I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as a director in patient safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as a director, facility patient safety and risk management and operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as a director, western region patient safety and risk management for the doctor's company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. As a registered nurse and attorney, Laura holds a bachelor of science from Regis University, a doctor of jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. We thank you for being here with us this morning, Laura, and invite you to go ahead and get us started. Okay, and thank you and welcome everyone. Our program today is on the topic of history and physicals. Now, granted, this topic has been around for some time, and it's gone through a few iterations, but we still have to mention it because there are deficiencies that come up once CMS does come around and do their survey. And it is really a very crucial part for that care that we provide to patients once they do come within our facility, and so that's why I'm glad that GHA is presenting this program for you today. Well, real briefly, here's my contact information, and also I've included in here the email addresses for CMS. If you have a question for them, just give them time to respond. You may have to nudge them again now and then, but they do eventually respond, and I would keep that. That way, if something comes up after the fact related to that question, you have it handy and ready to go. I always include my disclaimer that the information I'm providing today is that. It's informational only. It is not meant to serve as legal advice or establish any attorney-client relationship, so please consult with your in-house counsel, professional legal representative for advice, and specifically if there might be an issue regarding a specific state law that might affect you. For example, if you're doing informed consent for a minor, when does that kick in? So I want to just do a brief introduction on why we are here today. Again, those of you who have gone through a state survey or deemed status survey with an accrediting organization, you don't want to get one of these, and that is the notice statement of deficiencies, plan a correction where you do have to respond back to CMS to update or to fix, so to speak, what they found. And no provider, I don't care if this is a physician, a facility, whoever participates in Medicare and Medicaid, you don't want to get the notice of involuntary termination from the agreements with CMS, and that usually is almost a last resort. That's when any response or follow-up from the provider just didn't quite meet the expectations, it was very lacking, or it just simply didn't occur. Then they would go ahead and involuntarily terminate. How does all this regulation work? How do what we're going to be talking about, how does that work? Well, the regulation starts in the Federal Register, and then CMS has a couple jobs. One, of course, they're supposed to update their manual, and I'll show you what that looks like, but they're also to develop interpretive guidelines and survey procedures. Those are directed to their surveyors, but it's also helpful to us to know, what is the rationale? What does CMS expect to see when they're on site? And so not only interpretive guidelines, but survey procedures. What are they going to look at? Who are they going to talk to when they're on site? Three types of surveys, certification, that's when you're getting started, complaint, which no one really wants to have, and then a validation survey, which can be where you have deemed status, CMS is coming around to make sure, yeah, everything was according to what we would expect. In keeping up with changes, you want to perhaps subscribe to the Federal Register, that way you'll get notices when a new regulation is published, and, of course, make sure you have the most recent manual. For ACUTES, your most recent manual came out in April of 2024, this year. Well, for CRITICALS, they're still waiting on yours. The last update you had that's published is from 2020. Now, that doesn't mean there aren't changes in there or changes that affect it. It just means that's the last time the manual was put out. If there is a new manual, you'll want to check the transmittal page, and I would suggest you check the survey website monthly. That is where they put out memos, and I have the links here for you. Just copy-paste it to your SERF engine. You can't do it directly. For some reason, with this process, with Zoom in particular, it won't let you do that. So you might want to copy-paste those to your SERF engine. So as far as the manual that we're talking about, first off, the appendix lists out all of the services over which CMS is responsible to have oversight. Hospitals, you're appendix A, and CRITICALS, you are appendix W. Now, there's two other manuals in here that I would have handy. Now, one we're not going to talk about, and that happens to be appendix C, emergency preparedness, but that applies to everybody across the board. The other one is appendix Q, which is immediate jeopardy, and that's a very important one because if there's an issue that comes up with patient care where either CMS or one of the deemed status accrediting organizations comes out and finds something pretty egregious, they will notify CMS, the regional office, and then they're out in two days to come visit. So that's another one you want to keep handy. For the appendix, for appendix A, the table of contents, you can see here, again, you will see the date this has on it as April of 2024. So that's the last one. That's the most current manual. And the transmittals will come up in blue lettering. Doesn't matter if you're in appendix A or appendix W, the transmittals will pop up. When you're online, you can hit that blue lettering, and it will take you to that transmittal page, which will show you the last date it was issued and what it applied to. Now, I like this because it's a really quick way to find out what was revised, what's new, what has been deleted, and saves you having to go through that entire manual. By the way, the manual for appendix A, which now has appendix AA, the psychiatric hospitals, you're like 560 pages. Critical access, yours is 340-some-plus pages. So these aren't easy things to have to get through to find out what did they change. I mentioned the memos. Again, that's kind of the quick information that CMS sends out, hey, this is new. I have the link there for you. The nice thing now is you don't have to go and click it three times to get the most current date. It goes chronologically, starting with that newest memo. And that's just an example of what one would look like. And this happens to be one on QAPI that came out last year. What deficiencies? Again, no one wants to get that notice of deficiencies where we have to do a plan of correction. But one thing you can do, if you are wanting to do some benchmarking, you're trying to find out where has your facility been. Or if you're new to your role, it's very helpful to find out what were some of our deficiencies. You can access it. It will have the address, the name, date of the survey, the tag number, what they found in a very brief description. It is updated quarterly. So once you get to there, and here is the link at the top. This is slide number 18. Scroll to the bottom where it says deficiencies. Now when you open it, you get two Excel formats. And so make sure you get the right dates. Because the first one is from like 2010 to 2016. The second one is 2017 to current. And really, again, if you're starting to find out where have you been, if you're new, go to that most recent one. Because you probably have already made the corrections for that older material. But that's what will pop up when you do open up one of those Excel formats. I just put up here and highlighted deficiency by tag number. Because you can filter and sort. And that's what I do when I do these programs. Because then I can find out, OK, what are they really honing in on when they're doing these surveys? So I've got a couple pages here of some of the deficiencies that were in the most recent ones. This one, they didn't require the surgeon to update the history and physical, where there was an abnormal EKG and a stress test done. They didn't do that. The records were in there. But the HMP had been done prior to that. They didn't follow their own requirements, as put out in the bylaws. HMP not done within 24 hours of admission. It wasn't on the chart before surgery or any procedures. Now, this one still continues to be somewhat of an issue, where it's like, yeah, yeah, I know I dictated one. It's in there. But let's go ahead and go forward. And you can't do that. It has to be in the record. They didn't show the prenatal record was updated prior to that actual delivery. They didn't make sure that the hospital requirements for an HMP were actually in that HMP. Now, these are very basic requirements. Chief complaint. What's their past medical history, medications, allergies? You know, the things, items you would normally find in a history and physical. They weren't present in this one. And follow their own rules and regulations. One of those happened to be that information a patient brought in from the outside. The requirements said you have to scan that and include it into the medical record. Whether it's a chest X-ray that was perhaps done two years prior, the patient brings in their bylaws said you include that because we need to know that. The house physician did the history and physical, but the attending didn't get around to signing off to it for at least three days. And then just a few more. They forgot to update the history and physical. It was older than 30 days. The history and physical that was completed by a physician assistant wasn't signed off by a physician. There was no HMP before a C-section. The history and physical. This was on a foot surgery that was inadequate. And what they forgot to include in that history and physical was the patient's current medical problems. Now, this patient, by the way, happened to be a diabetic. And so that's crucial. We need to know that. And then, honestly, they found that the history and physical was simply inadequate. It didn't document what was that patient's condition prior to the start of surgery. So those are just a few examples of some of the deficiencies. And we're going to cover most of those areas that I touched on with the program today. Well, I'm going