I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of 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 the Director of Western Region Patient Safety and Risk Management for the Doctors' 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. Ms. Dixon is a registered nurse and attorney. Laura holds a Bachelor of Science from Regis University, a Doctor of Juvenile Prenups from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. And she is licensed to practice law in Colorado and in California. Thank you for being here with us today, Laura. I invite you to go ahead and get us started. Thank you, Lindsay, and welcome, everyone. We're talking on a subject today that has quite a bit of an impact, and telemedicine right now is undergoing a few changes, and changes in the way of reimbursement. Now, the good news is, right now, that reimbursement does not affect hospitals. It only affects clinics, so if you have clinics associated with your hospital, they may or may not extend payment for telemedicine services for clinical visits. Hospitals, yes, they are going to continue it. Now, they were going to discontinue that back in December with the expansion of the budget. They did keep that in. That is set to expire with, I believe, the end of this month. Whether they're going to then continue funding, I really hope so. Telemedicine has had such a benefit for so many of our patients, so I hope they do continue it. I always include my disclaimer that my program today is informational only. It is not meant to serve as providing legal advice or establishing an attorney-client relationship. Please reach out to your own counsel or legal representative for professional and legal advice. Just a quick introduction. For those of you who have not had an opportunity to listen, this is the reason that we're doing this, why GHA puts these programs on, so that you don't get that statement of deficiency, that you're aware of what the requirements are. Of course, no facility wants to be notified that they've been involuntarily terminated from that Medicare agreement because of a lack of compliance with the conditions, or it was insufficient, or they simply didn't let them in the door. That could also happen. On surveys and the overall process, the regulation, what we're talking about today, it all starts in what's called the Federal Register. From there, then, CMS has the responsibility to publish that regulation in what's called a transmittal. Essentially, it's a notice out to their surveyors. This is what's changed and what's been updated. They have to develop interpretive guidelines or rationales for why that regulation is there, and then what they expect to see. Of course, they have to update the manual. This is 2025. For critical access hospitals, your manual was last updated in 2020. For acute hospitals, yours was in April of 2024. They're coming up due for criticals. I've tried to reach out to find out when is that going to occur, because they're supposed to do it every five years at least, and I'm not getting a response. With all of the changes going on, I can't tell you when that new manual will be coming out. Three types of surveys. Certification, when you're going initially, then validation if they're coming back, or if you have deemed status, they will sometimes tag along and go with that survey. Then finally, the one hopefully you never have to have, and that's a complaint survey where a person, a patient has sent in a complaint to the state or regional office on the care that they received. The areas we're talking about, first starting with the acute manual. Now, I didn't include the whole page because it wouldn't fit, but we're looking at medical staff, which includes the telemedicine requirements. In critical access hospitals, yours doesn't have a separate title medical staff, but rather staffing and staff responsibilities, and likewise, that's where they put in your telemedicine requirements. I mentioned on deficiencies, nobody wants to get that notice of involuntary termination. I've gone back through the list and tried to find out what were some of the most common deficiencies that a hospital happened to be cited on, and these are across the nation. It's not one particular area, it's across the nation. One, we had a practitioner who wasn't, they were acting outside their scope of practice. These are generally advanced practice providers, or the hospital actually allowed the practitioner to do something, but they weren't privileged and credentialed to do it. They didn't hold the medical staff accountable for quality of care as required under the QAPI. We didn't have our physicians assessed for competency, a lot in that area, many in that area. Credentialing, privileging hadn't been done every two years. That's what CMS recommends. They didn't follow their own bylaws, their own rules and regulation. Not enough specific criteria to show competency. In other words, it might have said something to the effect of, the physician can perform this task safely. That can be broadly interpreted, what is safely, as opposed to they maintained a sterile field, they were able to control bleeding, they did follow up and make sure that everything was done appropriately and according to standards of practice. No history and physical on the chart, or it was simply inadequate. Not enough assessment on the chart. They didn't include documentation in the file, and this is in the practitioner's file, of what privileges were actually granted. HMP not done within 24 hours or updated prior to surgery requiring anesthesia. And then just a couple more, they didn't adequately assess a patient, so that the plan of care and treatment could be done. Again, not following their own policies. Medical executive committee didn't provide oversight for the quality of care. Here, another one, they didn't make sure advanced practice nurses were privileged and credentialed. Missing required policies or the policies were not updated. When there is a policy that is required, I will spell that out on my slides. Before I go into the actual medical staff polling, I want to talk about the overlap between the governing body and medical staff section. And there's three of them that we're going to talk about. And by the way, Lindsay did mention we have a few polling questions. Some are just for informational only. Others will bring in a situation that we all have to comment on. So here's our first one. Lindsay, do you want to start with this one? Sure will. So you should all see this question now on your screen that says, our board recently added other non-physician practitioners, my goodness, eligible for appointment to the medical staff, including midwives, psychologists, dietitians, and certain pharmacists. Your options here, yes, no, or not sure. And Laura, we have actually had one question come in that says, what about rural health clinics that are under the tax ID of a hospital but are outpatient clinics? Yeah, those will be under the rural health clinic manual. And I believe we're discussing those requirements later on during the year, Lindsay. So those have to follow those requirements as a rural health clinic. That's generally how CMS will survey them. Yep, absolutely. And I saw the question came in anonymously. But if you are a member of the Georgia Hospital Association, just pay special attention to our calendar of events later in the year. We will have a session or a series of sessions, I believe, on that topic. Okay, we'll go ahead and end this poll and share those results. Okay, so good. And again, there's no right answer on these. And this one in particular, it sounds like some of the hospitals are starting to expand some of their staff, which is great. I mean, if you can utilize them and they're beneficial, why not? They can help. I want to start with the governing body. By the way, those numbers you see in the upper right-hand corners, that is what they call the tag number. And these are for Appendix A. There will be four letters, four numbers, excuse me. So it'll be A0044. So what you have to do, this is a governing body. These are like your C-suite, et cetera. They have to make sure the medical staff requirements are met. In doing so, they start off by determining who gets to practice in your hospital, what category of practitioners are eligible. It must be include, the medical staff has to include MDs and DOs. Now, how you make up that combination, if you want to include DOs, whatever, or just straight DOs, that's your decision. But it has to be a doctor of medicine or doctor of osteopathy. They can also, though, include other types, dentists, podiatry, chiropractics, optometrists, whoever you want to include as a practitioner. And now practitioners included in that definition as a pharmacist, well, of course, we know they have to be legally authorized to practice within your state where your hospital is located and should be granted privileges and appointment to the medical staff. We know they have to stay within their circle. There's four walls or their scope of practice. CMS will not tell you what, a physician, a PA, a nurse practitioner, or anybody. They won't tell you what they can do. That's up to your medical boards. They determine that scope of practice. But you have, the board has that flexibility to determine if they want anyone else on the medical staff as long as it's consistent with state law. In the manual there, you will see what's called blue boxes. Those are, you're not cited on it, the information in there, but it's good information. And sometimes they will give you links, internet links to find this information. The blue box talks about how you can credential others that aren't on your medical staff if, as long as it's not prohibited by state law, such as a CRNA or a midwife, whoever you want to include. The governing body and medical staff, if that's what you're going to do, then exercise oversight for those granted privileges. And we do that through competency and credentialing. So