Www.FletcherAllen.org 1 Fletcher Allen Health Care Burlington, VT Is a CMS Survey in Your Future? Dawn LeBaron, Vice President for Hospital Services Jack

www.FletcherAllen.org 1

Fletcher Allen Health CareBurlington, VT

Is a CMS Survey in Your Future?

Dawn LeBaron, Vice President for Hospital ServicesJack Conry, Director of Security, Safety, and ParkingLindsay Harbour, Safety Specialist



Fletcher Allen Health Care

Three Main Campuses:

Medical Center Campus Fanny Allen Campus University Health Center (UHC) Campus 45+ Satellite Campuses



Medical Center Campus

Largest Campus – hospital occupancy

Facility = 1.5 million SF

Surface Parking & Grounds = 1 million SF

Two Garages = 585,000 SF



Fanny Allen Campus

2nd Largest Campus – hospital occupancy

Facility = 118,000 SF

Surface Parking & Grounds = 948,000 SF



University Health Center Campus

Physician Offices – business occupancy

Facility = 250,000 SF

Surface Parking & Grounds = 273,000 SF



Serving a population of one million: Level 1 Trauma Center 562 licensed beds, 458 staffed 2,183 births 50,419 inpatient and outpatient

admissions 60,356 emergency department visits 1,108,682 physician encounters



2.4 million lab tests 1.44 million meals served 6,700 employees (including per diem & part-

time) 450 UVM Medical Group physicians (770 total

medical staff) 280 house staff (physicians in specialty training);

15 residency programs $8.7 million in charity care



Today’s Discussion: Health care regulatory agencies CMS overview What lead to a full CMS survey at Fletcher Allen The CMS Life Safety tour and findings Life Safety hot spots EOC hot spots Fletcher Allen’s full Joint Commission Survey



Regulatory Agencies

Fletcher Allen is reviewed by 30+ agencies.

Primary agencies are:

Joint Commission Centers for Medicare /Medicaid Services ( CMS) State / Local Licensing Agencies



Fletcher Allen Health Care

FY11 (3 quarters)

10/1/10 – 6/30/11

27 Regulatory

“Site Visits”

AgencyName On-Site Visits

Division of Licensing and Protection 10

CMS 3

Food and Drug Administration 3

VOSHA 2

Joint Commission 2

American Association of Blood banks 1

American College of Surgeons Trauma 1

Division of Alcohol and Drug Abuse Program 1

Division of Mental Health 1

Environmental Protection Agency (EPA) 1

Homeland Security 1

Nuclear Regulatory Commission 1


Is a CMS Survey in Your Future?FY11 On-Site Regulatory Agency Visits

Division of Alcohol and Drug Abuse Program, 1

Division of Licensing and Protection, 10

Division of Mental Health, 1

Environmental Protection Agency (EPA), 1

Food and Drug Administration, 3

Homeland Security, 1

Joint Commission, 2

Nuclear Regulatory Commission, 1

VOSHA, 2

American Association of Bloodbanks, 1

American College of Surgeons Trauma, 1

CMS, 3



Fletcher Allen Regulatory Site Visits:

Division of Licensing and Protection/ CMS (13) Complaint Allegation Surveys (10) Full Survey (1) Durable Medical Equipment (2)



Other agencies (14) Joint Commission (2)

1 in response to CMS findings 1 Stroke Certification

Environmental Protection Agency (1) Nuclear Regulatory Commission (1) FDA (3) Department of Mental Health (1) American College of Surgeons (1) VOSHA (2) American Association of Bloodbanks (1) Homeland Security (1) Division of Alcohol and Drug Abuse (1)



Regulatory Costs:

Year to Date = $177, 000 Includes: Escort, coordination of surveys,

survey interview sessions, development of POC and writing of plans.

Other costs: TJC follow up survey = $5,000

Total = $182,000


Is a CMS Survey in your Future?

CMS



Who is CMS?

A branch of the U.S. Department of Health and Human Services.

A federal agency that: administers the Medicare program and monitors the Medicaid programs offered by each

state. The United States is set up into sections of CMS

boards Vermont reports to the Boston section.



What Triggers a CMS Survey?

Complaint Allegation

Self Report – Obligated to report: Allegations of abuse “Critical Incidents” in Mental Health (VT)

Validation Survey Within 60 days of TJC survey A quality check on TJC



CMS Survey Results:

“Statement of Deficiencies”

No Findings Standard Level Finding Conditional Level Finding Immediate Jeopardy



Standard Level Finding:

Typically do not require a response However if an organization is found to be out of compliance at

the condition level from a previous finding – they require response/ follow up survey

Condition Level Finding:

Requires a formal organizational response. It triggers:

A follow-up “focused survey” and A full CMS survey



Immediate Jeopardy: Defined by CMS as:

“A crisis situation in which the health and safety of individuals are at risk (see §SOM 3010).”

It carries a threat of termination procedures if “conditions” are not resolved within 23 days.

The hospital can lose Medicare funding. Requires a formal response by organization It triggers:

A follow-up “focused survey” and A CMS “full survey” and A follow-up “Joint Commission” survey


Is a CMS Survey in your Future?

