Problematic Compliance Issues
Identified by The Joint
Commission and CMS
Dale Brown, RN, MSN
Principal Consultant
Kent & Associates
Knoxville, Tennessee
2
Accreditation Decisions
• Preliminary Accreditation
• Accredited
• Accredited with follow-up survey (30
days to 6 months) (Non-CMS issues)
• Contingent Accreditation: follow up
survey within 30 days
• Preliminary Denial
• Denial
3
Flow of Decision
• Accreditation with follow-up survey
(1st failed condition level
deficiency)
• Contingent accreditation (2nd failed
CLD)
• PDA: Immediate threat to life
4
Flow of Decision
• Single or multiple instances
• Nature and significance of findings
• Failed On-site ESC
• Decision rules triggered
• Repeat findings
5
Condition Level Deficiencies
• Determination based on manner and degree:
▫ Manner: prevalence, how pervasive,
number frequency
▫ Degree: magnitude, how severe, how
bad
▫ Collaboration among team members
AND Central office staff
6
Survey Process Changes
• Minimum of 30 records or 10% of ADC
whichever is greater.
• Small hospitals with ADC less than
20, then 20 records
• Small hospital exception does not
apply to specialty hospitals.
7
Condition Level Deficiencies
• Noncompliance within the condition
stem statement
• Single requirement out of
compliance which is of such
magnitude to result in
noncompliance with entire condition
• Many requirements and standards
noncompliant
8
Condition Level Deficiencies
• Follow up survey MUST occur within
45 calendar days of last day of
accreditation survey
• If the problem remains a second
follow up survey MUST occur within
30 days of first follow up survey
9
Condition Level Deficiencies
• The follow up survey will focus on the
RFIs that were determined to be the
condition level deficiencies
• The surveyors can score other issues that
are identified during an onsite visit
• Failure to clear a condition level
deficiency after the second survey results
in notification to CMS
10
Condition Level Deficiencies
• Governing Body CoP:
▫ When any condition level
deficiencies are identified during
the survey, The Joint Commission is
required to include a condition
level deficiency in the leadership
standards.
Scoring Decisions
12
Scoring/Decision
• The frequency of “Bulleted” points has been
reduced.
• Elements of Performance and other
accreditation requirements will be tagged
based on their “criticality” – immediacy of the
impact on quality of care and patient safety as
the result of noncompliance.
• – Direct Impact requirements.
• – Indirect Impact requirements.
13
Scoring/Decision
• Potentially multiple submission
deadlines based on the “immediacy”
of risk.
• – Direct Impact Requirements: ESC
due within 45 days.
• – Indirect Impact Requirements: ESC
due within 60 days.
Scoring/Decision
•Partial compliance
•Insufficient compliance is not
resolved
Progressively
More Adverse
Accreditation
16
Scoring/Decision
• The Immediate Threat to Life
process has been modified. Upon
resolution of the threat, the
accreditation status will change from
Preliminary Denial of Accreditation
(PDA) to Contingent Accreditation
and include a follow-up survey.
17
Scoring/Decision
• The report which is presented to the
organization at the conclusion of the
survey will be modified, as follows:
• 1. Title changed to – “Summary of
Survey Findings”
• 2. The report is now sorted by
chapters in the applicable
Accreditation Manuals
18
Scoring/Decision
• 3. The content includes the standards,
elements of performance, and other
accreditation requirements which have been
found to be less than fully compliant at the
time of survey, as well as the associated survey
team observations.
19
Scoring/Decision
• 4. The report does not include a potential
accreditation decision. The “official” version of
the report which is posted to the organization’s
extranet site post-survey will contain the
potential accreditation decision.
• 5. The report will no longer include
“Supplemental Findings”
• Name of the survey team is no longer included
20
Scoring/Decision
“Immediate
Threat to Life”
PDA
“Situational Decision Rule”
Conditional or PDA
“Direct Impact Standards”
Shorter time frame
“Indirect Impact Standards”
Longer time frame
21
Immediate Threat to Life
• Situations, identified at the time of survey,
which have or may potentially have a serious
adverse effect on patient health and safety.
• The Joint Commission President can issue an
expedited Preliminary Denial of Accreditation
(PDA) decision.
22
Immediate Threat to Life
• PDA remains until corrective action
is demonstrated, via an on-site
validation survey.
• PDA changes to Contingent
Accreditation which includes a
follow-up survey to assess sustained
implementation
23
Situational Decision Rule
• Examples:
▫ Unlicensed facility
▫ Unlicensed individual who requires a
license
▫ Failure to implement LSC deficiencies
• Some standards will trigger a
situational decision rule directly and
immediately
Joint Commission
CMS Relationship
T
J
C
C
M
S
25
TJC-CMS
• CMS requires accreditation to
participate in Medicare and
Medicaid programs.
