Arizona CAH Leadership Network Arizona Department of Health Services - - PowerPoint PPT Presentation

▶
arizona cah leadership network
SMART_READER_LITE
LIVE PREVIEW

Arizona CAH Leadership Network Arizona Department of Health Services - - PowerPoint PPT Presentation

Aug 22, 2023 345 likes •709 views

Arizona CAH Leadership Network Arizona Department of Health Services September 12, 2014 azdhs.gov He alth and We llne ss fo r all Ar izo nans Contact Information Connie Belden Bureau Chief Medical Facilities Licensing Arizona Department of

slide-1
SLIDE 1

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Arizona CAH Leadership Network

Arizona Department of Health Services September 12, 2014

slide-2
SLIDE 2

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Contact Information

Connie Belden Bureau Chief Medical Facilities Licensing Arizona Department of Health Services Connie.Belden@azdhs.gov 602-364-3030

slide-3
SLIDE 3

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Objectives

  • Review the most common deficiencies related

to the Conditions of Participation for CAH in Arizona

  • Review the Arizona Administrative Code

Licensing Rules

slide-4
SLIDE 4

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

CMS Citations

  • 0241 - GOVERNING BODY OR RESPONSIBLE INDIVIDUAL
  • 0276 - PATIENT CARE POLICIES
  • 0278 - PATIENT CARE POLICIES
  • 0294 - NURSING SERVICES
  • 0330 - PERIODIC EVALUATION & QA REVIEW
  • 0337 - QUALITY ASSURANCE
  • 0046 - LIFE SAFETY CODE STANDARD
  • 0050 - LIFE SAFETY CODE STANDARD
  • 0056 - LIFE SAFETY CODE STANDARD
  • 0062 - LIFE SAFETY CODE STANDARD
  • 0069 - LIFE SAFETY CODE STANDARD
  • 0076 - LIFE SAFETY CODE STANDARD
  • 0147 - LIFE SAFETY CODE STANDARD
slide-5
SLIDE 5

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

State Licensing Deficiencies

  • Rules Effective October 2013

– 0722 - Nursing Services – 0920 - Pharmaceutical Services – 0925 - Pharmaceutical Services – 0270 - Quality Management – 0242 - Administration

  • Rules Effective July 1, 2014

– 1062 - Nursing Services

slide-6
SLIDE 6

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Tag 0241 - GOVERNING BODY OR RESPONSIBLE INDIVIDUAL 485.627(a)

  • The CAH has a governing body or an individual

that assumes full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment.

slide-7
SLIDE 7

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

485.627(a)

  • Policies updated to fully reflect its responsibilities as a
  • Demonstrate the governing body is involved in the day-

to-day operation of the CAH and is fully responsible for its operations?

  • The medical staff operates under current bylaws that are

in accordance with Federal and State laws and regulations.

  • The governing body apprised of the medical staff

evaluation of patient care services provided in the CAH, at every patient care location of the CAH.

slide-8
SLIDE 8

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0276 - PATIENT CARE POLICIES 485.634(a)(3)(iv)

  • The policies include:

– Rules for the storage, handling, dispensation, and administration of drugs and biologicals.

  • These rules must provide that:

– there is a drug storage area that is administered in accordance with accepted professional principles, – current and accurate records are kept of the receipt and disposition of all scheduled drugs, and – outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

slide-9
SLIDE 9

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0278 - PATIENT CARE POLICIES 485.634(a)(3)(vi)

  • The policies include the following

– A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

slide-10
SLIDE 10

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0294 - NURSING SERVICES 485.635(d)

  • Nursing services must meet the needs of

patients.

– A registered nurse must provide (or assign to

  • ther personnel) the nursing care of each patient,

including patients at a SNF level of care in a swing- bed CAH. – The care must be provided in accordance with the patient's needs and the specialized qualifications and competence of the staff available.

slide-11
SLIDE 11

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0330 - PERIODIC EVALUATION & QA REVIEW

485.641

  • This is the condition level for Quality review

and Performance Improvement

slide-12
SLIDE 12

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0337 - QUALITY ASSURANCE 485.641(b)(1)

  • The CAH has an effective quality assurance

program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.

  • The program requires that-

– all patient care services and other services affecting patient health and safety are evaluated.

slide-13
SLIDE 13

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Life Safety Codes

  • 0046 - LIFE SAFETY CODE STANDARD
  • 0050 - LIFE SAFETY CODE STANDARD
  • 0056 - LIFE SAFETY CODE STANDARD
  • 0062 - LIFE SAFETY CODE STANDARD
  • 0069 - LIFE SAFETY CODE STANDARD
  • 0076 - LIFE SAFETY CODE STANDARD
  • 0147 - LIFE SAFETY CODE STANDARD
slide-14
SLIDE 14

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Life Safety Tag 46 Emergency lighting of at least 1½ hour duration is provided in accordance with 7.9. 19.2.9.1.

  • The facility must document the annual testing of battery

back up emergency lighting.

– NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted

  • n every required battery-powered emergency lighting system

for not less than 1 1/2 hours. Equipment shall be fully

  • perational for the duration of the test. Written records of

visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

slide-15
SLIDE 15

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0050 - LIFE SAFETY CODE STANDARD Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. – The staff is familiar with procedures and is aware that drills are part of established routine. – Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. – Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead

  • f audible alarms. 19.7.1.2
slide-16
SLIDE 16

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0056 - LIFE SAFETY CODE STANDARD

  • If there is an automatic sprinkler system, it is installed

in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building.

