Accreditation and Survery Questions
Why does CMS continue to perform surveys if a hospital has deemed status?
Short Answ: CMS still comes because deemed status does not cover the 2 special conditions for psychiatric hospitals.
Longer Response: Hospitals are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment. The goal of a hospital survey is to determine if the hospital is in compliance with the CoP set forth at 42 CFR Part 482 which contains the minimum health and safety requirements that hospitals must meet to participate in the Medicare and Medicaid program. The CMS State Operations Manual (SOM) provides CMS policy regarding survey and certification activities. More specifically, all hospitals must meet the general requirements found in Appendix A (www.cms.hhs.gov/transmittals/downloads/R37SOMA.pdf ) of the SOM that are commonly referred to as the A tags. Note that the CMS requirements for seclusion and restraint are in this appendix. ‘Deemed Status’ means that a hospital that has TJC accreditation (or DNV accreditation) is deemed (presumed) to be meeting those standards as result of that alternate accreditation process. CMS does a small percentage of look behind surveys to keep tabs on TJC’s rigor, but generally accepts their findings. As you know, with TJC’s most recent application for deeming authority they have come even more in line with CMS standards… and that was because of CMS pressure to improve their fidelity to the COP. However, because psychiatry is considered a specialty, free-standing psychiatric hospitals are also required to meet 2 special COP. These are Medical Records and Staffing and they are found in Appendix AA (www.cms.hhs.gov/CFCsAndCoPs/downloads/som107ap_aa_psyc_hospitals.pdf) and are commonly referred to as B tags. These COP deal in more detail with the medical record (e.g., psychiatric evaluation, mental status exam) and staffing. This is also where CMS surveyors find the basis for their emphasis upon active treatment. CMS does not consider the TJC (or DNV) survey process adequate for evaluating these areas and so it is not part of deemed status and they require a separate survey. These surveys may be done by CMS contract surveyors or by state surveyors if elected by the state. Such surveys were originally expected to be annual, but with budget challenges over the years the frequency has declined. I do not know of any specific rate or formula, but there is a general sense that hospitals having more difficulty will be seen more often. Every 3-5 years is not uncommon.
What is a 'deemed status survey'?
Answer:
It means you are using the Joint Commission survey to get your Medicare Certification. The Joint Commission is deemed by Congress for the CMS Medicare certification, meaning if you are accredited by the Joint Commission you are certified to bill Medicare and Medicaid. Some hospitals such as the Veterans or Military hospital are not subject to CMS and therefore to not have a deemed status survey.
TJC Restrant standards: What Changed with 2009 Deemed Status?
Joint Commission Behavioral Health Update (Excerpt of "Effective July 1, 2009: New Restraint and Seclusion Requirements for Hospitals
Take Full Effect1003" in the June 2009 Newsletter from Barrins & Associates)
Are there any new requirements in the new restraint and seclusion standards? Yes, in the following areas:
* Written modification to the treatment plan when restraint or seclusion is used (PC.03.05.03 EP 2)
* In person re-evaluation by the LIP every 24 hours instead of 8 hours for adults and 4 hours for 17 years and under (PC.03.05.05 EP 5)
* Training requirements for physicians and other authorized LIPs (PC.03.05.09 EP 1)
* Definition of what constitutes the uses of medications as a restraint (PC.03.05.04 EP 1)
Are there any current requirements for restraint and seclusion that are not included in the new standards? Yes, in the following areas:
* Staffing levels
* Initial assessment of the patient regarding restraint or seclusion risks and techniques to help minimize use of restraint or seclusion
* Informing clinical leaders regarding multiple episodes of restraint or seclusion
* Patient debriefing following restraint or seclusion
* Data collection and PI activities related to restraint and seclusion
What has not changed?
* Restraint or seclusion is to be used safely and only when clinically justified or warranted by patient behavior that threatens physical safety
* Restraint or seclusion is based on an individual order
* Monitoring and evaluation of patients in restraint or seclusion
* Written policies regarding restraint and seclusion
* Medical record documentation of use of restraint or seclusion
* Staff training on the use of restraint and seclusion
Do these changes to the restraint and seclusion standards apply to Behavioral Health organizations that use restrain and /seclusion?
* These changes do not apply to Behavioral Health organizations surveyed under the Behavioral Health Manual. The current restraint and seclusion standards in the 2009 BH manual (PC.12.10 - PC.PC.12.90) remain in effect at this time. TJC plans to update the automated PPR and the E-dition of the standards by July 1, 2009 to include the CMS related changes. They also plan to publish FAQs on the new restraint and seclusion standards in the near future.
Last Edited on 15-Jun-2009 8:58 PM
What is Immediate Jeopardy/Abuse/Neglect?
The following definitions apply to all certified Medicare/Medicaid entities:
-
Immediate Jeopardy - “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.” (See 42 CFR Part 489.3.)
-
Abuse - “The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.” (See 42 CFR Part 488.301.)
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Neglect - “Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” (See 42 CFR Part 488.301.)
From: State Operations Manual: Appendix Q - Guidelines for Determining Immediate Jeopardy - (Rev. 1, 05-21-04)
Critical Results vs. Critical Tests in 2010
The term 'Critical Tests' was dropped from the language of NPSG.02.03.01 as part of the Standards Improvement Initiative (SII) for 2010. As such, the nature, relative importance or method of ordering a test (e.g., Stat) no longer matters in this requirement. The issue is whether or not the result, value or outcome produced by that test is considered critical (i.e., "…abnormal to a degree that may indicate a life-threatening situation" - from 2010 TJC glossary). The new language also clarified the applicability of the critical results concept beyond laboratory testing to 'diagnostic procedures' such as X-ray or EKG. Although it is not possible to define every possible critical outcome, organizations should anticipate the more common findings that should be quickly communicated. A failure to do so is likely to cause TJC surveyors to apply their own judgement to the matter. In the past, this has resulted in any result communicated orally, by telephone or in a 'stat' manner from the performing entity to be considered critical.