• Accreditation can be granted by
CMS, States surveying on behalf
of CMS, TJC, HFAB, or DNV.
26
TJC-CMS
• CMS issues Conditions of
Participation. These are regulatory
and compliance is not optional.
• In order to be accredited, hospitals
must comply with CMS Conditions of
Participation.
27
TJC-CMS
• By having a Joint Commission survey,
Joint Commission is “deeming” the
hospital to be compliant with CMS.
• Not all Joint Commission standards
are required by CMS.
• Not all CMS Conditions of
Participation are reflected in Joint
Commission standards.
28
TJC-CMS
• Recently Joint Commission has had
to release new standards to more
closely align itself with CMS, but the
revisions are not complete.
• Most CMS related TJC standards are
“A” elements of performance,
requiring 100% compliance.
29
TJC-CMS
• If hospitals are found to be noncompliant at a standards level,
accreditation can still be awarded.
• If hospitals are found non-compliant
at a “Condition Level”, then there
must be an additional CMS and Joint
Commission follow up survey.
30
TJC-CMS
• Much focus in consulting is now on
CMS in addition to Joint Commission
compliance.
• Hospitals must always be aware that
reporting to external agencies
occurs, including CMS, and DEA.
• Condition level citations will result
in a follow up survey.
Three Year Surveys
32
Three Year Surveys
• As of January 2011, all surveys will be
conducted within a 3 year period (36 months
from the last survey) rather than 39 months
which was the previous practice.
• Laboratory surveys will be continue to be
conducted 24 months from the previous survey.
2012
2015
Revised Joint Commission
Standards to Align with CMS
TJC
CMS
34
Changes to reflect the COP
• Selected standards were revised to meet relevant
Conditions of Participation (CMS) for psychiatric
hospitals who use the Joint Commission for
Deemed Status which became effective February 1,
2011.
• Standards involved EC. 02.03.01, EC. 02.05.03,
Emergency Management (EM 03.01.03), Information
Management ( IM. 02.02.03), Leadership(
04.01.05), Life Safety Code (LS. 02.01.30),
Provision of Care (PC 01.02.13, PC 01.03.01).
35
Environment of Care
EC. 02.03.01-Managing Fire Risks
• Applicable to Hospitals and Critical Access
Hospitals
• The organization must have a written fire plan
( LS. 02.01.70, EP. 4)
• Cross referencing to the roles of staff, when
and how to sound fire alarms , how to contain
smoke and fire, fire extinguisher use and
evacuation are also referenced at (EC.
03.01.01, EP.2 & HR. 01.04.01, EP 2)
36
Environment of Care
EC.02.05.03-Reliable Emergency
Electrical Power Source
• EP’s 1-6 modified to reflect the change of the
NFPA’99, 1999 edition (Section 12-3.3) versus
Section 13-3.3
37
Emergency Management
EM 03.01.03
• Special Note # 4- In order to satisfy the twicea-year requirement, the hospital must first
evaluate the performance of the previous
exercise and make any needed modification to
its Emergency Operations plan before
conducting the subsequent exercise in
accordance with the EP’s 13-17.
38
Information Management
IM 02.02.03
• The hospital retrieves, disseminates, and
transmits health information in useful formats.
• Revision: Hospitals that use CMS for deeming –
The medical records system allows for timely
retrieval of patient information by diagnosis
and procedure.
39
Leadership
LD. 04.01.05
• The hospital effectively manages its programs,
services, sites or departments.
• EP # 10 for those psychiatric hospitals that
use the Joint Commission for deemed status
must comply with having a Director of Social
Work who monitors and evaluates the social
work services furnished.
40
Life Safety Code
LS. 02.01.30
• The note for EP # 6 was removed as follows:
Unsealed spaces 1/8 inch wide or less around
pipes, conduits, ducts and wires above the ceiling
are permitted.
• The note for EP # 25 was removed as follows:
For The Joint Commission/s accepted amount of
alcohol based hand rub permitted within a single
smoke compartment was changed to
http://www.jointcommisison.org/assets/1/18/accepta
ble%20practices%20of%20using%20Alcohol2.pdf
41
Provision of Care
PC. 01.02.13
• EP # 2- For psychiatric hospitals that use Joint
Commission standards for Deemed Status
purposes: Patient’s who receive treatment for
emotional and behavioral disorders receive an
assessment that includes the following : The
reason for admission as stated by the patient
and/or others significantly involved in the
patient’s care.
