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© HTS3 2016 | Page 1
45 Years of Delivering Superior Results
Education
2016 Regulatory Series: Hospital Conditions of Participation, Part I
Welcome to the Webinar
© HTS3 2016 | Page 2
Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE
Regional Chief Clinical Officer
Diane has over 35 years of healthcare leadership experience, and many
years as a Chief Nursing Officer . She has expertise in many areas including
quality redesign, care management, and regulatory requirements. Bradley is
certified in Nursing Administration, Advanced through the American Nurses
Credentialing Center is a Licensed Nursing Home Administrator. She is a
Fellow of the American College of Healthcare Executives and the American
College of Health Care Administrators. Bradley also recently served as the
President of the New York Organization of Nurse Executives and Leaders.
© HTS3 2016 | Page 3
HealthTechS3 hopes that the information contained herein will be
informative and helpful on industry topics. However, please note that
this information is not intended to be definitive. HealthTechS3 and its
affiliates expressly disclaim any and all liability, whatsoever, for any such
information and for any use made thereof. HealthTechS3 does not have
responsibility for nor does it develop or provide policies intended for
direct use by any hospital, clinic or their respective personnel. Any and
all responsibility for such and for compliance with state and federal
requirements remains exclusively with the hospital, clinic or their
respective personnel. HealthTech recommends that hospitals, clinics,
their respective personnel, and all other third party recipients of this
information consult original source materials and qualified healthcare
regulatory counsel for specific guidance in adopting and customizing
policies for your particular healthcare entity’s use.
© HTS3 2016 | Page 4
Instructions for Today’s Webinar
If you are accessing the audio portion of the webinar by telephone, you must enter the pin provided when you logged in if you would like to ask a question.
If you are accessing the audio portion of the webinar by computer audio controls must be enabled if you would like to ask a question.
You may type any questions or comments you have during the webinar in the question box on your computer.
Please feel free to contact Diane Bradley after the webinar with questions or comments.
Phone: 585-671-2212 Cell: 585-455-3652
© HTS3 2016 | Page 5
• Complete Hospital Management
• Financial • Operations
• Corporate Compliance
• Board Development • Turn Around Services
• Regulatory Compliance
• Population Health
• Financial
• Operational
• Quality
• Compliance Executive Placement
• Gaffey Health
–AutoStatus
–AlphaCollector
• CrossTX Chronic Care Management
• Optimum Productivity Enhancer
• Lean Education and Certification
• Care Coordination Education
• Compliance Education
• Support Networks
• Webinars
• CEO Updates
• Clinical Connection Newsletters
Formerly known as Brim
Healthcare we have a
45 year track record of
delivering superior
clinical & operating
results for our clients.
We believe that the combination of People, Process & Technology transforms healthcare
and provides the
required results.
Our Company
Our Executive Team
has experience in
managing hospitals
from multi-billion $
healthcare systems to
community hospitals.
Our Team Our Mission
Management Education Consulting Technology
Strategy – Solutions – Support
Education
© HTS3 2016 | Page 6
Client Recognition & Awards
January 2015 Becker’s 50 Rural CEOs to Know • Nicole Clapp, Grant Regional Health Center • John Gallagher, Sunnyside Community Hospital
• Chandler Ralph, Adirondack Health • Phil Stuart, Tomah Memorial Hospital
April 2015 HealthStrong Top 100 Hospitals (iVantage Health Analytics)
• Barrett Hospital & Healthcare • Carlinville Area Hospital • Grant Regional Health Center • Hammond-Henry Hospital • Hillsboro Area Hospital • Tomah Memorial Hospital
May 2015 Becker’s Top Hospitals for Physician
Communication (scored 92% or higher) • Spooner Health System – score 94% • Tri Valley Health System – score 93%
• Grant Regional Health Center - score 92%
June 2015 Becker’s 100 Great Community Hospitals • Adirondack Health • Grant Regional Health Center
• Hammond-Henry Hospital
