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State Survey

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State Survey for Licensure of Hospitals George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems – PowerPoint PPT presentation

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Title: State Survey


1
State Survey for Licensure of Hospitals
George Mason University College of Nursing and
Health Science Regulatory Requirements for Health
Systems Summer 2004
2
State Board of Health
12 VAC 5-410 Rules and Regulations for the
Licensure of Hospitals in Virginia
Center for Quality Health Care Services and
Consumer Protection Virginia Department of
Health Richmond, Virginia
3
Governing Body
  • Administrator/president
  • Asst.. Administrator/ Vice President
  • Governing body by-laws
  • Date of last revision
  • Documentation of lines of authority for operation
    of hospital
  • Organizational chart
  • Board meeting minutes review
  • Frequency of meetings

4
Results of Other Surveys
  • Last JCAHO survey
  • Last CAP survey
  • State fire Marshall Inspection
  • Sprinkler system compliance status
  • OSHA
  • New services since last survey
  • Construction projects

5
Administrative Policies for Review
  • Licensure/certification verification policy
  • Organ donation
  • Moderate sedation policy
  • Restraint policy
  • Incident reporting policy

6
Contracted Services
  • List of contracted services
  • Review two contracts in-depth
  • Review of a Service Contract may include
  • Scope of service
  • Quality Assurance Responsibilities
  • Participation in Performance Improvement Projects
  • Supervision of personnel

7
Medical Staff
  • President medical staff
  • Total medical staff number
  • Active
  • Courtesy/consult
  • Medical staff status
  • Dentists/oral surgeon
  • Podiatrists
  • Allied health professionals practicing (e.g.
    certified registered nurse anesthetists and
    physician assistants)


8
Medical Staff Bylaws, Rules Regulations
  • Medical staff organization (diagram if available)
    departmental/department of the whole
  • Medical staff appointment criteria
  • Initial appointment
  • provisional period
  • Transition procedure from provisional to active
    status
  • Reappointment frequency
  • Board certification requirements
  • Temporary privileges/locum tenens

9
Medical Staff Bylaws, Rules Regulations
(continued)
  • Allied health appointment criteria
  • Reappointment frequency
  • Medical records
  • Time frame for completion
  • H P time frames (medical surgical)
  • H P for admissions of podiatrists and dentists
  • Verbal orders - 24 hours

10
Completeness of Credentialing Process
  • Current license
  • Data Bank Query - (within 12 months of
    appointment . or re-appointment)
  • Q.A. Review documentation
  • Board certification status
  • Documentation of other hospital queries when
    applicable
  • Initial appointment. -Verification of
    credentials/ character
  • Delineation of clinical privileges/approval
    signature
  • Hospital Governing Board approval

11
Infection Control
  • Meeting with Infection control officer and
    medical director
  • Review Infection control plan
  • Surveillance
  • Hospital-wide
  • Focused/targeted
  • Inpatient
  • Outpatient
  • Nosocomial infection rates

12
Infection Control
  • Reported outbreaks
  • Isolation categories
  • Negative pressure rooms (whole house)
  • TB control
  • Respirators used - length of use
  • Number of confirmed cases last year
  • Number of PPD conversions
  • Policy for PPD testing - who how often

13
Infection Control
  • Method of monitoring compliance
  • Education programs
  • Orientation/annual/ongoing
  • Hand washing
  • Small blood spill policy
  • Location of spill kits if used
  • Products used

14
Infection Control
  • Infection control committee
  • Frequency of meetings
  • Meeting minutes
  • Approval areas
  • Biomedical waste disposal
  • Linen procedures
  • Sterilization equipment procedures
  • Housekeeping chemicals

15
Quality Management
  • Meeting with Quality management director
  • Organization Performance Written Plan
  • Organizational reporting structure (diagram)
  • Hospital tracking system.
  • Clinical/critical pathways
  • Medical staff reviews, Reporting for
    re-credentialing
  • Quality council and QI Teams
  • Committee meetings frequency, minutes