So, what happened at Fletcher Allen?



Monday, December 20, 2010 3 surveyors arrive unannounced

for a 3 day survey 4 complaint allegations, 1

involving the Cardiac Cath LabCath Lab complaint allegation involved patient complaint about consent (only physician can treat).

No EOC involvement at this point

Tuesday, January 11, 2011 2 surveyors arrive unannounced

for a 2 day survey Follow-up from the 12/20/10

survey Focus of survey is Cardiac Cath

Lab and EP (Electrophysiology) Service

Tuesday, January 11, 2011 End of the day tour of Cath Lab. Debris and brown stains on the

floor. Cleaning process described.

Wednesday, January 12, 2011 7:30 am continuation of the Cath

Lab tour from 1/11/11. Room Cleaning – Trash emptied,

but debris and stains still on floor. Patient scheduled for 8:00 am



Cath Lab Survey Results-1/13/11

Four “Condition Level” Findings: Governance Medical Staff Infection Control Patient Rights & Ethics

Plan for Correction (POC) due 2/8/11

Sparked a full unannounced CMS survey



Statement of Deficiencies&

Plan of Correction

Corrective action the hospital will being implementing

Plan for educating

Plan for monitoring

CMS Form 2567



Wednesday, January 19, 2011

3 surveyors arrive unannounced for a 3 day survey (complaint allegation)

Survey focused on the Emergency Department and EMTALA

EMTALA Emergency Medical Treatment and Labor Act Perform medical screening exam Treat/ stabilize



EMTALA Survey Results

Immediate Jeopardy!

Posting of Signs (489.20.q) Medical Screening Exam (489.24.c) Stabilizing Treatment (489.24.c.1-3)

Plan of Correction Sparked a CMS focused survey Sparked another CMS full survey! Sparked a JC follow-up survey



Tuesday, March 8, 2011

Full CMS Survey:

13 surveyors arrive unannounced for a 4 day full CMS full survey (includes 2 Life Safety Surveyors)

Originally sparked by December 2010 Cath Lab complaint allegation.

Full Survey offers CMS surveyors the opportunity to look at all self reports.

Thursday, March 10, 2011

1 TJC surveyor arrives unannounced for a 1 day survey

A follow-up survey to the EMTALA finding.



Surveyor 1 Surgical Services Medical Records Infection Control Nursing: SICUSurveyor 2 Discharge Planning UR Emergency Services Nursing: OB, NICU, Pedi ICUSurveyor 3 & 4 Rehab: Cost reporting Rehab Services Outpatient Services Nursing: McClure 6Surveyor 5 Psych Unit (with Surveyor 9) Psych Unit Complaints (2) Organ & Tissue ProcurementSurveyor 6 Compliance with local, state, federal laws Governing Body Emergency Services (with Surveyor 2) Medical Staff Nursing: Administrative Review

Surveyor 7 Pharmacy with 1 complaint Radiology Nuclear Nursing: MICU, Baird 6Surveyor 8 Laboratory Services Physical Environment Respiratory Services Nursing: Shepardson 6, Baird 4Surveyor 9 Psych Unit (with surveyor 5) Shepardson 3, Shepardson 6Surveyor 10 & 11 Anesthesia Services Patient Rights QAPISurveyor 12 (Life Safety) ½ of Medical Center Campus Fanny Allen Campus 4 Satellite CampusesSurveyor 13 (Life Safety) ½ of Medical Center Campus UHC Campus 2 Satellite Campuses



Fletcher Allen’s Survey Plan:

CMS survey team assigned a large conference room as their home base.

Each CMS surveyor assigned a Fletcher Allen point of contact and escort.

Fletcher Allen home base established in close proximity to the CMS home base.



CMS Full Survey:

An opportunity for surveyors to review all

“self reports”

Plastic wrist restraints Pepper spray

Immediate Jeopardy!



Full Survey “Hot Spots”

Infection Prevention Dressing changes Sterile technique Toys in waiting rooms Cleaning of glucometersMedication Security Med carts locked Handling of medsEOC Refrigerator logs Hallway clutter Alarm responsePatient Confidentiality Use of WOW’s

Resuscitation Carts Checked per written policyMedical Records Were orders carried out Documentation of action takenPain Assessment Multidisciplinary assessment Documenting assessments Completion of care plans Assessment per policyRestraints Written order Documentation according to policyQuality & Safety Explain PI process and projects



Environment of Care Issues:

Remember: 13 surveyors look at all of the EOC

Goose neck faucets on Psychiatric Unit Shower controls on Psychiatric Unit Loose handrails in hallways Emergency Lighting in “procedure

rooms” Security of the Operating Room Access signs for the Operating room Refrigerator temperature logs in

Dietary Temperature and humidity logs in CSR Cracked vinyl (tables and mattresses)


Is a CMS Survey in Your Future?Before After



Before After





CMS Life Safety Tour:

Two Life Safety surveyors – Both state fire marshals

Two Fletcher Allen escorts

Four Facilities Management/Safety escorts

Survey locations divided in two

Main hospital campus and two satellites

Fanny Allen campus and four satellites



Life Safety ‘Hot Spots”

Fire stopping Door closers Fire doors close and latch Stairwell storage Door jambs with no doors Delayed egress signs Emergency lighting tests Obstructed pull stations GFCI outlets – 6’ from water Extension cords

Smoke Detectors spacing 36” from air supply

Power cord daisy chains Sprinkler heads in storage

closets Storage within 18” of sprinkler Electrical Panels

Labeling (including spares) Open spaces Broken latches



CMS Home Base

13 Surveyor talking among themselves

Life Safety surveyor to Ambulatory Site surveyor:

“Did you know that they are doing surgery at their Plastic Surgery site without emergency lighting?”