June 2015 Top 100 Critical Access Hospitals (iVantage Health Analytics)
• Barrett Hospital & Healthcare • Hillsboro Area Hospital
• Tomah Memorial Hospital
July 2015 Most Wired Hospitals – Small & Rural (published H&HN magazine)
• Hammond-Henry Hospital
• Sunnyside Community Hospital
September 2015 Becker’s 50 CAH CEOs to Know • Nicole Clapp, Grant Regional Health Center • Florence Spyrow, Hammond-Henry Hospital
• Ken Westman, Barrett Memorial Hospital
Management
© HTS3 2016 | Page 7
Strategy
Strategic Planning and Community Benefit • Community Health Needs
Assessment
• Market Share / Environmental Analysis
• Transaction Advisory
• Strategic Plan Facilitation
Turnaround Strategy • Turnaround Assessment
• Financial and Operational Restructuring
• Creditor Consultancy
Financial • Supply Chain Assessment
and Recomendations
• Accounts Receivable Analysis
• Revenue cycle and Business Office Operational Asssessment
Operations
Operations
• Physician Practice and Clinic Assessment
• Productivity / Manpower Assessment
• Optimum Productivity Enhancer Database
• Case Management / Utilization Review
Assessment
Corporate Compliance
• Compliance Assessment Compliance Program Consulting
• Compliance Education
Clinical & Quality
Quality / Performance Improvement • Quality Program
Assessment
• Lean Workflow Analysis and Process Redesign
• Lean Educational Services
Regulatory Compliance & Accreditation Preparation • Survey Readiness
Education and Consulting
• Mock Surveys
• Plan of Correction Development
Population Health Management • Care Coordination
Consulting
• Care Coordination Education
• Chronic Care Management
Executive Support
Board Advisory
• Education
• Retreats
Executive Recruiting
• Interim Executive Placement
• Mid-level and Specialty
Placement
Hospital Governance
Management
• Licensing Advisory Services
• Regulatory Strategy Development
• Annual Report Preparation
Consulting Expert Led Consulting Solutions
© HTS3 2016 | Page 8
Consulting
Phase 1
Strategy and Planning
Phase 2
Research and Analysis of Community
Phase 3
Identification and Prioritization
of Community Health Needs
Phase 4
Multi-Year Implementation
Plan
Phase 5
Annual Review of
Implementation Plan
In consultation with your governing board, steering committee and community
partners, HealthTechS3 consultants facilitate development and documentation of
your Community Health Needs Assessment and development of a multi-year
implementation plan that is actionable and measurable.
Community Health Needs Assessment
© HTS3 2016 | Page 9
33% Productivity Improvement
Proprietary billing & collections management platform
Total AR Mgmt. & Transparency
Complete Business
Intelligence and AR Management
Regulatory Compliance and
Accreditation Preparation
Your Solution for Continuous Survey
Readiness and Development of Effective
Plans of Correction
Facility Types ■ PPS Hospitals
■ Critical Access Hospitals ■ Skilled Nursing Facilities ■ Long Term Care Facilities ■ Home Health/Hospice ■ Rural Health Centers
Surveys based on your
accreditation status ■ CMS Conditions of
Participation ■ State Regulations ■ The Joint Commission ■ DNV
■ HFAP
Educate
Assess
Prepare
Achieve
Consulting Continuous Survey Readiness
© HTS3 2016 | Page 10
33% Productivity Improvement
Proprietary billing & collections management platform
Total AR Mgmt. & Transparency
Complete Business
Intelligence and AR Management
Compliance with
Regulatory Requirements Staff and Physician
Education
Criteria
Development
Consulting Swing Bed Reviews
Roadmap
for Growth
Swing Bed
Optimization
Strategies
© HTS3 2016 | Page 11
Peter Goodspeed leads our Executive Placement Services group.
With over 30 years experience Peter understands the unique
challenges of today’s hospitals. Whether finding a candidate for a
rural hospital or searching for a multi-hospital system, we focus on
your desired qualifications and specific needs. Services include:
Interim
Permanent
Executive Search Process
45 Years of Excellence
• HTS3 has been recruiting Senior
Executives for over 45 Years
• Our extensive understanding of
hospitals & healthcare helps us
find the right candidates for you.
Placement
Management Placement Consulting Technology
Finding The Right Leader
© HTS3 2016 | Page 12
Expert Education Tailored to Your Hospital Free Webinar
Series 2016 • CHNA Are You
ready?