to do a brief step back in time, go back about five years to 2019. I want to talk about some of the changes. CMS put out two major rules. And they actually combined it into one. It was called the Burden Reduction Rule and Hospital Improvement Rule. And they did make some changes for the better. And this was in the burden reduction part of it. Well, previously, CMS had required any patient who was undergoing a surgery or a procedure, you had to have a history and physical. Now, we know those have to be done within 24 hours of admission. And if another provider, say their PCP, happened to do the history and physical, it couldn't be older than 30 days. And it had to be updated the day of surgery before the patient went in. So essentially, we know that the history and physical has to be in the record before the patient goes to surgery. Well, with these changes, what they did was they took three laws and combined them into one. And what they really did, the major change was with those healthy outpatients. Those who are done in hospitals and ambulatory surgery centers. And what this did was they realized, you know, you now have a flexibility that you can do a pre-assessment instead of the full history and physical. But these are in selected surgeries and procedures. Now, one thing this rule did not do, it simply didn't address critical access hospitals. Those who are doing these same procedures on healthy outpatients and a critical access. So until CMS gets around to updating that manual, if you're a critical access hospital, you still must have a history and physical on all patients. Doesn't matter if they're inpatient or outpatient. But to do this, if this is what you want to do, you have to have a medical staff policy. It only is only applicable to outpatient procedures or surgeries. And what you can do now is an assessment. Of course, it still has to be documented in the record. You know, these are such things as cataract. Maybe you're just doing anything that requires minor sedation. So you can do that assessment. It's not required. You don't have to do this. It's just an option. And again, only for outpatients because it saves time. I had cataracts done. And though it was done outpatient, I didn't have to have the full history and physical. It was a nice, quick outpatient assessment that not only did the surgeon do, but the anesthesiologist also came around and did a brief assessment. So what do you have to do with this? One, you have to have a policy. That is a requirement. And of course, there's many things that policy you want to include in there. As far as your patient, who do you have? What is their age? What are their comorbidities? What's being done on them? What is the level of anesthesia? Are you doing a MAC? Are you doing a full general? Are there any national guidelines or standards of practice for these type of patients? And as I always mention, any applicable state laws that you have to have. So include that within your policy. And the reason they did this was that they found there's almost 29 million ambulatory surgeries that are done. And of these, 53% were performed in hospital. They're outpatient, but nonetheless, they're still performed within the hospital. And we know the most common are the endoscopy, your cataracts, and your spinal injections, your pain management services. And so CMS finally came around and said, you know what? Let's do something that's less burdensome. So these are simply assessments as opposed to the full history and physical. So it must be completed and documented after the patient has registered within your facility, but before this procedure occurs. If you do it before registration, then it needs to be updated. So let's say your surgeon does that in their office ahead of time. They still need to go in and do an update. And these are the ones, those procedures, those surgeries that your medical staff has decided it's ridiculous and really not beneficial, doesn't change anything if we're doing a full history and physical. And that's why you need to include in that policy, what kind of patient do you have? What are their comorbidities? What's their diagnosis? What level of anesthesia are you doing? And again, even if your procedure is on the list, well, you can still decide to do the full history and physical. And that's up to the surgeon and the medical staff. Of course, you still need to document something on this patient. You know, what is their pre-existing condition? Any appropriate tests that need to be done? Allergies, that's a nice one to always include in there. And again, all of this found was that a New England Journal of Medicine article, I have the link there for you, said many of these tests really don't add anything. They don't reduce errors or events if they're undergoing these minor procedures. You know, like a chest X-ray. Yeah, maybe not need that for a cataract or a UA. Now, again, you can still do them. You don't have to not do them. You know, if you've got a question about, is this patient under the influence? Okay, sure, go ahead and do it. But again, it's totally your decision if that's what you want to do. So for critical access hospitals, any changes that do occur, and we'll cover these, they're in the medical clinical record chapter and they're in the surgical section. These are in the interpretive guidelines. And again, this assessment is not referenced in Appendix W. Now, I want to point out one thing. Although there's only six, 700 hospitals in the U.S. that have DNV, that's Del Norte Veritas. It's an accrediting organization, very similar to CMS and Joint Commission. They do address it in theirs, an assessment for critical access hospital. CMS, Joint Commission do not mention it. So for other changes for ambulatory surgery centers, they know that, again, some of these subgroups may benefit from having a full history and physical. Maybe it's a patient who can't leave supine all the way, or maybe they have chest pain, shortness of breath, a pacemaker, they're on dialysis. These are some of the issues that maybe it's better to do that actual full history and physical. But the requirement is it must be done by the physician or someone who is otherwise qualified, licensed individual. And one thing they also didn't do for ambulatory centers is they didn't put into place that 30-day rule. So according to the way it's written right now, it could be older than 30 days if the ASC has a policy and a procedure that has been approved by the medical staff. Of course, it must be in the record before the patient does have that procedure done. That means you may need to look at your bylaws, your rules, regulations, make sure everything is consistent with that policy. And again, you can elect to allow the assessments as opposed to the history and physical. It's not required. And again, you may still require to do it. So for history and physicals, I'm going to now start with the conditions in Appendix A. Lindsay mentioned we have a few polling questions. And so I'm going to go ahead and start off real quick with the first one, Lindsay. Okay, let's get that one up here on your screen. So you should now see this question that says, our bylaws permit a surgeon to delegate the history and physical of a patient prior to surgery. Yes, no, or not sure. And for those of you who may have missed our initial introduction, several of these polling questions throughout the webinar today. And as we do so, we'll also pause for a few moments to address any questions that you have for Laura up to that point in the presentation. So at the bottom of your Zoom window, you should see that Q&A option. And you can go ahead and type in your questions there. And then I'll pull those up and address those questions as we pause for these polling questions as well. I don't see any at this time. I'll give you just another couple of seconds to send your responses here. Okay, let's go ahead and share those results. I said that if it'll let me share or let me end it, but it's not going to share. It looks like we are at 47% yes and 33% no and 20% not sure. Okay, so pretty evenly scattered throughout. There we go. Okay, great. And again, there's no right answer here. There isn't. All right, so it's right off the bat. And this is in the medical staff section for the acute hospitals. You have to have bylaws. So of course, the physicians know what are their responsibilities and in particular, responsibilities with history and physicals. And they must include, this is a must, that it be completed. It is no older than 30 days and it's done before surgery. It can be done. So when they check in, that's fine. But when they do that, perhaps the nurses, someone who needs to verify this, they need to make sure it's not older than 30 days. If that's the case, it's no good. They have to discard it. In other words, ignore it and redo it. Sometimes that can raise some hackles on some of the physicians. I know I had a few of them that I had to explain. I'm sorry, that's what CMS requires. 35 days ago, nothing changed in those five days. And nonetheless, we still had to explain. I understand that, but this is what the regulation says has to be. So if it is older than 30 days, it has to be redone. Unless you're having the outpatient exception. And that's that outpatient assessment. So here's just that example. You've got your PCP, did the history three weeks ago, but now something's changed. Then you do have to update it. It must be updated prior to surgery, anything that requires anesthesia. And that includes deep sedation, MAC, monitored, whatever it happens to be. It has to be in the record before the surgery or the procedure requiring anesthesia services. So here's a response to that question. Let's say it's who's going to do it. It has to be documented by a physician or let's say an oral maxillofacial surgeon. Because that's what included in a physician. That's a podiatrist, optometrist, dentist, chiropractor under CMS. That's a physician. They have to be legally authorized by state law to do that. So it must be within their scope of practice. It many states say podiatrist. Yes, you can do a history and physical. Now, Joint Commission has FAQs. Now, they indicate that for podiatry, chiropractic, their part can be very limited in what they can do under Joint Commission. But many states now do require, allow your physician assistants, your nurse practitioners to do the H&P. That asterisk I have here, I have maps and information in the appendix that show as of 2023, which states allow that. And they're starting to recognize these individuals are very highly