CMS Bans Texting of Patient Orders!

By Debra A. Geroux
248.258.2603
geroux@butzel.com

January 3, 2018

In a Letter to State Surveyors, the Centers for Medicare & Medicaid Services (“CMS”) has clarified its position on texting patient information, and more notably Orders, among members of a patient’s care team. In a nutshell: Don’t Do It!
In its December 28, 2017 Memo regarding Texting of Patient Information among Healthcare Providers, CMS recognizes the benefits and long standing practice of texting patient information among members of a patient’s healthcare team, but explains that it is only permissible if performed through a secure, encrypted platform in accordance with HIPAA privacy and security regulations. CMS expects that providers and organizations that utilize secure, encrypted texting systems will implement procedures for regularly assessing the security of the system.
However, CMS also indicates that, as it concerns Orders from a provider to a member of the care team, texting is never permissible, encrypted or otherwise, as the Conditions of Participation and Conditions for Coverage mandate that Orders be dated, timed, authenticated and promptly placed in the medical record. See 42 CFR 482.24(b).[1] According to CMS, the best (and preferred) practice for entering orders is through Computerized Provider Order Entry (CPOE), which ensure immediate and authenticated entry into the electronic health record.
While the texting prohibition has not yet been addressed in the Interpretative Guidelines,[2] Interpretive Guideline A-0454 concerning section 482.24(c)(2) provides slight guidance on the “promptly” directive, noting that it is to be “performed readily or immediately” so that all members of the patient’s care team have access to it. The use of texting for Orders does not meet either the requirements for authentication or prompt placement, at a minimum.
Healthcare providers and entities must take steps to educate staff about the problems associated with texting generally, and texting Orders specifically. While CMS recognizes texting is commonplace, it does not mean it can be condoned. If not already in place, hospitals and entities that are subject to certification surveys should take steps to eradicate these standard practices through policy changes and education.

 

 

Thanks to AHRQ: Toolkit To Promote Safe Surgery In Hospitals

The Toolkit To Promote Safe Surgery helps perioperative and surgical units in hospitals identify opportunities to improve care and safety practices and implement evidence-based interventions to prevent surgical site infections. The toolkit has evidence-based, practical resources that reflect the real-world experiences of the frontline clinicians and subject matter experts who participated in the AHRQ Safety Program for Surgery, a national implementation project in which approximately 200 hospitals participated and successfully reduced surgical site infections. It builds on AHRQ’s Comprehensive Unit-based Safety Program (CUSP) and the core CUSP toolkit by providing specific tools focused on the surgical setting to help hospitals reduce surgical site infections and other complications.
The toolkit has two complementary guides that should be used together and are a good starting point: Applying CUSP To Promote Safe Surgery, and Surgical Complication Prevention. These two guides address respectively adaptive and technical work, which are both critical elements for improvement to occur. Technical work changes procedural aspects of care that can be explicitly defined, such as surgical skin preparation procedures. Adaptive work is designed to change the attitudes, values, beliefs, and behaviors of the people who deliver care and improve safety culture within an organization, thereby enabling consistent use of evidence-based practices. Both guides should be used simultaneously. Supplemental tools accompany the guides.
The toolkit also includes 15 instructional modules to help clinical teams address specific areas of competency. The modules are spread across the three phases that clinical teams will undergo as part of their quality improvement efforts: onboarding, implementation, and sustainability.
Toolkit Materials
The toolkit includes two guides, supplemental tools for each guide, and 15 instructional modules within three phases to support change at the unit level.
Guides
Applying CUSP To Promote Safe Surgery
Supplemental tools
Surgical Complication Prevention
Supplemental tools
Instructional modules
Onboarding
Implementation
Sustainability

Go to:  https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/surgery/index.html

