MHA Survey Manual: Review and Q&A

Transcription

1 MHA Survey Manual: Review and Q&A Sharon Burnett, VP of Clinical and Regulatory Affairs, MHA Donya Lowrie, Chief, DHSS Bureau of Hospital Standards Kathie Thomas, Assistant Chief, DHSS Bureau of Hospital Standards 2

2 Imagine! Imagine a future where every survey was a congenial, supportive learning experience where hospital staff and surveyors worked and learned together to ensure quality, safe care.

3 MHA Survey Manual: A Guide to the Licensing and Certification Survey Process Developed in consultation with the Missouri DHSS Department of Bureau of Hospital Standards and the MHA Survey and Licensure Committee to assist hospital leaders prepare for and understand federal and state hospital survey process Written specifically for Missouri s hospital licensing and accreditation professionals, compliance officers, legal counsel, risk managers and other members of the hospital s licensing and compliance teams Manual sent to CEOs but available on the MHA website for easy access for your staff, and so we can update as changes in the regulatory and survey process occur 4

4 How To Access The Survey Manual MHANet.com, Advocacy & Regulation, then Hospital Laws & Regulation ces/mha-library/database-ofarticles/mha-survey-manual Access to the guide is password protected for MHA members. To obtain a password, click the sign in link at the top of MHA s homepage. 5

5 6

6 Chapters 1 Introduction and Background 2 Federal Surveys 3 State Surveys 4 Survey Process 5 Pre-Survey Guide 6 During the Survey Guide 7 Post-Survey Guide 8 Self-Reporting Adverse Events and Abuse and Neglect 9 Applicable Laws and Regulations 10 Appendices 7

7 Chapter 2 Federal Surveys Types of Surveys Certification/Recertification Survey Key points Almost all certification surveys are done by AOs with deeming authority because of CMS priorities Non-deemed hospitals recertified every 3 to 4 years Complaint/Allegation Survey Usually limited to possible condition-level complaints and only to CoPs R/T complaint Deemed hospitals Condition level citation, two CMS options Focus survey Full survey authorized Validation Survey of deemed hospitals 8

8 Chapter 2 Federal Surveys Survey Outcomes No deficiencies Standard-level deficiencies Condition-level deficiencies focus survey with 90-day termination tract or full Medicare survey follows Sustained noncompliance with any Condition will result in loss Medicare/Medicaid funding Immediate Jeopardy Unabated 23-day termination track Hospital must do everything it can to abate an IJ before surveyors exit How to abate IJ 9

9 Chapter 3 State Surveys Same surveyors as for CMS surveys State survey can trigger a CMS survey while on site Types of surveys Licensure Complaint Self-reported adverse event (see guidelines A-5-2 and Incident Report Form A-5-3) Patient abuse and neglect surveys leading to survey for placement on EDL (Chapter 8) 10

10 SURVEY PROCESS GENERALLY Announced/Unannounced Entrance Conference Survey Exit Conference Preparation of Preliminary Plan of Corrections Statement of Deficiencies Deficiencies No Deficiencies Condition level IJ deficiencies Standard level deficiencies Prepare POC Prepare POC CONGRATULATIONS! Credible Allegation of Compliance (POC accepted) Credible Allegation of Compliance (POC accepted) Focused revisit with 90 day termination tract or full survey No further survey activity but keep monitoring POC and reg compliance 11

11 Chapter 5 Pre-Survey Guidance Establish a survey readiness/response (SR) team Identify key leaders Develop resources (checklists, P&P, SR team binder) Establish communication structure Train appropriate staff EHR navigators Escorts Scribes Runners Do not forget medical staff 12

12 Chapter 5 Pre-Survey Guidance Maintain survey readiness at all times System to ensure P&Ps are current MHA Self-Assessment Checklists CMS Hospital Surveyor Worksheets Rounding and mock surveys 13

13 Chapter 6 During the Survey Oh no.. surveyors are here!! 14

14 Chapter 6 During the Survey Entrance conference take careful notes of issues, items and departments in which surveyors seem particularly interested Communication during the survey is key! Escorts, scribes and runners to make note of all staff and patients interviewed, all records, logs, P&Ps reviewed and any comments made by surveyors Debrief anyone who interacts with surveyors Daily SR team meetings How to handle problems with surveyors during the survey 15