trained and they can do these history and physicals. It's a lot of information gathering. But overall, as far as timing, done within 24 hours after admission on each patient. Now, it doesn't have to be signed off. It just has to be in the record. So just keep that in mind. It can be handwritten, transcribed, dictated, however it happens to be. So anyone who does do the HNP has to be allowed not only by their state law within their scope of practice, but your hospital bylaws. So it has to be both of them. The interpretive guidelines talk about what is the purpose of an HNP? Those of us in healthcare, we know it. Again, the interpretive guidelines are geared to their surveyors. So just kind of keep that in mind when you're reading them. So the purpose is to determine is there anything going on with this patient that could really impact the plan course? Is there an allergy? Do they have a comorbid condition that really, we gotta watch this patient, a diabetic patient, where they've been in PO for so long, or maybe there's some medications that would affect that blood sugar. The bylaws need to include those requirements. And this is the same for inpatients and outpatients. As far as the admission, we have to update that entry to reflect any changes. The person who does it, licensed and qualified. You know, state scope of practice has to allow, and policy also has to allow for advanced practice providers to do this. So let's say just another example. You've got a cabbage, patient's having a cabbage. Family practice doc does the HNP two weeks before. Surgeon looks at it, reviews it, updates it maybe, and determines if there are any changes that needed, and then they authenticate the document, and they're done. Well, what if there's more than one qualified practitioner who's gonna be doing this? That's fine. You can have that. You can have more than one individual doing the HNP. But if so, the practitioner authenticating it is responsible for what's in there. They're responsible for the contents. And if it is done within that 30 days, the update has to be completed and documented by someone who's privileged and credentialed to perform the HNP. So again, let's say the PCP did the HNP maybe more than 30 days, 30 days before admission. And then you've got your cardiac surgeon who works very closely with the nurse practitioner with the surgery. The nurse practitioner comes in and looks at it and wants to update the history and physical, but the nurse practitioner is not privileged and credentialed by the hospital to do that. That means that the surgeon must do that. So as ever, it's privileged and credentialed to do, and HNP is the one to do the update and document it. Now, there are a couple options they can do. If they wanna do a full-blown HNP, that's fine. They don't have to do it. But what they can do is make a note in the progress note. Maybe there's a stamp that has HNP reviewed, no changes. A sticker. I know they don't like us to use stickers in case they come off, and it's really hard to put a sticker sometimes on an electronic record. Maybe it's a checkbox, or they go right on that actual history and physical form and write it out. Now, a lot of these items I do wanna point out with CMS, these were done pre-computerized records. They were still, some of these you see references to. Just keep in mind, some of these were written when we were still doing a lot of paper records. So there are other ways to do it electronically. But for example, what you can include in their HNP reviewed, patient examined, two critical points there, no change occurred since the HNP was completed, and then sign off on it. But again, it has to be in the chart for everyone having surgery or a procedure, with the exception of an emergency. And in an emergency, the nice thing you can do is there just needs to be some kind of an entry in the progress note that said, this is what we've got, this is what I found, this is the examination, patient has to go to surgery. Who can do it? Well, the regulation, they did expand it. For those who can, most states and hospitals do allow your advanced practice to do an HNP. But nonetheless, if you do have that within your hospital, the physician is still responsible. And that means they have to sign off on it when it is done by an allied health professional or advanced practice provider. They are required to sign off on it. Oh, QAPI, you know I wasn't gonna let you have one program without mentioning QAPI, and that's Quality Assessment Performance Improvement. So you need to do QAPI in history and physicals, because what you wanna do is just make sure there is one in the chart, on every chart, especially if there is a surgery, unless of course that outpatient exception applies. So it's really good to help you identify, is there a gap somewhere? Maybe we need to work with that provider, or perhaps we just haven't quite honed up our outpatient exception, that we need to make sure everything is done according to what this exception allows us to do. What will the surveyor do? Well, first they wanna see your bylaws, because they're gonna look at it and say, okay, what's included? Have they gone for the outpatient exception? If so, is there a policy that applies to it? Then they're going to make sure and look at the history and physicals to see what date were they done. No older than 30 days and within 24 hours of admission. They'll make sure it's done by someone who is qualified according to state law and your policy and procedures. And they will know your state laws when they go in, they'll know what the expectation is. They'll make sure it's done for any surgery or procedure that does require anesthesia services. So I just wanna point out one thing, if you have a patient where the physician wants to go in and say, draining abscess, and it's not going to be done with anesthesia, it's gonna be maybe local by the physician. You don't need to do history and physical on that. Just make a note in the progress notes. Now, if you do have anesthesia present, say they're going to do a block, you might wanna consider updating that HMP or looking at, make sure you're not missing anything. Blocks are a little bit different. And I'm talking like say a stellate ganglion block or an epidural block, something that could affect that patient in the long run by the anesthesia and the medication that is administered. And if it is done by a non-physician, is this individual privileged and credentialed to do that? That's what they wanna see. They wanna see that privileging and credentialing. They will also look at several charts, both inpatient and outpatient. They wanna make sure this was done within that 30 days or for sure within 24 hours of admission. Again, unless the outpatient exception applies. Now make sure that what's in there is consistent with state law, it's consistent with your policy, and they wanna see the bylaws on history and physicals. And those on outpatient, they may look at those a little closer than they would on inpatient. And make sure that the policy and procedure is specifying the mandatory components of that history and physical. Is it there? If I look at that history and physical, can I know what's going on or have a good idea what's going on with this individual? So again, you have to consider what does your bylaws include? I just have an example of some of them. These are not anything you have to use, just some of those that you might wanna think about, you know, that it is done more than 30 days, et cetera. It must be completed, documented by a practitioner. If the practitioner is doing it, and I'm talking advanced practice provider, it must be signed off by the physician. So take a look at what your policy does spell out. They also must include, the bylaws have to include a reference that we're looking at this person, that we have an updated examination, that it has been completed and it's documented with that same timeframe, within 24 hours of admission or registration. And of course, anything that requires surgery or any surgery or procedure that requires anesthesia. Was it done 30 days before admission? Is there an outpatient exception that applies for that healthy outpatient? Again, if you have an ASA-3, you probably don't wanna be doing a healthy outpatient exception. You have an ASA-1? Why go through all of the H&P if it's not indicated and it won't change anything. But make sure there's any changes if they do occur, that they're documented by someone who is qualified, according to the state law and then the hospital policy. Interpretive guidelines, again, repeat, these must be done by one who is credentialed and privileged to perform it. And in all cases before surgery or that procedure requiring anesthesia, documented an examination, any changes since it was done, again, because that could really alter the course of treatment and how that patient is going to come out. Of course, they can use their clinical judgment based upon the assessment, core morbidities, if any, and how that relates to the plan of care to decide, how much of an assessment do I need to do and update? If that patient's been in for three weeks, they have to go for a wound debridement, you have to evaluate how much do I need to go in depth in doing this H&P or this assessment, this examination, in order for the patient to go down and have that procedure done. Now, if they've been in for quite some time and there's some major surgery that has to occur, now you probably don't wanna be doing that. Case in point, my husband's nephew had undergone a very minor procedure. And of course, that's the one that crashes and burns and has a really bad result. He had a really bad complication. To the point he went septic and there was a possibility there was a rupture, that they cut the bowel. Part of the bowel happened to be cut and he went septic. And because of this, he had to go back two or three times. Well, with each time he had to go back, his condition had drastically altered. One point he was looking a little tired and gray, and then the next point he's in full-blown sepsis. So that's what you have to look at. Use that clinical judgment to determine how much more do I need to look into this person to know what's safe? Can they proceed? If there is no change, then again, the provider can indicate H&P reviewed, patient examined, no change occurred since the H&P was completed. Otherwise, then you do have to document those changes, make sure it gets in the record, anything before surgery that again requires anesthesia. What if you happen to be doing some of your assessment, you're