Geisinger Holy Spirit Hospital Cited After Patient Dies Under Restraint

December 27, 2017

The patient became combative and was held down by two security guards while a physician and a nurse applied the restraints.
A hospital in central Pennsylvania has been cited by the Pennsylvania Department of Health after a patient died while being placed in restraints.
An investigation into Geisinger Holy Spirit Hospital’s handling of a restrained patient indicated staff failed to “protect the patient’s safety during restraint application” on September 26, reports Penn Live.
According to the health department’s investigative report, the patient became agitated and belligerent and attempted to exit the hospital, pushing through staff members.
Two security guards then held the patient down on a bed while a physician and a nurse applied restraints. The unidentified patient’s body went limp, their face turned blue and they began foaming at the mouth, according to the report.
The hospital staff declared a code blue, used to label a patient in cardiac arrest. The patient later died from what the hospital called a “diffuse anoxic brain injury,” which is typically caused by severe head trauma, according to The Sentinel.
The department says some of the restraints that were used did not have a required order from a doctor.
Another violation included failure to report the death to the Pennsylvania Patient Safety Authority within a week of the incident. The hospital also did not notify the patient’s family of the event, says the report.
The hospital submitted a plan of correction but the first version was rejected by the state.
The second plan was approved and includes educating staff about the use of restraints and the establishment of a “code grey team” to be trained in handling a combative patient who does not have a weapon. The report did not give elaborate details on the hospital’s plan to institute the team.

While we would prefer not to restrain patients, at times such measures are indicated for the safety of all involved. We are saddened whenever a patient passes away, and are confident that the care our team provided was consistent with Geisinger Holy Spirit’s mission of delivering professional and compassionate care to all,” says Lori Moran, director of corporate communications at Geisinger Holy Spirit.
Holy Spirit has a locked mental health unit and specializes in mental health crisis situations.

About the Author

Amy Rock, Web Editor
Amy Rock is the Campus Safety Web Editor.

The CMS Clarifies What It Means To Be A Hospital

“Hospitals must have at least two inpatients at the time of the survey in order for surveyors to conduct the survey. However, just because a facility has two inpatients at the time of a survey does not necessarily mean that the facility is primarily engaged in inpatient care and satisfies all of the statutory requirements to be considered a hospital for Medicare purposes. Having two patients at the time of a survey is merely a starting point in the overall survey and certification process.”

One of the industry’s fastest-emerging trends—micro-hospitals—could take a hit thanks to new CMS guidance that has hospital accreditors tweaking their policies regarding what counts as a hospital.

Micro-hospitals are small-scale, inpatient facilities with eight to 15 short-stay beds. They perform many of the same acute-care and emergency services done at larger hospitals, but are cheaper to operate. Micro-hospitals have cropped up in 19 states, mostly in underserved urban locations or areas that are farther away from large hospitals.

Prior to the CMS’ declaration in the fall, there was no guidance with respect to what it took to be considered “primarily engaged” or to count as an inpatient provider.

If smaller hospitals are not deemed to be primarily engaged in inpatient care, they may be prohibited from providing medical services or be paid at a lower rate for free-standing facilities.

Concerns are that the guidance was released without a public comment period, is effective immediately, and has a 12-month look-back period for compliance when there was not any clear guidance on expectations. That could affect the validity of surveys already performed.

Excerpts from Modern Healthcare Virgil Dickson | December 16, 2017

 

TJC Final Emergency Management Standards Effective November 15, 2017

Standard EM.01.01.01
Element(s) of Performance for EM.01.01.01
The hospital engages in planning activities prior to developing its written Emergency Operations Plan.  Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization’s services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events. The findings of this analysis are documented. (See also EM.03.01.01, EP 1; IC.01.06.01, EP 4)  Note 1: Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate. Note 2: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the “Infection Prevention and Control” (IC) chapter.

The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies within the organization and the community that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events. The findings of this analysis are documented. (See also EM.03.01.01, EP 1; IC.01.06.01, EP 4)  Note 1: Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate. Note 2: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the “Infection Prevention and Control” (IC) chapter.

