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Title: Department of Health Licensing Survey


1
Department of Health Licensing Survey
  • Meeting the minimum standards

2
Presented in cooperation with the Rural
Healthcare Quality Network
  • Speaker
  • Richard A. Bryan, BSN, RN, CCM
  • Vice President, Healthcare Risk Management
  • Arthur J. Gallagher Co. of Washington, Inc.

3
Department of Health Licensing SurveyMeeting the
minimum standards
  • Agenda
  • Introduction
  • Where the rules are located (WACs RCWs), Guide
    to Surveyors
  • Hospital Survey Process High level review of
    the steps the surveyors take
  • Top Ten Findings What they mean to you
  • Who has the rock in their pocket Assessing
    who, within the organization, should be
    responsible for specific areas of survey
    readiness and preparation (it may not be the most
    obvious person if you really want to pass
  • Wrap up and questions

4
  • It is the doctrine of war to not assume the
    enemy will not come, but rather to rely on ones
    readiness to meet him not to presume that he
    will not attack, but rather make ones self
    invincible.
  • Sun Tzu, The Art of War

5
RCW 70.41.030Standards and rules. The
department shall establish and adopt such minimum
standards and rules pertaining to the
construction, maintenance, and operation of
hospitals, and rescind, amend, or modify such
rules from time to time, as are necessary in the
public interest, and particularly for the
establishment and maintenance of standards of
hospitalization required for the safe and
adequate care and treatment of patients. To the
extent possible, the department shall endeavor to
make such minimum standards and rules consistent
in format and general content with the applicable
hospital survey standards of the joint commission
on the accreditation of health care
organizations. The department shall adopt
standards that are at least equal to recognized
applicable national standards pertaining to
medical gas piping systems. 1995 c 282 1
1989 c 175 127 1985 c 213 17 1971 ex.s. c
189 9 1955 c 267 3. NOTES Effective date
-- 1989 c 175 See note following RCW 34.05.010.
Savings -- Effective date -- 1985 c 213 See
notes following RCW 43.20.050
6
RCW 70.41.130 Denial, suspension, revocation,
modification of license -- Procedure.
  • The department is authorized to deny, suspend,
    revoke, or modify a license or provisional
    license in any case in which it finds that there
    has been a failure or refusal to comply with the
    requirements of this chapter or the standards or
    rules adopted under this chapter. RCW 43.70.115
    governs notice of a license denial, revocation,
    suspension, or modification and provides the
    right to an adjudicative proceeding.
  • 1991 c 3 335 1989 c 175 128 1985 c 213
    22 1955 c 267 13.
  • NOTES
  • Effective date -- 1989 c 175 See note following
    RCW 34.05.010.
  • Savings -- Effective date -- 1985 c 213 See
    notes following RCW 43.20.050.

7
RCW 70.41.170Operating or maintaining
unlicensed hospital or unapproved tertiary health
service --
  • Penalty. Any person operating or maintaining a
    hospital without a license under this chapter,
    or, after June 30, 1989, initiating a tertiary
    health service as defined in RCW 70.38.025(14)
    that is not approved under RCW 70.38.105 and
    70.38.115, shall be guilty of a misdemeanor, and
    each day of operation of an unlicensed hospital
    or unapproved tertiary health service, shall
    constitute a separate offense.
  • 1989 1st ex.s. c 9 612 1955 c 267 17.
  • NOTES
  • Effective date -- Severability -- 1989 1st ex.s.
    c 9 See RCW 43.70.910 and 43.70.920.

8
Chapter 246-320 WAC HOSPITAL LICENSING REGULATIONS
  • Provides a framework for the Department of
    Health Surveyors to inspect hospitals. It also
    Provides hospitals with the rules!