that's what that blue box looks like. It does expect that they have been granted privileges to be on the medical staff. On your non-physicians, again, others can be eligible as long as state law says they can do that. And we know they probably have a more limited scope of practice, like a PT or an OT. Again, governing body, medical staff, they have the responsibility to have oversight on these individuals through competency and credentialing review. As far as privilege types, again, the governing body and medical staff come up with that. Is it going to be courtesy? Is it going to be full privileges? Is it going to be temporary privileges? The governing body has to consult directly with the medical staff. Now, that can be one person, like the head of the medical staff, the CMO, president, whoever, however you title them. But they have to have some consultation. And that's the person who's responsible for the conduct of the medical staff. Direct has to occur periodically throughout the year. CMS does recommend at least twice a year. Now, if you're a large system, you may be, your medical staff or that individual may be actually meeting with the governing body 4, 5, 7, 12 times a year, depending on how large you are and the scope of your services. But it has to have those matters on quality of care provided. By the way, just because someone on the medical staff is on the governing body, that's not enough to meet that requirement, unless that they include meeting periodically to discuss matters of patient care. So, yes, it can, but be very careful on making sure that is what they're doing. If you're in a multi-hospital system, then the governing body has to have some direct contact with each CMO of the organized staff for each hospital. That could be how many people in your system, could be maybe it's five facilities, then it's five people. You can do direct, in other words, face-to-face telecommunication, synchronous communication. So, there is that dialogue back and forth. So, that is the overlap between the governing body and the medical staff. I'm going to move now just on to medical staff. This is for your acute hospitals. You have to have an organized staff operating under bylaws that the governing body has approved. And these bylaws apply across the board. I don't care if you're a temporary physician or if you have full privileges. Each hospital, by the way, if you're in a couple hospitals system, you can have separate You can have separate medical staff or you can share a medical staff as long as all the requirements are met. So, as far as eligibility and appointment, it can be doctors, other categories, non-physicians, as long as, again, state law says that's fine. You can do that. And their scope of practice is met. I put in here dieticians because a couple years ago, CMS recognized dieticians really can provide such a huge benefit for helping develop plant therapeutic diets where physicians might not have the opportunity to stay up to speed with them. You know, what's good for your kidney patients? What's good for your cascadic patients? What do we need to get them going? And they recognize dieticians have it. It's there. That's what they do. And so, CMS decided, okay, maybe they should be privileged and credentialed so they could write orders. If your state permits it, CMS is fine with it. But all practitioners have to be privileged and they have to follow and be evaluated under the bylaws and rules and regulations. So, of course, that means we start with their credentials. Where did they go to school? What are their levels? And are they licensed? We have to periodically look at their conduct and how are they performing? The bylaws spell out how often that's going to occur. And, again, CMS says every two years. So does, by the way, Joint Commission. Make sure they continue to be suitable for that continued membership at a minimum every two years. What you're going to look at, of course, is their qualifications and are they competent? Can they still perform those acts within that scope of practice and what they have asked for privileges? You want to look at any special training. How are their patient outcomes? Are they starting to have a lot of surgical site infections? How are they doing on readmissions? Are they keeping up with CME? Do your state require CME or do you require it as an eligibility for appointment? Licensure, education, adhering to the rules, and then, of course, compliance with all their licensure requirements. Requirements. You have to look at each and every member. Are you going to continue that level of privileges? Or do you need to change them or revise them? Or do you need to send them on their way, terminate their privileges? If you have a provider that wants to request certain privileges that goes way beyond or beyond that scope within that category, they have to be appraised by the medical staff and then the board has to approve them to do that. Likewise, if you're going to limit privileges, follow any laws that you have to have on limiting those privileges and any reporting requirements. You may have to report that to the National Practitioner Data Bank when their privileges have been suspended or terminated. On credentialing, we will look at those credentials and then make recommendations to the governing body. This is the person we want practicing at our facility and then the governing body appoints them. You look at what are they requesting to do, evidence of licensure, any education, training, do you have documented experience, and any supporting references on those competencies. Some of you probably have your privileging and credentialing team that goes out and collects all of this information for the medical staff then to review it and then make the recommendation. Any recommendation, of course, according to the scope of practice with the state law requirements and then what the bylaws say. You may have a phenomenal advanced practice nurse who is requesting privileges within the scope of practice by the state, but maybe outside of what the bylaws say they can do, rules and regulations. So, again, just because the state law says they can do it, you don't have to allow them to do it. It's up to you. Otherwise, just because they're board certified, that's not enough in CMS's eyes to make that recommendation. Again, you can require it, but just going on board certification is insufficient. The governing body, the medical staff, they have to enforce those requirements and take action when you've got a member who isn't playing by the rules. All members who do hold privileges have those protections and due process rights, which means if there is a concern or an issue regarding the care, they have due process rights and having that reviewed, having an opportunity to respond and present evidence. That's why keep those separate credential files for each person on your staff. Now, this is for those who are on your individual staff, not telemedicine necessarily, but your staff. And, again, if you limit them, make sure you're reporting according to National Protection or Data Bank, excuse me, because we know we've got to keep an eye on these folks. Have they been appointed and credentialed? This is a situation we know, it's old, it's like 11 years old now, but where Joan Rivers unfortunately died as a result of some complications. And here we had a physician who was doing a laryngoscopy and this person was not up to snuff. And this particular facility hadn't done their due diligence in making sure that doctor was appointed and credentialed. In other words, they were safe to practice within their boundaries. Otherwise, you have to have your medical staff accountable to the board, whether it's, again, a single board, just your hospital, or you're in a several hospital system. Organized, that's approved by the governing body. If you have an executive committee, the majority must be physicians, MD or DO. The responsibility for the medical staff is assigned to, though, an MD, a DO, or other practitioner, as long as the state law permits it. So even though you might have a medical executive committee where the requirement is a majority of physicians, you can have the responsibility for the medical staff assigned to other than an MD or DO. That's okay. The conditions create that checks and balances where there's a good framework between the governing body and your medical staff. In short, everybody has their lane that they have to operate in, their own areas of authority. Medical staff, you do oversight through peer review and privileging. Governing body, they spell out who gets to be eligible for privileging an appointment, but the medical staff then does that to review, are these folks safe to practice in our hospital? If, again, you have that medical executive committee, the bylaws and rules, again, they have to spell that out that you're going to allow. It's not required, but the bylaws have to spell it out. And the nice thing is they can delegate a lot of the functions to the medical staff more efficient and can improve policy and procedures, getting those done. Because especially if you have a massive or good-sized medical staff, it takes time to get things back when you're sending out, say, a policy and procedure for review and approval, and you've got 200 physicians that it has to go through that chain. Having that executive committee really makes it more efficient. They look at it, and then they can review and approve it. But, again, they're accountable to the governing body for care. And we do that through appointment, appraisals, peer review, participation, and quality assessment, performance improvement. The survey will look to make sure you have a formal, organized structure. This is going to be reflected through your bylaws, your rules and regulations. It will spell out what are the responsibilities of the governing body and the medical staff. It will make sure the majority on a medical executive committee, if you have one, are M.D.s