Standard EM.02.01.01
Element(s) of Performance for EM.02.01.01
The hospital has an Emergency Operations Plan.  Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This “all hazards” approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.
For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan includes a continuity of operations strategy that covers the following: – A succession plan that lists who replaces key leaders during an emergency if a leader is not available to carry out his or her duties – A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation Note: A continuity of operations strategy is an essential component of emergency management planning. The goal of emergency management planning is to provide care to individuals who are incapacitated by emergencies in the community or in the organization. A continuity of operations strategy focuses on the organization, with the goal of protecting the organization’s physical plant, information technology systems, business and financial operations, and other infrastructure from direct disruption or damage so that it can continue to function throughout or shortly after an emergency. When the organization itself becomes, or is at risk of becoming, a victim of an emergency (power failure, fire, flood, bomb threat, and so forth), it is the continuity of operations strategy that provides the resilience to respond and recover.

For hospitals that use Joint Commission accreditation for deemed status purposes: If a hospital has one or more transplant centers (see Glossary), the following must occur: – A representative from each transplant center must be included in the development and maintenance of the hospital’s emergency preparedness program – The hospital must develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant center, and the organ procurement organization (OPO) for the donation service area where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a procedure for requesting an 1135 waiver for care and treatment at an alternative care site.  Note: During disasters, organizations may need to request 1135 waivers to address care and treatment at an alternate care site identified by emergency management officials. The 1135 waivers are granted by the federal government during declared public health emergencies; these waivers authorize modification of certain federal regulatory requirements (for example, Medicare, Medicaid, Children’s Health Insurance Program, Health Insurance Portability and Accountability Act) for a defined time period during response and recovery.

The Emergency Operations Plan describes a means to shelter patients, staff, and volunteers on site who remain in the facility.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has one or more emergency management policies based on the emergency plan, risk assessment, and communication plan. Procedures guiding implementation are defined in the emergency management plan, continuity of operations plan, and other preparedness and response protocols. Policy and procedure documents are reviewed and updated on an annual basis; the format of these documents is at the discretion of the hospital.

Standard EM.02.02.01
Element(s) of Performance for EM.02.02.01
As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies.
For hospitals that use Joint Commission accreditation for deemed status purposes: As part of its communication plan, the hospital maintains the names and contact information of the following: – Staff – Physicians – Other hospitals and CAHs – Volunteers – Entities providing services under arrangement – Relevant federal, state, tribal, regional, and local emergency preparedness staff – Other sources of assistance

For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan describes the following: – Process for communicating information about the general condition and location of patients under the organization’s care to public and private entities assisting with disaster relief – Process, in the event of an evacuation, to release patient information to family, patient representative, or others responsible for the care of the patient Note: These processes are consistent with privacy and disclosure requirements specified under 45 CFR 164.510(b)(1)(ii) and 45 CFR 164.510(b)(4).

For hospitals that use Joint Commission accreditation for deemed status purposes:  The organization maintains documentation of completed and attempted contact with the local, state, tribal, regional, and federal emergency preparedness officials in its service area. This contact is made for the purpose of communication, and where possible collaboration, on coordinated response planning for a disaster or emergency situation. Note: Examples of these contacts may be written or email correspondence; in-person meetings or conference calls; regular participation in health care coalitions, working groups, boards, and committees; or educational events sponsored by a third party (such as a local or state health department).

Standard EM.02.02.03
Element(s) of Performance for EM.02.02.03
As part of its Emergency Operations Plan, the hospital prepares for how it will manage resources and assets during emergencies.
The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies that will be required throughout the response and recovery phases of an emergency.

The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies (including food, bedding, and other provisions consistent with the hospital’s plan for sheltering on site) that will be required throughout the response and recovery phases of an emergency.

Standard EM.02.02.07
Element(s) of Performance for EM.02.02.07
As part of its Emergency Operations Plan, the hospital prepares for how it will manage staff during an emergency.
The Emergency Operations Plan describes the following: The roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management during an emergency.

The Emergency Operations Plan describes the following: The roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management and evacuation during an emergency.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a system to track the location of on-duty staff during an emergency.