9
WAC 246-320-025   On-site licensing survey.
  •    The purpose of this section is to provide
    annual on-site survey requirements in accordance
    with chapter 70.41 RCW.
  • (1) The department will     (a) Conduct at
    least one on-site licensing survey each calendar
    year to determine compliance with the provisions
    in chapter 70.41 RCW and this chapter     (b)
    Notify the hospital in writing of state survey
    findings     (c) Contact the hospital to
    discuss the findings of an on-site licensing or
    joint commission on accreditation of health care
    organizations (JCAHO) survey when appropriate
    and     (d) Not conduct the annual on-site
    licensing survey when requested by a hospital
    accredited by JCAHO in accordance with
    subsections (2) and (3) of this section.

10
Department of Health Licensing SurveyMeeting the
minimum standards
  • There is a compelling reason for minimum
    standards!

11
Department of Health Licensing SurveyMeeting the
minimum standards
  • Our communities expect more from us!

12
Department of Health Licensing Survey State
Operations Manual Survey Protocol
13
Department of Health Licensing Survey
  • Hospitals must comply!

Should an individual or entity (hospital) refuse
to allow immediate access upon reasonable request
to either a State Agency or CMS surveyor, the
Office of the Inspector General (OIG) may exclude
the hospital from participation in all Federal
healthcare programs in accordance with 42 CFR
1001.1301.
14
Department of Health Licensing SurveySurvey
Process
  • Team Arrives
  • Entrance Conference
  • On-Site Team Meeting
  • Sample Selection
  • Information Gathering/Investigations
  • Survey Locations
  • Observation
  • Interviews
  • Document Review
  • Completion of Hospital/CAH Medicare Database
    Worksheet
  • Team Discussion
  • Determination of Severity of Deficiencies
  • Exit conference
  • Closure
  • Post Survey Plan of Correction

15
Department of Health Licensing Survey
  • Arrival
  • The entire survey team should enter the
    hospital together. Upon arrival, surveyors should
    present their identification. The team
    coordinator should announce to the Administrator,
    or whoever is in charge, that a survey is being
    conducted. If the Administrator (or person in
    charge) is not onsite or available (e.g., if the
    survey begins outside normal daytime
    Monday-Friday working hours), ask that they be
    notified that a survey is being conducted. Do not
    delay the survey because the Administrator or
    other hospital staff is/are not on site or
    available.

16
Department of Health Licensing Survey Entrance
Conference
  • The entrance conference sets the tone for the
    entire survey. Be prepared and courteous, and
    make requests, not demands. The entrance
    conference should be informative, concise, and
    brief it should not utilize a significant amount
    of time. Conduct the entrance conference with
    hospital administrative staff that is available
    at the time of entrance.

17
Department of Health Licensing Survey Entrance
Conference
  • During the entrance conference, the Team
    Coordinator will arrange with the hospital
    administrator, or available hospital
    administrative supervisory staff if he/she is
    unavailable to obtain the following
  • - A location (e.g., conference room) where the
    team may meet privately during the survey
  • - A telephone for team communications,
    preferably in the team meeting location
  • - A list of current inpatients, providing each
    patients name, room number, diagnosis(es),
    admission date, age, attending physician, and
    other significant information as it applies to
    that patient.

18
Department of Health Licensing Survey Entrance
Conference
  • The team coordinator will explain to the
    hospital that in order to complete the survey
    within the allotted time it is important the
    survey team is given this information as soon as
    possible, and request that it be no later than 3
    hours after the request is made. SAs may develop
    a worksheet to give to the facility for obtaining
    this information
  • - A list of department heads with their
    locations and telephone numbers
  • - A copy of the facilitys organizational chart
  • - The names and addresses of all off-site
    locations operating under the same provider
    number
  • - The hospitals infection control plan
  • - A list of employees
  • - The medical staff bylaws and rules and
    regulations
  • - A list of contracted services and
  • - A copy of the facilitys floor plan,
    indicating the location of patient care and
    treatment areas