42
Provision of Care
PC. 01.02.13
• EP # 6- For psychiatric hospitals that use Joint
Commission standards for Deemed Status
purposes: Based on the patient’s age and needs,
the assessment for patients who receive
treatment for emotional and behavioral
disorders include the following: A complete
neurological examination when indicated.
43
Provision of Care
PC. 01.03.01-Planning Care
• EP. # 5-For psychiatric hospitals that use
Joint Commission standards for Deemed
Status purposes: The written plan of care is
based on patient’s goals and the time frames,
setting, and services required to meet those
goals. The patient’s goals include both
short-term and long-term goals.
• EP. #43-The plan of care includes the
responsibilities of each member of the
treatment team.
Testing Fire Protection Systems
45
EC. 02.03.05
Maintenance of Fire Safety Equipment
• Changes will be in effect July 1, 2011 unless
otherwise dictated by CMS.
• For hospitals using the Joint Commission for
Deemed status purposes:
• EP # 2-At least quarterly the hospital tests
water-flow devices. (Was every 6 months)
46
EC. 02.03.05
Maintenance of Fire Safety Equipment
• EP # 25-Documentation of maintenance,
testing, and inspection activities for fire alarm
and water-based fire protection systems
includes the following:
– Name of the activity
– Date of the activity
– Required frequency of the activity
– Name and contact information, including
affiliation of the person who performed the
activity
– Results of the activity.
47
EC. 02.03.05
Maintenance of Fire Safety Equipment
• Additional guidance may be found at NFPA 24,
1998 edition (Section2-1.3) and NFPA 72. 1999
Edition (Section 7-5.2)
CMS
New Department
Requirements
49
RADIOLOGY
• New CMS requirements for oversight of
radiology.
• Policies and procedures must comply with
nationally recognized standards: ACR
• Physician supervision of all contrast
administration (CT and MRI).
• Physician must be permitted by director of
radiology to use radiology equipment.
50
RADIOLOGY
• Training of all providers who operate
radiology equipment: physicians and
staff using C-Arm, Fluoroscopy.
ANESTHESIA
52
ANESTHESIA
•
•
•
1: Director of Anesthesia Services
2: “Deep Sedation” now considered anesthesia
and is referred to a Monitored Anesthesia
Care.
3: MAC may only be administered only by an
appropriate practitioner privileged by director
of anesthesia services
53
ANESTHESIA
•
•
•
4: Director of anesthesia responsible for all
anesthetics (general to local).
5: Director of anesthesia services sets policies
for all anesthetic use.
6: Director of anesthesia services decides on
how to privilege for moderate sedation.
54
ANESTHESIA
•
•
7: Epidurals administered by CRNAs do not
require direct supervision unless they become
an anesthetic.
8: Post-anesthesia note may be written from
the time a patient can participate until
discharge or 48 hours whichever comes
sooner.
55
ANESTHESIA
• Practical effects:
▫ Nursing staff will no longer be able to administer
anesthesia agents: Etomidate, Ketamine,
Pentothal, or Propofol because this is MAC.
▫ Anesthesia will have to privilege for MAC (deep
sedation), and recommend privileging process for
moderate sedation
56
ANESTHESIA
• Reference: S&C-10-09-Hospital
• Tag: A-1000
• §482.52
Telemedicine
CMS REQUIREMENTS
58
Definitions
• Hospital: location where patient receives
telemedicine services
• Distant Site: where the physician is remotely
who is providing services
• Entity: a non-hospital providing location
Governing Body & Relationship
with Hospital
Hospital
Agreement
with distant
site
Distant site is
a “contractor”
for services
Governing
Body
Distant site
provides
services
allowing
hospital to be
compliant
Distant site
responsible for
compliance
Local hospital
may allow use
of documents
provided by
distant site
60
Medical Staff
Medical staff may rely on credentialing and
privileging decision of distant site (proxy).
• 1). Distant site must be Medicare-participating
hospital.
• 2). Privileged at distant site, and list provided
to hospital.
• 3). Individual holds license in state where
patients are located.
61
Medical Staff
• 4). Hospital performs internal review of
performance and sends to “distant site.”
• 5). Includes all adverse events and complaints.
62
Requirements of MEDICAL STAFF if the “distant
site” is a non-Medicare participating “entity”
• 1). Agreement requires that the services be
furnished in a manner that permits the hospital to
be in compliance with CMS requirements.
• 2). Distant entity credentialing and privileging
process meets CMS standards.
• 3). Distant entity providers privilege
list/delineations.
• 4). Holds license in state where patient located.
• 5). Hospital sends performance review to distant
entity.
• 6). Criteria for privileging established.