Refs
Archive: DB Posting @ NPSG
Discssion Board: Archived Articles Related to NPSG
NPSG.07.03.01 Applicability?
From:
Date: Sat, 21 Mar 2009 17:35:59 -0500
To: XXXXXXXXXXXXXXXXX
Conversation: Patient Safety
Subject: Re: Patient Safety
Re: NPSG.07.03.01: "Implment evidence-based practices to prevent healt care-associated infections due to multidrug-resistant organisms in ACUTE CARE HOSPITALS: for a psychiatric hospital that is not "acute care" what is the implementation expectation? We agree that MRSA, etc. certainly is an issue. Thank you.
Yes, this NPSG does apply to your facility. Your organization would implement the elements of performance for the NPSG.07.03.01. You may wish to review (the CDC's) Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 Thank you for your inquiry. Standards Interpretation, The Joint Commission
Cynthia Leslie
Joint Commission
Standards Interpretation Group
Phone: 630-792-5900
The above posted with the permission of the NYS Office of Mental Health (MAO) 3/24/09
4/1/09: We double checked this response with Ms. Laurel Shine (TJC SIG) who confirmed the above. Bottom line: Ignore the 'acute care hospital' language (for which TJC has no definition anyway). If you are a hospital this goal applies…for that matter, it also applies to BHC. To help with compliance, TJC posted a reference called A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. We recommend IC review it and identify relevant strategies for your population as a basis for your initial compliance efforts.
Verbal orders dated/Timed: Do CMS & TJC agree?
Answ: Not completely
Agreement:
- CMS changed the CoP for verbal and telephone orders requiring such orders be authenticated within the time frame specified by state law or within 48 hours if the state law is silent. JC standard IM.6.50 EP 3 requires authentication according to law or regulation, so no discrepancy here.
Discrepacny:
- CMS requires that all orders and entries be dated and timed.
- JC IM.6.10 EP 4 only requires that medical record entries be dated. The timing of entries is not required. However, if your organization’s policy requires timing, you will be scored against the higher standard.
Adopted from: HCPro Accreditation Monthly Vol 8 #3
What is the Verbal Order Sunset Provision?
The sunset provision is the reference in the CMS Interpretive Guidelines 482.24(c)(1)(i), which notes that it is acceptable for another practitioner who is responsible for the patient's care to authenticate the verbal order of the ordering practitioner for a temporary period expiring on Jan. 26, 2012. You'll also see that mentioned in TJC's RC.02.03.07, EP 4, Note 2. See also final ruling CMS-3122-F pg13 (11/27/06)
Physician Handoffs: How to do in state hospitals?
>>> 05/23/07 12:41 PM >>>
Our facility is a Psychiatric Hospital that has some patients who have been here for up to 20 years. When our staff physicians hand off to the on-call physician are they expected to go over all 150 patients? Is it acceptable to discuss only the patients who have had some recent problems, or the physician expects some problems, keeping in mind the on-call physician has the opportunity to ask questions about all 150 patients?
It is acceptable to do the hand-off communication by exception if the two parties are familiar with the patients. The important aspect of the hand-off communication is that the important patient information that might be needed for the on-coming physician is communicated from the departing physician.
Merlin Wessels
Joint Commission
Standards Interpretation Group
Phone: 630-792-5900
Does NPSG #15A require sucide risk scales?
Answers:
1. Are there written regulations for this?
•{(Requirement 15A The organization identifies patients at risk for suicide.) and that risk factors be addressed. No specific tool or scale is specified. That is up to the organization.}
2. Is this to be done on every admit or only if there is a suspicion that a patient is suicidal? (Is this a second level screen to a positive prompt in the existing psych evaluation or the nursing assessment?)
•{A - JC can sometimes be confusing with its language @ assessment. In order to identify pts at risk you need to assess EVERY pt in some way. Yes, this generally means a front end screen with the potential to trigger a more in-depth evaluation when indicated. Goal 15 seems to have raised the bar on the quality of the up front screen in that the address of risk factors is now specified for inclusion.
B – Reassessment is important and should be performed at key points of transition and other times known to increase such risk (e.g., discharge, transfer to another LOC or unit, return from upsetting pass, etc)}
3. Can any professional do this? Is it okay if it’s in the nursing assessment? Note, it is already in the nursing assessment in a watered down version?
•{A - When the Joint is silent, that generally means you have choice as long as the choice is rational. In this case, yes, it would seem reasonable for other professionals such as nurses to be able to do at least the front end screening assessment. The key here would be to ensure their competence for being able to do so by having provided them with appropriate training, etc. However, more general standards of practice would strongly suggest that the more in-depth evaluations be performed by disciplines such as psychiatry and/or psychology.
B – ‘Watered down’ versions will no longer suffice. Ensure the screen meets requirements of Goal 15 no matter who is performing it.}
4. Do they need to use Likert scales
•{No, this is not required. However, whatever tool is utilized, it should be able to produce a rating of the relative risk (e.g., high, medium, low) so that appropriate follow-up action is clear. }
Archive: DB Posting @ HR
Discssion Board: Archived Articles Related to NPSG
H&P's within 30 days: Do CMS and TJC agree?
Answ: Almost, but not quite.
- CMS has now adopted the JC standard of allowing an H&P to be as old as 30 days as long as an update is noted within 24 hours of admission.
- Although TJC standard PC.2.120 EP 7 requires the update at the “time of admission,” an FAQ (Updates to the Patient's Condition 2/16/06) clarified that an update within 24 hours of admission would be acceptable.
In (a recent) conference call, surveyors were reportedly told:
- Score the lack of policy defining the required H&P time frames at PC.2.120 EP 1 (A)
- Score the lack of a documented H&P or H&P update within 24 hours of admission at PC.130 EP 2 (C).