19
Department of Health Licensing Survey
Information Gathering/Investigation
  • General Objective
  • The objective of this task is to determine the
    hospitals compliance with the Medicare CoP
    through observations, interviews, and document
    review.
  • Guiding Principles
  • Focus attention on actual and potential patient
    outcomes, as well as required processes.
  • Assess the care and services provided, including
    the appropriateness of the care and services
    within the context of the regulations.
  • Visit patient care settings, including inpatient
    units, outpatient clinics, anesthetizing
    locations, emergency departments, imaging,
    rehabilitation, remote locations, satellites,
    etc.
  • Observe the actual provision of care and services
    to patients and the effects of that care, in
    order to assess whether the care provided meets
    the needs of the individual patient.
  • Use the interpretive guidelines and other
    published CMS policy statements to guide the
    survey.
  • Use Appendix Q for guidance if Immediate Jeopardy
    is suspected.

20
Department of Health Licensing SurveyInformation
Gathering/Investigation
  • The objective of this task is to determine the
    hospitals compliance with the Medicare CoP
    through observations, interviews, and document
    review.
  • Focus attention on actual and potential patient
    outcomes, as well as required processes.
  • Assess the care and services provided, including
    the appropriateness of the care and services
    within the context of the regulations.
  • Visit patient care settings, including inpatient
    units, outpatient clinics, anesthetizing
    locations, emergency departments, imaging,
    rehabilitation, remote locations, satellites,
    etc.
  • Observe the actual provision of care and services
    to patients and the effects of that care, in
    order to assess whether the care provided meets
    the needs of the individual patient.

21
Department of Health Licensing SurveySurvey
Locations
  • For hospitals with either no or a small number
    of off-campus provider-based locations, survey
    all departments, services, and locations that
    bill for services under the hospitals provider
    number and are considered part of the hospital.

22
Department of Health Licensing SurveyPatient
Sample Size and Selection
  • Review the patient list provided by the hospital
    and select patients who represent a cross-section
    of the patient population and the services
    provided
  • Minimum of 30 inpatient records. For small
    general hospitals (this reduction does not apply
    to surgical or other specialty hospitals) with an
    average daily census of 20 patients or less, the
    sample should not be fewer than 20 inpatient
    records, provided that number of records is
    adequate to determine compliance.
  • To conduct an initial survey of a hospital there
    must be enough inpatients currently in the
    hospital and patient records (open and closed)
    for surveyors to determine whether the hospital
    can demonstrate compliance with all the
    applicable CoP.

23
Department of Health Licensing SurveyPatient
Review
  • A comprehensive review of care and services
    received by each patient in the sample should be
    part of the hospital survey. A comprehensive
    review includes observations of care/services
    provided to the patient, patient and/or family
    interview(s), staff interview(s), and medical
    record review.

24
Department of Health Licensing SurveyObservations
  • Surveyors are encouraged to make observations,
    complete interviews, and review records and
    policies/procedures by stationing themselves as
    physically close to patient care as possible.
  • When conducting observations, particular
    attention should be given to the following
  • - Patient care, including treatments and
    therapies in all patient care settings
  • - Staff member activities, equipment,
    documentation, building structure, sounds and
    smells
  • - People, care, activities, processes,
    documentation, policies, equipment, etc., that
    are present that should not be present, as well
    as, those that are not present that should be
    present
  • - Integration of all services, such that the
    facility is functioning as one integrated whole
  • - Whether quality assessment and performance
    improvement (QAPI) is a facility- wide activity,
    incorporating every service and activity of the
    provider and whether every facility department
    and activity reports to, and receives reports
    from, the facilitys central organized body
    managing the facility-wide QAPI program and
    Storage, security and confidentiality of medical
    records.-

25
Department of Health Licensing SurveyInterviews
  • Interviews provide a method to collect
    information, and to verify and validate
    information obtained through observations.
    Informal interviews should be conducted
    throughout the duration of the survey
  • Staff interviews should gather information about
    the staffs knowledge of the patients needs,
    plan of care, and progress toward goals. Problems
    or concerns identified during a patient or family
    interview should be addressed in the staff
    interview in order to validate the patients
    perception, or to gather additional information.
  • Patient interviews should include questions
    specific to the patients condition, reason for
    hospital admission, quality of care received, and
    the patients knowledge of their plan of care. For
    instance, a surgical patient should be questioned
    about the process for preparation for surgery,
    the patients knowledge of and consent for the
    procedure, pre-operative patient teaching,
    post-operative patient goals and discharge plan.