doing this QAPI and you find maybe it's inaccurate or it's incomplete, or maybe the provider is looking through the record and they're called in to perform surgery and they find out this isn't the right H&P or there's something missing here. Well, then of course they have to examine the patient and complete the update. They can disregard the existing history and physical and do a new one. They can. I would wanna make sure there's documentation to support that. Why are you doing this H&P again? Just that you've reexamined the patient and you found these changes and that's why you're doing the full history and physical. You don't wanna be pointing fingers saying this thing is terrible, it's not complete, et cetera. It's just what I found. The surveyor, again, wants to see your bylaws. They wanna make sure there's a requirement that this H&P is in the chart. It's done 30 days before admission. Updated changes and examination have occurred and documented and if your bylaws do require it in all surgeries and anesthesia that it has been done, it's updated and it's documented. What else will they do? Again, like with the actual history and physical, they're going to look at a sample of records for those cases where it was done before admission. They wanna make sure it's in the chart, any updates are documented and this is done within 24 hours and that this is for all surgeries that require anesthesia or, excuse me, anesthesia for surgery or procedures. Now let's switch over to medical records. Remember the first one we're in medical staff, now we're in medical records. All records have to have documented evidence of a history and physical. Same regulations, same timeframes, no older than 30 days and 24 hours after admission. This goes in before surgery that requires anesthesia, again, unless you're having that healthy outpatient and in the record within the timeframes that we've already covered. Now, interpretive guidelines here are pending. This is one of those new changes that they made and they haven't done quite the interpretive guidelines yet but otherwise we have to have an updated examination. Same thing as we're in the medical staff regulations unless we're using that healthy outpatient in 30 days before admission and it's done prior to surgery. Again, interpretive guidelines are pending on this one but all records regardless have to have some documented evidence that an assessment was done of this patient before they go in and have these procedures and when the medical staff has also chosen to develop and keep a policy for those patients who don't require the comprehensive history and physical. So they do, again, have guidance pending on this but pretty much what you've heard already, I have a feeling they're gonna apply it here when that gets done. So what are the implications for TAG-462? That's the one for the outpatient assessment. Outpatient procedures, you must have a clear policy that is developed and maintained. In other words, we're going back and assess it when it's on its time cycle. Which patients are eligible? What are the specific procedures? And again, guidance is pending. This is the same information as what's in the medical staff section. I guess CMS is really trying to convince us or make sure we understand the importance of a history and physical by repeating it a couple of times. So that brings us now to our second question. Lindsey, please. Okay, I'll get us unfolded up here on the screen. Okay, you should see this one now that says, hospital B's circulating nurse has noted on occasion that the history and physical was either not in the record or an update had not been completed. What would you advise here? And you can check all that apply. Notify the surgeon immediately. Stop the surgery from proceeding a hard stop. Notify medical record to check on the status of a dictated HNP or update or do nothing. Allow the surgery to proceed. Not the first time it has happened and no bad outcome resulted. And Laura, it looks like we do have just a couple of questions here. Great. This person says, can a podiatrist use an emergency department physician note as a history and physical on a separate surgical visit and update it? Ooh, that could be. So help me understand, is this the same hospitalization? That's one question you need to ask. Number two, what's the gap between the emergency department notes and what the podiatrist is doing? If it's been a while, we hope that patient is somewhat stabilized different and that may change the focus. So that's one thing you wanna look at. It could be, it is the same visit within one day. You could be okay, but I would definitely wanna see what's in those notes to see is that applicable for this procedure? Or again, what's the timeframe between the ER visit and the podiatrist surgery? That's a good question. And if you're starting to see that happen, especially if you've got a lot of auto accidents, motorcycle accidents where the foot comes down, et cetera, a lot of damage, make sure the policy addresses that when you can or cannot use those ER notes as the basis for that history and physical. Usually that's one where patient comes into ER, they're stabilized and they're sent right into surgery. That's really where CMS was coming with that one as opposed to a couple of days gap. Okay. And then this next question, if a procedure is done without anesthesia and HMP is not needed, is that correct? That's the way I read it. Yeah. If anesthesia services are not required, then now again, keep that in mind. Look at what the hospital bylaws have said. Is that okay to do that? But usually it's something very minor and anesthesia services are not required. Then yes, that's the way the regulation reads. Okay. I think that was the last question. I'll go ahead and end that. Those are good questions. Results here. Okay. All of the above. Yes. Yeah, you can do any of those. And it can be challenging. I'm not going to kid you. Some of you have probably talked with your charge nurse in OR and that can be hard to stop it and it's like everything's set up. Why didn't we see this before? That's a good question, but really a hard stop needs to occur. It's like, wait a minute. We need to find out where's the HMP and why isn't it in the record? Okay. So moving on. Now we're in surgery. So HMPs are in three spots, medical staff, medical records, and now surgery. And this is for the acute hospitals. Same wording. I swear they did a copy paste on here. Anything that requires anesthesia, I have to have a history and physical. No older than 30 days, 24 hours after admission. The two exceptions, emergencies, and that healthy outpatient. It must be update documented and before surgery. And even if surgery occurs less than 24 hours after admission, we still have to have it in there. The surveyor will determine, was there an HMP required? And if so, was it done and documented timely? And was it done by medical staff requirements? The records have that required history and physical or update or emergency or outpatient. They want to see something that we looked at this person and documented their status. Now there was clarification from CMS regarding history and physicals. I have it in the appendix also for you. You can adopt a policy and procedure that allows a history and physical to be used by a practitioner who may not be a member of your medical staff. In other words, not privileged and credential. They don't have admitting privileges or you've got a licensed qualified practitioner who doesn't practice at your hospital, but they're acting within their scope of practice. So you can have a policy and procedure that says we're going to let this history and physical come in and be used by our surgeon. Nonetheless, it still has to be updated for any changes and it must be conducted. That examination of the patient must be done by that practitioner who is privileged and credentialed by your hospital. And that updated note must be documented of any changes since the HMP was originally done. So you can use those if you want. You don't have to, but you can use them. You can allow them. Now, again, if the practitioner who's going to be signing off on that finds no changes, then they could do that simple paragraph. Now, this was the wording from CMS. I would use it if I were you, if that's how you're going to do it. Maybe it can be a statement like one of the automatic fills, just make sure, yes, indeed, it is happening. It was reviewed, the patient examined, et cetera. Those are the two big things. The extent of the exam is not specified. They leave that to the judgment of the provider. And again, this is for anyone who requires anesthesia in particular. So here's an example. It was done when the patient was admitted. Several days later, patient's now stabilized. The HMP doesn't need to be updated. If the updated information is in the progress notes, so keep that in mind. So take, for example, you've got a patient who came in through ER. They were found unresponsive, not sure what's going on. All tests indicate it's nothing of immediate surgical need. So they get the patient in, get them stabilized. They're in for two days. And then it's determined, okay, they're not getting better. And now we are starting to see signs and symptoms of something going on in their gut. And then we can do an exploratory lap, okay? In that case, the history and physical based upon the clinician's clinical judgment doesn't need to be updated if there's sufficient information in the his or her progress notes. So you don't need to go back and start all over again. Joint commission says the same thing. And again, this was an exception to also that outpatient exception. So just keep that in mind. If you do have that patient who's in long-term, nothing's changed, use your progress notes and just make that indication. Okay, critical access hospitals. A couple of sections on history and physicals. Overall, it's in the medical record system, that's clinical records, and surgery. The healthy outpatient is not referenced. Now this section is much, much shorter than acute hospitals, very much shorter. However, if you have a 10-bed dedicated rehab unit or a 10-bed psychiatric unit and those patients require surgery, you must follow the requirements under appendix A. So if you have those two, you have to go back and look at what does A say, not what appendix W says. So under clinical records, any part, all our part can be delegated to other practitioners if your state law and your bylaws permit it. Otherwise, the MD or DO, your physician, they still have full responsibility if you're going