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

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 Health Services Connie.Belden@azdhs.gov 602-364-3030 azdhs.gov He alth and We llne ss fo r all Ar izo nans

Objectives • Review the most common deficiencies related to the Conditions of Participation for CAH in Arizona • Review the Arizona Administrative Code Licensing Rules azdhs.gov He alth and We llne ss fo r all Ar izo nans

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

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

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

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

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

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

0294 - NURSING SERVICES 485.635(d) • Nursing services must meet the needs of patients. – A registered nurse must provide (or assign to other 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 . azdhs.gov He alth and We llne ss fo r all Ar izo nans

0330 - PERIODIC EVALUATION & QA REVIEW 485.641 • This is the condition level for Quality review and Performance Improvement azdhs.gov He alth and We llne ss fo r all Ar izo nans

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

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

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 on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational 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." azdhs.gov He alth and We llne ss fo r all Ar izo nans

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 of audible alarms. 19.7.1.2 azdhs.gov He alth and We llne ss fo r all Ar izo nans

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

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

0069 - LIFE SAFETY CODE STANDARD 19.3.2.6, NFPA 96 • Cooking facilities are protected in accordance with 9.2.3. azdhs.gov He alth and We llne ss fo r all Ar izo nans

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

0147 - LIFE SAFETY CODE STANDARD • Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 azdhs.gov He alth and We llne ss fo r all Ar izo nans

Life Safety Citations • K046 Battery backup light testing they must document the 30 second monthly test and Annual 90 minute test on a form for each light they have either in the operating 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. azdhs.gov He alth and We llne ss fo r all Ar izo nans

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 on the sprinklers cleaned off. azdhs.gov He alth and We llne ss fo r all Ar izo nans

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. • azdhs.gov He alth and We llne ss fo r all Ar izo nans