26
Department of Health Licensing SurveyDocument
Review
  • Document review focuses on a facilitys
    compliance with the CoP.
  • Patients clinical records, to validate
    information gained during the interviews, as well
    as for evidence of advanced directives, discharge
    planning instructions, and patient teaching. This
    review will provide a broad picture of the
    patients care. Plans of care and discharge plans
    should be initiated immediately upon admission,
    and be modified as patient care needs change.
  • Closed medical records may be used to determine
    past practice, and the scope or frequency of a
    deficient practice. Closed records should also be
    reviewed to provide information about services
    that are not being provided by the hospital at
    the time of the survey
  • Personnel files to determine if staff members
    have the appropriate educational requirements,
    have had the necessary training required, and are
    licensed, if it is required
  • Credential files to determine if the facility
    complies with CMS requirements and State law, as
    well as, follows its own written policies for
    medical staff privileges and credentialing

27
Department of Health Licensing SurveyDocument
Review
  • Maintenance records to determine if equipment is
    periodically examined and to determine if it is
    in good working order and if environmental
    requirements have been met
  • Staffing documents to determine if adequate
    numbers of staff are provided according to the
    number and acuity of patients
  • Contracts, if applicable, to determine if patient
    care, governing body, QAPI, and other CoP
    requirements are included and
  • Policy and procedure manuals. When reviewing
    policy and procedure manuals, verify with the
    person in charge of an area that the policy and
    procedure manuals are current

28
Department of Health Licensing SurveyCompletion
of Medicare Database Worksheet
  • Arrange an interview with a member of the
    administrative staff to update and clarify
    information from the provider file. The
    Hospital/CAH Medicare Database Worksheet will be
    used to collect information about the hospitals
    services, locations, and staffing by Medicare
    surveyors during hospital surveys. The worksheet
    will be completed by the surveyors using
    observation, staff interviews, and document
    review. The worksheet will not be given to
    hospital staff to complete. The worksheet is used
    to collect information that will later be entered
    into the Medicare database. During the interview
    clarify any inconsistencies from prior
    information or information gathered during the
    survey.

29
Department of Health Licensing SurveyTeam
Discussion Meeting
  • The teams preliminary decision-making and
    analysis of findings assist it in preparing the
    exit conference report. Based on the teams
    decisions, additional activities may need to be
    initiated.
  • At this meeting, the surveyors will share their
    findings, evaluate the evidence, and make team
    decisions regarding compliance with each
    requirement. Proceed sequentially through the
    requirements for each condition appropriate to
    the facility as they appear in regulation. For
    any issues of noncompliance, the team needs to
    reach a consensus. Decisions about deficiencies
    are to be team decisions, with each member having
    input.

30
Department of Health Licensing SurveyDetermining
the Severity of Deficiencies
  • The regulations at 42 CFR 488.26 state, The
    decision as to whether there is compliance with a
    particular requirement, condition of
    participation, or condition for coverage, depends
    upon the manner and degree to which the provider
    or supplier satisfies the various standards
    within each condition. When noncompliance with a
    condition of participation is noted, the
    determination of whether a lack of compliance is
    at the Standard or Condition level depends upon
    the nature (how severe, how dangerous, how
    critical, etc.) and extent (how prevalent, how
    many, how pervasive, how often, etc.) of the lack
    of compliance. The cited level of the
    noncompliance is determined by the
    interrelationship between the nature and extent
    of the noncompliance.

