Current%20Hospital%20Regulatory%20and%20Patient%20Safety%20Issues%20GPS%20to%20Quality%20Maryland%20Association%20For%20Healthcare%20Quality%20October%2029,%202009

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Current Hospital Regulatory and Patient Safety
IssuesGPS to QualityMaryland Association For
Healthcare Quality October 29, 2009

• Renee B. Webster, Assistant Director
• Office of Health Care Quality

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Mission of Office of Health Care Quality (OHCQ)

• Protect Marylands Citizens through Regulation
  and Enforcement
• Develop Standards for Providers
• Educate Providers and Consumers
• Respond to the Public
• Improve Quality

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What OHCQ Does

• The OHCQ is the agency within the Department of
  Health Mental Hygiene charged with monitoring
  the quality of care in Marylands 8,000 health
  care community residential programs.
• The OHCQ licenses certifies the states health
  care facilities.
• The OHCQ uses state federal regulations, which
  set forth minimum standards for provision of care
  conducts surveys to determine compliance.
• The OHCQ also educates providers, consumers
  other stakeholders through written materials,
  presentations, its Web site at conferences
  seminars.

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What Do We Regulate ?

• Hospitals
• Nursing Homes
• Assisted Living Facilities
• Home Health Agencies
• Ambulatory Surgery Centers
• Residential Treatment Centers
• Prison Hospitals
• Staffing Agencies
• ICF- MR

• Group Homes
• Laboratories
• Adult Medical Day Programs
• Outpatient PT
• ESRD
• Alcohol/Drug Treatment Facilities
• HMOs
• Residential Service Agencies
• Birthing Centers

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Current Issues

• Understanding the Role of OHCQ
• Areas of Frequent Regulatory Citations
• Patient Rights
• EMTALA and Recipient Hospital Responsibilities
• Discharge Planning
• Medical Records
• QAPI
• Current Patient Safety

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Licensing vs. Accreditation

• Voluntary
• Paid for by the provider.
• Private organization
• Inspections are not public information
• Facility can still operate without accreditation

• Mandatory
• Allows a provider to operate
• State or local jurisdiction
• Inspections are publicly disclosable
• Loss results in closure of the facility

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Certification

• Allows a provider to obtain reimbursement from
  Medicare or Medicaid for services.
• Decision making body is Centers for Medicare and
  Medicaid Services (CMS).
• CMS delegates the oversight to each state and
  instructs the states how to conduct oversight
  activities.
• OHCQ is the State Agency charged with oversight
  in MD but CMS is the final decision maker over
  any Federal oversight by OHCQ

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Hospital Regulatory Oversight

• Complaint Investigations
• FU on deficiencies and TJC surveys
• Validation Surveys
• Look Behind Surveys ( 2/year)
• Loss of Deemed Status Surveys
• Average 3 year
• EMTALA Surveys
• Patient Safety ( State only program)

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Deemed Status

• Loss of deemed status results in the hospital
  being placed on a termination track for the loss
  of Medicare funds if an acceptable POC is not
  implemented within the specified time frames.
• Loss of Deemed Status means that the hospital is
  now under OHCQs oversight and all complaints
  concerns can be investigated during that time
  without prior approval of CMS.
• Loss of Deemed Status does not mean the release
  of hospitals status to the media, loss of
  Medicare funds or loss of licensure.

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Patient Rights -Restraints

• CMS definition a restraint is any manual method,
  physical or mechanical device material or
  equipment that immobilizers or reduces the
  ability of a patient to move his or her arms legs
  body , head freely or
• If it keeps the patient from doing something they
  normally would have been able to do and cannot
  be easily be removed by the patient, it is a
  restraint.
• Consider patients condition, age and ability

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Types of Restraints

• Self Destructive and Violent Behaviors
• Require complete orders and time renewal
• One hour face to face evaluation by MD or trained
  LIP/RN/PA
• Face to face at the end of 24 hours
• Frequent monitoring
• Release at soonest possible time
• Non- Self destructive or Non-Violent Behaviors
• Require an order
• Monitoring of patient and
• Discontinue as soon as possible.

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Seclusion and Restraints

• Failure to document the patients self
  destructive or violent behavior.
• Failure to document that less restrictive methods
  were attempted.
• Incomplete or no MD orders.
• Failure to renew orders.
• Failure to release as soon as possible.

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Other Patient Rights Concerns

• Maryland Health Care Decision Act
• Health General Article 5-601
• Was the patients capacity determined ?
• Advance Directives
• Does the patient have AD ? Was it followed ?
• Complaint Processes
• Failure to Respond to Complaints
• Medicare Notice Of Discharge
• Give to patient 2 days before discharge .

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EMTALA

• Recipient Hospital Responsibilities
• Revised by CMS in 2006
• Reaffirmed in a letter from CMS in 2009
• If a hospital has the capacity and capability to
  care for a patient with an emergency medical
  condition, a hospital has a responsibility under
  EMTALA to accept a patient from a another
  hospital that does not offer the same level of
  care.

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EMTALA

• If an ED in a hospital that does not have a
  specialized service (PICU, burn, psychiatric,
  trauma , specialized diagnostic equipment,
  obstetrics) contacts another hospital with the
  specialized service to transfer the patient, that
  hospital has an EMTALA obligation to accept the
  patient regardless of their insurance status if
  the hospital have the capability and capacity.

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EMTALA

• Delays in transfer and treatment to check on
  insurance status are violations of EMTALA and can
  be referred to OAG by CMS for further
  investigation and fines.
• CMS makes the final determinations on EMTALA not
  OHCQ. CMS sends some cases to the QIO for review
  before finalizing their determinations.

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Medical Records

• Legible orders
• Authenticated, timed and dated orders
• Verbal Orders signed within 48 hours
• History and physicals done and timely

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Discharge Planning

• Patient/family involvement
• Safe discharge
• Does the facility provide the needed discharge
  services for the patient?
• Is it licensed?
• Medication Reconciliation
• Discharge summaries to LTC and ALF

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Quality Assurance Performance Improvement (QAPI)

• Comprehensive
• Hospital Leadership
• Current hospital problems being addressed
• Recent adverse events and root cause analysis
• Flow of information from risk management, patient
  safety and all departments
• Recent incidents and accidents
• Regulatory citations

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Patient Safety

• 190 Level 1 events received in FY 2009
• Reporting is occurring from nearly all
  hospitals but some hospitals are more effective
  and aggressive at examining their processes and
  systems.
• Falls continue to be most reported events with
  delays in treatment as the second most frequent.
• Slight increase in the number of reports of
  pressure ulcers and HAIs has been noted but
  clearly are not being reported.

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Patient Safety

• Poor RCAs are resulting in deficiencies. POC and
  revised RCA is required.
• Onsite reviews are being performed at hospitals
  where few or no reports have been received or if
  reports have declined significantly. Deficiencies
  are cited and if appropriate fines.
• Hospital specific reviews and feedback to the
  hospital.

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Patient Safety

• Falls RCA form brought Falls to the forefront
  and increased reporting .
• Sinai Hospital staff designed a form for Pressure
  Ulcers .
• Some revisions have been made and it is available
  for hospital use.

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Contact Information

• Email rwebster_at_dhmh.state.md.us
• OHCQ website www.dhmh.state.md.us/ohcq/
• OHCQ Hospital Unit [phone]
• FAX [phone]

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Questions ?