There is a remaining discrepancy:
- CMS does not require the author of the H&P to hold privileges at your hospital
- JC MS.2.10 EP 8 continues to require that the person(s) performing and/or updating the H&P be privileged to do so at your hospital.
Adopted from: HCPro Accreditation Monthly Vol 8 #3
H&P within 24 hrs at a Hospital outpt clinic?
Q: We run an aftercare clinic that falls under the license of our hospital. As such, it is TJC surveyed under CAMH and HAP standards. Do we have to meet the requirement for H&P within 24 hours?
Short A:
No. Refer to MS.2.10
Longer Expl:
Background:
It does not fit/make sense that an outpt clinic should be held to the 24 hour requirement of the hospital and TJC standards do make allowance for this. MS.2.10 , EP#11 allows the medical staff to define the nature of the H&P that it believes is needed/appropriate for its affiliated, non-inpatient services. While we still believe it is best practice (and good risk management) to obtain a recent H&P and place it in the chart in a timely manner (at intake or before) this can be tailored to your population and program.
Recommendation:
I would recommend that the medical staff review PC2.30 and 2.40 from the BHC manual (extract attached) and structure their approach according to the parameters suggested there. Be sure that the approach decided on by the medical staff is documented (e.g., Med Staff Rules & Regs or P&P)
- Drs. Knight and Fields (11/07)
Screening vs. comprehensive neurological examination?
While CMS acknowledges that there is no precise definition of a screening neurological examination it does at minimum call for a gross assessment of the central nervous system (CNS) and specifically points out the unacceptability of using the statement “Cranial Nerves II to XII intact”. The same would hold true for indicating ‘WNL’ beside the cranial nerve divisions as a description (vs. interpretation) of the testing performed is what is desired.
In a comprehensive neurological examination, CMS expects ‘detailed, fine testing’. Such an exam would be expected (in descriptive fashion) when indicated by the screening exam, a system review that indicates positive neurological symptoms or an accurate baseline of neurological functioning is important (e.g., patients for ECT).
For more details refer to:
State Operations Manual
Appendix AA - Psychiatric Hospitals – Interpretative Guidelines and Survey Procedures - (Rev. 1, 05-21-04)
B109 §482.61(a)(5) When indicated, a complete neurological examination must be recorded at the time of the admission physical examination.
Spiritual Assessment minimum requirements?
Short Answ: Not any more.
Longer Explanation: In 2001 and 2004 TJC issued FAQ on the topic of Spiritual Assessent that included the following 3 minimum requirements:
- Denomination
- Important beliefs
- Important Practices
However in their most recent FAQ on this topic (11/24/08) the minimum requirements are ommitted. Instead, TJC calls ont he organization to define the content and scope of the spirital (and other) assessments for itself. Assessment questions are suggested.
Click here for details of the 2008 FAQ on Spiritual Assessment
Q15min Assessments ( PC12.130): How to
Conducting the Q15minute Assessment (Q15M) and complying with PC12.130
The question frequently arises as to how much (and what kind) of action is required q15 minutes in order to comply with PC.12.130. Folks tend to get hung up on EP#2 and its list of 7 assessments. The issue is further clouded by the Joint’s 2005 FAQ on Behavioral Seclusion and Restraint that included the following statement as part of an answer about the q15 minute issue “No, it is not expected that all of the bulleted items in the intent statement of PC.12.130, be assessed every 15 minutes.” This has been used as justification by a number of facilities for a Q15M practice that as a routine may only check certain of the 7 assessment issues once every 1-3 hours. They even have forms with matching timeframes. I believe this is an over (and probably mis-) interpretation of the standard and its true intent.
EP #1 makes it very clear that some assessment is to occur every 15 minutes. EP#2 attempts to define the nature of a minimally acceptable assessment by listing a set of 7 elements to include. However, there is a wise recognition of the fact that the process of carrying out some of the (required) assessments (e.g., vital signs) might exacerbate the patient’s condition (i.e., increase agitation) and thereby undermine the safety such assessments are designed to ensure. That is why the Joint Commission allows for the use of clinical judgment in deciding which of the 7 assessments are safe and appropriate to carry out at any given time. However, that determination should in fact be a real use of clinical judgment that is exercised every 15 minutes. It should not be made once at the start of seclusion/restraint and never re-considered nor should it be assumed and established as a routine (e.g., hydration every 60 minutes or toileting ever 2 hours). Beyond this, staff* should understand that assessment is an active process of seeking information and not of simply waiting for the patient to express concern/need in the area of one of the assessments (e.g., I’m thirsty, my arm is numb).
Staff may find it useful to review the fact that there are at least 3 basic methods available for carrying out any of the 7 assessments. It is also important to note that for each of those 7 assessments, more than one method can be applied to allow for evaluation of some aspect of that assessment issue. This is illustrated in the table below.
In this context here are some specific recommendations for conducting the Q15M and complying with PC.12.130:
1. Make it clear that staff* are to ASSESS (not just monitor) the patient
2. Make it clear that staff* are to do some number of assessments at the start of S&R and every 15 minutes thereafter
3. Every 15 minutes, all 7 of the assessments should be considered by staff* in the following manner:
a. At a minimum, those aspects of the assessment process that can be performed based on sight/hearing/smell (A – observation) should be conducted every 15 minutes.
b. Staff* is then to use clinical judgment to determine which of those aspects of the assessment process that require oral interaction (B- Interview) or physical contact (C- Phys Exam/Vital Signs) could be conducted without making the patient’s condition (physical and/or psychological) worse.
4. Staff* should then perform all A and those B and C aspects of the assessments that have been judged to be appropriate.