to do this. And they have to sign off on that H and P. The surveyor wants to see your bylaws and they wanna determine when it must be done and who is doing it. So that's why it's always important to make sure they're on the record before they go to surgery, unless it's an emergency. And again, that's where your clinical records step in. So they'll look at your bylaws. Does it spell out in there when history and physicals must be done? They will look at your medical records. Did the appropriate practitioner sign off on it? Was there a physical exam? What about test results? Were there any indicated test results and have they been reviewed and signed off? Consultative findings, same thing. And again, we just wanna make sure it's in the record before they go to surgery. And I have to keep stressing this because that's tends to still be a problem that the history and physicals are missing in the records before they go in. And surgical services, again, very similar, done according to course of standards of practice. When would it be indicated? Documented in the record, in the chart before they ever go to surgery unless an emergency. And of course, when it is an emergency, what they're looking for are just that really vital information, the vital signs, what's going on with this patient, cardiovascular pulmonary status, those critical x-rays, you know, like chest x-ray or extremity x-rays, film show commutative fracture of the left femur. Those, that type of information is what they really wanna make sure if it's an emergency, is it there? They can delegate it if your state law permits it. And again, the surgeon has to sign off and they assume full responsibility for the content in there. So just make sure that they are aware of their duties and responsibility if you're having say PAs, nurse practitioners in your hospital. So it's very short for criticals. And until we get more guidance from CMS, I would do as much as you can to follow what's in the acute. I mean, the more you have, great. CMS would appreciate it. Now, again, you have to keep it up and make sure that it is current. And yes, indeed, the staff is doing that. Oh, excuse me. All right, joint commission. There are three areas again on joint commission, medical staff, provision of care and the medical record, record of care. So I'm gonna start with medical staff. Medical staff, they address the self-governance, accountability to the governing body. That's nothing new. And that includes the bylaws. And the bylaws must include for hospitals with deemed status. You're familiar with that. That's where you don't have to have a CMS survey if you have deemed status. But for those who do, the requirement to complete and document the HNP has to be someone who's allowed by state law and your policy. Whether it's the physician, a maxillofacial surgeon, a qualified licensed individual, such as a PA or nurse practitioner. The medical staff, of course, we know they oversee the quality of care that is provided and those who are privileged. And the medical staff, what they have to do is specify what's the minimum information that goes into those HNP. That can vary, of course, by setting and what you're doing. And the medical staff has to monitor the quality of the history and physicals. They require a person to be privileged to do the history and physical and any of the updates. Now, again, those who, if you're going to allow others bringing in history and physicals, then they have to be reviewed and signed off according to joint commission. You want them reviewed and signed off by someone who is privileged and credentialed to do any update. Again, those who are not licensed, they can do all or part according to state law and policy. So it can be done under the supervision or appropriate delegation by a qualified physician. But again, the physician is totally responsible for what's in there. Medical staff defines when it must be validated and countersigned by that individual. And the scope of the history and physical exams when required for non-inpatient services, that's your outpatient individuals. Under provision of care, you assess, reassess the patient and their conditions at the defined times. They have the same timeframes for that history and physical for admitted patients, no older than 30 days and within 24 hours of admission. This does discuss the healthy outpatient. That's in what they call note number one. It does discuss it. If you're going to use deemed status, it's the same rules that we already applied. It's done for outpatient services and assessment on those who are so identified at those requiring anesthesia. But otherwise you have to have a history and physical. Now note two does refer to the conditions of participation that we've already covered. Otherwise we have to update any changes that aren't older than 30 days. And of course, if they do come in with an HMP, it must be done before surgery. It's the same notes as in one and two, again, with that healthy outpatient exception. So for deemed status, if you allow an assessment as opposed to a history and physical for outpatients, that's great. Completed and documented before it happens. It does refer again to the medical staff that I mentioned before. And also the conditions of participation. And because some of that information is very lengthy, I did not add it to the actual slide. So if you have joint commission accreditation, you can just go ahead and read it. Otherwise it's exactly what I covered previously. So then for the record of care, they also talk about the history and physical. The record includes that history and physical before operations or high risk procedures. Now, see, that's a little different than what CMS says. This is high risk procedures where you are using moderate and deep sedation. So just a little bit different for joint commission. Now, I do have some frequently asked questions that joint commission has put out on history and physicals, and they really cover quite a bit. I have them in the appendix in depth for you, like delegation, outpatients, medical students doing HMPs. Remember, that wasn't covered in the conditions of participation, but joint commission has put it out. When can you delegate it? What about a podiatrist or dentist doing a history and physical? Even authentication of that history and physical. So there are key requirements of an HMP that joint commission has identified. And they of course say that your organized medical staff has to determine what is the minimum amount of information I need in that history and physical and enough to address the patient's conditions and needs. So we're addressing them and meeting them. That can vary, of course, by setting what's your patient population. It's gonna be a little different when you're having a child come in for tonsillectomy versus the adult who comes in for a tonsillectomy. Same surgery, but different setting, different patient population. High risk procedures. Anything that requires anesthesia. A history and physical, I have the link there for you. Qualified practitioners. Of course, we want somebody who's qualified to do this. That can be advanced practice providers, physician, another qualified, maybe it is that dentist. More than one practitioner. They could have, you've got patients who have probably two or three physicians on their staff or on their case. If you do that, more than one can participate, but again, they have to document and authenticate their entries. And each entry has to be signed and dated and timed by that author when they do enter it. If under joint commission, you have a dentist or a podiatrist, then your medical staff has to determine the extent to which they can do one. And of course, based on state law, is that permitted? And generally, they're only allowed to do those parts of the HNP that apply to that practice. So the person who asked about the podiatrist doing or relying on that emergency room physician's HNP, is what's in there applicable to what that podiatrist will do? Same thing for, let's say it's a dentist and the patient was in a car accident. Now they've been stabilized. They need to have reconstructive surgery on their jaw. If that's what the dentist or oral surgeon does, is that applicable in that history and physical to what they need to do and the outcome, hopefully, for that particular patient? They also talk about practitioners who don't have privileges. You can allow them if your policy says you can permit their HNP to be done by them. That's for those who are not privileged and credentialed at your hospital to do it, such as your PCP. They're not privileged in an orthopedic hospital, but the orthopedic surgeon who is privileged and credentialed doesn't know anything about this patient. They can rely on that PCP if, again, there's a policy and procedure that allows that to occur. Those who are privileged have to be familiar with what your policy says, the minimum content, make sure that it is compliant with what your hospital requires. Then if not, what's missing? They have to go out and get it. They have to do that further assessment, update it to make sure it is totally included in the condition. Sign and date any updates, any revision. There just have to be something that said this is current as of today. So the question of medical students and outpatients. Med students have no legal status. They're not a provider of healthcare services yet. And therefore, if your hospital allows medical students to do it, and they want that HMP to fulfill the requirements that is not compliant, they can do it. But the surgeon, somebody has to review it and sign off and make sure it's done right. Because they're going to assume full legal responsibility for that history and physical. It's crucial when you're doing have, when you are part of a teaching hospital. Medical students, not residents, medical students. Otherwise non-inpatient services, interventional diagnostic, maybe you're doing wound care centers. The medical staff has to define what's to be in their HMPs if it is required, such as an angiogram. You may want them to have sedation for that angiogram. They would need then some type of an assessment if it's done outpatient. We also had it where those of you who work in radiology services, there are certain mammograms where the patient is laying face down for a long period of time. They're like ultrasound mammograms. And that can be quite distressing when you're laying face down and you can't move for this test to occur. And the test could take 45 minutes, easy. I've worked with a couple of them where they want to