– The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. – It is fully supervised. – There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5

slide-17
SLIDE 17

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0062 - LIFE SAFETY CODE STANDARD 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

  • Required automatic sprinkler systems are

continuously maintained in reliable operating condition and are inspected and tested periodically.

slide-18
SLIDE 18

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0069 - LIFE SAFETY CODE STANDARD 19.3.2.6, NFPA 96

  • Cooking facilities are protected in accordance

with 9.2.3.

slide-19
SLIDE 19

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0076 - LIFE SAFETY CODE STANDARD . NFPA 99 4.3.1.1.2, 19.3.2.4

  • Medical gas storage and administration areas are

protected in accordance with NFPA 99, Standards for Health Care Facilities.

  • (a) Oxygen storage locations of greater than

3,000 cu.ft. are enclosed by a one-hour separation.

  • (b) Locations for supply systems of greater than

3,000 cu.ft. are vented to the outside.

slide-20
SLIDE 20

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0147 - LIFE SAFETY CODE STANDARD

  • Electrical wiring and equipment is in

accordance with NFPA 70, National Electrical

  • Code. 9.1.2
slide-21
SLIDE 21

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Life Safety Citations

  • K046 Battery backup light testing they must document

the 30 second monthly test and Annual 90 minute test

  • n a form for each light they have either in the
  • perating rooms or the facility. Note: This is not the

exit signs.

  • K050 Fire drills held one per quarter per shift, we

advise they read the 2000 Life Safety Code and Annex portion of the code to make sure all the fire procedures are annotated on their form especially sounding the fire alarm on the first and second shifts. The third shift they can use a coded announcement but again documented on the fire drill form.

slide-22
SLIDE 22

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Life Safety Citations

  • K056 This K Tag has to do with two things

being fully a sprinklered facility and the clearance of storage from sprinklers being 18 inches.

  • K062 Sprinklers missing the escutcheon plates

from the sprinkler assembly. Paint, rusted sprinklers or corroded must be replaced. Lint

  • n the sprinklers cleaned off.
slide-23
SLIDE 23

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Life Safety

  • K069 The kitchen hood must have semi-annul

cleaning and semi-annual fire inspection. The hood baffles need to be cleaned as necessary free from grease if that means daily, then daily code says clean to bare metal at all times.

  • K076 Oxygen cylinders secured in a rack or stand

and the oxygen cylinders segregated meaning empty in one rack and full in another. No combustibles within 5 feet of the cylinders.

slide-24
SLIDE 24

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Life Safety

  • K147 Electrical There is a lot in the electrical

code but once again not using extension cords

  • n a permanent basis except for construction
  • r repair temporary, All medical equipment

plugged directly into wall receptacle outlets not power strips including large wattage appliances like refrigerators, microwaves commercial coffee pots, vending machines etc.; some of the few K Tags always written during a survey.

slide-25
SLIDE 25

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

State Licensing Citations

  • Rules Effective October 2013

– 0722 - Nursing Services – 0920 - Pharmaceutical Services – 0925 - Pharmaceutical Services – 0270 - Quality Management – 0242 - Administration

  • Rules Effective July 1, 2014

– 1062 - Nursing Services

slide-26
SLIDE 26

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0722 - Nursing Services R9-10-214.

  • A nurse executive shall ensure that:

– 14. A registered nurse assesses, plans, directs, and evaluates nursing services provided to a patient;

slide-27
SLIDE 27

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0920 - Pharmaceutical Services R9-10-218 Pharmaceutical Services

  • An administrator shall ensure that:

– 12. A medication is administered in compliance with an order;

slide-28
SLIDE 28

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0925 - Pharmaceutical Services

R9-10-218

  • Pharmaceutical Services

–15. Policies and procedures specify a process for review through the quality management program of:

  • a. A medication administration error,
slide-29
SLIDE 29

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0270 - Quality Management R9-10-204

  • Quality Management

–A. A governing authority shall ensure that an ongoing quality management program is established that:

  • 2. Evaluates the quality of hospital

services and environmental services related to patient care.

slide-30
SLIDE 30

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

0242 - Administration R9-10-203

  • Administration

–C. An administrator shall ensure that:

  • 2. Policies and procedures for hospital

services are established, documented, and implemented that: –f. Cover dispensing, administering, and disposing of medication;

slide-31
SLIDE 31

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

1062 - Nursing Services R9-10-214 (Same as Tag 0722 for October 2013)

  • Nursing Services

–C. A nurse executive shall ensure that:

  • 14. A registered nurse assesses,

plans, directs, and evaluates nursing services provided to a patient;

slide-32
SLIDE 32

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Be Proactive with Regulations

  • Know and understand the State Rules in the

Arizona Administrative Code

– R9-10-Article 1 and Article 2

  • Know and understand the CMS Conditions of

Participation

  • Watch for updates through the Survey and

Certification notifications

  • Keep the Bureau of Medical Facilities Licensing

informed of changes within your facility

– Construction/Redesign – Administrative Changes

slide-33
SLIDE 33

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Be Proactive with Regulations

  • Integrate regulations into the in-service

education programs:

– Staff – Medical Staff – Governing Board

slide-34
SLIDE 34

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Resources

www.azdhs.gov www.azcarecheck.com www.cms.hhs.gov

  • Medical Facilities Licensing

– 602-364-3030

slide-35
SLIDE 35

He alth and We llne ss fo r all Ar izo nans

azdhs.gov

Questions/Comments/Thoughts

Thank you for listening and inviting us to participate with you.