5. The specific aspects of the assessment carried out should be documented
6. If Q15M forms are used, they should indicate a q 15 minute timeframe for each of the 7 points of assessment (or show no times at all)
*Special Nursing Note: Virginia Knight, RN, PhD, a senior nurse consultant, former Joint Commision surveyor and JCR consultant recommends that while constant observation can (and is usually) be done by a non-RN, that the 15 minute assessments should be done by an RN. She says in most states, the Nurse Practice Act requires an RN to do a nursing assessment---other staff members can gather data but not assess ( PC.12.30 EP6) She also provided the following additional thoughts:
• There are not many direct care staff members who are prepared to attend to each of these items competently.
• Non-RNs are working under the RNs license, and patients in seclusion/restraint tend to get into physical distress that the RN would be able to detect early.
• Seclusion or restraint is an episode that deserves intensive care monitoring----like pts in ICU.
• 15 minute assessment by an RN tend to get the pt out of seclusion/restraint sooner. It is simply better care.
What is Chemical Restraint, CMS vs. TJC?
Bottom Lines (as of 6/11/09):
- CMS does not prohibit the use of drugs/medications as restraint. But if used as such must meet all restraint requirements.
- TJC considers chemical restraint an ‘inappropriate’ use of medication. This is different from CMS.
- CMS does not use the term Chemical Restraint (not in CoP) but considers it equivalent to 'Drugs used as restraint'
- As such, TJC has a more restrictive (not allowing Chemical restraint) definition.
- Whenever there is a difference, the more restrictive/higher standard is to be applied.
- Therefore, TJC-accredited hospitals must go with the more stringent standard
See additional details below:
As per TJC:
Comprehensive Accreditation Manual
for Hospitals:
The Official Handbook
CAMH Update 2, September 2006
Glossary – Page GJ – 21
Restraint: Any method (chemical or physical) of restricting a patient’s freedom of movement, including seclusion, physical activity, or normal access to his or her body that (1) is not a usual and customary part of a medical diagnostic or treatment procedure to which the patient or his or her legal representative has consented; (2) is not indicated to treat the patient’s medical condition or symptoms; or (3) does not promote the patient’s independent functioning.
Chemical Restraint: The inappropriate use of a sedating psychotropic drug to manage or control behavior. physical restraint Any method of physically restricting a person’s freedom of movement, physical activity, or normal access to his or her body.
.
As per CMS:
State Operations Manual
Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
(Rev. 1, 05-21-04)
§482.13(f) Standard: Seclusion and Restraint for Behavior Management Interpretive
Guidelines §482.13(f)
Drugs Used as a Restraint- Page 99-101
Both standards (e) and (f) specify that a drug used as a restraint is a medication used to restrict the patient's freedom of movement in medical or post-surgical situations (standard (e)) or for the emergency control of behavior (standard (f)), and is not a standard treatment for the patient's medical or psychiatric condition. A fundamental right that appears in both standards (e) and (f) is that the patient has the right to be free from restraints of any form that are imposed for coercion, discipline, convenience, or retaliation by staff, including drugs that are used as restraints. Two examples serve to clarify drugs as restraint in standards (e) and (f):
• Example 1: A patient has Sundowner's Syndrome. She gets out of bed in the evening and walks around the unit. The unit's staff finds the patient’s behavior bothersome, and asks the MD/DO to order a high dose of a sedative to “knock out” the patient and keep her in bed. The patient has no medical symptoms or conditions that indicate that she needs a sedative. In this case, for this patient, the drug is being used inappropriately as a restraint.
• Example 2: A patient is in a detoxification program. He becomes violent and aggressive one afternoon. Staff administers a PRN medication ordered by the patient's MD/DO or LIP to address this outburst of specific behaviors. The use of the medication enables the patient to better interact/function. In this case, the medication used for this patient is not considered a “drug used as a restraint.” The availability of a PRN medication to manage outbursts of specific behaviors, such as, or aggressive, violent behavior is standard for this patient's medical condition (i.e., drug or alcohol withdrawal). Therefore, this patient's medication does not meet the definition of “drug used as a restraint” since it is “a standard treatment for his medical or psychiatric condition. The use of this medication for this patient is not affected by standard (e) or (f).
The regulation states, “A drug used as a restraint is a medication used to control behavior or to restrict the patient’s movement, and is not a standard treatment for the patient’s medical or psychiatric condition.” The regulation is not intended to interfere with the clinical treatment of patients who are suffering from serious mental illness and who need appropriate therapeutic doses of psychotropic medication to improve their functioning state so that they can more actively participate in their treatment. Similarly, the regulation is not intended to interfere with appropriate doses of sleeping medication prescribed for patients with insomnia or anti-anxiety medication prescribed to calm a patient who is anxious...hence the notation that medications that are a standard treatment for a patient’s medical or psychiatric conditions are NOT subject to the requirements of the regulation.
Of course, as with any use of restraint, staff must engage in active patient assessment to determine whether there is some root cause or issue for the targeted problem that can be alleviated through other types of clinical or non-clinical interventions before using the drug intervention. A patient may be agitated because of pain, an adverse reaction to an existing medication, or an unmet care need or concern.
A “standard treatment” for a medication used to address a patient’s medical or psychiatric condition would include all of the following:
• The medication is used within the pharmaceutical parameters approved for it by the Food and Drug Administration and the manufacturer, for the indications it is manufactured and labeled to address, listed dosage parameters, etc.;
• The use of the medication follows national practice standards established or recognized by the appropriate medical community and/or professional medical association or organization; and
• The use of the medication to treat a specific patient’s clinical condition is based on that patient’s target symptoms, overall clinical situation, and on the MD/DO’s or other LIP’s knowledge of that patient’s expected and actual response to the medication.