• CoPs for Critical
Access Hospitals
• Building a Lean
Culture in
Healthcare
• Office of Inspector
General 2016 Work
Plan Overview
• About Swing Beds
• CoPs for PPS
Hospitals
• CoPs Long Term
Care
• Compliance Field
Guide 2016
Education
Management Education Consulting Technology
Ongoing Peer Support and Education Networks
Lean
Train the Trainer
Education
Management and
Executive Courses
Certification
Care Coordination
Train the Trainer
Education
Assessments
Chronic Care
Management
Implementation
Advance Care
Planning Program
Compliance
Assessment
Program Planning
Compliance Officer
Orientation
Board Education
Virtual Networks for:
Lean
Compliance
Care Coordination
Benefits:
Provides targeted Education
Receive and Share Best
Practices
Builds Peer Network
Education & Support Networks
© HTS3 2016 | Page 13
HealthTechS3 is a trusted partner for the hospitals we work with. We are fair, honest, professional, and provide ongoing support. Integrity
HealthTechS3 has been around for 45 years and successfully navigated many hospitals through an ever changing healthcare market. Longevity
HealthTechS3 knows how to work with community hospitals and health systems
to best leverage their assets and resources to serve their market and maintain independence.
Market
HealthTechS3 is flexible and affordable relative to many large national consulting firms who focus on strategic work and ideas rather than implementation and impact.
Value
HealthTechS3 is an award winning healthcare services company. We are a renowned management company with award winning hospitals, health systems and physician practices with CEOs of long tenure.
Performance
HealthTechS3 only has consultants with deep experience; Consultants are former hospital leaders and executives, clinical resources are best in the industry.
Expertise
Who we are and what drives us?
© HTS3 2016 | Page 14
Building Leaders – Transforming Hospitals – Improving Care
Hospital
Conditions of Participation
What’s New for 2016
© HTS3 2016 | Page 15
Instructions for Today’s Webinar
• You may type a question in the text box if you have a question during the presentation
• We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail
• You may also send questions after the webinar to Carolyn St.Charles (contact information is included at the end of the presentation)
• The webinar will be recorded and the recording will be available on the HealthTechS3 web site
www.healthtechs3.com
HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.
© HTS3 2016 | Page 16
What We’ll Cover
• Regulatory References
• Compliance with the CoPs
• PSI Worksheets
• April 2015 Revisions to CoPs
• Implementation & Interpretive Guidelines
• Questions
© HTS3 2016 | Page 17
Regulatory References
• Medicare Conditions of Participation
– 42 CFR Part 482
• Survey authority and compliance regulations
– 42 CFR Part 488 Subpart A
• PPS Exclusionary Criteria
- 42 CFR 412.20 Subpart B
• CMS State Operations Manual (SOM)
• Immediate Jeopardy Guidelines
– State Operations Manual Appendix Q
• Responsibilities of Medicare Participating Hospitals in Emergency Cases
– Appendix V
• Your State
© HTS3 2016 | Page 18
Why do I need to be
in compliance with the CoPs?
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
© HTS3 2016 | Page 19
Common Findings from AOs
– First Half of 2015 Environment of Care
• EC.02.05.01 Managing risks associated with its utility systems.
• EC.02.03.05 Maintaining fire safety equipment and fire safety building features.
• EC.02.06.01 Establishing and maintaining a safe, functional environment.
• EC.02.02.01 Managing risks related to hazardous materials and waste.
Life Safety
• LS.02.01.30 Providing and maintaining building features to protect individuals from the hazards of fire and smoke.
• LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire,
smoke, and heat.
• LS.02.01.20 Maintaining the integrity of the means of egress.
• LS.02.01.35 Providing and maintaining systems for extinguishing fires.
• LS.01.01.01 Designing and managing the physical environment to comply with the Life Safety Code
Infection Control
• IC.02.02.01 Reducing the risk of infections associated with medical equipment, devices and supplies.
• IC.02.01.01 Implements infection prevention and control plan.
Medication Management
• MM.03.01.01 Hospital safely stores medications.
© HTS3 2016 | Page 20
Other Findings
• Medical Record Content – Dating and timing of entries and orders
• Anesthesia – Incomplete/missing pre and post anesthesia evaluations
• Care Plans – Incomplete or not dated Plan of Care
• Verbal Orders – Missing/delayed authentication of verbal/telephone orders
• Medication Security – Labeling
• Informed Consent – Missing elements of the consent
• Medical Staff – Missing/limited quality/performance data for profile; OPPE – not using the profile data for evaluation as part of initial appointment and reappointment
• Restraint and Seclusion – Timeframes for orders and incomplete documentation
• Advance Directives – Missing documentation regarding patient’s Advance Directive – not present in the record or not following process when requested by the patient
• Staffing – Orientation not including contract labor or students in the process
• Quality Management – not implementing a documented process of evaluation of all organized services
• Governing Body – not having a current list or not including scope/nature of service for contracted services.
