Tag C 330 COP: Periodic Evaluation s1

PIN CAH CMS Standards Review Conference Call Notes

Call: June 30, 2010

Tag C 242-244 Governing Board, Disclosures

- Reminder to notify the State as soon as possible of changes in owners, administrator and/or medical director of the CAH

Tag C 250, 251, 252 Staffing and Staff Responsibilities

- Maintain a current list of providers and their work schedules showing normal CAH hours and staff coverage of those hours

- Ancillary staff supervised by professional staff are required to have a medical director overseeing the department. Variability in requirements for professional staff signing orders for treatments or interventions. They include: o Pharmacy o Imaging o Lab o PT/OT/ST o Dietician

Tag C 253 The staff is sufficient to provide the services essential to the operation of the CAH

- Can demonstrate ‘sufficiency’ through collection/reporting of performance measures: o Wait times (ED) o Diversions for lack of provider o Delinquency of H & P completion, orders authenticated, imaging reads, dictation, etc o Patient safety measures o Productivity reports o For nursing, nurse staff ratios

Tag C 254 An MD, DO, NP, CNS, or PA available to furnish care at all times the CAH operates

o All of those on today’s call have an MD or DO; all have several providers so providers share availability during and after normal clinic hours o For smaller CAHs with only one or two providers, routine use of locums to cover the relief needs of permanent staff is often necessary

1 PIN CAH CMS Standards Review Conference Call Notes

Tag C 255 An RN, CNS or LPN is on duty whenever the CAH has one or more patients

o No issues with this tag among call participants was noted

Tag C 256, 257 Responsibilities of the MD or DO

- Provides ALL medical oversight activities, including: o Medical direction o Consultation o Medical supervision of the health care staff

- Demonstrated for surveyors by: o Medical director appointments o Medical dept meeting minutes (ED, OB, medsurg, etc) o Medical committee meeting minutes (P & T, Infection Control/Surveillance) o Participation in clinical care policies/procedures/protocols development o Approval of clinical care policies/procedures/protocols o Documentation of review and recommendations of mid-levels’ clinical cases o Co-signing of mid-levels’ orders when required to do so o Contracts between CAH and providers for medical direction/supervisory activities when the CAH does not have an MD or DO on staff

Tag C 258 Participates in developing, executing and periodically reviewing the CAH’s written policies governing the services it furnishes

- Note: medical staff are not required to participate in development of all CAH policies; only those related to clinical care/clinical service delivery during routine and emergent conditions

- Pioneer: has a Policy Advisory Group (PAC) that meets quarterly o Members: mid-level, a doc, use a retired RN as the outside member o Minutes are kept to document compliance w/ the standard

- Barret: has Policy Manager software to manage this process o Software tracks when policies are due for review, and forwards it to those whose review is required; each one reviews it and adds mark up for revisions as needed o The Clinical Practice Council (CPC) meets once a month to discuss revisions, new policies o CPC members include MD/DO, mid-level, and a pharmacist member of the Board as the outside reviewer. This has always been acceptable to surveyors there.

- St John’s (Libby): has found it difficult to get medical providers to a meeting for this purpose. So: o Policies in need of review are circulated to managers first o Recommendations for revisions are reviewed, approved, modified by medical staff at their meetings o Once approved by MS, go to the BOD for final approval.

Tag C 259 With the PA or NP members, periodically reviews the CAH’s patient records, provides orders, and provides medical services to patients of the CAH:

- All on the call have one or more physicians who see and write orders for inpatients; none have mid-levels with admitting privileges - Smaller facilities may contract with physicians in other locations to come onsite regularly to perform these functions

Tag C 260 Periodically reviews and signs the records of patients cared for by nurse practitioners, clinical nurse specialists, or physician assistants

- See tag C 261- “periodically” means at least once in every 2 week period

- See CMS Clarification, distributed June 9, 2005:

 Must review and sign 100% of PA inpatient and outpatient records

 In MT, NP’s are allowed to practice independently, therefore, the requirement for NP’s records to be reviewed by a physician are: o 25 % of outpatient records (this includes ED records) o 100 % of inpatient records

- Libby: has an Urgent/Prompt Care setting in their ED; functions like a clinic setting; they require physicians to review 10% of the PA’s records for this service

- What constitutes “reviews and signs”? Is it necessary for physician to sign every piece of paper in the record? Every mid-level order?

 Pioneer: doc co-signs the H & P and discharge summary for all inpatients and all ED patients; does not co-sign all orders; was recommended to them by a healthcare consultant

 Barrett: physician signs all discharge summaries, as recommended to them by a surveyor

Tag C 260, cont

 CRNA’s: are not specifically mentioned; one could argue that because the surgeon does an entire review of each case, including the anesthesia record, this constitutes review of the CRNA’s care record and meets the requirements of the standard (100% review of all inpatient records)  At a minimum, would recommend following the guidelines above for other advanced practice nurses: physician review and signature of 100% of inpatient records, 25% of outpatient records

Tag C 261 Present for sufficient periods of time, at least once in every 2 week period (except in extraordinary circumstances, to provide medical direction, medical care services, consultation, and supervision…

- “Sufficient time” means, for a long enough time to perform all of the required responsibilities

- See Tag C 260: “periodically” means at least once in every 2 week period

Tag C 262, 263 PA, NP and CNS Responsibilities: participate in development, execution and Review of the written policies governing the services the CAH furnishes

- Included in the policy management processes described above, Tag C 258

Tag C 264 Participates with a physician in a periodic review of patients’ health records:

- St John’s/Libby: this happens one on one with mid-levels and their supervising physician, but no documentation that demonstrates it does; CRNA’s review each other’s cases, but this is not the same as reviewing cases with a physician

- Pioneer: MS conducts case reviews at its regular meetings (utilization, mortality, any problems, etc); mid-levels participate at that meeting as members of the staff, and at trauma case review 4 PIN CAH CMS Standards Review Conference Call Notes

Tag C 265 Provides services in accordance with the CAH’s policies

- Performance measures, internally generated or from external sources, can be used to demonstrate compliance. Some examples are:

 Written clinical care protocols/practice guidelines being followed  Peer review results: internal, external  Patient safety measures related to medication therapy, nosocomial infections  Admission procedures followed; physician notified of admit  Timely appearance in the ED when called to come  MR documentation requirements met  EMTALA documentation requirements  CART data: AMI, HF, CAP, etc  PIN clinical improvement studies performance data  Patient satisfaction data

Tag C 267 Arranges for, or refers patients to, needed services… & records transferred

- Pioneer: physician reviewer of mid-level records would note when a consult was need, whether or not it was obtained, and make recommendations as appropriate to the mid-level, and/or discuss the case at medical staff meetings

- Pioneer: has an approved patient transfer policy and forms; collect data routinely concerning:  completion of the transfer form, including provider’s signature  number of patients transferred

Tag C 268 Physician is notified whenever a PA, NP or CNS admits a patient to the CAH

 Nurse midwife: required to call a physician with OB privileges at the time a patient is being admitted to the CAH  Per policy, the midlevel calls the physician at the time of admission  Others on the call: mid-levels do not have admitting privileges; do not write orders for inpatients

Next Call: Wed, July 28, 2:00 pm Beginning with Tag C 270, 271 Patient Care Policies

Large section on drug management and adverse drug event

5 PIN CAH CMS Standards Review Conference Call Notes reporting