or T.O.s. And they sit down and they talk to your C.E.O. and then leadership of the medical staff. How do you make sure medical staff and governing body are fulfilling those responsibilities, whether it's accountability for quality of care or appointment to the medical staff? How is that occurring? They will interview your leadership on medical staff and other members of medical staff. What's your duties? What are your responsibilities? How do you carry those out on a day-to-day basis? How do you describe accountability for medical care? How do you do that? That could be something as simple as our leader sits down with our governing body every month during a board meeting. It's on the menu or it's on the agenda and we go through. These are the issues that are going through. And then we work together on coming up with a solution if there's a problem. And we participate in QAPI. So those are just some of the things that they're looking for when they want to find out how are you accountable to the quality of care. I'm going to talk briefly about if you're part of a system. They had a few changes that came out about four or five years ago. If you're part of a system or separately certified hospitals, you have an advantage. You can have a unified integrated medical staff. You can do that. As long as state law or any local law says it's okay. Now each hospital, if you're going to do this, the nice thing is each hospital doesn't have to have that distinct medical staff organization and structure. You can have hospital specific bylaws, rules and regulations, but you don't have to. That's one of the advantages. Same with leadership. You have a larger pool to choose from for leadership. Credentialing and peer review can be shared, so to speak. Share the wealth in those duties and responsibilities. Now if you're under a multi-campus hospital with several inpatient locations, provider based remote locations, that is not a multi-hospital system. That's a multi-campus hospital. In other words, you have one certified hospital. You can't have medical staffs at each location, separate ones, and you're not using that unified medical staff according to how the regulation is. Again, that's a multi-campus hospital. If a multi-campus hospital is part of the system, that's great. Then you can share. You can do everything we just talked about. You can share staff, duties, and responsibilities. If you're going to do this, each hospital has to show that the medical staff who hold privileges of each hospital voted by a majority to accept a unified and integrated structure, or they opt out and you all play along in your own individual hospitals. If your physicians happen to hold only telemedicine privileges, they cannot vote, and the governing body must elect and approve the unified medical staff. That means you may have to go back and look at your bylaws, rules, and regulation. If you had rules and regulation before 2014, and you had a shared staff, then you had to have some evidence the board elected to do that. That's going to be usually through your board minutes. You are expected that bylaws, rules, and requirements, everything is amended in a timely fashion. Again, hospitals can opt out if they wish to do so. What happens if your hospital is acquired by a system, but you've decided or the decision was made to maintain separate participation in Medicare? The governing body can still elect to use a unified medical staff, and the staff has to accept that election. They are expected to make changes to the bylaws, rules, and regulations, and no later than six months after you have been acquired. Again, that's when your hospital was bought out by a system. Bylaws, rules, excuse me, they describe the process for self-governance, appointment, privilege and credentialing, peer review, due process, rights, everything, including that you can opt out of that shared medical staff at a later date if you wish to do so. They again want to see documentation on that. If you're part of a system and you're sharing a medical staff, then you must take into account each hospital's unique circumstance. Maybe it's patient care or patient population, the services you provide, whether it's a behavioral hospital or an acute care hospital, different sizes, different locations, teaching hospitals where you may have different requirements. And then policies, of course, have to be updated, make sure that the needs and concerns of each hospital is given consideration, and how you make sure those issues localized to that particular hospital are also considered, because they could be vastly different from a large teaching hospital from your acute care hospital that's maybe 200 beds. They could be very different. The surveyor is going to do a couple things here, and this again is with your shared staff. First off, how about standing orders? How are they going to be approved by the medical staff and nursing and pharmacy? Any policy and procedures on drug errors? Policies on unique circumstances? The formulary, your pharmacy formulary, who's going to make the decision on that, on what goes into it, based upon maybe some unique circumstances? Ensuring infection prevention and control problems are identified for each hospital based upon their needs. And then leadership, how do they make sure QAPI program requirements are met? So again, if you're going to participate, there's a lot that goes into that. Otherwise, on bylaws, the medical staff has to adopt and enforce them, the governing body approves them, along with any changes. The bylaws include those categories, those statement of duties and privileges in each category. On categories, the bylaws have to have a statement of duties and privileges, whether active or referring, that whole spectrum that's in there. Specific privileges have to reflect activities that the majority, most of the practitioners in that category can perform, cardiac surgeon, general surgeon, trauma surgeon, because we can't assume that just because I'm a physician, I can do every task or activity that's in that category. An individual's ability to perform each task has to be individually assessed. So again, even though I'm a physician, maybe I'm doing OBGYN, I don't want to be doing general surgery because I may have got a little rusty on that, but I can probably take out a uterus or do other obstetrical gynecological surgeries in a heartbeat, not a problem. And that brings me to my second question. Lindsay, will you take care of that, please? Absolutely. I'm going to read this first part to you, then I'll post the question there on the screen through the says, hospital C is due for a state survey. One week prior to the anticipated visit, the CMO, who is a neonatologist, had privileges summarily revoked, concerns surrounding his capabilities. Two other physicians, a neonatologist and pediatric intensivist, submitted resignations in protest, leaving the hospital without sufficient specialty coverage. Could this be a concern during a survey, is the question here? And you should see this on your screen now. Your options here, yes, no, or not sure. And by the way, on some of these situations, I've been able to take them from some of the complaints and also from some of the deficiencies that have come out from CMS. So that's where some of these issues do come from. Perfect. And we've had another question come in, Laura, that asks, what about if you're part of a health system and the critical access hospital is in a different state than your main campus? Are you required to have separate governing board and bylaws, rules and regulations? That's a good question. That may be beneficial for you because having separate ones, because there may be a specific state law in that other state that isn't applicable in your state. And so that's what your bylaws, rules and regulations spell out. How are we going to address our smaller hospital that may be governed by different rules, just by state law, that may be governed by state law. So that may be a benefit to have separate policies for them. I don't know if CMS has ever approached that question. That's a good one. I may have to send that off to them and get their input into that. Absolutely. Okay. That was the only question. Let me go ahead in this poll and share those results. Okay. Okay. Oh, yeah. Yeah. Sorry. Our poor hospital is going to have a little bit of an issue with this one. So on the bylaws, on your organization, the bylaws have to spell out the structure of the medical staff. And that's why rules and regulations have to make it clear what are the acceptable standards of care to take care of your patients, whether it's surgical, medical, behavioral health. And the surveyor will make sure those bylaws spell out that formation of the leadership. Who is responsible for the review and evaluation of the care provided by the medical staff? Any candidate, the bylaws have to spell out those qualifications for any candidate. What is the privileging process? And that there is criteria on determining privileges. You probably heard, what are the qualifications? Here's the criteria. These are the ones that the bylaws have to spell out. Character, training, experience, current competence, and individual judgment. No longer, again, can it be just simply because they're board certified, they belong to the American College of Surgeons. That's not sufficient. We have to go through those five qualifications. I'm going to leave the individual medical staff. I want to talk about history and physicals now. We know we have to have an HMP that is no older than 30 days before admission, or it's completed 24 hours after admission on each patient. They decided to really put this thing across. They wanted to get this word out. So not only is it in the medical staff section, it's in surgery, and it's in medical records section. The medical staff has to come up with the bylaws to carry out those responsibilities on HMPs. One of the main things, it has to be on the chart before surgery unless