Upon completion, the active participant will: Review the top - PDF document

4/20/2017 Bridget Weidner, Program Manager North Dakota Department of Health Upon completion, the active participant will: Review the top deficiencies identified in hospital surveys in ND Discuss current hot topics 1

4/20/2017 Federal Fiscal Year 2016 ‐ current (Oct 1, 2015 – March 28, 2017 Governing Body/Responsible Individual (C‐0241) Administration of Drugs (C‐0297) Drug Management (C‐0276) Quality Assurance of Patient Care Services (C‐0340) Infection Control (C‐0278) Nursing Services (C‐0294) Medical Records Content (C‐0304) Quality Assurance of MD/DO Services (C‐0337) Education Programs (L‐1804) Radiology Services (L‐2303) There must be an effective governing body that is legally responsible for the operation and conduct of the hospital . 2

4/20/2017 All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a MD/DO, or PA in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. There must be rules for the storage, handling, dispensation, and administration of drugs and biologicals. A drug storage area must be administered in accordance with accepted professional principles. Current and accurate records must be kept of the receipt and disposition of all scheduled drugs. Outdated, mislabeled, and unusable drugs are not available for patient use. 3

4/20/2017 The quality assurance program requires the quality and appropriateness of the diagnosis and treatment furnished by physicians at the CAH are evaluated by a hospital that is a member of the network or a quality improvement organization or equivalent entity. There must be a system/active program for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. 4

4/20/2017 Nursing services must meet the needs of patients. Nursing services must be under the direction of a registered nurse. Records must include: Identification and social data Properly executed informed consent forms Pertinent medical history Assessment of the health status and health care needs of the patient Brief summary of the episode, disposition, and patient instructions 5

4/20/2017 All patient care services and other services affecting patient health and safety are evaluated. Ensure training program covers the following topics annually for all staff: Infection control measures, including blood‐borne pathogens Safety and emergency procedures, including procedures for fire and other disasters Procedures for life‐threatening situations, including cardiopulmonary resuscitation Lifesaving techniques for choking victims Patient rights 6

4/20/2017 The physician responsible for radiology services shall document as to the acceptability of the qualifications specific to each radiology technician or technologist. Medicare Learning Network Call for EPR Final Rule April 27, 2017 S&C 17‐22 New Hospital Buildings! Medical Marijuana Budget 7

4/20/2017 Appendix W Appendix A North Dakota Licensing Rules for Hospitals in ND CMS ASPEN Database www.cms.gov Contact Information: www.ndhealth.gov/HF/North_Dakota_Hospitals _Critical_access.htm (701)328‐2352 bweidner@nd.gov 8