An additional component of “standard treatment” for a medication is the expectation that the standard use of a psychotherapeutic medication to treat the patient’s condition enables the patient to more effectively or appropriately function in the world around him/her than would be possible without the use of the medication. Psychotherapeutic medications are to enable, not disable. If a psychotherapeutic medication reduces the patient’s ability to effectively or appropriately interact with the world around him/her, then the psychotherapeutic medication is not being used as a “standard treatment” for the patient’s condition. If a medication is used as a standard treatment (as described above) to address the assessed symptoms and needs of a patient with a particular medical or psychiatric condition, its use is NOT subject to the requirements of this regulation. The patient would still need to receive assessments, monitoring, interventions and care that are appropriate for that patient’s needs.
A medication that is not being used as a standard treatment (as described above) for the patient’s medical or psychiatric condition and that results in controlling the patient’s behavior and/or in restricting his or her freedom of movement would be a drug used as a restraint.
The regulation supports existing State laws that provide more vigorous promotion of the patient’s choice and rights. Therefore when a State’s law prohibits the administration of drugs against the wishes of the patient without a court order, the State law applies.
Do treatment plans require name and profession?
Q: Is it not permissible (at least per CMS/TJC) to state in the treatment plan that the" profession" will be responsible for a particular intervention? (E.g.: "Social worker will conduct weekly family therapy")... or do specific people need to be named (e.g. Dr Smith or designee will prescribe medication...)??
A: No. The regulatory body of concern on this issue is CMS and their requirements for treatment plan documentation (ref B123 below). They have indicated in the past that identification of just discipline is not sufficient. They call for treatment plans to identify an individual (initials are adequate) and their discipline. Even though there may be more than one person in a discipline involved in providing the care, CMS wants there to be one person with overall/ultimate responsibility for each intervention… a place where the buck stops. Its the old adage of if everybody is responsible, no one is.
CMS Standard B123 §482.61(c)(1)(iv) The responsibilities of each member of the treatment team; and Guidance §482.61(c)(1)(iv)
There are no “correct” number of staff who comprise the treatment team. The disciplines involved in the patient’s treatment depend upon the problems to be treated, the short-term and long-range goals and the treatment approaches and modalities used to achieve the goals.
The intent of the regulation is to insure that each individual on the treatment team who is primarily responsible for ensuring compliance with particular aspects of the patient’s individualized treatment program is identified. Identification of the staff should be recorded in a manner that includes the name and discipline of the individual. If other professionals or paraprofessionals provide care, the facility has the latitude to decide the manner with which it will identify them on the treatment plan. The patient, as well as family/significant others, should be aware of the staff responsible for various aspects of treatment.
Probes §482.61(c)(1)(iv)
Are staff who are designated in the treatment plan observed carrying out treatment activities and therapies? Is the information in the plan consistent with surveyor observations?
Are the patients able to name the staff responsible for implementing their treatment? Is this information consistent with the treatment plan?
What is acceptable Medication Administration Timeframe?
Answ: It depends on whether or not the medication is considered 'time critical' or not. However, if it is, then 30 minutes before or after the schedule administration time is still the expectation.
Detail:
Survey and Cert Letter 12-05 (PDF, 144 KB) [REF: JCSC, P&T, Phrm, MDx and RNx] Issued 11/18/11: State Operations Manual (SOM) "Appendix A guidance concerning medication administration in hospitals is being updated to reflect current standards of practice related to timeliness of medications. Hospitals are expected to establish policies and procedures for the timing of medication administration that appropriately balance patient safety with the need for flexibility in work processes". Based on ISMP survey of 18,000 nurses who self-reported unsafe practices directly related to efforts to comply with the uniform "30-minute rule" for all medications (CMS guidance, tag A-0405) that expectation is no longer considered the desired standard of practice. Instead, hospitals will be given the flexibility and responsibility to make distinctions about timeframes based on whether or not the medication is appropriate for scheduled dosing and if so whether that dosing is time-critical. Medications that require "exact or precise" dosing times would not be eligible for scheduled dosing (e.g., stat or first time doses). However, if a medication is eligible, a distinction is to be made between those that are time-critical and those that are not. [PEARL] A medication is considered time-critical if it requires scheduled dosing and "an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect" (e.g., antibiotics, anticoagulants, anticonvulsants). Medication administration policy and procedure should then be developed and implemented accordingly. Note this update is also being incorporated into policy regarding standing orders from S&C-09-10. Tip: P&T, Phrm, MDx and RNx should review the details of 'Timing of Medication Administration' on pages 5-8 of the Pub 100-07 attached to S&C12-05. Tip: JCSC should incorporate the CMS recommended 'Survey Procedures' (pg 9-11) for surveyors into a medication mangement tracer.
by R. Fields, MD
.
A-0209**
§482.23(c)(1) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.
Survey Procedures §482.23(c)(1)
Verify that there is an effective method for the administration of drugs. Use the following indicators for assessing drug administration:
• Verify that there are policies and procedures approved by the medical staff covering who is authorized to administer medications, and that the policies are followed.
• Review a sample of medication administration records to see that they conform with the practitioner's order, that the order is current, and that drug and dosage are correct and administered as ordered.
• Observe the preparation of drugs and their administration to patients in order to verify that procedures are being followed. Are patients addressed by name and/or identiband checked? Does the nurse remain with the patient until medication is taken? Are drugs administered within 30 minutes of the scheduled time for administration?
• Verify that nursing or other personnel authorized by medical staff policy to administer drugs have completed appropriate training courses or are licensed or authorized to do so by State law and function under supervision as necessary.
• Check the QAPI activities to see if the administration of drugs is regularly monitored. The monitoring should include reports of medication irregularities or errors, their nature, frequency and the corrective action taken.
• Interview supervisory nursing personnel to determine how supervision is provided. Also interview personnel who administer medication to verify that the supervision is, in fact, provided.
o Are personnel other than nursing personnel administering drugs or biologicals? If yes, determine if those personnel are administering drugs or biologicals in accordance with Federal and State laws and regulations. Use the above procedures to determine compliance.