you have a healthy outpatient. And I'll get to that in just a little bit. But that exception came around about three or four years ago. But continuing on with HMPs, if you have advanced practice providers, under CMS now, those advanced practice providers can do HMPs if the state law permits it. And of course, your hospital bylaw is permitted. It's fine under CMS. But the physician is still responsible. In short, they have to sign off when it is done by one of those other type of practitioners, regardless of what state law says. So in my state, advanced practice nurses, they're fairly independent. But under Medicare, if they're working with a patient that's inpatient, they do the HMP, that physician still has to sign off on that HMP. So it still has to be some entry, an updated entry in the record. So it was done outside. Now it's in. It's inpatient. Something to reflect any changes. Whoever does it has to be licensed and qualified. So let's say you've got your family practice. They do the HMP two weeks ago. They're now patient. It's inpatient. Surgeon reviews, determines any changes, and then authenticates it. You can include that authentication or update, review, whatever it happens to be in the progress notes. You can use a stamp sticker, a checkbox, whatever it is. And here's just some of the wording if you wanted to use HMP reviewed. Patient examined. No change occurred in the condition since it was completed. But you have to have a completed HMP in every chart, again, unless it's an outpatient procedure. And that's when, again, it's outpatient. Say your hospital runs an infusion outpatient therapy, or maybe they have an outpatient surgical process or a surgical system. If you're having an outpatient procedure, pain procedure, I'll use that for example, they're coming in outpatient to do it. You can do an assessment that you don't have to do the full history and physical. These are the ones where these folks don't require anesthesia services. If they do require anesthesia services, yes, you have to do the HMP. But if it's outpatient and no anesthesia, you can do the assessment. So these, again, if you have to have anesthesia, but you have to have a policy on it. Which patients, which procedures is it going to apply to? And the bylaws have to reflect those requirements. If you're going that route, the assessment has to be completed and documented after registration, but before you do anything on the patient. So this is what your policy would have to consider. Age and diagnosis of the patient. How many surgeries or procedures are you going to be doing? And then looking at your patient, what any comorbidities that they may have, whether it's diabetes, heart disease, or maybe they're a person of size. What level of anesthesia is required? Are we talking MAC? Are we talking full anesthesia? Any national guidelines, standards of practice that we have to comply with? And of course, any state or local health laws that we still have to comply with. So if your state says no, under no certain circumstances can a patient go or have a procedure without an HMP that trumps this HMP requirement or assessment that CMS has spelled out. On the criteria for determining privileges, it's again, the bylaws have to have that. What are the criteria and how are you going to apply it? Then the governing body grants privileges based upon the medical staff's review and recommendations. Telemedicine is a little different. I'm just going to say briefly here, we'll get into it later. Under telemedicine, the nice thing is the governing body can allow the medical staff to rely on the privileging and credentialing processes and information that a distant site hospital or entity has when making a recommendation on privileges. But it has to be in that telemedicine agreement. It must be in writing. Just a quick note on certified nurse midwives. In September of 23, there was a memo, because I think there was a lot of confusion back and forth on supervision of certified nurse midwives. CMS did recognize that these practitioners do provide access and good quality care to mothers and infants. So, an acute hospital, you can privilege and credential them. But here's the exception. You don't have to have oversight for Medicaid or non-Medicare patients if that nurse midwife is admitting them, if the state law and policy permits it. Critical access hospitals, however, you still have to provide oversight for all inpatients, including non-Medicare patients. Somewhere along the line, there was some confusion that that applied to all hospitals. CMS came back and recognized, no, according to the law, the way it's written, CMS kind of overstepped their bounds. And now, for criticals, they have to have oversight for any inpatient that a certified nurse midwife may admit. Moving on to medical staff for critical access hospital, it is very similar. You have to have a professional staff that includes at least one physician and one or more advanced practice providers. The surveyor wants to see your organizational chart. They want to see the scope of reporting. And they're going to look at the work schedule. What are your hours of operation? And how much of coverage do you have? Ancillary, your tag numbers, by the way, start with the letter C and then the four-digit number. Ancillary personnel, they're supervised by your professional staff. You have to have enough to provide services. And they have to be available. Your providers have to be available at all times to provide care. If you have an RN, a clinical nurse specialist, or an LPN, you have to have at least one on duty whenever you have one or more inpatient. The surveyor, again, is going to look at work schedules. They will talk to staff. They want to make sure you have enough personnel to provide care to those patients and especially the acuity of the patient. You could have a moderately sick inpatient where you have one RN and one LPN. That could be fine. That's what they want to do is compare the acuity and the staffing and the overall patient population you have. And criticals, the duties of the physician, are to provide direction, medical direction for everything that occurs, whether it's consultation, supervision, or direct care. With advanced practice providers, they work with the physicians in developing and carrying out and reviewing written policies on patient care. And also, they periodically review with the physician patient records. They provide orders and care and services, of course. So the physician periodically reviews and signs off all inpatients cared for by those advanced practice providers and a sample of outpatient records. The interpretive guidelines, again, inpatient, they're expected to cover all records that are open at the time of review. That could be five patients. It could be the full 25 patients. But they will cover all of those records. They will also at the same time look at any outpatient records. At that time, right now CMS is recommending 25% of your outpatient visits. It's not required. It is a recommendation. So they may go ahead and look at the full 25. And states where you don't have to have physicians review or co-sign, again, they're not required to review and sign outpatient records, just inpatient records. The critical, you establish that maximum time between that inpatient record review. Put it in your policy and procedures. Is it going to be once every three days for an inpatient, once every 24 hours for an inpatient? You determine that. And you can do it either in person or offsite, like by telephone, if you have the luxury of being able to pull up the computer and see the record and do it over the phone or by computer, that's a good way to do it. Otherwise, the physician has to be present there long enough to provide direction and supervision. Being present in a critical access hospital meant being on site, but the minimum amount of time isn't spelled out in the interpretive guidelines. They don't do that. You determine that. Again, how long do you want them there? That may depend on what's the acuity of the patient, what's going on. They can do this oversight by phone or in person, however it works. And you can use telemedicine to fulfill that requirement. Just a couple other provisions, the physician has to be notified when an advanced practice admits a patient. They must be under the care, Medicare, Medicaid patients under the care of a physician. And quality and appropriateness of care by that advanced practice has to be evaluated by a member of your medical staff. That review can be by a physician, because we still need to review their care also. If you're part of a network, quality improvement organization, or another entity that is qualified per your rural health plan. And that's the same for telemedicine providers. It's the same thing. So if you're using telemedicine and you don't have enough physicians on site or on staff to really do an effective review, you have those three other options that you can do. So other considerations, the hospital improvement rule, they took out the requirement that in an autopsy program, you have to have one to qualify for reimbursement because they did that to take out some of the old requirements. Now they defer to state laws. Try, what they're saying now, is try to get those autopsies when you've got an unusual death. Maybe there's a medical issue that happened or a legal issue or educational interest. Now, your state coroner or whoever that happens to be, your state medical examiner, however they're identified in your state, they will determine if they say yes, an autopsy must be done, then that rules. So just keep that in mind. But they did take out the requirement that you have to have an autopsy program in order to get reimbursed. But you still have to have some way that if you're going to do one, that you get permission to do an autopsy. Again, it doesn't apply if the coroner or medical examiner orders it. There you don't have to have consent. There's other conditions of