Patient Rights
64
RI.01.07.01
The patient and his or her family have
the right to have complaints and
grievances reviewed by the
organization.
65
RI.01.07.01
• 6-M,C: The hospital acknowledges
receipt of a complaint that the
hospital cannot resolve immediately
and notifies the patient of follow up
to the complaint.
RI.01.07.01
18-M, D, C- In its resolution of
complaints, the hospital provides, the individuals with a
written notice of its decision, which contains the
following:
11/3/2525
Dear Ms. Concern:
Mr. Care (contact person) has been
appointed the contact person for
your situation. On your behalf, we
have taken the following steps to
investigate your situation… The
results of this process are… As of
November 3, 2525, we are now
considering that this matter is
resolved (date complaint process
completed)
67
RI.01.07.01
• 19-A: The hospital determines time
frames for grievance review and
response.
68
RI.01.07.01
• 20-A: The process for resolving
grievances includes a mechanism for
timely referral of patient concerns
regarding quality of care or
premature discharge to the Quality
Improvement Organization (QIO).
Medical Staff
MS. 01.01.01
• Many individual requirements to be found in the
Medical Staff Bylaws.
• EP # 12: The structure of the medical staff. (CMS
CoP requirement)
• EP #13: Qualifications for appointment to the
medical staff. (CMS CoP requirement)
• EP #14: The process for privileging and reprivileging licensed independent practitioners,
which may include the process for privileging and
re-privileging other practitioners. (CMS CoP
requirement)
71
15: A statement of the duties and
privileges related to each category of
the medical staff (for example,
active, courtesy). (CMS CoP
requirement)
Note: The word “privileges” can be interpreted in several
ways. The Joint Commission interprets it, solely for the
purposes of this element of performance, to mean the
duties and prerogatives of each category, and not the
clinical privileges to provide patient care, treatment,
and services related to each category. The Joint
Commission is in discussion with CMS to clarify this
term’s meaning.
72
16: The requirements for completing
and documenting medical histories and
physical examinations. The medical
history and physical examination are
completed and documented by a
physician, an oral maxillofacial surgeon,
or other qualified licensed individual in
accordance with State law and hospital
policy. (CMS CoP requirement)
Provision of Care,
Treatment, and
Services
74
PC. 02.01.03
The organization provides care,
treatment, and services as ordered
or prescribed, and in accordance
with law and regulation.
75
PC. 02.01.03
Elements of Performance
1-DI, A: Prior to providing care, treatment, and
services, the hospital obtains or renews
orders (verbal or written) from a licensed
independent practitioner in accordance with
professional standards of practice and law
and regulation.
7-DI, A: The hospital provides care, treatment,
and services using the most recent patient
order (s).
76
PC.02.01.03
14-DI, A: Respiratory services are provided only
on, and in accordance with, the orders of a
doctor of medicine or osteopathy.
77
PC.03.01.03
The organization provides the patient with care
before initiating operative or other high-risk
procedures, including those that require the
administration of deep sedation or anesthesia.
78
PC.03.01.03
18-DI, A: A pre-anesthesia evaluation is
completed and documented by an
individual qualified to administer
anesthesia within 48 hours prior to
surgery or a procedure requiring
anesthesia services.
79
PC. 03.01.07
The organization provides care to the
patient after operative or other high-risk
procedures and/or the administration of
moderate or deep sedation or
anesthesia.
80
PC.03.01.07
Elements of Performance
7-DI, A: A post-anesthesia evaluation is completed
and documented by an individual qualified to
administer anesthesia no later than 48 hours after
surgery or a procedure requiring anesthesia
services.
81
PC. 03.01.07
Elements of Performance
8-DI, A: The post-anesthesia evaluation
for anesthesia recovery is completed in
accordance with law and regulation and
policies and procedures that have been
approved by the medical staff.
Restraints
PC.03.05.03
The hospital uses restraint or seclusion
safely
• The use of restraint and seclusion is
in accordance with a written
modification to the patient's plan of
care.
Imminent Jeopardy
CMS Examples
Actual injury NOT required to
occur for a citation
85
CMS: Abuse
• Failure to protect from abuse
• 1. Serious injuries such as head trauma or
fractures;
• 2. Non-consensual sexual interactions; e.g.,
sexual harassment, sexual coercion or sexual
assault;
• 3. Unexplained serious injuries that have not
been investigated;
86
CMS: Abuse
• 4. Staff striking or roughly handling an
individual;
• 5. Staff yelling, swearing, gesturing or calling
an individual derogatory names;
• 6. Bruises around the breast or genital area; or
Suspicious injuries; e.g., black eyes, rope
marks, cigarette burns, unexplained bruising.