.
**This is the actual standard
Is a UR Committee Required?
Question Detail:
LD.04.01.01 and 42 CFR 482.30 both require hospitals to have a utilization review plan. However, CMS standards (482.30(b)) also require a utilization review committee that is not specifically referenced in TJC standards. Under the TJC accreditation process is any hospital required to have a utilization review committee?
Answer: Yes
If you are CMS certified there must be a committee but it does not have to be an internal committee as long as you follow the CoP requirements (see below).
§482.30(b) Standard: Composition of Utilization Review Committee
A UR committee consisting of two or more practitioners must carry out the UR function. At least two of the members of the committee must be doctors of medicine or osteopathy. The other members may be any of the other types of practitioners specified in §482.12(c)(1).
(1) Except as specified in paragraphs (b)(2) and (3) of this section, the UR committee must be one of the following:
(i) A staff committee of the institution;
(ii) A group outside the institution--
(A) Established by the local medical society and some or all of the hospitals in the locality; or
(B) Established in a manner approved by CMS.
(2) If, because of the small size of the institution, it is impracticable to have a properly functioning staff committee, the UR committee must be established as specified in paragraph (b)(1)(ii) of this section.
(3) The committee or group's reviews may not be conducted by any individual who--
(i) Has a direct financial interest (for example, an ownership interest) in that hospital; or
(ii) Was professionally involved in the care of the patient whose case is being reviewed.
Ref: 12TJCsig0106@URcommittee0112FIEL3800-1.pdf
What is the Emergency Management Tracer like?
I have sat through many of these and here is the inside skinny on how they typically proceed; the first hour- hour & half are dedicated to the traditional EC Interview- several cream puff questions and the surveyor gathering information regarding your EC program. They may ask to see some documents but they usually have acquired most of what they already needed by said time. The second half of the EC Interview (the next hour to hour & a half) is dedicated to the EC Tracer. The surveyor will choose one of seventeen different disaster scenarios and ask the group specific scripted questions relating to the incident / event. The surveyor will evaluate how confident and capable the group demonstrates their knowledge and ability to these questions as if it were a table top drill in a Q&A format.
In order to prepare for this activity, you may wish to establish a meeting of your team and conduct your own exercise utilizing this very same method. We have done this with most of our clients and achieved outstanding success come time of actual survey.
Contributed on 3/26/07
George A. Rivas, CHSP
Vice President, Consultation Services
TSIG Consulting, Inc. Suite 1001
740 Broadway New York, NY 10003
Office: (212) 420-8724Cell: (847) 612-8424
Fax: (212) 420-4792
Email: rivasg@tsigconsulting.com
Is transportation wrap (of children) considered restraint?
Yes, I am familiar with the wrap board for transporting kids who are out of control. I have considered this restraint. (JC still allows holding for a brief time, but this is intended to be human contact with a small child. I have worked with orgs that tried to use this standard for the board, but it is not appropriate). Only when the kid or adult is held for a treatment procedure is similar restraint not considered behavioral (Spinal tap or treating a wound are examples.). However, wrap use can be acceptable, depending on the entire process and how it is applied. How staff are demonstrating competence, how the process is supervised, injuries, evidence of effectiveness evidence of reduction and implementation of alternatives, etc. Leaders who teach and supervise should be able to provide. current literature re their wrap, preferably evidence based. - Sara Virginia Knight, RN, PhD
09sig_Is the use of OSHA Log 300/Form 301 required by TJC?
SHCC Answ: It depends on what is required by your state and its OSHA approved plan if it has one.
More details & background:
In response to our query, SIG basically said compliance with OSHA was required (see response below), but the question was not asked in the specific context of state hospitals. Our research has found that state and local government workers are excluded from Federal coverage under the Occupational Safety and Health Act of 1970 (the "OSH Act"). However, Section 18 of the Occupational Safety and Health Act of 1970 (the Act) encourages States to develop and operate their own job safety and health programs. OSHA approves and monitors State plans and provides up to 50 percent of an approved plan's operating costs. The idea is for states to provide essentially equivalent protection.
There are currently 22 States and jurisdictions operating complete State plans (covering both the private sector and State and local government employees) and 4 - Connecticut, New Jersey, New York and the Virgin Islands - which cover public employees only. (Eight other States were approved at one time but subsequently withdrew their programs).
An article in the July EC News discusses OSHA reporting. Is the use of
OSHA Log 300 and/or OSHA Form 301 required by Joint Commission
standards?
Yes, The Joint Commission has a standard in the leadership standards
which states all accredited organizations must comply with all
applicable federal, state, and local laws and regulations. Standard
Name: LD.04.01.01 Standard Text: The hospital complies with law and
regulation. EP Text: 1. The hospital is licensed, certified, or has a
permit, in accordance with law and regulation, to provide the care,
treatment, or services for which the hospital is seeking accreditation
from The Joint Commission. Note: Each service location that performs
laboratory testing (waived or non waived) must have a Clinical
Laboratory Improvement Amendments of 1988 (CLIA '88) certificate as
specified by the federal CLIA regulations (42 CFR 493.55 and 493.3) and
applicable state law. (See also WT.01.01.01, EP 1 and WT.04.01.01, EP 1)
Footnote: For more information on how to obtain a CLIA certificate, see
http://www.cms.hhs.gov/CLIA/downloads/HowObtainCLIACertificate.pdf.
Jerry Gervais
Joint Commission
Standards Interpretation Group
Phone: 630-792-5900
09sig_C&P of Outside Providers
4/16/09 Update: Over the last 6 months, member hospitals had been receiving unexpected deficiencies for what TJC surveyors considered inadequate credentialing and privileging of outside providers. First it was related to the interpretive services of radiologist but then went on to include physicians in emergency departments or specialty clinics…even in TJC accredited hospitals. For a while this was supported by SIG with the explanation that it was actually a requirement of CMS. This approach was questioned and constructively challenged during recent surveys of Pennsylvania hospitals. Consequently, there were discussions between CMS and TJC that resulted in a return of TJC to acceptance of C&P work and data from accredited hospitals.…at least in PA. We are awaiting a formal announcement on this issue from TJC.