participation for compliance that are addressed throughout the entire manual. It's everything from verbal orders, patient rights, advanced directives, restraint seclusions, that somewhere along the line medical staff is involved. But this, if you look at it, it really talks about the overall provision of medical care. Not just one thing, overall provision. So let's talk now telemedicine. And starting with acute hospital, I have the tag numbers only 52 by reference only. And here's our third question, Lindsey. Okay, let's get that one up here on the screen. Okay, there it says, our facility has a policy on telemedicine that includes, and you can select all that apply to your organization here, proper use of the service, who can access the service, privileging and credentialing for the remote site providers, practitioners who can provide telemedicine to other sites, circumstances when telemedicine cannot be utilized, or not sure that we have a policy on telemedicine. We have had a couple of questions come in as well, Laura, while we're waiting on those responses. So this says, where can we find the requirement of signing off on the HMP if completed by the NP or PA? Yeah, that's with looking at tag number. And I can't recall the tag number right off the bat. But I will try to, yeah, I'll identify that and send that to you, Lindsey, by email. Okay. Yep. Perfect. And Sadie, I see that question came from you. So if you'd like to email education at gha.org, I can send that question over to Laura for further information. And the slides are linked in the chat as well. So you always have that as a resource. And as you mentioned earlier, those tag numbers are in the top right hand corner on the slide pages. So hopefully that helps as well. Okay. What does it mean that the assessment must be completed after registration? Does it have to be day of, or can it be within 30 days with an update? No, this is the one where they're talking about the assessment versus a history and physical. So I'm checking in for an outpatient cataract surgery. And this is the best way to describe it. I'm checking in for an outpatient cataract surgery. My physician who's doing the cataract has to do that assessment after registration, but before he or she can start my cataract procedure. That's what they're talking about. 30 days is for the history and physical, not just the outpatient assessment. It's the history and physical. That's 30 days. That is within 30 days of admission or within 24 hours after admission. So I hope that clears up that distinction. Perfect. And then what timeframe does the physician have to be notified of an admission made by the PA or NP in a critical access hospital? That's a good question. They didn't spell that out. Usually it's as soon as possible. And that's where your governing body and medical staff have to determine how soon, because again, they have to be signing off on this care that's provided by those advanced practice providers in a critical access hospital. They have to make sure that's being done as soon as possible would be my recommendation for an admission. Okay, good. Excellent. Everybody's pretty much got it across the board. That's good, except for the last one, of course. But let's talk telemedicine. It's been around for a long, long time, and it's been a huge help for us. Huge help in that I'm a smaller hospital. I don't have a neurosurgeon on staff, but that neurosurgeon, I can reach out and say, this is what's going on. What do we do until we can get them over there or where they need to go? It's the provision of services by practitioners from a distance using electronic communication. We can do it simultaneously like I'm in ICU and the telemedicine provider is on the screen talking to me, seeing me, or non-simultaneously where we have teleradiology, where they're looking at them overnight. COVID-19 really expanded that use of telemedicine and it helped protect. This really did a huge benefit because it kept us away from each other. In other words, providers and patients, we cut our transmission down by doing so. In 19, there were 840,000, 2020, 52.7 million telemedicine visits. Now CMS has asked, add this to keep it so we can continue with telemedicine and telehealth because it makes a huge impact. I don't know if any of you have used telehealth yourself for say clinical visits, but it's a huge advantage. I don't have to worry about weather if it's bad. I live in Denver where once in a while we get a snow storm or some bad weather and I don't want to leave the house. It's nice I can go on and use telehealth. The physician sees me, I see them. It is a huge benefit. I am hoping they do continue it. Here are the trends for 21. This was the last one that I could find for how the increase, we had that spike, especially in June of 2021. Then it leveled out and started to come in. We know it's a strategic tool and not only can it help improve outcomes and safety, again, we're not transmitting all these bugs, especially if you've got a sick person with maybe pink eye. That's always something nice to spread around. It can help grow your revenue because now patients have that alternative option. It can be very efficient. Those hospitals, in fact, hospitals using telemedicine had higher profits according to one study. This was 16 hospitals and they almost doubled their revenues. For one year. That speaks volumes right there. Increased access to care when maybe we don't have that specialty care. Maybe 80 more services can be allowed and provided through telehealth, like telebehavioral health. They can bill now for visits outside at the same rate as inpatient. Again, that's why we're hoping it continues that we can make sure, yes, indeed, this is a huge benefit and we found some great success with it. Overall, telemedicine, we've got two individuals, two bodies here. You, the originating hospital, and then we have the distant site hospital. That's who you're contacting. But the governing body has to determine, are we going to use this service? And in doing so, again, they can allow the medical staff to use the privileging and credentialing at that distant site hospital and making a recommendation on privileges for your patients at your hospitals. Again, this was covered in 52 under their duties. So let's start with the distant site hospital. That's those other, the others. This is the hospital. The board has to make sure there is a written agreement and that all of the following of these bullets are met. One, they must be Medicare participating hospital. Any provider has to be privileged at that other hospital. The hospital has to give you a list of their privileges that they're allowed to do, and the provider holds a license in the state where your patients are located. Now, under COVID, yes, they lax those rules, but now that is back in effect. So they must be licensed in the state. Your duties as the originating hospital, you have to also show you are somehow reviewing their performance of the practitioners that are providing this telehealth service. You have to then send information back to the other hospital, the distant site hospital, of any performance issues that you found through periodic appraisal. It must have all adverse events. It must have all complaints that did come up as a result of those telemedicine services. If you use an entity, which is you, that can be like a group of physicians that work off-site or a non-Medicare participating hospital, that's now an entity. It's similar. The governing body can have your medical staff rely on those privileges and credentialing decisions and making a recommendation on privileges, and that's for the individual providers. So the governing body has to make sure in that written agreement with that entity that their privileging and credentialing processes are the exact same as yours. In other words, they have to make sure those processes meet the conditions of participation. Then the rest is similar. The practitioner is privileged at that entity. The entity has that list of privileges they give to you, and they hold a license where the patient's located. Now again, an entity is a group of docs that get together or a non-participating hospital. The originating entity, they have to have evidence of internal review of their performance, and again, this is you, and you have to send that information of their performance back to the entity or the non-participating hospital. Adverse events or complaints can be good stuff, all good stuff. Yeah, we like them. They're great, but these are the two minimum that must be included. The surveyor wants to see that written agreement. They want to make sure all of the requirements are there. Participation in Medicare, the list of providers, they are licensed, you have proof of that, and that there's a statement you relied upon that privileging and credentialing in making your recommendation. They will look for evidence that you have reviewed the services that were provided. Now here, as opposed to having individual files for individual providers, you can have one file with everybody, or you can keep a separate file, whatever works for you. They don't make that determination. Critical access hospitals, you are very, very similar, and that's our next question. Lindsay, please. Okay, this says that county hospital is a critical access hospital with one emergency physician and one APN on staff. There are situations where the on-call provider is occupied and another patient presents and is experiencing a possible medical emergency. County would like to utilize telemedicine for the assessment and treatment of the presenting patient. Would you recommend such? And let's get that question up here. And your options are yes, no, or not sure. Okay, and this other question has come in, Laura, that asks, actually, I guess it's more of a statement here for those who may be joining us from Louisiana, that Louisiana rural health clinics cannot bill for telehealth on general medicine or specialty-only