16
Fire and Safety
  • Meet Fire and safety safety officer
  • Review fire plan
  • Fire drills (one per shift per quarter)
  • Who participated
  • What procedures practiced
  • What areas were involved
  • Performance evaluation
  • Corrective actions if indicated

17
Fire and Safety
  • Construction drills (two per shift per quarter)
  • Interview employees re Fire plan (at least 3)
  • Safety committee
  • Frequency of meetings
  • Review of committee meeting minutes
  • Committee safety surveys of departments
  • Frequency, Who participates
  • Scope of survey/checklist used

18
Electrical Equipment Checks
  • Initial use check - policy - how documented
  • Hospital owned equipment
  • Privately owned equipment
  • Patient use
  • Personnel use
  • Hospital bed preventive maintenance
  • Frequency
  • How documented

19
Biomedical Equipment Checks
  • Biomedical equipment checks
  • By whom
  • List of frequency categories
  • How tracked and documented
  • Emergency generator log
  • Number of emergency generators
  • Frequency of testing
  • Log of testing and actual use

20
Disaster and Mass Casualty
  • Meet the chairman of the disaster plan
  • Review written plan - Last revision
  • Documented rehearsals twice a year
  • Dates of drills
  • Drills evaluated with corrective actions
  • Documentation of drills kept 2 years

21
Emergency Services
  • Meet emergency department manger
  • Emergency dept. Medical director must be Board
    Certified
  • Number of rooms
  • Number of patients seen last year average
  • Number of patients seen/day
  • Average transfers/month
  • Average number of patients that leave Against
    Medical Advice (AMA)/month

22
Emergency Department Staffing
  • Nursing
  • RN on duty all shifts
  • Physicians
  • Physician on-call duty roster - posted
  • Obstetric - newborn roster of physicians with
    clinical privileges

23
Continuing Education
  • Written plan for unit specific continuing
    education
  • Documentation of education activities for last
    year
  • Plans for current year
  • Required personnel competencies and skills
  • Required frequency of validation
  • Checklist of content
  • Certifications, ACLS, PALS, Other

24
Medication Administration
  • PYXIS SUR-MED Other
  • Refrigerated medications
  • Secure
  • Thermometer
  • Irrigation solutions
  • policy for use
  • Timed/dated

25
Medication Administration
  • Buffered Xylocaine use
  • policy for mixing
  • Multiple dose vials
  • policy for use
  • Single dose vials
  • Compliance with one use poison control center
    used
  • Telephone number posted

26
Other Checks
  • EMTALA (The Emergency Medical Treatment and
    Active Labor Act ) signage posted in waiting room
    triage
  • Triage protocols/Triage privacy
  • Crash carts
  • Number of cart Adult and Pediatric
  • Documented shift checks
  • Who checks carts for outdates
  • How documented

27
Other Checks
  • Toxicology reference materials
  • Master file of MSDS sheets
  • where kept if not in E.D.
  • 24 hour availability
  • HAZMAT facilities

28
Nursing Medical/Surgical Units
  • Medication system used
  • Pyxis Sur-Med Med carts other
  • Policy for multi-dose vials/irrigation solutions
  • Refrigerated medications
  • Temperature monitoring
  • Sharps container compliance
  • Blood glucose machines

29
Nursing Medical/Surgical Units
  • Documented quality controls crash cart with
    defibrillator
  • Documented daily checks
  • Who checks outdates-how documented linen storage
  • Clean/soiled equipment storage
  • Clean/soiled
  • Stretcher/Wheel chair cleaning schedule
  • Who is responsible for cleaning

30
Nursing Medical/Surgical Units
  • Hallways must be totally clear for fire egress
  • Clinical resource information
  • Current pharmaceutical manual
  • Infection control manual
  • Clinical pathway information-if applicable
  • MSDS sheets
  • Fire plan and disaster plan