start providing sedation in order for that to happen. And I'm not talking valium. I am talking IV anesthetic type sedation, such as propofol, maybe fentanyl and Versed, those type, where you want to kind of keep an eye on the respiratory status of your patient. And so in that respect, we had to develop policy and procedures on how is this going to occur? Who's going to be providing the anesthesia? Who's going to be monitoring the patient? What equipment do we need? All of that had to be included in here, including the assessment for that patient for this to occur, because these were being done outpatient. There's no standard on how soon they have to authenticate it that required dictated, transcribed, be authenticated before it occurs. But have a policy. What do you feel comfortable? What does your medical staff feel is appropriate for that authenticated timeframe? Because you have to have something written on the timely entry, please not over 30 days. And the signature authentication is considered an entry. So let's say they're looking at that HNP was done 20 days before. If that's okay with your medical staff to authenticate it, fine, but we know once they're discharged, things have to be updated and authenticated. Ah, this one, the dictated, but not transcribed. This will get people into trouble. And I'm just basing that upon my experience working with med mal suits. The mere existence that it is dictated, that I'm in typed out or entered into the record that is not compliant with this requirements, dictated, but not transcribed. Essential information has to be present so we can continue to properly man and safely manage and take care of our patients. If it is dictated and it's not in the record, it's not gonna help anybody. Again, the exception and emergency when there's simply no time to complete that HNP, then the progress notes and that pre-op diagnosis, as long as those are recorded, you're okay. And I mean, they mean an emergency. I come in, I'm exhibiting signs of a dissecting aortic aneurysm. I'm in through ER and I have to get into that surgical suite ASAP. That's what they mean. Two days on the floor stabilizing isn't going to probably meet that requirement. Prenatal record is another one. Can the prenatal record be used as an HNP? It can, but it has to be updated to show their condition on admission because that does show the course of care, any updates from when they were first, that first visit, that first prenatal visit to once they're admitted to the hospital. Now, this is a special circumstance, the prenatal record. It's usually planned to get it over there and you can systematically update it. So again, you can use that as the HNP, but it has to be updated once they show up at your hospital. Same thing for the healthy outpatients. This is still one of the FAQs that you can, your medical staff can decide, this is what we're going to do when we're going to have an assessment rather than an HNP. And again, healthy outpatient, and it does reference you back to the medical staff element of performance number 19. So what is considered a healthy outpatient? You could have a very, very stable type one diabetic. They could be considered ASA2. Maybe that's considered healthy enough based upon the clinician's expertise and in working with what has to be done, especially if say they're coming in for a spinal injection or maybe a shoulder manipulation, but they want to do that under anesthesia. Be very stable. Excuse me. Again, on what needs to go into the policy on the requirement, this is for deemed status. Age, diagnosis, what are you doing? What's your comorbidities? Are they ASA1 where you're just doing monitored care? Are they going to be doing general anesthesia? Still ASA1. Those specific procedures, so specific types of patients. And then what does state law and national guidelines say is good practice? What do you accept as for that area? And then our third question, Lindsay, please. Okay, let's get that one up on the screen. I'm gonna read this first part to you. That says deemed status critical access hospital frequently has patients who require additional surgery during their inpatient stay. Such patients are part of the SNF of the critical access hospital. Patient B has been inpatient for five days for DM management and requires a BKA. Would you recommend deemed require a new HNP prior to surgery? And then let's get that question up here for you. Okay, and your options, yes, no, or not sure. And Laura, we do have a couple of questions while everyone is putting in their responses here. Okay, and April, I saw this question came in from you in the chat and just asked for some, okay, perfect, I see your response here. So her initial question was, how does this compare to facilities that are not deemed status? And then she's saying, compared to the joint commission standards as the VA doesn't follow CMS, I'm just looking for more of what should be listed in the HNP. That's a very good question, because you're right, if VA is not following what CMS says, that's where you look to your national guidelines and what they would require. You know, with CMS, I mean, I understand they're there to protect the patients. That's what they want to do. That's the whole idea behind, hey, if you're gonna take our money, we wanna make sure you're doing it safely and that the patients are gonna be safe. And so they sometimes go quite extensive to what they want, but I get it. If you can follow what CMS finds, I don't think you're gonna go wrong. Does it require a little more work? Yeah, yeah. But if you're not deemed status, but you are taking Medicare and Medicaid patients, which you could, you could still have those patients. You'll have to be following what CMS says. So I would do as much as you can as close to CMS unless there is a particular VA rule and regulation that I am unaware of that says otherwise. But again, these are, CMS is trying to do the best they can to keep patients safe. I don't know if that answers the question, but that's pretty close, I think. Yep, absolutely. And April, if we can help further, and you can always reach out to us after the session as well. Okay, and then this says, can medical students do HMP if signed by a physician? Again, the physician is ultimately, ultimately responsible. And so essentially what we usually see, what I've usually seen is the hit, the med student will go in and do it. They'll do their thing. I always call it kind of almost a practice run. But then the surgeon, the physician there, who is watching over them, so to speak, they still have to make sure that's correct. And everything in there is accurate. The HMP by the medical student alone isn't sufficient. The supervising physician has to do something to verify, yeah, this is correct. So again, they're not licensed. They're not considered, quote, qualified, end quote, a qualified licensed provider, because they're not licensed. They're just in there. So medical students, it's great if you can do it. A lot of them will take that information and agree with it, but they still have to do a history and physical, make sure it's done correctly. And the information is correctly. I know some of you who work in education, hopefully you're not finding this. I'd found it years ago where I would be reading the information from the med students. And we all know they go about two or three pages long, but they have to do that. They're expected to check out this patient. And then the next person comes in, it's pretty much a repeat. And the same thing, it's a repeat, where you go back and look at the original one, and the original one was wrong. And that kept getting populated down the road until the physician went in and recognized, no, that's not correct. This is what it is, as opposed to this finding. I hope that answers the question, but in short, no, medical students cannot, let me back up, a history and physical by a medical student, it will not fly in and of itself. Their supervising physician must review it and make sure everything is correct. Because again, they're ultimately and legally responsible for it. And then as a follow-up here, it says, I know that you just spoke about the medical student is not a qualified LP, but does that rule also apply to medical residents? Does the physician still have to sign off on the HNP? And that's a good question. Residents are licensed. They are licensed individuals. They can do one, if that's what the program allows. And that's the other thing. What kind of a program are they in? What is the medical staff? Usually the supervising physician still signs off on it, but the HNP by that resident can be recognized under the bylaws as, yeah, we're gonna allow that to go through, but it's the same thing. The supervising physician still has to review and sign off on it. Okay, and then how does the physician indicate they have reviewed the HNP and that it's correct? Is the signature enough? Oh, a signature alone, I don't think so. There has to be some action that it's very similar to that wording, history and physical review, patient examined, everything is true and correct. Just like they did with that update. And so if you can have that language easily available for the physician, just gonna help them, but they have to understand if it's there, that's what's expected that they did indeed review it and know it as correct, reviewed and approved. However, your bylaws say you can do it. Okay, do you have that language in the presentation here in the follow-up? She was asking where that requirement is. Yes, yeah, the language is, it's in where it talks about the updates. Okay, and let's see. So I'll make sure that I link the slides there for you on the chat, so you'll have that again as a resource. Okay, and this next question says, following up on the podiatrist ED note question, if the ED note does not include an assessment and plan or impression, would it be considered an unacceptable HNP? No, it doesn't have to be, because for what the patient came in through ED could be totally good. It's what is the podiatrist going to do? And then you have to, they just have to go in and do an HNP on what that patient needs for the podiatrist. Yeah, it's not that it's unacceptable. It's just maybe patient didn't present with that or it wasn't noted at the time of the ED visit. And I'm trying to think like, let's say you have a child who has an ATV accident and they're concentrating on the abdominal wall injuries, as opposed to, okay, maybe he jammed his foot on the way down or whatever. And then two days or a day after admission, they're observing him