behavioral health. Wow, so that's a Louisiana law. That's too bad. Yeah, I say it's too bad because so many states are seeing such a decrease in the behavioral health services that are available to them. Absolutely, absolutely. And if you have, I saw something else come in earlier, and I responded to the person individually as well, but if you have a more state-specific question, you can always send that over to us at education at gha.org. But I know Laura is presenting this information today more from the CMS perspective, and you may very well have, you know, different state state law as well. But that's nice that your participants are sharing that information. That's excellent. Absolutely. Okay, we've gotten some good responses here. Okay, so yes, no, and again, and I will qualify that based upon that reference. It could depend on what your state law does permit or not permit. So let's talk telemedicine. Remember, our patient came in through the emergency room, okay, because we know some criticals, they don't have a physician 24-7 in the emergency department. They could have an advanced practice provider who has that training, that extra training. But what the conditions say for criticals is you have to have a physician immediately available by phone or radio contact if they're not there. You can use telemedicine for that requirement, and there can be also any physician who practices actually on site within the hospital. On emtala, now you may have an RN do initially assess that patient. They can be deemed a qualified medical provider that has been approved by the medical staff and board because they can do that medical screening exam, and they can use the services of a telemedicine provider to help with that, which is great because there may be something that the telemedicine physician or practitioner sees that the advanced practice would not. But just note, emtala does require a practitioner be available in the ED that can respond. They're on call, they can respond and be on site within 30 minutes if required. You can't get around that requirement by telemedicine. So if the nurse practitioner gets a patient in and telemedicine is there helping assess this patient and say, you know what, you need your MD in there, the MD has to go in, and they have to be there within 30 minutes of time frame. So the physician on call who is requested to make an in-person appearance, that's a hard one, after they've been evaluated, they have to come in within a reasonable amount of time. So for the telemedicine on your hospital, it's the same that we covered under the acute. The governing body makes sure you have an agreement that spells out what are the responsibilities, that they're appointed to the medical staff on the recommendation of the current medical staff at your critical access. The disincide hospital participates in Medicare, the provider is privileged and credentialed at that other hospital, and they're licensed in the state where you're located. Again, this agreement has to be in writing. There has to be internal review of, again, the services provided by that telemedicine provider and events, complaints, they're communicated back to their own hospital. I already mentioned they have to participate in Medicare and give a list of those physicians who are telemedicine providers and their privileges. Same with an entity. Governing body has to make sure the agreement's in writing and sets out what are the responsibilities of those telemedicine providers, that again, they're contractor services, that they provide those services in a way that allow the critical to comply with all the conditions at hospital with you. In other words, they're responding, doing what they're supposed to, and licensed in the state where you're located. Now, it used to be CMS didn't allow entities, they wouldn't reimburse for entities, but they recognized that sometimes criticals don't have the option of having another hospital. So that's why the entity may be more economical. CMS recognized that, well, wait a minute, if they're going to be doing this, but we're not paying for it, maybe we're missing out on something. And so this way, they can provide a little bit of oversight for those entities or non-Medicare participating hospitals, a little bit, and it's gone through you as a critical access. But otherwise, they rely on the privilege and credentialing of the entity or hospital. That's what the agreement has to ensure, that the provider's licensed, they have a list of their privileges, and you send back information on complaints or any issues or adverse events. The interpretive guidelines, as far as the definition of an entity, that's one that provides telemedicine services, but they're not Medicare certified. It's contracted, and they have to just make sure you meet all of the conditions of participation. For credentialing, it's an alternative way that you can do privileging credentialing of telemedicine providers. Proxy credentialing, again, that's a distant site hospital or entity. Again, as long as they're doing their business and making sure it's done appropriately, then you can use it. Written agreement has to be present, and it states that the entity is a contractor of services. CMS does not have jurisdiction. I mentioned that they don't have jurisdiction over the entities, but in a way, they can help enforce some of the requirements because it goes against you. That's who they're looking at. In that agreement, with that entity, are they providing services so you, as a critical access hospital, meet those needs, meet those requirements? Contract provisions in a hospital, again, what you want to include in there that they participate in Medicare, the practitioners are privileged at their hospital, and you have got a list of those privileges and the providers licensed in your state. Same thing with an entity. The entity is a contractor to you. This is what the written contractor has to say, that the entity has credentialing and privileging processes that meet the standards that they provide a list of physicians or providers, including privileges, and that they're licensed in your state. You also have evidence of review of services provided and sends it back to that entity for periodic review. You want to include that in your written contract, that, yes, indeed, we are going to review their services, and you will be notified of any adverse events or complaints. Medical staff should do annual review, approve that list, because you may have had a situation or an event where that just didn't work out for everybody. We don't want that telemedicine provider back. Monitor these events. Monitor those complaints. Be aware of any grievance requirements, because if you get a grievance from a patient, from the care provided by a telemedicine provider, you have to act on that. You do have to review it. Make sure, if you have what's called a consumer advocate, that they know about any telemedicine requirements. Any events go back to that facility and any compliance to the relevant committees, whether it's medical executive, credentialing, whoever it happens to be. Here's just some additional comments. These aren't part of it, just some items that I've picked up. Privilege and credentialing, they don't apply in circumstances where you're only utilizing the telemedicine equipment. In other words, the patient is not a hospital patient, but they want to come in and use your equipment for this service. Then you don't have to do that. But you may also need to look at checking up on some of your documents on telemedicine, the bylaws, administrative policy and procedures, the board report. I would include those in your board report. Any OPPE or FPPE, any policy and procedures for review of those credentials. Have one file for the telemedicine docs. If you start having a whole bunch of them, you may start to, one may slip through the cracks. That's why one's enough. Make sure the contract's approved by your board, medical staff, and have that list of practitioners. Make sure that you've got that checkbox, everything's been checked off. I always include in here just some suggested contents for your telemedicine agreement. Again, I'm not providing legal advice. Please consult with your own counsel on this. Just some suggestions to look at. Make sure you clearly identify the name for each party. Because if it's been bought out or acquired by a system, you want to make sure you have that appropriate name in that agreement. Confirm if it is a hospital, if they are a Medicare provider. Who are you going to include in this bevy or this bucket of providers? Is it going to be APs, APNs, PAs, and any of their respective specialties? Allow for the amendment to that list also. The distant hospital, yes, they have to give you a list of those providers and the privileges, but you may want to keep that handy in there too. What are the provisions on credentialing and privileging decisions by each party? In other words, who has to do what, and then who makes the final decision? Credentialing of the hospital, make sure it complies with all standards under the conditions of participation, even though they're Medicare participating, you wanna make sure that's spelled out in your agreement. You, your hospital staff, you can rely on those privilege and credentialing that's spelled out in the agreement. And any hospital, any providers, they're licensed where you're located. You're going to look at the list of those providers before you grant privileges, and you're going to do periodic review of those providers who are giving services to your patients, that you're going to give specific details of any complaints or adverse events, and how and when, meaning like the number of days when that agreement can be terminated and under what circumstances, if any. Like, are you going to have, we require a 60 day notice for termination of our agreement, 30 day, 90 days, or in the event of an egregious event with serious patient harm or death, it may