For hospitals that use Joint Commission accreditation for deemed status purposes: Initial and ongoing training relevant to their emergency response roles is provided to staff, volunteers, and individuals providing on-site services under arrangement. This training is documented and then reviewed and updated annually and when these roles change. Staff demonstrate knowledge of emergency procedures through participation in drills and exercises, as well as post-training tests, participation in instructor-led feedback (for example, questions and answers), or other methods determined and documented by the organization.
For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan describes the use of volunteers in an emergency, including emergency staffing strategies, such as the role and process for integration of state or federally designated health care professionals to address surge needs during an emergency.

Standard EM.02.02.09
Element(s) of Performance for EM.02.02.09
As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency.
As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity.

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity and lighting.

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and steam for sterilization).

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and steam for sterilization). Note: The essential utility systems include mechanisms for maintaining temperatures at a level that protect patient health and safety and the safe and sanitary storage of provisions.

For hospitals that use Joint Commission accreditation for deemed status purposes: The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, TIA 12-6); Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, TIA 12-4); and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

Standard EM.02.02.11
Element(s) of Performance for EM.02.02.11
As part of its Emergency Operations Plan, the hospital prepares for how it will manage patients during emergencies.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a system to track the location of patients sheltered on site during an emergency. This system includes documentation of the name and location of the receiving facility or alternate site in the event a patient is relocated during the emergency. Note: The name and location of receiving facilities or alternate sites may be defined in the emergency management plan, formal transfer agreements, or other accessible documents.

Standard EM.04.01.01
Element(s) of Performance for EM.04.01.01
For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital is part of a health care system that has an integrated emergency preparedness program, and it chooses to participate in the integrated emergency preparedness program, the hospital participates in planning, preparedness, and response activities with the system.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital demonstrates its participation in the development of its system’s integrated emergency preparedness program through the following: – Designation of a staff member(s) who will collaborate with the system in developing the program – Documentation that the hospital has reviewed the community-based risk assessment developed by the system’s integrated all-hazards emergency management program – Documentation that the hospital’s individual risk assessment is incorporated into the system’s integrated program – Documentation that the hospital’s patient population, services offered, and any unique circumstances of the hospital are reflected in the system’s integrated program – Documentation of an integrated communication plan, including information on key contacts in the system’s integrated program – Documentation that the hospital participates in the annual review of the system’s integrated program

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has implemented communication procedures for emergency planning and response activities in coordination with the system’s integrated emergency preparedness program.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s integrated emergency management policies, procedures, or plans address the following: – Identification of the hospital’s emergency preparedness, response, and recovery activities that can be coordinated with the system’s integrated program (for example, acquiring or storing clinical supplies, assigning staff to the local health care coalition to create joint training protocols, and so forth) – The hospital’s communication and/or collaboration with local, tribal, regional, state, or federal emergency preparedness officials through the system’s integrated program – Coordination of continuity of operations planning with the system’s integrated program – Plans and procedures for integrated training and exercise activities with the system’s integrated program.

The role private accreditation has on improving health care quality By Dr. Mark R. Chassin, opinion contributor — 10/03/17 11:20 AM EDT THE HILL

Health care quality is a vital issue for every American because all of us will one day need to rely on it. For that reason, private accreditors of health-care providers are subject to enormous public scrutiny even when everything works as it should. Lately, our industry has come under criticism for a perceived lack of transparency and findings that seem to contradict government regulators. But much of that is rooted in a fundamental misunderstanding of what we do and what the public expects.
I have worked in both the public and private sectors to ensure health care quality, first as Commissioner of the New York State Department of Health and now as the head of the nation’s largest private healthcare accreditation organization.
Among the many things I’ve learned over my career is that being a state health commissioner is very different than being a private accreditor. The former has a duty to protect and improve the health of the public while the latter is a means of improving the way health care is delivered.