© HTS3 2016 | Page 21
Shift to High Reliability
© HTS3 2016 | Page 22
Personal Observations of Focus Areas
• Life Safety & Environment of Care – ALWAYS
• Medical Staff – Credentialing and Privileging including Peer Review
• Policies and Procedures
• Performance metrics and evaluation of contract services
• Infection Prevention & Control
• Quality Program – Use of data to improve outcomes. No changes
made
• Competency and continued education of staff
• Nutritional assessment
• Nursing Plans of Care – Updates
• Assessment and Reassessment – Pain; Medication Efficacy
• Unsecured drugs
• Unlabeled drugs (open vials)
• Anesthesia carts – unmarked medications; carts unlocked
© HTS3 2016 | Page 23
What has Changed in 2015
• Many CAHs have affiliated with Hospitals,
therefore it is essential for Hospital leaders to
understand the CAH standards.
• Hospital standard changes are minimal.
• State surveys are increasing – 231% ↑ of
validation surveys in 2015.
© HTS3 2016 | Page 24
CoP Major Revisions
April 1, 2015
• Outpatient Services (Orders) §482.54
• Radiopharmaceuticals for Nuclear
Medicine §482.53
• Nutrition §482.28
• Governing Body §482.12
• Medical Staff §482.22
© HTS3 2016 | Page 25
1. Stay Up-To-Date
2. Review the interpretative guidelines carefully – they include
many references to required policies along with general
guidance information
3. Read for words like “must” or “required”
4. Sign up with CMS to receive information on changes to CoPs
– as well as draft regulations, and take advantage of comment periods
5. If you are DNV Healthcare accredited, DNV does not include
every CoP in a standard, however you are responsible for
being compliant with all CoPs.
© HTS3 2016 | Page 26
Regulations and Interpretive Guidelines
Outpatient Orders – Greater flexibility §482.54(c) Standard: Orders for Outpatient Services
Outpatient services must be ordered by a practitioner who meets the following conditions:
(1) Is responsible for the care of the patient.
(2) Is licensed in the State where he or she provides care to the patient.
(3) Is acting within his or her scope of practice under State law.
(4) Is authorized in accordance with State law and policies adopted by the
medical staff, and approved by the governing body, to order the applicable outpatient services
IG: This regulation allows hospitals to accept orders for outpatient services both from practitioners who hold hospital privileges as well as practitioners
who do not, including those who are not located in the hospital’s close geographic area.
© HTS3 2016 | Page 27
Regulations and Interpretive Guidelines
Radiology/Imaging – Good change
§482.53(a) Standard: Organization and Staffing
The organization of the nuclear medicine service must be appropriate to the
scope and complexity of the services offered.
§482.53(b)(1) Hospitals are expected to develop policies and procedures with
respect to supervision of nuclear medicine technologists.
IG: A doctor or pharmacist does not need to be present for a trained nuclear
medicine technologist to push the contrast during the nuclear medicine test.
Permits preparation of
radiopharmaceuticals by trained nuclear medicine technicians in hospitals on
off hour without a physician or a pharmacist being
Present.
Note: CMS memo was issued on May 15, 2015 which rewrote most of the
radiology and nuclear medicine standards under Appendix A.
© HTS3 2016 | Page 28
Regulations and Interpretive Guidelines
Nutrition – Good news
§482.28(b)(2) - All patient diets, including therapeutic diets, must be
ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by
the medical staff and in accordance with State law governing
dietitians and nutrition professionals.
IG: The hospital’s governing body may choose, when permitted under
State law and upon recommendation of the medical staff, to grant
qualified dietitians or qualified nutrition professionals diet-ordering
privileges.
Medical Staff (MS) can grant hospital privileges for registered dietician
or nutrition specialist to write diet orders, e.g diet orders, TPN, or supplemental feeding
© HTS3 2016 | Page 29
Regulations and Interpretive Guidelines
Governing Body – Medical Staff involvement in quality
§482.12 – There must be an effective governing body that is legally
responsible for the conduct of the hospital. If a hospital does not have an
organized governing body, the persons legally responsible for the conduct
of the hospital must carry out the functions specified in this part that
pertain to the governing body. The governing body (or the persons legally
responsible for the conduct of the hospital and carrying out the functions
specified in this part that pertain to the governing body) must include a
member, or members, of the hospital's medical staff.
IG: Each hospital can have separate medical staff or shared (unified
integrated medical staff) with specific rules in a multi hospital system.
Board must consult with an individual responsible for the Medical Staff for
each individual hospital regarding quality of medical care provided in the
hospital. Minimally should occur biannually.