be immediate. Just make sure that, again, your council has that listed in there. What is that timeframe? When's this agreement going to be effective? Is it the date it's signed? Who is going to sign off? Usually it's someone in your governing body or the president of the board, whoever it happens to be. That the agreement constitutes everything, every understanding of the party and any changes have to be in writing and approved. And then, which state law prevails? If you're in different state, where's this case going to be brought? Is it going to be in your state or their state? Are you going to use binding arbitration? Again, these are just some suggestions to consider. And then just some resources as we start to close out today. There is a Medicare Learning Network on telemedicine. It talks about services and billings. There is actual telehealth website from CMLs. And also a Medicaid telehealth website that's available for you. Again, I've got the links there. You will have to copy paste into your surf engine on telehealth. They are trying to give us as much information as possible. Now, some of these do have additional information. Like if we ever have to go back to that 1135 waiver and in effect, if we ever have to. But generally follow the national standards of care and practice. CMS didn't tell you that. Whether it's mental health, videoconferencing, diabetic retinopathy, telestroke, telehealth. How are you going to take care of wounds? Is that going to be one that you're going to allow? Remote prescribing, telepathology. There is a whole scope of what we think about when we think about telemedicine. Just not a medical surgical patient or an AER patient. There's a whole gamut of services that are available. I've got just a few of these practice guidelines. You can just put those into your surf engine and bring them up. I can't tell you which ones anymore require a membership, but most of these you can get fairly free. There is a rural telehealth toolkit. And this is evidence-based. It has resources on putting together a telehealth program for you with several modules. Everything from introduction to how do you keep this thing going? How is it going to be sustainable? And then AMA has telemedicine resources. They talk about synchronous and asynchronous technologies. There's even a playbook you can download for free. Overall, verify with your liability insurance on who's doing what. And you may want to make that part of your agreement that they will provide what's called the deck page or declaration page to that policy for that telemedicine provider. Confirm if they can give it a cross state line. And again, AMA, same with everybody. Patient safety, quality of care, and confidentiality in telemedicine, especially in that behavioral health arena. I was working with the system over in Hawaii and they use telehealth behavioral health services. And it was wonderful because some of those on the remote islands didn't have the luxury or ability to get to the main island in order to receive these services. And so they had a very secure room where the telehealth was set up and patients were able to come in and get that service and it was confidential. Everything, the windows were all, we had all the curtains closed. They used a headset, so it was very confidential with that conversation. And it was getting confidential with what was going on. They even have a federation for state boards that talk about telemedicine. It's the model policy for appropriate use on it. And in July of 23, this was the most requirement that talks about how many states require them to register, get a waiver, reimburse for Medicaid, or even the private sector. And so there is the link down there for you on what's required. And then just some additional issues for your policy and requirements. Standards of care during in-person, they apply whether it's electronic. So I have the same standard of care for being on my Zoom call, for being face-to-face with my doctor. Establish that physician-patient relationship and to make sure that we're looking at our patients, they're being properly evaluated. And of course, adhering to privacy and other standards of care. Don't forget the medical record. We still have to document telehealth visits. That's still a requirement. License where they're located, the patient's located, and an evaluation and history documented. So again, I've just tried to provide this federation state medical boards and telemedicine, what is required along with their references. I would download that page to you so you can click on what's applicable to your state. There is a federation for state medical boards. They have a verification service. This is a lifetime repository. PAs, physicians, they can store their core standards, which is nice because then the state medical board just goes and get it. And they can rely on that for a primary source verification. And also it's cost information, policy tips, everything on how to apply. We know many states now have our interstate compact licensing. This was actually initiated by that federation and it makes it easier for us to practice across state lines. It helps solve a lot of those telemedicine reimbursement issues that come up and can help with shortages and improve access. This is as the December 37th state. So that happens to be the link where it is allowed, whether you're an interstate compact licensure state or not. You can see on here whether or not you are, or if it's mixed. There are two resources on state laws, Center for Connected Health Policy and National Conference of State Legislature. They have a list and selection on current laws and policy that could help you with telehealth when you're trying to get it instituted. And again, here one is for Medicare and Medicaid, private payers and reimbursement for whether it's just Medicaid only, not private payers. So again, just some comments, have a list of all your contracts in one place. And that's just the list. So you make sure, oh yeah, we got that one. No, we don't. Always have performance measures in that contract and make sure they're being met. So in other words, if you're using telehealth in your contract, you have performance measures that this telemedicine provider will respond within a certain amount of time and will help share documentation if that's the case. How is that going to occur? Make sure that that's being done. AHIMA has a policy or some recommendations on what should be included. Of course, we need to know our staff are up to speed on it and that there's compliance, they're following the policy. And then they just have recommendations. So with our last few minutes, I do wanna go over this discussion. We have a Medicare certified level one trauma, 700 bed. They contract with several other facilities in their own state and a nearby state to provide telemedicine services. So they are the distance site. Everyone who's on the team has compact licenses. Again, you have to be on the telemedicine team and you have a compact license. We have a critical access hospital in a neighboring state. They have a contract with university for neurotrauma. The written agreement spells out that university will provide telemedicine services to the extent it does not interfere or affect care provided to patients at their own hospital. So sure enough, we have a neurosurgeon, they're privileged and credentialed, but they're just in one state. She's not a part of the telemedicine team. Sure enough, our critical access gets ahold of the university, says we need assistance. We had a patient who came in, we believe they have a brainstem infarct associated with substance abuse. Another neurosurgeon who is on the team, sure enough is scrubbed into a surgery for a gunshot wound. They're not getting out anytime soon. The surgeon who is not on the team is scheduled for a non-emergent surgery. So you have two neurosurgeons, one's on the team, one is not. What can or should university do to respond to this request? So I've just got some examples in here. Lindsey, I don't know if we put it up to where they can choose more than one or how you decided to set that up. It actually is just single choice here, but if you'd like to expand upon any of your answers or anything like that, you can, of course, utilize the chat there, but those options are up there on the screen now. Okay. Now this is kind of a toughie. Do you pull somebody out of surgery? And when they're amidst of somebody's cranium and their brain, it can be somewhat challenging to have that happen. What do we do to make sure this can happen and that we're not falling outside of our contractual observations or requirements, obligations, not observations, obligations? And yes, I will put one out. You want to consult with your risk manager as soon as possible, who will probably then consult with their in-house counselor. What do we do in this situation? Because there may be no answer to this. There may be. And we have a couple of questions. Laura, do you want to wait until we- Yes, no, go ahead. Final discussion or- No. Perfect. So while you're all putting in your responses here, I'll pull up your questions that you have pending right now. And this one says, what policies does your MEC have to approve in a critical access hospital? The governing board approves all the, the governing board or body, person, approves all of the policy and procedures, but medical staff has to know what they are too. Usually it's the patient care component that the medical staff develops, reviews and approves in a critical access hospital, which makes sense. You know, like what kind of care are we going to provide? What services are we going to, and who's going to be able to provide those? How are we going to provide services when a patient comes in through ED? The patient care policies are the ones that they're primarily responsible for. Shoveling snow, cleaning the parking lot, the building. No, not necessarily. But if it involves patient care, that's what they