An Update: What's New and
Problematic: Joint Commission
Standards and CMS Regulations
1
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 isn’t 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 can’t 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
2
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.
• Don’t think “what is the right answer” think about what
you do day after day.
• Know where policies are kept & how to access them
3
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 don’t need to memorize
• Call on experts around you
4
When They Leave Your Unit
• After the team leaves, find all “IOUs”
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Find the missing stuff, if it exists
Find the order
Find the anesthesia record, the consent, etc
Copy it, highlight the part the surveyor couldn’t
find
• Send to your command center
• Make a copy to the surveyor room during special
issue resolution, escort should record this
5
Role of the Escort/Note Taker
• Record the potential problems
• Warn senior leadership of anticipated RFI’s
• 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.
6
GOOD IDEAS FOR TRACER INTERVIEW
• During tracers staff on MS units may be asked to
show documents including:
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History and physical
Update to the H&P
Nursing assessment
Consults
Orders
Home medication list, reconciliation if inpatient
If surgical, pre anesthesia 1+2, time out,
Post procedure note with all elements
post anesthesia note.
• Train escorts and scribes where to find these.
7
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 don’t just restart talking.
8
Tracer Tips For Staff, cont.
• Never, never “fix” a chart to avoid an RFI
• Never “make up” answers to please the surveyor
• Don’t 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
• Don’t affirm the leading question…” this isn’t a very
good process, is it?”
9
Focus on the Top 10 & NPSGs
• The 2013 standards have 1700 EPs that
can be scored
• The Joint Commission does >90% of its
scoring on about 25 standards/NPSGs
• Implement the top scored and all NPSGs
• Spend you time and energy here!
• If it’s a problem in 30% of the nations
hospital make sure it is solid at yours.
10
HOT BUTTON TOPICS WITH TJC
• Physical environment
– Air pressures and exchanges
– Fire safety documentation EC.02.03.05
– Temperature and humidity monitoring
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High level disinfection and sterilization
High reliability
Risk assessment
Clinical contracting
11
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
12
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
13
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
14
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%
15
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,
shouldn’t we prepare too?
16
The Top 10 Most Frequently Cited TJC Hospital
Standards First Half 2013
1. Medical Record Entries
RC.01.01.01 EP 6, EP 11, EP 19
55%
– Information needed to justify the
patient’s care, treatment, and services
missing
– Entries are not dated, timed, signed
– Illegible hand writing
17
The Top 10 Most Frequently Cited
2. Maintaining the Path of Egress
LS.02.01.20 EP 13, 16-22
54%
– Corridors are not free of clutter
– Rules don’t apply to crash carts and
isolation carts in use
– Suites are not designated where clutter
rules don’t apply
– Clinicians remember the 30 minute
rule!
18
Top 10
3. 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
19
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?
20
Top 10
4.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 don’t know what the requirement is and
can’t help to support it
21
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?
22
Top 10
5. 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?
23
Top 10
6. 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
24
Top 10
7. Maintain building features to protect against
fire and smoke
LS.02.01.30
43%
– Smoke barrier penetrations, hazardous
areas not protected
– Gaps under doors
25
Top 10
8. 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
26
Top 10
9. 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 >60%RF
27
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?
28
Top 10
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
29
Lessons Learned from
Recent TJC Surveys
Not the top ten, but very frequently scored
issues
30
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
31
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
• PRN’s must have an indication for use
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
33
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
34
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!
35
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
36
Sterile Processing Tour
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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, heavyduty gloves, eye protections
• Follow manufacturers IFU
• Temp and humidity monitor and actions
• Competency assessment
37
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
38
SPD Facility
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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
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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 (>10, 2 fresh)
Pos/Neg pressure relationships
Humidity not > than 70% in sterile storage
18 inch, 6 inch, 2 inch, solid lower shelf
40
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
41
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
H&P and Update
• An H&P is done no more than 30 days prior to
admission or within 24 hours of admission.
• If the H&P 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 H&P was reviewed, changes___ or no
changes.
– In EMR – use a SmartText: e.g., .no changes or
.changes
43
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 doesn’t meet your
requirements
• CMS now prohibits anything but a
“comprehensive H&P” for ASC; Hospitals?
44
HISTORY AND PHYSICAL
• EP 7, A – “The medical staff monitors the
quality of H+P’s”.
• 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?
45
Sample H&P 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.
46
Document Operative & High Risk Procedures
(RC.02.01.03)
 H&P 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)
47
Document Operative & High Risk Procedures
(RC.02.01.03)
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

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)
48
Informed Consent
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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
49
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
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
51
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, N+V, postoperative hydration.
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!
53
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
56
57
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
58
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., H&P, consent, nursing
assessment, preanesthesia assessment)
– Labeled radiology and lab tests
– Any required blood products, implants,
devices, or special equipment
69
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
70
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…
71
Time Out and 2 identifiers
Three Options
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•
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 preprocedure 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:
 H&P/progress note relevant to the intended procedure
H&P 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.)
73
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 >500ml 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)
74
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 patient’s 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?
75
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”?
76
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
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
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
79
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
80
EMR AND TIMING
• Patient is being prepared for surgery in PAT.
– Physician documents H+P 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….
81
EMR AND TIMING
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6:30 am, patient arrives, IV started
H+P update 7 am
Pre-anesthesia assessment 7:15 am
Pre-procedure medication orders and IV by
anesthesia written at 7:30
Pre-procedural verification by staff 7:45
Time out 7:55
Anesthesia record case ends 10 am
Immediate post procedure note timed 7:30
Post procedure orders timed 7:30
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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 unpend them which includes physician authorization
83
EMR Scavenger Hunt
1. Race and ethnicity
2. Preferred language for healthcare communication
1.
Evidence you provided it
3. Initial nursing assessment including:
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•
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Nutritional screen
Fall risk
Abuse screen
Skin risk assessment
Suicide risk assessment, if appropriate
Pain assessment
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EMR Scavenger Hunt
4. History and physical
5. Advance Directive – you asked and you tried to
obtain a copy
6. Learning needs assessment
7. Plan of care
8. Pain assessment and reassessment - pick one
method and one location to document
9. dietary consult report, if needed
10. Discharge plan
11. Patient education
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EMR Scavenger Hunt
12. 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
86
EMR Scavenger Hunt
13. Summary list for outpatient care
14. Telephone order authentication
15. Med reconciliation on admission & discharge
16. PRN Medications have an indication for use
17. Restraint orders, per your policy
18. Restraint monitoring, per your policy
19. Restraint included in the care plan
20. Glucose reading and matching MAR dose administered
21. RASS or Ramsey rating and matching sedation drip rate
or PTT and matching heparin drip adjustment
87
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*
88
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
89
MANAGING THE NON SURVEY YEARS
• Implement the new stuff as soon as
published – Don’t 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
90
DESIGN FORMS FOR ENHANCED COMPLIANCE
 Consent Obtained
... Other text …
Signed: ____________ MD
 H and P Updated
... Other text …
Signed: ____________ MD
... Other text … Consent obtained.
Signed: ____________ MD
... I have examined the patient,
reviewed the findings of the history
and physical and any changes are
specified as follows:
______________________________.
Signed: ____________ MD
 Pre-induction assessment
conducted.
Identify natural components of the
pre-anesthesia evaluation.
91
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
92
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
93
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
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
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.
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
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.
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.
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.
BEHAVIORAL HEALTH TOP 10
• #8 MM.03.01.01 Storage of medication
– Similar issues to what was discussed in
hospitals
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
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
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
Questions?
• John R. Rosing, MHA, FACHE
• johnrosing@pattonhc.com
• www.pattonhc.com