© HTS3 2016 | Page 30
Regulations and Interpretive Guidelines
Medical Staff – Broader representation
§482.22 – The hospital must have an organized medical staff that
operates under bylaws approved by the governing body and is
responsible for the quality of medical care provided to patients by the hospital.
IG: Medical Staff can include PharmD, registered dieticians, PA,
NP, dentist, podiatrist, speech pathologist and comply with respective state law and state scope of practice
© HTS3 2016 | Page 31
October 2015 Changes
• Pharmaceutical Services: Revisions were made to portions of the pharmaceutical
services CoP to bring them into alignment with current accepted standards of
practice. To improve clarity, the revised guidance addresses: accepted professional
pharmacy principles, including United States Pharmacopeia (USP) standards;
compounding of medications, particularly compounded sterile preparations (CSPs);
determining beyond-use dates (BUDs); safe and appropriate storage and use of
medications; and, policies and procedures related to high-alert medications and
minimizing drug errors.
• Additional Tag: A new standard-level tag was added to allow surveyors to cite to the
regulatory language found in the condition stem statement at either the standard- or
condition-level, as appropriate, in the Automated Survey Processing Environment
(ASPEN).
• Preparing CSPs Outside of the Pharmacy: CMS is updating their guidance for the
nursing service regulatory requirements concerning medication administration to
clarify that hospitals must ensure staff adherence to accepted standards of practice
in those limited instances when CSPs may be prepared outside of the pharmacy.
© HTS3 2016 | Page 32
Proposed Rule – Discharge Planning
November 3, 2015
• §482.43 – The most notable revision would be to
require that all inpatients and specific categories of
outpatients be evaluated for their discharge needs
and have a written discharge plan developed.
Many of the current discharge planning concepts
and requirements would be retained, but revised to
provide more clarity.
• Also proposed is to require specific discharge
instructions for all patients. At present, hospitals
have some discretion and not every patient
receives specific, written instructions.
© HTS3 2016 | Page 33
Discharge Planning
• §482.43 – Require that a hospital have a discharge
planning process that focuses on the patient's goals
and preferences and on preparing patients and, as
appropriate, their caregivers/support person(s) to
be active partners in their post-discharge care,
ensuring effective patient transitions from hospital to
post-acute care while planning for post-discharge
care that is consistent with the patient's goals of
care and treatment preferences, and reducing the
likelihood of hospital readmissions. Source: Federal Register. Nov. 3, 2015
© HTS3 2016 | Page 34
Pay particular attention to:
– Pain Assessment and Reassessment
– Fall Risk Assessment and Fall Prevention
– Skin Assessment (Braden) and Prevention skin
break-down
– Nutrition Screening and Assessment
– Restraints
– Assessment and Reassessment
– Care Planning
– Infection Control
– Medication Management
– Discharge Planning
© HTS3 2016 | Page 35
CMS Recommendation for
Continuous Survey Readiness
1. Identify top compliance issues with CMS and the
accrediting organization that is applicable to your
hospital
2. Drill down to the root cause of noncompliance
and embrace this as an OFI for patients
3. Develop a sustainable compliance model, e.g.
assess, plan, implement and evaluate outcomes
4. Hold process owners accountable
© HTS3 2016 | Page 36
CMS Recommendation for
Continuous Survey Readiness
5. Educate leadership and the respective process
owners and team members
6. Present and review results with leadership and
staff, at least quarterly
7. Coordinate, communicate, and collaborate with
leaders and staff on progress
8. Share your excellence by publishing, presenting
poster session(s), and/or public speaking
9. Celebrate your success
Source: CMS Financial Report (www.cms.gov/Research-STatistics-Data-and-Systems/Statistics-Trends-and-Reports/CFOReport/Downloads/CMS-Financial-Report-for-Fiscal-Year-2014.pdf)
© HTS3 2016 | Page 37
Continuous Survey Readiness
It Takes a Village
Consider annual External Mock Survey
Conduct Internal Surveys – Tracers
Initiate a Survey Readiness Committee
Involve staff
Use the 3 Worksheets: discharge planning, infection control & QAPI
Review CMS Form 2567
Develop Quality initiatives for non-compliant standards
© HTS3 2016 | Page 38
Questions?
© HTS3 2016 | Page 39
Contact Information
If you would like to schedule
a mock survey or a review of specific
standards and areas, please contact:
Diane Bradley
Regional Chief Clinical Officer
Email: [email protected]
Phone: 585-671-2212