and they happen to see his ankle get nice and big and pretty colors. Maybe the podiatrist then would come in and evaluate. It would be reasonable. They wouldn't necessarily check the ankle unless the patient had reported a discomfort until after the fact, then that's when you have to do it. Okay, just another couple of questions here. And then I'll end that polling question. It says, can an office note from any other member of the medical staff be used as an HNP as long as it is within the 30 days? If so, if the note is in draft status, does the surgeon need to sign off on the draft report? I'd be careful with an office note. I'm not clear on what would be included. I mean, if the office note and you look at it and a prudent physician would say, yeah, that's easily a history and physical. Then again, the policy has to indicate we're going to accept this office note as the history and physical for this situation. Then you can do it as long as it's within that timeframe and then just sign off just like you would for any update. I identify this as true and updated and correct and they sign off on it. I hope that answers the question. Okay, and then the last one here is, does the medical staff determine what the health system will consider a healthy outpatient? If so, should this be documented in policy or elsewhere? And should there be any wiggle room or the standard should be set and not deviated from? Good question. That's up to the medical staff, what they want to allow and the governing body. As far as any wiggle room, I love the one phrase that I see quite a bit. This policy, and I used to put in my two, I put it in my policies that I put together, said this policy is not meant to substitute for sound, identified, evidence-based medical practice or decision-making. That's a nice catch-all that just indicates, hey, listen, we understand things change. Patients are not cookie cutter. They could be very different. And I'm going to allow, we are going to allow a physician, a clinician to make that decision based upon their assessment and knowledge of the patient to maybe do something not specifically listed. So you want always having that nice little catch-all phrase. And probably your state attorney or your council knows it according to what your state law would allow or what your legal, your malpractice suits have identified saying, yeah, that's okay. We see that quite a bit because that's not what CMS ever meant to do was substitute their judgment for clinical judgment. And they made that quite clear. They will not establish the standard of care. Okay. It looks like just one final question came in that says, if an H&P update is not completed on a medical record with an appropriate H&P from the office, do you recommend requesting the missing update after discharge during analysis? After discharge? Not too sure how we could do that after discharge, but okay. I guess I need a little bit more information on that one, Lindsay. Okay. Yeah, Mary, I see that question came in from you. If you want to give a possibly a little bit more information or if you have a specific example or something that you've maybe experienced, you can certainly send that over to us at education at gha.org. And we'll be happy to follow up with you and maybe go through a detailed example there. And especially if it's happened to you in the past, it probably better to do it that way, Lindsay, to have it come directly to you and then we can address it offline. Perfect. And I did have one question here asking if you could repeat that suggestion that you just made for the policy. The wording? Would you want us to maybe include that in an email or do you just want to repeat it? I think it'd be easier. Okay, yeah, that's perfect. We can include that in the email so everyone can see that. But then also for those of you who are joining us live today, you do have access to the recording as well. So you can actually use today's Zoom link to also go back and access the recordings. If there's ever any part that you'd like to get back and listen to again or just for further clarification, you can always go back and access the recording just using the same Zoom link and that will be available for 60 days from today's date. So hopefully that'll be helpful as well. And for those of you who do listen, again, please check with your council to make sure your state law doesn't prohibit it. The states I've worked in, they have not prohibited that. Absolutely. Great, okay. It's taken a second to share these polling question results for some reason. I'm not sure why it's doing that, but it looks like we had about 45% yes, 32% no, and 23% not sure. Okay, I love it, they're all over. Okay, so we've got an additional surgery. They're part of a SNF unit, skilled nursing facility unit, okay? Do they have to have a new HMP? Well, maybe. So let's say you have a person that comes in on Monday. They go to surgery on Wednesday. The update isn't necessary as long as progress notes indicate and include what normally would go into that HMP because that HMP is still good throughout the entire hospital stay. Now let's say our patient was in the SNF unit and they were, you know, maybe they were initially inpatient, had a prolonged recovery. They decided, okay, we're gonna put them in the SNF unit to continue with physical therapy. And during that course of time, they maybe got a wound and now that wound is an ulcer. And with this patient, a below the knee amp, why did that have to occur? What happened in that patient's condition? Is it so stark? Was it so different from that HMP that maybe a new one would be done? But normally what happened, the progress note should show, this is the patient's status and this is what changed. And that's why we have to have the surgery. In that situation, you may decide, I'm just gonna do a new HMP. Maybe they threw a clock. Maybe it was something other physical that happened. They had a fall that required this to happen. You can do one, but otherwise that history and physical was valid throughout their stay. All right, I'm gonna briefly go through DNV. And again, that stands for Det Norske Veritas. This is actually an overseas company, but joint commission, I'm sorry, CMS has recognized them and their standards and expectations are pretty much mirror what CMSs are. So they have given them deemed status. Granted, there's only about 680 some hospitals in the entire US that have DNV. But for those of you who do, this is just an idea about what's expected. Medical staff, surgical, medical records. Overall, these mirror most of the conditions of participation. And the only difference is they do mention an outpatient assessment if it's a critical access. CMS hasn't gotten around to doing that. Perhaps with the next update, they will get around to doing it. For acute hospitals, the bylaws have to have a requirement for the HNP for each patient. Same timeframe, 30 days and 24 hours after admission. And those that require anesthesia. It shall be, it's not a must, it shall be in the record for anything that does require anesthesia services. Completed within 30 days. That means you have to have an updated entry. If it's, you know, 30 days beforehand. Documenting any changes, any, if they do occur, by those who are qualified. Either physician or maxillofacial or surgeon. Other licensed qualified practitioner that have been granted privileges. Again, per medical staff and state law. The update has to show that patient was examined. You looked at the HNP. Any changes were noted or no changes. And also the exam and update is done within 24 hours of admission or registration. And of course, prior to any surgery or procedure that requires it. Who does it? That's up to your medical staff. They say physician, oral surgeon, qualified practitioner. They can do it. Scope and content. That is determined, of course, by the assessment of the patient's condition. What are their comorbidities? How does that relate to the surgery or their admission? And again, anybody that requires anesthesia. They have the outpatient exception if you want to do that. But likewise, you have to have a policy and procedure. Specifies the proceed, not only the patient, but also the procedure. Which one are you going to allow for these to occur? And the policy has to show that it applies to only those in outpatient areas. These are not inpatient. These are outpatient. It's based upon the patient, their comorbidities, nationally recognized guidelines, evidence-based standards of practice, and any state, local health and safety laws. The medical staff has to make sure this assessment is completed and done by someone who's allowed to do it. Also that it is completed and documented before procedures that require anesthesia. Surgical services, they repeat it again for what's in CMS. Unless you have an emergency, it has to be in the record before the patient goes to surgery. And the remaining requirements, the bylaws, the timeframes, what goes into that, who can do it. Again, the outpatient assessment. If you do not have an HMP, or it's not available, it's dictated but not there, here they say that the admitting practitioner has to write a statement to that effect. That it has been dictated, but it is not yet available. CMS is silent on this respect. And usually this is only in an emergency, not when the patient is scheduled. So it's that emergency exception. Otherwise, medical records section, the same thing. All records shall document a history in physical or outpatient assessment. And it's done within 30 days or 24 hours after admission. If completed before 30 days, you have to have that updated assessment, including an examination. And the guidelines, they provide that same language for that updated note. And so for those of you listening on slide 114, the DNV, they have exactly what's in with the CMS, that language that you could include. They also have the outpatient assessment that you can elect to have this, that there's a policy that has been developed and maintained. They identify the patients, and they identify which procedures that they're going to allow this occur. Critical access for DNV, the standards are the same. These were updated in July of 23 to include what's in the acutes. And there's a reference in that update from 23 of an outpatient assessment, as opposed to the comprehensive H&P for those specific procedures. I really have a feeling CMS will come on board and also follow that. But until they have done that in writing, we'll still have to do the full history and physical. So just a few takeaways with what we've got left here. Make