31
Department of Health Licensing SurveyDetermining
the Severity of Deficiencies
  • A deficiency at the Condition level may be due to
    noncompliance with requirements in a single
    standard or several standards within the
    condition, or with requirements of noncompliance
    with a single part (tag) representing a severe or
    critical health or safety breach. Even a
    seemingly small breach in critical actions or at
    critical times can kill or severely injure a
    patient, and represents a critical or severe
    health or safety threat.
  • A deficiency is at the Standard level when there
    is noncompliance with any single requirement or
    several requirements within a particular standard
    that are not of such character as to
    substantially limit a facilitys capacity to
    furnish adequate care, or which would not
    jeopardize or adversely affect the health or
    safety of patients if the deficient practice
    recurred.

32
Department of Health Licensing SurveyDetermining
the Severity of Deficiencies
  • When a deficient practice (noncompliance) is
    determined to have taken place prior to the
    survey and the hospital states that it has
    corrected the deficient practice/issue
    (noncompliance), issues for the survey team to
    consider would include
  • Is the corrective action superficial or
    inadequate, or is the corrective action adequate
    and systemic?
  • Has the hospital implemented the corrective
    intervention(s) or action(s)?
  • Has the hospital taken a QAPI approach to the
    corrective action to ensure monitoring, tracking
    and sustainability?
  • The survey team uses their judgment to determine
    if any action(s) taken by the hospital prior to
    the survey is sufficient to correct the
    noncompliance and to prevent the deficient
    practice from continuing or recurring. If the
    deficient practice is corrected prior to the
    survey, do not cite noncompliance. However, if
    the noncompliance with any requirements is noted
    during the survey, even when the hospital
    corrects the noncompliance during the survey,
    cite noncompliance. All noted noncompliance must
    be cited even when corrected on site during the
    survey.

33
Department of Health Licensing SurveyExit
Conference
  • The general objective of this task is to inform
    the facility staff of the teams preliminary
    findings.
  • It is CMS general policy to conduct an exit
    conference at the conclusion of each survey.
    However, there are some situations that justify
    refusal to continue or to conduct an exit
    conference. For example
  • If the provider is represented by counsel (all
    participants in the exit conference should
    identify themselves), surveyors may refuse to
    conduct the conference if the lawyer tries to
    turn it into an evidentiary hearing or
  • Any time the provider creates an environment that
    is hostile, intimidating, or inconsistent with
    the informal and preliminary nature of an exit
    conference, surveyors may refuse to conduct or
    continue the conference. Under such
    circumstances, it is suggested that the team
    coordinator stop the exit conference and call the
    State agency for further direction.

34
Department of Health Licensing SurveyExit
Conference Sequence
  • Introductory Remarks
  • Ground Rules
  • Presentation of Findings
  • Closure

35
Department of Health Licensing SurveyPost Survey
Plan of Correction
  • Regulations at 42 CFR 488.28(a) allow
    certification of providers with deficiencies at
    the Standard or Condition level only if the
    facility has submitted an acceptable plan of
    Correction POC for achieving compliance within
    a reasonable period of time acceptable to the
    Secretary. Failure to submit a POC may result in
    termination of the provider agreement as
    authorized by 42 CFR 488.28(a) and
    489.53(a)(1). After a POC is submitted, the
    surveying entity makes the determination of the
    appropriateness of the POC.

36
Department of Health Licensing SurveyTop Ten
Findings
37
Department of Health Licensing SurveyTop Ten
Findings
  • Inpatient - Individual Plan of Care, Initial
    Assessment Reassessment
  • WAC 246-320-345
  • Citations reflect a failure by hospitals to
  • Establish a plan of care based on the patient
    assessment
  • Reassess the patient periodically to determine if
    the initial needs/problems were resolved or
    continued or
  • Reassess periodically to identify new patient
    problems needing different interventions
    according to a revised plan
  • Individualize patient plans of care when the
    patient has very obvious special needs outside a
    standard plan of care that may have been based on
    a single medical diagnosis, or single procedure.