15 Chapter 6 During the Survey Exit conference goal is to learn as much information as possible about the possible citations and how to mediate them Ask questions Take good notes Consider pros and cons of recording, having legal counsel present You already should have a very good idea from your daily staff briefings what you might be cited on. Surveyors do not disclose tag numbers. 16

16 Chapter 7 Post Survey 17

17 Chapter 7 Post-Survey Communicate survey results quickly to senior leadership, medical staff, governing body and employees Begin immediately Remember 23-day and 90-day termination tracks begin the final day of the survey. Do not wait until you receive your 2567 report to begin writing and implementing your POC. Immediately compile exit conference notes for review by SR team and appoint someone to coordinate 2567 response. If needed, appoint a hospital spokesperson and involve legal counsel or a consultant DHSS will not speak with lawyers or consultants without CEO or hospital designee 18

18 19

19 Chapter 7 Post-Survey Develop preliminary POC Identify Medicare CoP/standard(s) or state regulation(s) that may be associated with each deficiency noted during the survey (See Chapter 9, Applicable Laws and Regulations) Review the interpretive guidance associated with the CoP(s) to identify corrective action steps Develop preliminary action steps for each deficiency, assign responsible person(s) and deadline for completion which is generally 30 days, except for IJs. Establish monitoring plan to ensure POC is effective (how long, how frequent, what data collected, who is responsible) Keep detailed notes/minutes of everything done 20

20 Chapter 7 Post-Survey Receipt of final 2567 Statement of Deficiencies CMS-2567 DHSS POC form Reconvene SR Team and compare final 2567 and cover letter to your preliminary action steps Are there any new deficiencies listed? Are there any deficiencies addressed in preliminary POC, for which you need to add or revise action steps? Are there any deficiencies addressed in your preliminary POC that are not listed in the final 2567 and need to be removed? 21

21 Drafting the Final 2567 Response One fact/issue can lead to several deficiencies and each has to be addressed. Respond with corrective action steps to each specific finding within the context of the specific standard, condition or state requirement cited in the exact order they are listed. If a new issue is presented, develop corrective action steps immediately. If there are findings described during the exit conference that are not included in the 2567, all references to corrective actions taken regarding them should be excluded from the final If the findings include surprises or different facts, adjust the hospital s 2567 response accordingly. Forget the old, anticipated facts! Augment with any additional information or corrective actions as needed. 22

22 What Must Be Included in the POC Corrective actions that will address and correct the processes or systems that failed and led to each deficiency cited Procedure for implementing the POC for each deficiency cited Monitoring procedure to ensure that the POC is effective; that the specific deficiency cited remains corrected and in compliance with regulations, and what quality assurance indicators will be implemented to ensure ongoing, sustained compliance Title of the person responsible for implementing the acceptable POC Date when the hospital will be in full compliance. This date must be no later than 30 days (for a full survey) or 45 days (for a complaint) after the exit date of the survey. 23

23 After the 2567 Is Submitted Do everything you said you were going to do within the stated timeframe in your POC. Monitor and maintain documentation that irrefutably demonstrates compliance. If significant deviations in POC actions need to be made to achieve/sustain compliance, notify DHSS. Take follow-up questions from surveyors very seriously. 24

24 DHSS Actions After POC Is Received Verify that all deficiencies listed on 2567 are addressed and corrective actions are sufficient to eliminate deficiency and sustain compliance. POC for state licensure tags only POC for standard-level citations (deemed and nondeemed) POC for condition-level citations or immediate jeopardy 25

25 26

26 Abuse and Neglect Occurring Outside the Facility Who, what, when to report Children, elderly and other eligible adults Verbal, sexual, physical, mental abuse How and to whom to report Guidelines for Mandated Reports of Child Abuse and Neglect Missouri Department of Social Services Children s Division Abuse, Neglect and Financial Exploitation of Missouri s Elderly and Adults with Disabilities It s A Crime 2011 DHSS Report Have a policy/procedure for abuse or neglect discovered or suspected upon admission. Educate staff on signs and symptoms of abuse and what to do when they suspect abuse or neglect. 27

