log back in and sign/ release/initiate the orders
  post-OP, OR
• Sign orders pre-OP and justify via risk
  assessment and policy having the RN reassess the
  patient and release/initiate the order based on
  the very nature of conditional/PRN orders

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CPOE Pre/Post-Op Orders

• Physicians and staff seek ways to expedite
  patient flow by writing post procedure orders
  before the procedure starts (sometimes hours,
  days, weeks). This is noble!
• EHR/CPOE systems allow organizations to build
  standard order sets or pre-printed orders to
  reduce/eliminate redundant work and expedite
  care. Also noble!

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CPOE Pre/Post-Op Orders

• The organization must decide whether it will
  allowing practitioners to write post-procedure
  orders prior to the procedure if yes, then
• Construct a risk assessment and policy that
  defends a process where conditional orders (i.e.,
  if this, then that/PRN orders) may be
  entered/written ahead of time by the LIP and then
  allow licensed/competent PACU RN to review the
  order post-OP AND match the order to the assessed
  needs of the patient
• The RN then initiates or activates the order or
  consults with the ordering LIP if patient
  condition warrants/changes

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Sterile Processing Tour

• Attire donned at the hospital, changed daily
• Red line no one enters without proper attire
• No artificial nails, nail polish, jewelry,
  watches
• Head AND facial hair covered at all times
• In Decontamination liquid-resistant garb,
  heavy-duty gloves, eye protections
• Follow manufacturers IFU
• Temp and humidity monitor and actions
• Competency assessment

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Reduce Risk of Infection

• Surveyors will observe staff as they process
  dirty equipment
• Surveyors will check manufacturer instructions
  for use (IFU) for three things the
  device/instrument, the sterilizer itself, and the
  packaging (i.e., blue wrap or flash pan.)
• Check your policy, check staff understand and
  follow both. Create a recipe book or OneSource
• Will observe proper use of PPE

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SPD Facility

• Easily cleaned walls, floors and ceiling
• Daily housekeeping
• No exposed pipes, etc. that collect dust
• Maintain neg/pos pressure by keeping doors and
  windows closed test pressures monthly
• Sinks available for hand washing
• Eye wash within 10 second travel time single
  action lever, tepid water temperature to allow 15
  minute flush time

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HVAC Temperature, Humidity, Storage

• Monitor and record daily
• Temp 68-73 in clean area of department
• Temp 60-65 in decontamination
• Humidity 20-60 in work areas
• Proper of Air Exchanges (gt10, 2 fresh)
• Pos/Neg pressure relationships
• Humidity not gt than 70 in sterile storage
• 18 inch, 6 inch, 2 inch, solid lower shelf

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Relative Humidity to 20

• CMS finally agreed to lower the minimum
  acceptable humidity level from 30 to 20
• Requires an internal waiver
• You need not submit a waiver request to CMS or
  TJC, but simply discuss at a committee of record
  (e.g., EOC, IC, OR Operations, etc.) and conclude
  and memorialize in minutes that you have adopted
  the 20 minimum acceptable

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EYE WASH STATIONS

• Bottles are red flags
• Bottles are only good for blood, body fluid,
  minor irritant splashes
• Corrosives must have plumbed eyewash or
  equivalent
• Staff must be able to find MSDS
• Staff must be able to correctly operate eyewash
• ANSI recommends weekly testing
• Water must be tepid

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HP and Update

• An HP is done no more than 30 days prior to
  admission or within 24 hours of admission.
• If the HP is done anytime in the 30 days prior
  to admission you must update it within 24 hours
  of admission, or prior to an invasive procedure
  on the day of the procedure, whichever comes
  first.
• Must document the patient was examined, and the
  HP was reviewed, changes___ or no changes.
• In EMR use a SmartText e.g., .no changes or
  .changes

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HISTORY AND PHYSICAL

• MS.03.01.01, EP 6, A,D The organized medical
  staff specifies the minimal content of medical
  histories and physicals, which may vary by
  setting, level of care, tx and services.
• Problem a long form, short form or ad hoc form
  is spotted which doesnt meet your requirements
• CMS now prohibits anything but a comprehensive
  HP for ASC Hospitals?