38
Department of Health Licensing SurveyTop Ten
Findings
  • Inpatient - Restraints 
  • WAC 246-320-345(5)(g)
  • The citations reflect a failure by hospitals to
    develop and implement complete policies for use
    of restraints or a failure to follow hospital
    policies for restraint. Specific examples
    include
  • Failure to define restraint devices versus safety
    devices
  • Failure to define a physical restraint versus a
    chemical restraint
  • Failure to define use of restraints for
    medical/surgical reasons versus use of restraints
    for emergent behavioral/psychiatric reasons
  • Failure to obtain appropriate orders for
    restraints
  • Failure to document specific less restrictive
    interventions attempted
  • Failure to document the reasons for the
    restraint

39
Department of Health Licensing SurveyTop Ten
Findings
  • Failure to document the actual restraint used
  • Failure to periodically assess/reassess the
    patient to determine if restraints continue to be
    needed and/or if the patient physical needs and
    safety are met
  • Failure to remove the restraint as soon as safely
    possible
  • Failure to provide continuous face to face
    monitoring of patients in seclusion and
    restraint or
  • Failure to provide and document annual training
    for staff caring for patients in restraints.

40
Department of Health Licensing SurveyTop Ten
Findings
  • In-Patient Blood Transfusions
  • WAC 246-320-345(5)(o)
  • Citations reflect failure by a hospital to
    follow established policies such as
  • Failure to verify patient identify with two
    persons
  • Failure to verify blood/blood product
    identification for the patient by two persons
  • Failure to document the assessment of the patient
    pre and post administration of blood/blood
    products
  • Failure to document initial, incremental and
    final vital signs
  • Failure to document patient reaction/non reaction
    to transfusion or
  • Failure to administer blood or blood product at
    the ordered infusion rate.

41
Department of Health Licensing SurveyTop Ten
Findings
  • HR - Qualified/Competent Staff
  • WAC 246-320-165
  • Failure to establish staff competency standards
    for specialized care areas or
  • Failure to ensure that licensed, certified or
    registered staff practice only within their scope
    practice.
  • Failure by a hospital to provide and document
    staff competency for specialized duties, such as
  • - The registered nurse administering/monitoring
    conscious/ procedural sedation according to the
    January 2000 Nursing Commission Policy Statement
    for Registered Nurses Performing Procedural
    Sedation
  • - Use of restraints and
  • - Assessment and management of malignant
    hyperthermia.

42
Department of Health Licensing SurveyTop Ten
Findings
  • Pharmacy - Prepare, Dispense, Administration
  • WAC 246-320-285
  • Failure to have an organized and systematic
    pharmacy service under the direction of a
    hospital pharmacist
  • Failure to have clear orders for medications
    which include parameters for dose, route,
    frequency and reasons for administration
  • Failure to monitor medication effectiveness or
    therapeutic levels
  • Failure to review and assure pharmacy approval of
    medication protocols, and/or pre-printed
    medication orders
  • Failure to authenticate medication orders
    according to policy
  • Failure to monitor for and remove outdated
    medications
  • Failure to label medications in syringes and
  • Failure to keep medications secure according to
    hospital policy.

43
Department of Health Licensing SurveyTop Ten
Findings
  • Air Pressure Relationships
  • WAC 246-320-405 (9)(c)(ii)
  • Hospital facility conditions that lead to these
    improper pressure relationships are
  • Dampering air flow
  • Closing/altering a doorway and
  • Alterations/repairs to the ventilation system.

44
Department of Health Licensing SurveyTop Ten
Findings
  • Tamper Resistant Receptacles
  • WAC 246-320-405 (9)(e)(ii)
  • Tamper resistant receptacles are required in the
    following areas per the requirements of WAC
    246-320-405 (9)(e) (ii) and as noted in Table
    525-5
  • Pediatric areas
  • Alcoholism and Substance Abuse units
  • Psychiatric units
  • Exam rooms and
  • Waiting areas.

45
Department of Health Licensing SurveyTop Ten
Findings
  • Plant Cross Connections
  • WAC 246-320-405 (9)(b)(iii)
  • Whenever equipment is connected directly or
    indirectly to a potable water supply a backflow
    prevention device needs to be installed when or
    if
  • The equipment contains or might contain a
    contaminated or contaminating water, liquid, gas
    or mixture
  • The equipment has the potential to contaminate
    other equipment and or
  • The equipment is connected to a non-potable water
    supply, sewer or drain.