have to be responsible for. Okay. And this other question says, is the provider also required to be licensed in the state that they are practicing via telemedicine? Yes. Yes. So let me see if I understand it. So I'm in Colorado. The requester means, yeah, they're in a different state and then they're providing telemedicine here. Yes. Yeah. They have to be licensed in the state where they're providing that telemedicine service. I don't know if you have any circumstances where you're on a border, you're located on the border between another state and maybe you reach out to a provider in that other state for a consult or run a question past them. That we have seen and CMS isn't going to block that. What they're going to say is, okay, the real to a verbiage is, okay, understand I'm not licensed in your state. This is what I would do if the patient were in my state. And because they recognize you share, you reach out to your colleagues for that consultation. Here we're talking something much more formalized and often used than just that one-off. What would you do in this situation? That bed curbside consult. That's what it's commonly known as. Unfortunately, physicians have gotten very good with that. Disclaimer. And there's a follow-up question here that says, I'm licensed where the patient is located. But what about also being licensed in the state where the provider lives? I guess I'm not clear on the question. So if I'm living in Georgia and the patient is living in Georgia or Louisiana, either way, I'm not clear on the question. Kim, I take this question as if the physician is located, for example, in Georgia, but is providing telemedicine in South Carolina where the patient lives. Then I think she's asking if the provider also needs to be licensed in the state where they live in Georgia. Yes, yes, because they would be providing care. They could be deemed as providing care in that state also. But yes, they should be licensed in their own state too. Okay, and then I'll move over here to the Q&A. And it says, is reasonable amount of time for surgeons to respond documented as 30 minutes or is the term reasonable? Reasonable. Are you talking response? Okay, the 30 minute is within the EMTALA requirements that if I am requested to come in, I have at least about 30 minutes to get in there in order to see and evaluate that patient. So that's where it comes into play when under EMTALA, the physician is requested to come in. I'm not, I don't know of any other- There were a couple of questions around that. I think that was the similar question here that said, I have not seen 30 minutes specified in the CMS condition of participation, but I do see where it says reasonable timeframe and then asking where the 30 minutes is an industry standard but you just answered that that is EMTALA requirement. Correct, correct. 30 minutes is EMTALA. They said that is a reasonable amount of time to get in. Unless you are in a remote location or in a mountainous and then you have 60 minutes and that's the only way you can respond. You don't want to get killed trying to get up there in 30 minutes. But the 30 minutes is EMTALA, you're correct. Reasonable time, you folks spell it out based upon your location. Are you Metro? Are you rural? Where are you located? Okay, and then the final question I see here is, and you may or may not have this information, Laura, but what about physicians who live out of the country and they're providing telemedicine? They still have to be licensed in the state where the patient is located. Because we do see that with some of those remote, the radiology that has services across the world. They have to be licensed in the state where the patient is located. That is a requirement under telehealth. Now that is silent on out of the country, but they still have to be licensed probably in the state of their residency. Okay, and then Laura, would you be able to provide the EMTALA, I guess, maybe if it's a tag number, wherever that is that references back to that 30 minutes. I'm happy to send that out, that'd be great. And then the last question I see before I end this, final discussion questions asked, or when I said that one another came in. Can your GB delegate approving policy and procedures to the MEC, can your governing board delegate approving? As long as they understand they are ultimately responsible for that. They have to approve that. They can, again, the governing body can delegate to the medical executive committee review and approval, but the governing body has ultimate responsibility for that to make sure it's occurring. And what they might wanna do is just make sure they're aware of what they're approving. So like in the governing board book, I guess it's the best way to put their agenda that is reviewed, this is what we've reviewed and approved. And that it is clearly specified in the regulations, the bylaws, the medical staff can do that. They want proof that the medical executive committee or medical staff is acting within their boundaries or appointed boundaries, I should say. Great, okay, and then this is the last question that I see here that is more specific. It says, what if a patient is a Georgia resident, but it's visiting in Florida, what would the telemedicine licensure requirement be for that Georgia position? Yeah, and that's a good one because we also get it for college students who happen to reach out to their doc when they're away at college. What they're gonna look at is where's the residence of that patient usually. So if the patient has to go to, and is this an outpatient or an inpatient, Lindsey? That's one thing, again, this talks about inpatients. That's what they're talking about for telehealth. And so if the patient is inpatient at that Florida hospital, then the physician, yes, has to be licensed in Florida to provide that care. But they know that sometimes for outpatient visits, college kids will reach out to their own doc in their own state, and the physician just has to understand that, be aware, I'm acting as though you were here in my office. So that could be something that they'd want to talk to their own, the doctor's own liability carrier and how they would see that. Again, the CMS regs I'm talking about was when you're a patient in the hospital. Yes, perfect. Okay, I'm gonna end this final discussion question. Yeah, there was quite a bit. And I just want to point, I don't think there was any right answer on this one. Because they were stuck between a rock and a hard place on this one. And again, I think the one that spelled, look, we can't help with you at this time because our one qualified practitioner has got their hands on a person's brain. It's not, we can't do it. That was part of the contract, and that's what they relied on, as long as it did not interfere with the care and services provided to their own patients. So yes, they did have to pass on providing that one. But you could step in, maybe consult, but I would have done what the majority of you did spell out. I'm sorry, we can't help you in this one. And then just finally, I do want to point out there are a couple pages with other resources. There's not many of them. I only include in this some of the pictures that I talked about, like with memos and what the deficiency reports and how you can find them. And then additional information for the medical staff. I only have about six pages here for a change, and they actually have a guidebook in PDB. With that, Lindsay, I'm going to turn it back to you. I have a couple assignments on my end to get to you on tag numbers, and so I will send those over to you and which ones they refer to. Otherwise, thank you, and I'll turn it back to you, Lindsay. Wonderful, thank you so much for doing that, Laura. I did just quickly post some final information there for you all in the chat as a reminder that you should receive an email tomorrow morning. Just note that it will come from educationnoreplyatzoom.us. So because it is coming to you from that Zoom email, it may very well get called in your spam, quarantine, or junk folders, so if you don't see that in your inbox in the morning, I would first encourage you to check those additional folders, and if it's still not there and you would just like to access the recording of today's session, you can always just use the same Zoom link that you used to join us for the live presentation today to also access the recording. And just remember that the link to the recording is available for 60 days from today's date via Zoom, and once you click on that Zoom link, it will ask you to enter your information. That will prompt an email to come to us for approval of that recording access request. We do typically approve those requests very quickly, but we ask that you give us one business day to grant those approvals as well. And also included in that email tomorrow morning will be a link to the slides that Laura presented today, and as she just mentioned, those additional tag numbers and other information, we'll try to include that in that email tomorrow morning as well. But I did go ahead and provide that link there for you in the chat now that will take you to the slides that Laura presented for us today, so you can have that as a resource now as well. Thank you all so much for joining us today. Thank you for asking your wonderful questions, and thank you, Laura, as always, for your time and your information that you shared with us, and I hope you all have a wonderful afternoon. If you do have any additional questions, please don't hesitate to send those over to education at gha.org. We're happy to work with Laura to get those responses back to you in a timely manner. Thank you again, Laura. I hope you all have a wonderful afternoon. Thanks so much. Thank you, everyone. Thank you, Lindsay.

Laura Dixon

risk management

patient safety

telemedicine

reimbursement policies

hospital compliance

medical staff

peer review

regulatory process

telehealth policies

COVID-19

telemedicine agreements