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HISTORY AND PHYSICAL

• EP 7, A The medical staff monitors the quality
  of HPs.
• Surveyors score failure to obtain within 24 hours
  of admission or prior to surgery, then look for
  actions taken by MEC to improve.
• If quality data indicates that indeed sometimes
  there are performance gaps, what do the minutes
  show for actions?

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Sample HP Bylaw Language

• A medical history and physical examination be
  completed and documented for each patient by a
  hospital practitioner with appropriate privileges
  no more than 30 days before or 24 hours after
  admission or registration, but prior to surgery
  or a procedure requiring anesthesia services.  An
  updated examination of the patient, including any
  changes in the patient's condition, be completed
  and documented within 24 hours after admission or
  registration, but prior to surgery or a procedure
  requiring anesthesia services, when the medical
  history and physical examination are completed
  within 30 days before admission or registration.

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Document Operative High Risk Procedures
(RC.02.01.03)

• HP in record before procedure (EP 3)
• Post op/post procedure report is written or
  dictated before transfer to next level (EP 5)
• (Unless a post op/post procedure note is entered
  immediately see EP 7, if so, report may be
  written or dictated per policy)
• The post operative/procedure report includes
  name of LIPs, procedure name and description,
  findings, EBL, specimens, post op diagnosis (EP 6
  - Top Scorer)

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Document Operative High Risk Procedures
(RC.02.01.03)

• No premature Post-OP notes!!!
• Medical record includes the LIP release order or
  approved DC criteria (EP 9)
• Medical record includes the use of DC criteria/pt
  readiness (EP10)

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Informed Consent

• Physician responsibility
• Risk of not receiving treatment
• Paper form needs date and time for all signatures
• CMS requires patient to sign, date, time
• May need to have them re-initial, date, time on
  day of surgery
• Form may include potential use of blood
• Process includes discussion of likelihood of
  desired outcome
• Anesthesia consent is usually in anesthesia
  record
• Sedation consent is on presedation assessment
• RN confirms patient understanding, advocate

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PREANESTHESIA ASSESSMENT

• PC.03.01.03
• EP 1 Presedation/anesthesia assessment required
  for any type of anesthesia including moderate
• EP 8 Immediate reassessment just prior to
  induction
• Not optional, always a 2 step process
• Know where these 2 assessments are documented

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CMS/TJC Anesthesia 1/11 Changes

• Post-Anesthesia assessment must occur (and be
  documented) within 48 hours of recovery.
• No premature Post-Anesthesia Evals!!!
• May be based on data collected by a nurse (as in
  the case of SDS where discharge is by RN using
  criteria approved by the medical staff.)
• No requirement for an LIP post-sedation
  assessment.
• All entries to medical record are dated/timed

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Elements of Post Anesthesia Eval

• Remember required elements should conform to
  current standards of anesthesia care including
  respiratory function, rate, airway patency and O2
  sat, CV function including pulse and BP, mental
  status, temp, pain, NV, post-operative
  hydration.

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Laryngoscope Blades

• Clean and (at least) high level disinfect them
  per manufacturer instructions for use
• Store in manner that prevents recontamination
• One blade per Zip-Lock bag if HLD, or
• Peel pouch if steam
• Consistent practice throughout the hospital
• Look everywhere!!!
• Testing light source?
• Hand hygiene and/or use gloves
• Place back into Zip-lock bag or peal pouch
• Battery expiration dates!

54
Disposable ET Tube and Stylet

• Often found in/on an anesthesia cart ready for
  next case where the factory package is opened and
  stylet is inserted to save time in a STAT
  induction package is not dated or timed with new
  expiration date/time.

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ET Tubes/Stylets

• Video-assisted laryngoscope (e.g. GlideScope)
  re-usable stylets must be sterilized and packaged
  per manufacturer instruction
• Often found unwrapped on cart ready for re-use
• Check the ED and non-OR anesthetizing locations

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Most surgical complications are avoidable

• Preventable surgical site infection through
  flawless timing of antibiotic prophylaxis
• Preventable surgical site infections and
  anesthesia-related complications through flawless
  prep technique and checklist use
• Wrong-patient, wrong-site operations avoided
  through supportive culture and checklist use
• Data suggests we still have 6 events per day in
  the US