Immediate Jeopardy!



90 Life Safety Findings: GFCI outlets (22) Smoke detector/air handler (8) Power strips interconnected (7) Electrical panel labeling (5) Smoke detector spacing (4)



90 Life Safety Findings (continued): Penetrations/fire stopping (4) Sprinkler head needed (4) Door self closer needed (4) Fire door does not close and latch (3)



90 Life Safety Findings (continued): Electrical panel, open spaces (3) Extension cords (3) Electrical panel, broken latch (2) Stairwell storage (2) Kitchen hoods needed for frying (3)



90 Life Safety Findings (continued): Emergency light malfunction (1) Emergency light needed in

generator room (1) Pull station blocked (1) Store room door removed (1) Pre-action valve in stairwell (1) Dirty smoke detector (1) Storage 18” of sprinkler (1) Strobe light blocked (1) Outlet cover broken (1) Cabinet on power cord (1)



90 Life Safety Findings (continued): Suspended light blocking sprinkler (1) Breaker lock missing (1) Delayed egress sign (1) Delayed egress not approved (1) Fire proofing spray on metal beam (1) Cooking staff knowledge of fire

suppression system (1) Wires above ceiling not supported (1) Emergency light malfunction (1)





CMS Lessons Learned:

It doesn’t matter how old the building. It is still held to current standards.

Know your “procedure rooms”.

Alert others in advance about the route of the tour.

In most cases, arguing gains nothing.

Surveyors take pictures and share with other surveyors.


Joint Commission Survey

Joint Commission Full Survey

Monday, August 15, 2011

Seven (7) surveyors including one (1) Life Safety Engineer

Full five (5) day survey

Two (2) day Life Safety survey



Environment of Care & Emergency Management Session:

Documents provided upon arrival: EOC Committee Meeting Minutes Management Plans Emergency Operation Plan Annual Program Evaluations Hazard Vulnerability Analysis Inventory of Assets and Resources



EOC & EM Issues:

EM.02.02.13 (EP2) – Not documented in the medical staff bylaws who may grant disaster privileges.

EC.02.06.01 (EP1) – Clean utility room with storage stacked too high to the ceiling. Hazardous to staff.

EC.02.02.01 (EP5) – Unlocked soiled utility room with hazardous items accessible to children (used AA batteries and bottles of cleaning solution).

IC.02.02.01 (EP3) – Expired surgical gloves, biogel gloves, and tampons.



LD.04.01.01 (EP3) – Exposed pipes under sinks in handicapped bathrooms (ADA violation).



Life Safety Survey:

Day One:

Documentation Review

Day Two:

Building Tour



TJC Life Safety Survey:Fletcher Allen Issues

EC.02.03.05 (EP6) – Documentation that electric fire pumps were run weekly for 10 minutes.

EC.02.03.05 (EP10) – No documentation for the quarterly inspection of water supply connections.

EC.02.03.05 (EP19) – No inventory of fans to ensure that all air handling units shut down properly.

EC.02.05.07 (EP4) – 42 days between generator tests one month of the year.

EC.02.05.07 (EP6) – 42 days between automatic transfer switch test one month of the year.



TJC Life Safety Survey:Fletcher Allen Issues (continued)

EC.02.05.07 (EP7) – No documentation that emergency generator was operated for 4 continuous hours at least every 36 months.

EC.02.05.07 (EP8) – No documentation that emergency generator was operated at 30% nameplate rating for 4 continuous hours at least every 36 months.

LS.01.02.01 (EP3) – Written ILSM risk assessments not completed for each SOC Plan for Improvement.

LS.02.01.10 (EP5) – Fire door did not close and latch with vertical gap greater than 1/8”.



TJC Life Safety Survey:|

Issues continued:

LS.02.01.01 (EP6) – Fire door with kick plate larger than 16”.

LS.02.01.20 (EP13) – Hallway clutter (medication carts and soiled linen hampers).

LS.02.01.35 (EP4) – Conduit and HVAC duct resting on sprinkler pipes.



Joint Commission Lessons Learned:

Documentation – Get it to the surveyors early.

Binders – Develop binders for documents the surveys are likely to request.

Have a plan for replacing organizational “experts”, if they are “on vacation”.



Questions?



Fletcher Allen Contact Information:

Dawn LeBaron, Vice President for Hospital Services 802-847-2805 [email protected]

Lindsay Harbour, Safety Specialist 802-847-2284 [email protected]

Jack Conry, Director of Security, Safety, and Parking 802-847-2812 [email protected]