31
Nursing Medical/Surgical Units
  • Unoccupied room check Call bell
  • Wall oxygen and suction outlets
  • Electrical biomedical equipment checked
  • Emergency electrical plugs identified
  • Sharps box/gloves
  • Negative pressure rooms
  • Current isolation
  • Respirator storage (if applicable)

32
Nursing Medical/Surgical Units
  • Restraint use
  • Observation of patient
  • Chart review for orders and documentation
  • Clean/dirty utility rooms
  • Hazardous waste storage/disposal
  • Dirty linen storage
  • Kitchen/nourishment room
  • Ice machine, Refrigerator/ Temp and Contents
    monitoring

33
Nursing Medical/Surgical Units
  • Housekeeping
  • Janitor's closet
  • Chemical storage
  • Housekeeping cart
  • No food or drink
  • Parking/storage

34
Critical Care Unit
  • Number of beds
  • Nursing /manager medical director
  • Unit designed and equipped for special function
  • Crash carts/emergency equipment
  • Documentation of checks
  • Medication system
  • Pyxis Sur-Med other
  • Stock drugs - who monitors for outdates
  • Refrigerated medications - temperature monitoring

35
Critical Care Unit
  • Blood glucose machine
  • Documented quality controls
  • Nursing assessment/documentation
  • Use of critical pathways
  • Other care planning used
  • Critical care nursing assessment tool used

36
Critical Care Unit
  • Staffing
  • Staffing policy,Staffing schedules
  • last 3 months/with census
  • Categories of personnel assigned to unit
  • RN LPN Aide/Tech Respiratory therapist
  • Continuing education
  • Written plan for unit specific continuing
    education
  • Documentation of plans and activities

37
Critical Care Unit
  • Required personnel competencies and skills.
  • Frequency of re-qualification
  • Documentation/checklist
  • ACLS
  • Certifications of personnel

38
Nursing Service
  • Chief Nurse Executive
  • Director of nursing
  • Organizational Chart
  • Staffing
  • Acuity/system used
  • Procedure used for verification of current
    licensure

39
Nursing Service
  • Required training/continuing education.
  • Blood glucose monitoring
  • Active participation in conscious sedation
  • Policies
  • Administration of blood and blood products
  • Restraint
  • Moderate sedation

40
Employee Health
  • Hepatitis B vaccine
  • Policy
  • Who is eligible
  • Tuberculin testing (PPD - x-ray)
  • Policy
  • Methods used
  • Conversions/follow up

41
Obstetric Services
  • Administrative manager
  • Nurse manager
  • Postpartum, LD, Newborn services
  • Medical director
  • Board Certified or Board Eligible
  • Appointment by Governing Body
  • Responsibilities in writing
  • Joint Committee - Ob Newborn services

42
Obstetric Services
  • Joint conference committee meeting, Minutes.
  • Services management plan
  • Protocol for pregnant women who present in labor
  • Copy at each nurses station
  • Policies procedures
  • Identification of high risk patients
  • Anesthesia personnel available on site within 30
    min.

43
Obstetric Services
  • Policies procedures
  • Ob physician accessible within 10 min during
    oxytocic administration
  • Criteria for use of Labor Delivery Rooms/Labor,
    Delivery, Recovery, and Postpartum Rooms
  • Gynecologic patients - definition - if cared for
    on Ob
  • Infection control.
  • Written criteria for isolation or segregation for
    mothers and infants

44
Obstetric Services
  • Physician availability
  • Ob physician - 30 min. On-call
  • Accessible - 10 min during oxytocic admin-
  • On-call duty schedule posted at each Ob nurses
    station
  • Roster of Ob Neoborn services physicians with
    privileges at each nurses station

45
Obstetric Services
  • Staffing schedules (available for last 3 months)
    1.
  • Ratios
  • Post Partum 16-8
  • Mother/baby 14
  • Ld 11-2
  • Post op recovery 12
  • Policies for use of personnel from other hospital
    Areas