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Just Culture by David Marx

• Human Error
• Inadvertent lapse, a mistake
• At-Risk Behavior
• Maybe my way is safer/better/quicker?
• Reckless Behavior
• Knowingly, willfully disregarding process

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February 2009
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AAO, OMIC, ASCRS, ASORN, and OOSS Ophthalmic
Surgical Checklist Task Force
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TJC Pre-Procedure Verification (UP.01.01.01)

• A Process (involves patient when possible)
• Uses a standardized list (paper, EMR or poster
  need not become part of record)
• Documentation (e.g., HP, consent, nursing
  assessment, preanesthesia assessment)
• Labeled radiology and lab tests
• Any required blood products, implants, devices,
  or special equipment

70
TJC Site Marking(UP.01.02.01)

• Identify procedures that require marking
• Laterality, or when there is more than one
  possible location, gross spinal levels
• Prior to procedure outside the room, patient
  involved if possible
• Marked by the LIP (for all intent and purposes)
• Method is unambiguous and consistent
• Written alternative process

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TJC Time Out (UP.01.03.01)

• The final verification process must be conducted
  in the location where the procedure will be done,
  just before starting the procedure
• All are actively involved, paying attention
• Cath, Endo, ASC, IR, bedside, etc.
• Compare two identifiers on the arm band (if
  visible) against the medical record, OR select
  one of the following three options

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Time Out and 2 identifiersThree Options

• Two team members confirm patient ID upon arrival
  in the procedure suite using two identifiers.
• One of the two team members remains with the
  patient during the entire pre-procedure process.
• During the final time out, this team member
  confirms patient ID.
• OR
• Two team members ID patient upon arrival in
  procedure suite as previously described.
• Two patient identifiers are written on white
  board in procedure room and confirmed by the two
  team members.
• During final time out, the team confirms patient
  ID against information on white board.
• OR
• Place a patient ID on an exposed extremity
  alternate wrist or either ankle.
• Reference the two identifiers on this ID band
  during the final time out.

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Pre-Procedure Verification

• Verification of patient, procedure, site at time
  of admission or entry
• Relevant documents match to the correct patient,
  procedure and site
  
  
  
• HP/progress note relevant to the intended
  procedure
• HP is updated if performed prior to day of
  procedure
• Nursing assessment
• Pre-anesthesia/sedation assessment performed
• Completed informed consent form signed by
  Physician (LIP) and patient
• Correctly labeled diagnostic and radiology test
  results
• Required blood products, implants, devices and/or
  special equipment
• SCIP Measures (Antibiotic, VTE, Beta Blockers,
  etc.)

74
Pre-Induction Pause

• Has the patient confirmed his/her identity, site,
  procedure and consent?
• Is the procedure site marked (if applicable)?
• Is the anesthesia machine and medication check
  complete?
• Is pulse oximeter on and functioning?
• Does the patient have a
• Known allergy?
• Difficult airway/aspiration risk (if yes, is
  difficult airway cart in room?)
• Risk of gt500ml blood loss (if yes, are 2
  IVs/central access and fluids planned?)
• Risk of hypothermia (if yes, fluid and forced air
  warmer is available)
• Risk of malignant hyperthermia (if yes, discussed
  with staff)

75
Pre-Incision Timeout

• Have all new team members been introduced by name
  and role?
• Are there any anticipated critical events (e.g.,
  airway, blood, duration)?
• Time Out
• What is the patients name? Second identifier???
• What procedure is planned and does it match the
  informed consent?
• Does the site marking match the
  procedure/informed consent?
• Is the patient positioned correctly?
• Is any alcohol based prep fully evaporated? Is
  any ignition source secured?
• Are relevant images and results properly labeled
  (match pt) and displayed?
• Has antibiotic been started (less than 59 minutes
  before incision) and are needed irrigation fluids
  available?
• Are anticipated blood products, implants,
  devices, special equipment available?
• Are there any safety concerns patient Hx,
  allergies, medications, position?

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Intra/Post-Op Debrief/Huddle

• How shall I record the name of the procedure
• Are the instrument, sponge and needle counts
  complete?
• Have the specimens been correctly labeled and
  correct testing ordered?
• What are the key concerns for recovery and
  management of this patient?
• Any went wells?
• Any to improves?