As a private accreditor, we create evidence-based quality standards; conduct in depth, on-site surveys of hospitals and other health care providers; evaluate compliance with those standards; work with providers to address opportunities to improve care; and inspire them to excel in providing the safest, highest quality care.
The goal of the private accreditation system is to identify deficiencies in care and have the hospitals correct those deficiencies — it is not to find as many deficiencies as possible to justify removing accreditation from those organizations. Denying accreditation is sometimes necessary if hospitals cannot bring their care up to an acceptable level. However, in the overwhelming majority of cases, hospitals do come into compliance once deficiencies are pointed out.
Regulators, on the other hand, are public institutions with the authority to impose penalties and enforce laws, and their activities are therefore subject to public scrutiny and oversight.
Private accreditors have no such authority and need to balance public transparency with the need for candor between surveyor and healthcare provider. In addition, regulators are typically the first to receive complaints from the public, but often don’t share information about what was found to be noncompliant with private accreditors.
This balance is well understood in high-stakes industries that deal with complex risks every day, such as aviation, rail and marine transportation, and commercial nuclear power. All of these industries combine public reporting of important data with systems of confidential reports that contain sensitive information about safety risks, solutions, and uncertainties around potential process failures.
These oversight systems facilitate the identification of safety hazards – real and potential — in a safe harbor that is free from the fear of reprisal, public humiliation, or litigation. The system works. Confidential evaluations such as these are credited with promoting and sustaining a safety culture that reduces harm substantially over time.
By maintaining an open and candid relationship with a broad range of institutions across the country, private accreditors are able to spot overlooked risks that might appear to be singular events at an individual hospital but are actually part of a nationwide issue. Private accreditors, not public regulators, were the first to identify the presence of concentrated electrolyte solutions such as potassium chloride in patient care areas as the reason for accidental injections of these agents. Today, deaths due to these accidents are unheard of.
It is also important to acknowledge an uncomfortable reality. There are no perfect hospitals anywhere in the world. No known methods or procedures have succeeded in abolishing preventable harm to patients. Neither private accreditors nor government regulators can guarantee that such events will not occur in hospitals that have “passed” their reviews.
Critics of the private accreditation system say there is too much confidentiality between healthcare institutions and accreditors and that hospital survey reports should be made public.
We strongly support the goal of putting valid, useful data on quality of care in the hands of the public. In fact, we were the first to create a program that reports publicly a variety of standardized quality measures that assess hospital performance, a program that continues to this day.
But the responsibility for assessing all sources of data and making a judgment on a healthcare institution’s ability to serve the public rests with a publicly accountable regulator, not a private accreditor.
That’s why we and others have called on the Centers for Medicare and Medicaid Services (CMS) to engage in a dialogue with private accreditation organizations to identify a more effective strategy to better educate the public while ensuring necessary protection for health care quality improvement.
In the end, we all want the same thing: a health care system that consistently delivers the best quality of care and exhibits a culture of excellence that inspires institutions to continually improve their performance.
We are ready to work with CMS and other stakeholders to ensure that we achieve that goal in a way that properly balances public data with confidential quality improvement.
Dr. Mark R. Chassin, M.D., is President and Chief Executive Officer of The Joint Commission, nation’s largest health care standards-setting and accrediting organization.

CMS Review of Accrediting Organizations Disparity Report

The Social Security Act requires a performance evaluation of each CMS-approved accrediting organizations(AO) to verify that the accredited provider demonstrate compliance with the Medicare Conditions of Participation (CoPs). The CMS annual report to Congress (RTC) details the review, validation and oversight of the AOs Medicare accreditation programs as well as those under Clinical Laboratory Improvement Amendments (CLIA).

The CMS evaluation process includes, but is not limited to, the following components:
• On-site observations are conducted to ensure that the accreditation program is fully implemented and operational
– Corporate on-site review
– Survey observation
• Comprehensive review of AO accreditation standards to ensure that the AO standards meet or exceed those of Medicare
• Comprehensive review of the AO’s
– Policies and procedures to ensure comparability with those of CMS
– Adequacy of resources to perform required surveys to ensure comparability with those of CMS
– Survey processes and enforcement to ensure comparability with those of CMS
– Surveyor evaluation and training to ensure comparability with those of CMS
– Electronic data to ensure the AO has the capacity to provide CMS with the necessary facility demographic, survey-related, deficiency, adverse action and accreditation decision data, etc.
– AO financial status to ensure organizational solvency and ability to support operations

 

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-40.pdf

Vizient 8/2017