CMS: The following updated clarifications are based on two conversations with David Eddinger, Lead Analyst for the CMS Hospital Survey & Certification section and the CMS reference document, Survey and Cert Letter 05-04 (S&C-05-04)
1. CMS requires each hospital to evaluate each of its clinicians, to gather its own primary source verification and make its own privileging decisions.
2. Hospitals can agree to share quality data (e.g., competency) but you cannot rely upon another hospital’s credentialing process
3. If patients are sent to a provider at another Medicare participating hospital, it is not necessary to C&P that provider since that hospital is required to do so. It is your responsibility to do the best you can (reasonable man standard) to ensure you are sending patients to a hospital that provides safe, appropriate, quality care.
4. If patients are sent to a provider of medical care who is not at a Medicare participating hospital, that provider must be considered a member of the medical staff (not necessarily with voting privileges) and subjected to the C&P process.
5. CMS considers radiology interpretive services to be a provision of care and as such requires C&P for outside radiologists, individually and by name.
6. Although a written document is not required, they do recommend having an agreement in place especially to ensure that referred patients with emergencies are seen in a timely manner
TJC: The following updated clarifications are based on recent TJC correspondence and relevant standards.
1. Re: Need to C&P providers at other accredited hospitals – “…as long as the local hospitals are Joint Commission-accredited, there is no requirement for additional privileging/credentialing” – 4/2/09 by Anne Scott Blouin, RN. PHD, Exec VP. Accreditation and Certification Operations, Joint Commission
2. Re: Need to C&P providers without hospital affiliation or at non- accredited hospitals - We have no official word from TJC
3. Re: Contracted Services – For TJC this is governed by standard LD.04.03.09
Recommended Strategy
1. Re: Outside providers at other accredited hospitals –
a. Minimum: Ensure that patients are referred only to providers who are credentialed and privileged for the desired services at a TJC-accredited hospital
b. Better: In addition to the minimum above, implement an MOU or other written agreement with all referral hospitals that requires use of appropriately privileged providers and the ability to periodically monitor a sample of C&P data on relevant providers (ala the approach indicated in the TJC Glossary reference to CVO) . Also require compliance with all relevant TJC standards. A sample of contract language successfully used in a 2009 TJC survey is available.
2. Re: Outside providers without hospital affiliation or at non- accredited hospitals – Credential and privilege them as consulting medical staff (this may or may not include voting privileges depending on your particular bylaws)
3. Re: Outside Radiologist/Radiology Groups – The general approach here is according to #2 above. However, if you are supported by a large radiology group, consider requesting (in a written agreement) that the agency limit service for your patients to a smaller, more manageable subgroup. Still, you must privilege each individual radiologist used by name.
************************************************
From: SIG_Response@jcaho.org [mailto:SIG_Response@jcaho.org]
Sent: Monday, March 23, 2009 4:17 PM
To: XXXXXXXXXXXXXXXX
Subject: Re: Medical Staff
Mr. Herringer, Thank you for responding to my query. As we are preparing a training session for our medical staffs, could you clarify the specific CMS standard(s) you referenced in your response? I want to ensure I am quoting the correct CMS standard(s) in our training sessions. Thank you for your assistance.
Original Question & Response:
The following scenario applies to an inpatient psychiatric hospital accredited under the CAMH hospital standards: An inpatient psychiatric hospital sends one of their inpatients to a local Joint Commission accredited acute care hospital emergency room, with which they have a contract, because the patient needs an evaluation and possible treatment for a medical problem. Our patient is evaluated and treated by one of the ER physicians on staff at the acute care hospital. Our patient is then evaluated by a physician specialist while in the ER and receives treatment from that physician as well. On occasion, some of these patients have to be admitted to the local acute care hospital for continued treatment prior to returning to our psychiatric hospital. Our question is this: Is our inpatient psychiatric hospital required to credential and privilege each and every physician at the acute care hospital with whom we have a contract because we would have no way of knowing which physician might see and treat our patient? Or is it acceptable for our hospital to maintain a current list of credentialed providers and their approved services which the acute care facility provides for us?
If you are CMS certified then you are required to credential and privilege contracted offsite providers, since CMS requires full credentialing and privileging for all providers. The is most often outpatient services, as you describe with the ER. Once the patient is admitted to the inpatient acute care hospital they are no longer your patient and you would not need to credential and privilege the inpatient provider. John Herringer Joint Commission Standards Interpretation Group Phone: 630-792-5900
Additional Response:
It would be 482.22 (a)(2) - The medical staff must examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates." In the interpretive guidelines is the statement "The medical staff makes recommendations to the governing body for each candidate for medical staff membership/privileges that are specific t the type of appointment and extent of the individual practitioner's specific clinical privileges and then the governing body takes final action." At 482.22 (c)(6) it reads "the bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges". The interpretive guidelines include the following: "All patient care is provided by or in accordance with the orders of practitioners who meets the medical staff criteria and procedures for the privileges granted, who has been granted privies in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges. Privileges are granted by the hospital's governing body to the individual practitioners based on the medical staff's review of that individual practitioner's qualifications and the medical staff's recommendations for that individual practitioner to the governing body."
John Herringer
Joint Commission
Standards Interpretation Group
Phone: 630-792-5900
With permission of Alabama Dept of Mental Health (DR)
Does a DEA require PSV? If so, how is it obtained?
Answ: Yes.