77
PRIMARY SOURCE VERIFICATION OF LICENSURE

• Only the state board website counts. May be print
  out or documented conversation
• Original licenses and photocopies are worthless
  for primary source verification
• Printout must have a date printed!
• If you really do miss one and they are
  unlicensed, you can get PDA

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CLINICAL CONTRACTS

• Patient care services that would otherwise be
  performed by employees/practitioners of the
  hospital that are clinical in nature or would
  otherwise be performed by a professional.
• Laundry is not clinical, radiology technician is,
  sterile pharmacy compounding is, vendor night
  call radiologist is clinical
• TJC focuses on clinical contracts only
• 3 required elements
• Contract contains performance measures
• Someone evaluates performance
• Medical staff has input in evaluating data

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Sentinel Event Alerts

• Program areas must be familiar with the content
  and must have conducted an evaluation, gap
  analysis.
• Program areas must know what changes will be made
  and why other recommendations are not accepted.
• See opiate use, alarm fatigue, unintended foreign
  object and Jacob Cruezfeldt

80
STANDARDS THAT BECOME MORE CHALLENGING WITH EMR

• Find me the pre-anesthesia assessment
• Show me the immediate reassessment just prior to
  induction
• Show me the immediate post procedure note
• Show me the documentation of time out
• EMR will date and time these notes automatically
  so audit and evaluate how your records look.
• Make sure staff can even find these documents

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EMR AND TIMING

• Patient is being prepared for surgery in PAT.
• Physician documents HP or update
• Anesthesiologist does pre-anesthesia assessment
• Staff will document the pre-procedural
  verification and final time out times.
• One or more physicians may open, initiate or
  document something on a post surgery page in the
  EMR.

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EMR AND TIMING

• 630 am, patient arrives, IV started
• HP update 7 am
• Pre-anesthesia assessment 715 am
• Pre-procedure medication orders and IV by
  anesthesia written at 730
• Pre-procedural verification by staff 745
• Time out 755
• Anesthesia record case ends 10 am
• Immediate post procedure note timed 730
• Post procedure orders timed 730

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EMR AND TIMING

• If you want to start post procedure notes prior
  to the case filling out demographic, diagnostic
  information, make sure the note has a final time
  documented electronically or by author.
• If you want to write post procedure medication
  orders, there must be a process to pend, and
  un-pend them which includes physician
  authorization

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EMR Scavenger Hunt

• Race and ethnicity
• Preferred language for healthcare communication
• Evidence you provided it
• Initial nursing assessment including
• Nutritional screen
• Fall risk
• Abuse screen
• Skin risk assessment
• Suicide risk assessment, if  appropriate
• Pain assessment

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EMR Scavenger Hunt

• History and physical
• Advance Directive you asked and you tried to
  obtain a copy
• Learning needs assessment
• Plan of care
• Pain assessment and reassessment - pick one
  method and one location to document
• dietary consult report, if needed
• Discharge plan
• Patient education

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EMR Scavenger Hunt

• For Procedures and Surgeries
• Informed consent with evidence of translator used
  if needed
• Pre-anesthesia assessment
• Immediate pre-induction assessment
• Pre procedure checklist
• Timeout
• Immediate post procedure note
• Post anesthesia assessment

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EMR Scavenger Hunt

1. Summary list for outpatient care
2. Telephone order authentication
3. Med reconciliation on admission discharge
4. PRN Medications have an indication for use
5. Restraint orders, per your policy
6. Restraint monitoring, per your policy
7. Restraint included in the care plan
8. Glucose reading and matching MAR dose
   administered
9. RASS or Ramsey rating and matching sedation drip
   rate or PTT and matching heparin drip adjustment

88
What You Can Be Scored On

• The Elements of Performance/Standards
• Situational rules in manual
• The Frequently Asked Questions
• Information found in Perspectives
• Your own policies
• CMS Survey and Certification Letters

89
Clarification

• Evidence that the organization was compliant with
  the element of performance at the time of survey
• We found it, here it is
• We audited and are compliant 90 of the time
• Corrective actions do not count in your favor
  except for condition level findings