46
Obstetric Services
  • Education training
  • Written plan for unit specific continuing
    education with documentation of activities for
    last year and current year
  • Training for identification of substance abuse in
    women infants
  • Required competencies skills
  • Frequency of validation
  • Certifications, CPR - Adult - Neonatal

47
Obstetric Services
  • Discharge planning
  • Policy and Procedure/substance abusing post
    Partum women
  • Appropriate referrals
  • Include father and/or family members
  • Documented in Medical Record
  • Family planning information given to patient
  • Documented
  • Discharge teaching documentation

48
Obstetric Services
  • Control plan
  • Control station
  • Visibility of unit
  • Bracelet system used
  • Cameras
  • Medication system
  • Pyxis Sur-Med Med cart other
  • Refrigerated medication - temp monitoring
  • Sharps containers

49
Obstetric Services
  • Crash cart/defibrillator
  • Daily monitoring with documentation
  • Documentation of outdate monitoring
  • Unit design
  • Separate and distinct unit
  • Soiled workroom janitor's closet - exclusive
    use by Ob
  • Patient bath facilities with showers
  • Staff clothing change areas

50
Newborn Services
  • Nurse Manager
  • Medical director
  • Qualified for highest level of newborn services
    offered
  • Appointed by governing body
  • Responsibilities in writing
  • Conduct joint conference with Ob Physicians
    quarterly
  • Participation in Performance Improvement
    Initiatives

51
Newborn Services
  • Written medical protocols
  • To include management of medical conditions
    offered
  • Consultation - stabilization - transfer
  • Copy in nursery
  • Approved by governing body
  • Hospital to have written collaborative agreements
    with other hospitals providing higher levels of
    care

52
Newborn Services
  • Newborn physician coverage
  • On-call - on-site - 30 minutes
  • On-call duty schedule - posted - each nurses
    station
  • Roster of newborn services physicians with
    clinical privileges at each nurses station in
    newborn unit.
  • Policies procedures
  • Care of eyes, skin cord, Formula use
  • Assessment with Apgar Scores

53
Newborn Services
  • Breast milk use storage
  • Education training
  • Written plan for unit specific continuing
    education with documentation of activities for
    last year and current year
  • Training for identification of substance abuse
    women infants

54
Newborn Services
  • Required competencies skills
  • Frequency of validation
  • Certifications, CPR - Adult - Neonatal
  • Staffing
  • Ratios - according to level of care offered
  • General - intermediate - specialty -
    sub-specialty
  • LPN - student nurses - nurse aides - require
    direct supervision of a registered nurse in
    newborn services

55
General Level Nursery
  • Nurse manager
  • Medical director
  • If not Board Certified or Board eligible, a
    Pediatrician-written agreement with Board
    certified or board eligible Pediatrician for 24
    hr. Consult by phone
  • If no 24 hour basis Neonatologist on staff at the
    hospital, there must be a written agreement with
    another hospital for 24 hr telephone consult with
    a Board certified or Board eligible Neonatologist

56
General Level Nursery
  • Hospital written collaborative Agreements
    providing higher levels of care
  • Staffing Ratios
  • Newly born/close observation 14
  • Routine care 18
  • Mother/baby care 14

57
General Level Nursery
  • Identification control
  • Bracelet system
  • Two Bracelets on infant
  • One on mother
  • Bassinet/incubator ID card
  • Policy for transport

58
General Level Nursery Design Criteria
  • No more than 16 bassinets/nursery
  • Special care area required for close observation.
  • If 16 beds or less - require 2 nurseries - 8 beds
    each for cohorting
  • Minimum of 24 sq.. Ft. floor area.Three ft.
    between bassinets
  • 25 more bassinets than Ob beds.Multiple births
  • One electrical outlet for each bassinet
  • One incubator for every 10 bassinets

