2019 Florida Society of Ambulatory Surgical Centers Quality and Risk Management Conference: Regulatory Update & Most Cited Deficiencies April 11, 2019 Kimberly R. Smoak, MSH, QIDP Chief of Field Operations/State Survey Agency Director Division of Health Quality Assurance Agency for Health Care Administration Florida Objectives Overview of the Most Frequently Cited State Risk Management Deficiencies from Calendar Year 2018. Overview of Federal Emergency Preparedness Rule and Calendar Year 2018 Most Frequently Cited Deficiencies. Transparency and Balance Billing. Briefly discuss Revised Risk Management Survey Process. 1
Risk Management Rank Tag Requirement 1 M0410 Incident Reporting System (395.0197(1)(e); 59A-10.0055(2)(a-b) 2 M0426 Patient Safety Officer And Committee (395.1012(2), F.S.) 3 M0412 Incident Reporting System - Reports (59A-10.0055(2)(c)-(e), F.A.C.) 4 M0404 Incident Reporting Training (395.0197(1)(b)1, {59A-10.0055(1)} 5 M0405 Approp. Measure Recovery Room Prohibition (395.0197(1)(b)(2)) 3 #1-M0410 The development and implementation of an incident reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. 4 2
M0410 Reports Must Include: The patient's name, locating information, admission diagnosis, admission date, age and sex; A clear and concise description of the incident including time, date, exact location; and elements as needed for the annual report. 5 #2-M0426 Each licensed facility shall appoint a patient safety officer and a patient safety committee, which shall include at least one person who is neither employed by nor practicing in the facility, for the purpose of promoting the health and safety of patients, reviewing and evaluating the quality of patient safety measures used by the facility, and assisting in the implementation of the facility patient safety plan. 6 3
#3-M0412 Incident Report Must Include: Whether or not a physician was called; and if so, a brief statement of said physician s recommendations as to medical treatment, if any; A listing of all persons then known to be involved directly in the incident, including witnesses, along with locating information for each; The name, signature and position of the person completing the reports, along with date and time that the report was completed. 7 #4-M0404 Risk management and risk prevention education and training of all non physician personnel as follows: Such education and training of all non physician personnel as part of their initial orientation; and At least 1 hour of such education and training annually for all personnel of the licensed facility working in clinical areas and providing patient care, except those persons licensed as health care practitioners who are required to complete continuing education coursework pursuant to chapter 456 or the respective practice act. 8 4
#5-0405 A prohibition, except when emergency circumstances require otherwise, against a staff member of the licensed facility attending a patient in the recovery room, unless the staff member is authorized to attend the patient in the recovery room and is in the company of at least one other person. However, a licensed facility is exempt from the two-person requirement if it has: Live visual observation; Electronic observation; or Any other reasonable measure taken to ensure patient protection and privacy. 9 Federal Emergency Preparedness 10 5
Emergency Preparedness In November 2017, the Survey Agencies commenced surveying for the federal emergency preparedness rule. There are four core elements to the rule: An emergency plan Policies and procedures A communication plan A training and testing plan 11 Emergency Preparedness Let s review the citations identified in Florida Ambulatory Surgical Centers in calendar year 2018. 12 6
Plan E-0006-Emeregency Plan. The ASC must develop and maintain and emergency preparedness plan that must be reviewed, and updated at least annually. The plan must: Be based on and include a documented, facility based and community based risk assessment, utilizing an all-hazards approach. 13 Work with local Emergency Management Officials E-0004 The emergency plan must be reviewed and updated annually The plan supports the ASC s ability to work with local emergency management officials plan considers particular hazards most likely to occur in surrounding area, including natural/ man made or facility based disasters 14 7
Policy & Procedures E-0026 - The ASC must develop and implement emergency preparedness policies and procedures, based on the emergency plan set, risk assessment, and the communication plan. The policies and procedures must be reviewed and updated at least annually. 15 Policy & Procedures E0013-The ASC must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. 16 8
Tracking E-0018-The ASC must develop a system to track the location of on-duty staff and sheltered patients in the ASC s care during an emergency. *If an ASC is able to cancel surgeries and close (meaning there are no patients or staff in the ASC), this requirement of tracking patients and staff would no longer be applicable. If an emergency was imminent and able to be predicted (i.e. inclement weather conditions, etc.) CMS would expect that ASCs cancel surgeries and cease operations, which would eliminate the need to track patients and staff. 17 Reminder: Transparency and Balance Billing 18 9
Price Transparency & Patient Billing Section 395.301, Florida Statutes Applies to hospitals and ambulatory surgical centers, excluding state-owned hospitals Must have a transparency website Must provide a general or personalized estimate upon request Must provide an itemized bill upon request 19 Price Transparency & Patient Billing Requirements for facility websites: Link to AHCA s transparency and service bundles website http://pricing.floridahealthfinder.gov Information about requesting personalized estimates Information about financial assistance, billing and collections policies Information about providers who may bill separately and may be out of the consumer s health insurance network Information about and links to insurance plans for which the facility is a participating network provider 20 10
Revised Risk Management Survey Process 21 Tasks Survey Process Off-Site Preparation Entrance Conference Tours and Floor Visits Sample Selection Information Gathering Decision Making and Analysis of Findings Exit Conference Post Survey Activities 22 11
Off-Site Prep Review ASC compliance history Review ASC website for price transparency Make team member assignments 23 Entrance Conference Conduct meeting with ASC administrator/risk manager or designee Provide entrance conference checklist Explain purpose of the visit 24 12
Tour Objective of this task is to visit areas of the ASC where areas of concern have been identified to determine compliance with the risk management regulations. This is intended to be a brief task. 25 Sample Selection The surveyor will select up to ten incident/adverse reports to review. The sample size can be expanded depending on the ASC s volume and/or other factors. 26 13
Information Gathering Observations Staff Interviews Patient and Family Interviews Patient Record Reviews Grievance and Incident Review Personnel Records 27 Decision Making and Analysis of Findings The objective of this task is to integrate findings, review and analyze information collected from observations, interviews, and record reviews, and to determine whether the ASC meets compliance as outlined in the rules and regulations. 28 14
Exit Conference The objective of this task is to inform the ASC of the team s findings. The exit conference provides an opportunity for the surveyor to discuss areas of concern with the administrator and/or staff in charge. Tag numbers are not provided. 29 Post Survey Activities The general objective of this task is to complete the survey requirements, in accordance with the regulations and Agency protocols. The team members and coordinator are responsible for meeting the timeliness for completing and submitting the survey. 30 15
Contact Information ahca.myflorida.com ( contact us ) Kimberly Smoak 850-412-4516 Kimberly.Smoak@ahca.myflorida.com 31 16