90
MANAGING THE NON SURVEY YEARS

• Implement the new stuff as soon as published
  Dont wait!
• Do internal mock tracers
• Assume nothing, rely on data to self assess
• Consider smart phone or tablet applications for
  tracer teams to capture, photo, fix and track
  compliance. (iAuditor, AuditBee, Comply Flow
  Audit)

90
91
DESIGN FORMS FOR ENHANCED COMPLIANCE
Problematic
Consider Instead
92
Send Checklist to All Unit Managers

• Each manager to print or pull punch list from
  their TJC folder, give location specific list to
  staff to review
• Medication room
• Hallways and nurses station
• Clean utility
• Dirty utility
• Each list is specific to their area, check
  everything, initial, call in work orders

93
Help Staff by Conducting Internal Tracers

• Train staff on what to expect during the survey
• Ask yourself, ask your staff
• Do we do this?
• Where is it written we do this?
• How well, or how often do we do this?
• Show me the evidence that we do this
• Validate the doing with high risk and high
  priority standards

94
BEHAVIORAL HEALTH TOP 10

• 1 37 CTS.03.01.03 Treatment planning
• Assessed needs, strengths and preferences
• Goals of the individual served
• Timing and updates match policy

95
BEHAVIORAL HEALTH TOP 10

• 2 23 HR.02.01.03 LIP assignment of clinical
  responsibilities
• Similar to privileges and easier to implement in
  behavioral health programs affiliated with
  hospitals

96
BEHAVIORAL HEALTH TOP 10

• 3 15 CTS.02.01.05 physical health screening
• Non 24 hour programs have a written process on
  health screening to determine an individuals need
  for a medical history and physical exam.

97
BEHAVIORAL HEALTH TOP 10

• 4 HR.01.06.01 15 Competency assessment
• Staff are deemed competent to perform their
  duties
• Competencies are updated in accordance with
  organization policy and frequency

98
BEHAVIORAL HEALTH TOP 10

• 5 NPSG.15.01.01 15 - Suicide screening
• Patients are screened for the risk of suicide and
  the physical environment is assessed for hazards
  which are mitigated or removed.

99
BEHAVIORAL HEALTH TOP 10

• 6 EC.02.06.01 14 - The organization maintains a
  safe, functional environment
• If you have patient safety hazards, suicide
  hazards in the environment that have not been
  assessed and mitigated, you will be scored.

100
BEHAVIORAL HEALTH TOP 10

• 7 HR.01.02.05 13 Verification of staff
  qualifications
• Licensure using primary source, education using
  any source, health screening, criminal background
  check if required by law or policy.

101
BEHAVIORAL HEALTH TOP 10

• 8 MM.03.01.01 Storage of medication
• Similar issues to what was discussed in hospitals

102
BEHAVIORAL HEALTH TOP 10

• 9 CTS.04.03.33 13 The organization has a
  process for preparing, distributing food and
  nutrition processes.
• Sanitary storage, temperature controlled, special
  diets are accommodated, cultural preferences are
  honored, supervision of dining areas

103
BEHAVIORAL HEALTH TOP 10

• 10 CTS.02.01.11 13 Screening for nutritional
  status
• Screen newcomers to identify those for whom a
  nutritional assessment is appropriate

104
TOP 10 CMS FINDINGS 2013
TAG DESCRIPTION
A 0159 -A 0208 PATIENT RIGHTS RESTRAINT OR SECLUSION
A 0395 RN SUPERVISION OF NURSING CARE
A 0144 PATIENT RIGHTS CARE IN SAFE SETTING
C A 2400 ED COMPLIANCE WITH 489.24 (MEDICAL SCREEN, NURSING, TRANSFER, STABILIZE)
A 0115 PATIENT RIGHTS
A 0396 NURSING CARE PLAN
A 0404 0405 ADMINISTRATION OF DRUGS
A 0123 PATIENT RIGHTS NOTICE OF GRIEVANCE DECISION
C-0294 A-0385 NURSING SERVICES
A 0131 PATIENT RIGHTS INFORMED CONSENT
A-0043 C-0241 GOVERNING BODY
A 0450 MEDICAL RECORD SERVICES
A 0116 0117 PATIENT RIGHTS NOTICE OF RIGHTS
105
Questions?

• John R. Rosing, MHA, FACHE
• johnrosing_at_pattonhc.com
• www.pattonhc.com