Expl: An LIP must apply for and obtain a Drug Enforcement Administration (DEA) controlled substance registration (aka DEA License or Certificate) in order to prescribe certain controlled substances. This registration like an LIP license, needs to be verified via a primary source. That verification may be obtained online (free) through a link (see below) on the website of the DEA's parent body, the US Dept of Justice.
DEA Registration Validation
For PSV of DEA NOAH Contrib 0711
See also:
SL3_ United States Department of Justice (USDOJ)
- Drug Enforcement Administration (DEA)
How do you get doctors into 'survey mode'?
1 – The Joint publishes a monthly update called ‘This Month for Physicians’. Although it is essentially the same info as found in ‘This Month ...” for everybody else, the fact that it has ‘physician’ in the title may get their attention. Try highlighting a few (this is important – no more than 3) of the most relevant portions/issues in the newsletter and send it to out (at least to MEC).
2 – Have the Medical Staff bylaws reviewed, preferably by an external source (e.g., a gov body physician, sister hospital Med Dir or consultant). Pay particular attention to the new requirements in the area of credentialing and privileging. Physicians will generally pay attention (i.e., get into survey mode) to credible concerns raised about their bylaws.
3 – Physicians listen to physicians. Find a credible and JC-knowledgeable physician (perhaps from a sister hospital that has recently completed survey) to speak during Med Staff meeting about the physician's role in the new survey process and the relevant standards they will be evaluated on.
4 – Make sure physicians are involved in your mock patient tracers.
What can we do about Illegible MD handwriting?
The first thing to do is not accept it!
Bad handwriting is one thing. Illegible is another. The latter is increasingly being seen as a serious contribution to medical/medication error. Your physicians should be informed that 6 states, "Delaware, Florida,Washington, Montana, Tennessee, and Maryland have enacted laws requiring physicians to write legible prescriptions, and Montana fines doctors $500 for each illegible prescription [Ref #1 below]. Successful suits related to poor physician handwriting are already on record. You should also be aware that under standards IM.6.10 (accurate medical record - RC.01.04.01, EP#1 in 2010) and MS.3.20 (Physician PI - MS.05.01.03, EP#1 in 2010) illegible handwriting could also result in findings of non-compliance.
Step 1 - Give the physician in question courteous but honest feedback about the handwriting and the effect it has on staff and ask him/her to read this FAQ.
Step 2 - If there is no improvement, formally report the concern to the Medical Director/Medical Executive Committee.
Step 3 - The Medical Staff/Director should consider illegible handwriting as a matter of physician competence (remember those 6 new physician competencies) and provide training, counseling, even progressive discipline if needed.
The Joint Commisson on Illegibility
- MEDICATION SAFETY: Even Legible Handwriting Can Cause Harm (Moving toward electronic communications) - Joint Commission Perspectives on Patient Safety, December 2006, Volume 6, Issue 12
- "In addition, MS.8.2.3 (Comprehensive Accreditation Manual for Hospitals) requires that data regarding "accurate, timely and legible completion of patient's medical records" be specifically addressed in the privileging and credentialing program, and that this data must not only be aggregate data, but how specific physicians do compared to the norm. Failure to do so can result in multiple Type I recommendations, even if not part of a Medication Use Evaluation or Performance Improvement program. Multiple Joint Commission standards require legibility of physician orders and that hospitals take appropriate action to improve the legibility of physician orders".- Sentinel Event Alert Issue 23 - September 1, 2001
Some resources to consider for improving physician handwriting:
Is there a TJC requirement for Medical Staff Meeting Attendance?
Short Answ: No
Longer Expl: There is no specific requirement in TJC standards for a specific number meetings to be attended. However, we would recommend that the medical staff itself require a some minimum number to ensure there is sufficient attendance to accomplish official business.
Archive: DB Posting @ Nursing
2008 Articles
Is the DON/Nurse Exec required to have a masters degree?
Answer: No, but... it is strongly encouraged/recommended. Read details below
Standard B147
§482.62(d)(1) The director of psychiatric nursing services must be a registered nurse who has a master’s degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill.
Guidance §482.62(d)(1)
During the interview with the DON, assess his/her educational background and psychiatric nursing and leadership skills. If the DON has less than a Master’s Degree in Psychiatric Nursing, expect to see evidence of experience and on-going training in psychiatric nursing. Documented consultation from a nurse with a Master’s in Psychiatric Nursing constitutes on-going training.
Source: State Operations Manual Appendix AA - Psychiatric Hospitals – Interpretative Guidelines and Survey Procedures - (Rev 1, 05-21-04) [goto SL2 – CMS: 2200 Appendix AA (B Tags - Psych Hospital) {PDF}]
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Additional Nurse Associate Comment: Sara Virginia Knight, RN, PhD (3/2007)
Both Joint Commission and CMS surveyors have become more vocal about needs for all Nurse Exec to have at least a masters degree. My understanding is that when the Nurse Exec does NOT have an advanced degree, Joint Commission surveyors look closely for the following:
- (NR.2.10 EP2) Evidence that the Nurse Exec demonstrates that she/he uses advanced skills, especially for leadership and management.
- Alternative: Evidence that the Nurse Exec is actively enrolled in courses or other training to acquire needed skills and knowledge. (The surveyor is supposed to verify that the courses are leading to relevant skills or a degree.)
- (NR.2.10 EP6) Evidence that the Nurse Exec functions as a peer with the leadership team.
My perception is that many state hospital Nurse Execs have difficulty with leadership/management skills or functioning on a peer level with the leadership team---whether they have a masters degree or not! The idea of having a masters level nurse who provides regular, scheduled "supervising" to the Nurse Exec who does not have an advanced degree is less acceptable than it was years ago. Currently, my understanding is that both Joint Commission and CMS surveyors do not accept this as a long range fix. My perception is that CMS and Joint Commission will accept the supervisory relationship as a support for a nurse who is filling the Nurse Exec position temporarily or while the Nurse Exec is pursuing further education and training.
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