59
Intermediate Level Nursery Staffing
  • Nurse manager
  • Medical director, Board Certified or Board
    Eligible Pediatrician
  • If no 24 hour basis Neonatologist on staff, the
    hospital, must have written agreement with
    another hospital for 24 hr telephone consult with
    a Board Certified Or Board Eligible Neonatologist
  • Hospital written collaborative agreements with
    other hospitals providing higher levels of care
  • Routine care 14 All personnel neonatal CPR
    trained

60
Intermediate Level Nursery Design Criteria
  • No more than 16 bassinets/nursery
  • 50 sq.. Ft. Floor area - 4 ft. Between bassinets
    and five feet wide aisles - (if renovated after
    8/10/95)
  • Eight electrical outlets/infant station _ checked
    monthly
  • Two oxygen outlets/infant station
  • Two pressed air outlets/infant station
  • Two suction outlets/infant station
  • Portable x-ray machine outlet/nursery

61
Specialty Level Nursery Staffing
  • Nurse manager. Advance training for high risk
    neonates
  • Medical directorBd. Cert or bd. Elig.
    Neonatologist
  • Hospital written collaborative agreements with
    other hospitals providing higher level of care.
    May have more than one.
  • Nursing Ratios Routine care 13. All personnel
    must be neonatal CPR trained
  • Education requirement for RNs Advanced training
    and experience in management of neonatal
    specialized care and ventilation care

62
Specialty Level Nursery Design Criteria
  • No more than 16 bassinets/nursery
  • 80 sq.. Ft. Floor area - 6 ft. Between bassinets
    and eight feet wide aisles - (if renovated after
    8/10/95)
  • Twelve electrical outlets/Infant station checked
    monthly
  • Two oxygen outlets/Infant station
  • Two compressed air outlets/Infant station
  • Two suction outlets/infant station
  • Portable x-ray machine outlet/nursery

63
Sub-Specialty Level Nursery Staffing
  • Neonatal clinical specialist
  • Medical director Bd. Cert or Bd. Elig.
    Neonatologist
  • Nursing Ratios
  • Sub-specialty care 12
  • Multi-system support care 11
  • Education requirements for RNs
  • Advanced training and experience in Management of
    high risk neonates, Unstable neonates and
    Multisystem problems

64
Sub-Specialty Level Nursery Design Criteria
  • No more than 16 bassinets/Nursery
  • 80 sq.. Ft. Floor area - 6 ft. Between bassinets
    and eight feet wide aisles - (if renovated after
    8/10/95)
  • Twelve electrical outlets/infant station -
    checked monthly
  • Two oxygen outlets/infant station
  • Two compressed air outlets/infant station
  • Two suction outlets/infant station
  • Portable x-ray machine outlet/nursery

65
Surgical Services
  • Nurse manager
  • Operating room register
  • Computerized
  • Roster of surgical privileges
  • Current medical staff
  • Temporary locum tenens
  • Non employee pass and scrubs
  • Manufacturer's reps visitors
  • Safety policies and procedures posted or check
    sheet on chart for hp- informed consent - pre op
    diagnosis

66
Surgical Services
  • Medication system used Pyxis Sure-Med
    Other
  • Crash cart for OR
  • Where located, Documented checks daily
  • Medication outdate checks, how documented?
  • Linen and hazardous waste disposal procedure
  • Equipment storage
  • Education
  • Written plan for surgical unit specific
    continuing education documented activities for
    last year current year
  • Certifications

67
Post Anesthesia Care Unit
  • Nurse manager
  • Medication system used
  • Pyxis Sur-Med Other
  • Documentation of narcotic use/waste
  • Sharps boxes
  • Small blood spill policy awareness
  • linen storage Clean, Soiled

68
Post Anesthesia Care Unit
  • Crash cart/defibrillator
  • Documented daily checks
  • Medication outdate checks - how documented
  • Unit specific written continuing education plan
  • annual activities
  • May be combined with surgery

69
Anesthesia Service
  • Chief of anesthesia
  • Number of anesthesiologists number of CRNAs
  • Contracted service?
  • Medication system used
  • Narcotic use and waste documentation
  • Anesthesia carts
  • Standardized-
  • Who checks for outdated medications