sure your bylaws address history and physicals. Who can do it? To whom can you delegate it? Who can delegate it? The minimum content, that update note, that there is a process for history and physical, that it should have a process, should it not be present before the patient goes to surgery. So in other words, well, I know it's dictated, I just don't know where it is. Okay, how are you gonna do that? What's the next step? If you elect that assessment, make sure the bylaws, the policy and procedures are clear, which procedures you can do it and which ones aren't. And then the minimum patient criteria. Know your patient, what is the ASA level? Because that's what the anesthesiologist, those providing it, or anesthesia provider, they have to make that determination. If it's a three or a four, probably you need an H&P as opposed to that assessment because there's a lot going on with that person. And then our final one, and I'll just read through this and have Lindsay put it up. We've got a 300 bed multi-specialty hospital, specialize in orthopedic care. Good reputation for low post-op complication. We have an orthopedic surgeon, he's been on the staff about a year and a half, doing mainly joint replacements. That's everything from shoulders, hips, and knees. They have requested to do a shoulder replacement on an outpatient basis in the surgery center owned by the hospital. After a lengthy discussion, a lot of research on the risk, the benefits, et cetera, medical staff and board said, okay, fine, we'll do it. But there's strict criteria on patient selection and adherence to the policy that they put together. So here's the patient criteria that they came up with. Nobody under 70, no more than two identified comorbidities. ASA one through three only. Anesthesia has the final say on this. If anesthesia said, nope, it's not done there. Then they have to have a full HMP prior to the procedure. So we have a 65 year old, good health, total left shoulder replacement, only hypothyroidism. PCP completed the HMP 40 days before, again, this is outpatient. When the patient shows up, the charge nurse noted the date of the HMP, called Dr. J and said, hey, this is not valid. We need to do another one. So Dr. J sends over the PA, surgical PA to do the HMP. PA reviewed the record, talked to our patient, entered a progress note, patient cleared for surgery. How do you feel about that? Will this result in citations? And if so, which ones? And of course it's none. Requirements, incomplete HMP, not following their policy and bylaws, insufficient bylaws, no clear definition about what is a valid HMP. And then anything else that you can come up with. And there can be more than one right answer. And Lindsey, I'll let you decide how that you want them to complete that. Absolutely. I do have that up there on the screen. So you can always select your options here. And if you do select others, feel free to type that into the chat as well. And for those of us who worked in healthcare for many years, just the idea of doing a hip replacement as an outpatient, they're doing it. They are doing this outpatient. I just find that amazing. Again, those of us who were in the dark ages with healthcare, we didn't let our hips move, let alone do it outpatient, but now we progressed and our systems have become so much more refined that yeah, it's very possible that they are doing these joint replacements outpatient. And by the way- While you are doing that, there is one question too, Laura. Yes. Okay. It says, if a patient is acute inpatient and then moved to hospice, does an HMP need to be done for hospice? That is a good question. And you know, I did send off a very similar question to CMS. And that's a good reminder because I haven't heard back from them. I guess if it's the same continued stay, I would follow what they said for SNF, but hospice could have different requirements. And so they may want to see a new HMP. Why is this patient going into hospice now? But yeah, that's, I'm sorry. I'm going to have to follow up with CMS on that one. What is the change in that patient's condition that it is so that this now they're in this new situation of hospice? Because again, we have to remember the hospice is reimbursed as opposed to the hospital. I know that sounds kind of funky, but that's the way I read the billing regulations for hospice. Okay. I'm going to end this and share those results. All right, good. I saw that question came in anonymously. So if you'd like to reach out to us at education at GHA.org and then we can work with Barron. You know, when she hears back from CMS, we're happy to follow up with you. And I'll put that also hospice, just to follow up with them. Hey, I forgot about this one. Okay, excellent. Yeah, these are all, yeah, they're going to get tapped on this one, unfortunately. That was an insufficient one. I do want to just show you some of the links. This is the 2023 for nurse practitioners as far as what their full practice is. I keep trying to go back and find the one if there was an update from 2024. So this is the most recent one that I did have based upon years. Physician assistant, what they have on their scope of practice. And, oh, I guess that was the end of it. So if there is anything additional, I will send off that language to you, Lindsay, in an email suggested, but please make sure your council has reviewed it and said, yeah, that looks pretty good. I don't want to get anybody in trouble, but those are the ones that I have used, especially in Colorado, that statement for the suggested policy and procedures. Perfect. Okay, I'm going to post some information here for you all in the chat, just as a quick reminder that you will receive an email tomorrow morning. Just note that it does come from educationnoreplyatzoom.us. So if this is your first webinar, just pay special attention that this email may get caught in your spam quarantine junk folder because it does come from that Zoom email address. So if you don't see it in your inbox in the morning, I would just encourage you to check those additional folders. If it's still not there and you would just like to access the recording, you can, of course, just go back and use the same Zoom link that you used to join us today to also access the recording. And just remember that the recording link is available for 60 days from today's date. And then we do have an additional security measure in place so that we can protect Laura's intellectual property here. So whenever you click on that Zoom link, it will ask you to enter your information, and then that will prompt an email to come to us for approval of that recording access request. We approve those very quickly, typically within just a few moments of receiving and then validating that request, but we ask that you give us one business day. And then also included in that email tomorrow morning will be a link to the slides that Laura presented today, but I did go ahead and provide that link there for you again in the chat. You'll have that as a resource now as well. And then if you're joining us as a member of the Georgia Hospital Association, please pay special attention to that final link that will be included in that email tomorrow morning, and that is a link to the survey. You'll need to complete that in order to obtain information regarding continuing education credits and to receive your certificate of attendance for today's presentation. If you're joining us as a member of a partner state hospital association, I encourage you to reach out to your contact within your hospital association to obtain any information they may be able to provide to you regarding continuing education credits that they are offering from your state as GHA is only able to offer those CEs to GHA members. And then, as I mentioned, if you do have any follow-up questions at all, please don't hesitate to send those to education at gha.org. We'll be happy to get those over to Laura. She is wonderful and very thorough in her responses, and we so appreciate her doing that. I saw a request come in asking to also be included in the information about hospice when that's shared from CMS. So if you'd like to be included in that, if you would just send me an email, you can send that to L, Kason, so L-C-A-S-O-N at gha.org. I'll post that here in the chat or to the education email address as well, and then I'll make sure to include that response there for you as well. Okay, I know, Laura, your content information is included here as well in this slide, and then, of course, all of your resources are there as well, but don't hesitate to reach out to us, and we're happy to help any way that we can. Okay, let's see. So can you explain the answer to the last question? I must have misunderstood the outpatient and healthy patient exception. H&P still must be within 30 days, no matter what, is that correct? Sure, sure, because if you're referring to this last discussion, what happened is he just put into the progress note, patient cleared for surgery. That was the extent of the H&P, and so that's why it was not considered sufficient. So they didn't follow their own policy and procedures on what had to be included. The bylaws were also a little fuzzy on what's considered valid, and then it was simply incomplete. We didn't know what was going on with this patient. Granted, she had one comorbidity, which would have been fine for the assessment, but it really wasn't documented. What happened? What did you look at? You know, I talked to the patient. This is what I have. This is her vital signs. She's cleared. She's going to surgery. It's okay, and by the way, then the physician has to sign off on that final one. So there was some information still not there. Now granted, anesthesia should also have picked up on this one, and that was another one that was part of the deficiency. Anesthesia didn't do their own assessment of this patient because she was going to have to have anesthesia that was required. So good catch on that one. Perfect. Okay, I don't think I see any other final questions, so we will give you back some of your time this morning, and Laura, we always appreciate all of your time and information that you shared with us. We look forward to having you all back with us for future sessions, and I hope you have a wonderful afternoon. Thank you so much, Laura. Okay, thank you, everyone. Thank you, Lindsay. Bye-bye.

Laura Dixon

patient safety

risk management

history and physicals

H&P

CMS surveys

surgery

anesthesia

documentation

regulatory compliance

medical records

hospital bylaws

advanced practice providers