87
CMS: Neglect
• Lack of timely assessment of individuals after
injury;
• Lack of supervision for individual with known
special needs;
• Failure to carry out doctor’s orders
• Repeated occurrences such as falls which place
the individual at risk of harm without
intervention;
88
CMS: Neglect
• Access to chemical and physical hazards by
individuals who are at risk;
• Access to hot water of sufficient temperature
to cause tissue injury;
• Non-functioning call system without
compensatory measures;
• Unsupervised smoking by an individual with a
known safety risk;
89
CMS: Neglect
• Lack of supervision of cognitively impaired
individuals with known elopement risk;
• Failure to adequately monitor individuals with
known severe self-injurious behavior;
90
CMS: Neglect
• Failure to adequately monitor and intervene for
serious medical/surgical conditions;
• Use of chemical/physical restraints without
adequate monitoring;
• Lack of security to prevent abduction of infants;
• Improper feeding/positioning of individual with
known aspiration risk
91
CMS: Infection/Sterility
• Pattern of ineffective infection control
precautions; or
• High number of nosocomial infections caused by
cross contamination from staff and/or
equipment/supplies.
92
CMS: Fire/Hazards
• 5. Widespread lack of knowledge of emergency
procedures by staff;
• 6. Widespread infestation by insects/rodents;
• 7. Lack of functioning ventilation, heating or
cooling system placing individuals at risk;
Frequently
Cited
Standards
First 6
months
2011
Data
94
RC.01.01.01
The hospital maintains complete
and accurate medical records.
2010
65%
EP: 11,19 (Date/Time),
EP 4, 9 (Patient ID,
Continuity of Care)
First 6 Months 2011
69%
EP: 11,19 (Date/Time),
EP 4, 9 (Patient ID,
Continuity of Care)
Factors: dating/timing entries: CMS requirement
95
LS.02.01.20
The hospital maintains the
integrity of the means of egress
2010
51%
EP 13, 30, 31
First 6 Months 2011
57%
EP 13, 30, 31
Factors: Corridor storage, exit signs, 30 minute
rule, “computers on wheels”. IMMEDIATE
THREAT POTENTIAL
96
LS.02.01.10
Building and Fire protection features are
designed and maintained to minimize the
effects of fire, smoke, and heat.
2010
49%
EP 4, 5
First 6 months 2011
57%
EP 4, 5
Factors: Fire and smoke doors, penetrations
IMMEDIATE THREAT POTENTIAL..
97
LS.02.01.30
The hospital provides and
maintains building features to protect
individuals from the hazards of fire and smoke.
2010
40%
EP: 2, 11, 18
First 6 months 2011
47%
EP: 2, 11, 18
Factors: Hazardous areas like boiler rooms,
flammable liquid storage rooms, laboratories,
piped oxygen tank supply rooms, dampers,
corridor doors
98
EC.02.03.05
The hospital maintains fire safety
equipment and fire safety building features.
2010
42%
All EPs
First 6 months 2011
42%
All EP’s
Factors: inspecting, testing and maintaining
various features of fire protection
– Includes fire alarms, sprinklers, portable fire
extinguishers, tamper switches, etc.
99
IC.02.02.01
Infection risk: equipment, supplies,
devices
2010
29%
EP: 2, 4
First 6 months 2011
36%
EP: 2, 4
Factors: Flash autoclaving, cleaning, high level
disinfecting, QC checks, and equipment storage.
100
RC.02.03.07
Qualified staff receive and record
verbal orders
2010
33%
EP: 4
First 6 months 2011
36%
EP: 4
Factors: Authentication within 48 hours, Law
and regulation. Un-authorized individuals
taking and transmitting verbal orders.
101
MM.03.01.01
The hospital safely stores
medications.
2010
31%
EP 2, 3, 6
First 6 months 2011
34%
EP 2, 3, 6
Factors: medication storage, manufacturer’s
guidelines, security, potential for diversion,
control between receipt and administration,
expired medication
102
LS. 02.01.35
The hospital provides and maintains
systems for extinguishing fires.
Not a frequently
scored
Recommendation for
Improvement in 2010
First 6 months 2011
33%
EP: 2, 4, 5
Factors: Storage <18 inches from sprinkler
heads, damaged sprinkler heads, Fire
extinguishers within 30 ft of grease producing
cooking devices
103
PC.01.02.03
The hospital assesses and reassesses
the patient and his or her condition
according to defined time
Not a frequently
First 6 months 2011
scored
33%
Recommendation
EP: 2, 4, 5
for
Improvement in
2010
Factors: H&Ps present, H&Ps within 30 days,
Updates with correct CMS wording.