70
Anesthesia Service
  • Anesthesia policies
  • Pre-anesthesia evaluation
  • Done by a physician
  • Review of pt's condition just prior to induction
  • Both events recorded
  • Post-anesthesia evaluation
  • Inpatients - (within 24-36 hours)
  • Outpatient - may be done by another physician
  • Epidurals for pain management Where performed

71
Sterile Supply Service
  • Physical barrier between contaminated work areas
    and clean work areas
  • Cleaning, prep, sterilizing, aeration, storage
  • Sterilizers/autoclaves
  • New equipment approved by infection control
    committee
  • Written procedures
  • Approved by infection control committee
  • a. Sterilizing and storage procedures
  • b. Waste disposal
  • Safety procedures/personnel/patients

72
Laundry Services
  • Distinct areas for the separate storage and
    handling of clean and soiled linens
  • Soiled areas - negative pressure
  • Transport of clean linens
  • Transported in containers exclusive for clean
    linen
  • Stored in areas designated exclusively for this
    purpose

73
Respiratory Therapy Service
  • Compliance with infection control policies
  • Compliance with oxygen safety policies
  • CLIA number if applicable
  • Number of blood gas machines

74
Physical Therapy
  • Number of physical therapists
  • Number of occupational therapists
  • Number of speech therapists
  • Verification of current license for all
  • License posted
  • Whirlpool culture policy
  • Frequency/review of culture results if done
  • Debridement procedures done by pt

75
Physical Therapy
  • Compliance with infection control policies
  • Linen storage
  • Thermometers for hydroculators thermometers for
    refrigerator
  • Preventive maintenance for equipment

76
Pharmaceutical Services
  • Pharmacy director/chief pharmacist
  • Personnel
  • Number of pharmacists Full time Part time
  • Technicians
  • current license posted
  • Pharmacists
  • Pharmacy
  • Hours of operation
  • Access to pharmacy after hours, Method of access

77
Pharmaceutical Services
  • Number of satellite pharmacies
  • Where located
  • Medication systems used
  • Pyxis Sur-Med Med carts
  • Refrigerated medication monitoring
  • Outdate monitoring
  • Policy for multi-dose vial use
  • Procedure for destruction of drugs
  • Outdated, Narcotics, and Others

78
Pharmaceutical Services
  • Procedure for reconciliation of In-house use of
    narcotics
  • Anesthesia
  • Other clinical areas
  • Quality assurance
  • Pharmacy Therapeutics Committee
  • Adverse drug reaction reporting
  • Definition, Average number/month, Number last
    year
  • Formulary

79
Pharmaceutical Services
  • Laminar hoods
  • Horizontal
  • Date of last certification
  • Vertical
  • Date of last certification
  • Chemical bio-hazardous waste (chemotherapy)

80
Dietary Services
  • Contracted service
  • Food services manager
  • Dietitian
  • Number of dietitians
  • Full time/part time/consultant
  • Consultant reports with hours and activities
  • Policies for patient consult
  • Assessment/teaching documentation

81
Dietary Services
  • Approved diet manual
  • Frequency of approval
  • Sanitation check
  • Frequency,Last report
  • Temperature monitoring policy
  • Refrigerator/freezers
  • Checksheet with temp guides/action taken
  • Who reviews checksheet

82
Dietary Services
  • Dish machine
  • Final rinse temp.
  • Who reviews temp. Log
  • Over range hood cleaning
  • Frequency -(directly over range)
  • Exhaust ducts
  • Inspected and/or cleaned 2x/year
  • By whom

83
Dietary Services
  • Dry storage
  • 6 inches from floor
  • 8 inches below sprinkler heads
  • 36 inches circumference around sprinkler head
  • Chemical/housekeeping storage - separate from
    food storage
  • Covered dumpster fly control
  • Employee interviews
  • Fire plan and dietary fire extinguishing
    equipment
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