27 Abuse and Neglect Occurring Inside the Facility DHSS and CMS expect hospitals to proactively look for actual and potential abuse rather than reacting only to reported events. Proactive recommendations: Have a P&P for abuse or neglect that occurs after admission that covers staff, visitor or other patient suspected of being the abuser. (See Appendix A-9 for samples) Identify and monitor events that could lead to or contribute to abuse Fosters a no fear of retaliation due to reporting culture Provide training on de-escalation techniques Educate staff on signs and symptoms of abuse and what to do when they suspect abuse or neglect 28

28 Abuse and Neglect Occurring Inside the Facility What to do when you become aware Take immediate steps to protect alleged and potential victims. The alleged abuser may not have any patient contact during investigation and while determination pending. Examine, treat and document suspected injuries in MR and in investigative report. Consider using SANE for sexual assault. Conduct immediate and thorough internal investigation Interview victim, eye witnesses and circumstantial witnesses (other patients, staff and family members). Include staff and patients on other shifts alleged abuser has worked. Consider involving law enforcement if unable to determine perpetrator, criminal offense. Document and preserve all physical and documentary evidence including video, specimens collected, medical records, interviews. 29

29 Abuse and Neglect Occurring Inside the Facility What to do when you become aware If allegation is credible and meets definition of abuse or neglect, notify DHSS or DSS hotline ASAP after incident Document all corrective actions taken including notifying licensure boards, states, adult protective services or children s services, law enforcement Prepare investigation report to include, if applicable: Description of incident including sequence of events and conclusion reached Identifying information for alleged victim and perpetrator Injury documentation Sources of information used including staff interviews/statements, nurses or progress notes, video surveillance Corrective actions taken and changes to PI plan 30

30 Other Resources IN CASE YOU MISSED IT! 31

31 Regulatory News Survey and certification memo Hospital updates SOM Appendix A Pharmacy services Nursing services Revisions bring the COP guidance in alignment with current accepted standards of professional practice Updates guidance for compounded sterile operations outside the pharmacy for medication administration. 32

32 Regulatory News CMS Discharging Planning proposed rules revise the discharge planning requirements hospitals, critical access hospitals, long-term care hospitals, inpatient rehabilitation facilities and home health agencies implement the discharge planning requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). D/C Planning would apply to all inpatients outpatients in observation status outpatients undergoing surgery or same day procedures requiring anesthesia or moderate sedation emergency department patients identified by the ED practitioner, in accordance with the hospital s P&P as needing a D/C plan any other category of patient recommended by the medical staff and approved by the governing body Comments due to CMS by Jan. 3

33 MHA Resources MHANet.com My MHANet log in and password Sign up for MHA Today Law and Regulation Federal Regulations Medicare Conditions of Participation Crosswalks Self-Assessment Checklists Quality/Regulatory Orientation Guide Required Signage Required Orientation and Education State Regulations Crosswalk between regulations and L Tags Education Seminars/webinars 34

34 MHA Regulatory Contact Information MHA Staff 573/ Sharon Burnett VP, Clinical and Regulatory Affairs ext. 1304, Jim Mikes VP, Rural Services and Regulation, ext. 1393, Jane Drummond VP, Legal Affairs and General Counsel, ext. 1328, Jennifer Graham, Associate General Counsel, ext. 1389, 35

35 DHSS Contact Information Donya Lowrie - Bureau Chief, Section for Health Standards & Licensure, 573/ , donya.lowrie@health.mo.gov Kathie Thomas - Assistant Bureau Chief, Section of Health Standards & Licensure, 573/ , kathie.thomas@health.mo.gov Julie G. Creach, Administrator, Section for Health Standards & Licensure, 573/ , julie.creach@health.mo.gov Jeanne Serra, Division Director, Division of Regulation & Licensure, 573/ , jeanne.serra@health.mo.gov 36

36 Thank You! 37