46
Department of Health Licensing SurveyTop Ten
Findings
  • Examples of such equipment include
  • Beverage carbonators
  • Fluid disposal docking units
  • Chemical feeders
  • Food preparation sinks
  • Commercial style laundry machines
  • Hose bibs
  • Dialysis units
  • Ice machines
  • Dish washers
  • Pasteurizers
  • Film developers
  • Ultra-sonic washers

47
Department of Health Licensing SurveyTop Ten
Findings
  • Safety
  • WAC 246-320-405(2)(a)
  • Department of Health staff frequently identify
    the following unsafe conditions
  • Unsecured gas cylinders
  • Electrical receptacles in wet areas that are not
    protected by ground fault circuit interrupters
    (GFCI's)
  • Lights over patient beds or in work areas that
    lack shields or shatterproof bulbs, unsecured
    windows
  • Electrical panels in patient areas that are left
    unlocked and
  • Plumbing and accessory fixtures installed in
    certain patient treatment areas that allow for
    self harm.

48
Department of Health Licensing SurveyTop Ten
Findings
  • Nutrition - Food Service
  • WAC 246-320-305 (6)
  • Department of Health staff have identified
    non-compliance with the Food Service Code for the
    following items of concern as well as others
  • Food preparation sinks lacking indirect drains
  • Potential cross-contamination of food products
  • Improper food holding temperatures, both hot and
    cold and
  • Improper dishwashing and sanitizing temperatures.

49
Department of Health Licensing SurveyWho has the
rock in their pocket?
  • Those facilities most successful during survey
    have assessed who within the organization should
    be responsible for specific areas of ongoing
    survey readiness and preparation.

50
Department of Health Licensing Survey Who has
the rock in their pocket?
Finding the owner of the rock may be difficult.
Sometimes it may not be the most obvious
person. This if further compounded by siloing
within organizations.
H U M A N   R E S O U R C E S
F A C I L I T I E S
P A T I E N T   C A R E
51
Department of Health Licensing Survey Who has
the rock in their pocket?
when individuals, groups, or divisionsout of
fearseek to make themselves vital to their
organizations and unconsciously or sometimes
deliberately try to protect their turf or reshape
their environment to gain as much control as
possible over what goes on. Bob Herbold

52
Department of Health Licensing Survey Who has
the rock in their pocket?
  • Assigning the most competent individual may
    require dealing with departmental silos or
    fiefdoms.
  • Every department must understand that it is in
    the best interest of the facility to meet the
    minimum standards.

53
Department of Health Licensing Survey Who has
the rock in their pocket?
  • Real time examples
  • Facilities In smaller facilities, the
    maintenance person that is so adept at keeping
    the place running may not be competent enough
    with the record keeping necessary to meet the
    minimum requirements of the Department of Health.
  • Do you sacrifice day to day operations, or do
    you assign someone who is proficient in the paper
    requirements to work with them?
  • In smaller facilities it may be someone from
    Upper Management.

54
Department of Health Licensing Survey Who has
the rock in their pocket?
  • Other Examples?

55
Department of Health Licensing SurveyWrap Up
  • Survey is mandatory
  • Facilities are surveyed to minimum standards
  • Survey criteria is defined by CMS Conditions of
    Participation so tied to Federal
  • Surveyors follow State Operations Manual that
    is 307 pages of specific instructions and
    guidance
  • DOH has identified top ten most frequently
    written citations
  • Senior management must engage in the process at
    all times, not just the week of survey
  • DOH wants you to stay open.

56
Department of Health Licensing Survey
  • Questions?

Richard A.Bryan, BSN, RN, CCM Vice President,
Healthcare Risk Management Arthur J. Gallagher
Company of Washington 425-586-1057 Richard_bryan_at_a
jg.com
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