I'd like to introduce our speaker to get us started with our final session 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 COPEG 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 COPEG, she served as a 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. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence 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. And we are so thankful that you're back here with us today, Laura, to wrap up our series. We invite you to get us started. Okay. Thank you, Lindsay, and welcome everyone. As Lindsay said, this is number five out of five, and we have roughly 10 areas that we're addressing today. Some of them are much shorter than the others, but nonetheless, I do want to touch upon them because they're really so much a part of everyday service that we provide to hospitals and to our patients. My program today is informational only. It is not meant to serve as providing legal advice nor establishing attorney client privilege. Please reach out to your in-house counsel, your own attorney, to address a situation within your facility, and especially if there's any particular state law that might impact how you respond in that particular area. Those of you who've had the opportunity to listen to our last four sessions, you know this. This is why we're here, so that you don't get the statement of deficiencies when we haven't met one of the conditions, and then where you have to do that plan of correction. And of course, no facility wants to be notified they've been terminated from the agreement, and that's Medicare and Medicaid, where that can be a huge financial hit to any facility or even a provider in that fact. So the area we're talking about today is Appendix A, and when you go in and look at the Appendix A, you'll see tag numbers associated with it. So if you want to find out a particular tag number, it's always the letter A and then a four-digit number. I have included those tag numbers on the slides where it is applicable, so you can go into the manual and check it out quickly. By the way, your last manual was updated just last year, April of last year. Whether they will do another one, because some of the information we're talking about today, they need to add those in, and that has not yet been done. So this is the areas we're touching upon today, all of these listed. Plus, I'm going to talk about some new changes that just came out late last year on obstetrical services where providing emergency care to OB patients. I want to start right off the bat with Infection Prevention and Control and Antibiotic Stewardship Program. Now, this was updated back in September of 2019. They added several tag numbers, and essentially what they did was they tightened up that system for infection prevention and control. It used to be just infection control. And that's when they realized, well, why don't we kind of work to have systems that we can prevent them from even getting started, ergo prevention? And then the Antibiotic Stewardship Program, that was also developed because they realized using information from the specialty societies that we were over-prescribing antibiotics leading to multidrug-resistant organisms, maybe C. diff, et cetera. And so that's why they put this program, so we can really be more judicious in the use of our antibiotics. So essentially, what you have to do is we're following evidence-based guidelines with this program. So you may need to update them. And again, the idea is to prevent that control, not only between what goes on in your hospital, but when you have patients coming into your hospital that may have an infection, or they've been in your facility and now they're leaving. We don't want to spread that fun time to those new facilities. They do encourage you to look at CDC documents on the Guide to Prevention and Outpatient Centers, because again, it's to and from you and the outpatient setting. So I included the link on here. Yes, you have to copy-paste it to your engine, because I couldn't get them to click and then automatically attach. I mentioned they didn't update the name of the regulation, and partly because they did notice a change in our infectious or communicable disease threats that are coming out. Remember, all of us lived through COVID, and that how much we had to do to try and stop it from either coming in or taking away from the hospital. But as Lindsay did estimate, this was a couple of years ago granted, and I've looked for some updates to see if they've had some. I don't have any just yet, but one in 31 of our patients will get at least some type of infection within our healthcare setting. Now, Lindsay mentioned we have questions, so I thought, why not just start right off the bat? So, Lindsay, I'll go ahead and have you pop that up for me, please. Absolutely. Okay, so this question says that Bayley Hospital recently experienced an increase in surgical site infections involving joint atheroscopies, am I saying that correct, arthroscopies? Arthroscopies, yes, it depends on what part of the country you're from, but arthroscopies is good enough. Perfect. So, the infection preventionist has requested input from personnel at all phases of a procedure, but not sterile processing, and is this sufficient, yes, no, or not sure? I see lots of you putting in your responses here. We'll give you just a couple of seconds. Okay, we're getting some good responses here, pretty unanimous here. Yeah, exactly. Why are we having all of these surgical site infections when it comes time to an arthroscopy? What's going on? So, overall, your program has to be hospital-wide, it just can't be in surgery, it just can't be, say, in med-cert, it has to be hospital-wide, and it has to be an active one, meaning there is ongoing surveillance, prevention, and control, not only of hospital-acquired issues, but also infectious diseases that may come through, again, through the hospital, or it's ED, or wherever. And that's why we also need to optimize our antibiotics through that stewardship program, so that we're not creating more problems by trying to cure one. We follow nationally-recognized guidelines, CMS won't establish those, that's those experts in the field, and, of course, use best practices on our antibiotics. Problems, any antibiotic issues, we send through our QAPI, and that's the Quality Assessment Performance Improvement Program. Every hospital has to have one, and it has to be an ongoing process. We've already touched upon QAPI. The guidelines, the interpretive guidelines, they talk about optimization of our antibiotic use, and it's not just antibiotic use, it's also, are we keeping our food safe so that we're not contributing to food-borne pathogens? We do an individual assessment of our program, and we monitor it. And that means we also have to have policy and procedures. CMS loves their policy and procedures, and they're only as good as they are reviewed, updated, and analyzed, and then implemented. And so that's why CMS is so hard on policy and procedures, because they want us to stay abreast of what's new and out there. So on your program, you have to be able to show, when the surveyor comes around, they want to be able to show that you have someone, either someone or a couple people, that are qualified through education, training, experience, or they want to go to the length of certification to be what's called the preventionist. We used to call them the infection control nurse. Now it's the preventionist, because sometimes it's not a nurse. It could be someone who, again, is qualified. The board appoints this individual after the recommendation and approval of medical staff and nursing leadership, because they have to know this person knows what they're talking about. The new guidelines talk about the qualities of that preventionist. So we know they have to be trained, and they have to have adequate resources to do their job, just like anyone else in the hospital. On training and competencies, there's a couple of them. APEC, they have a competency model. Joint Commission does have a chapter on infection prevention and control. Pretty much dovetails what CMS is saying. By the way, you see the asterisks? I have information in the appendix for you on what that entails, what your APEC. That is the preventionist professional society for those folks. Your program has to prevent and control sending our infections around, our transmission of the infections. And as I mentioned, that includes between hospital settings and other institutions or home. You document what you're doing. Make sure your policy and procedures reflect it. And the guidelines talk about that need for them and the importance of preventing our multidrug-resistant organisms. So that involves surveillance, prevention, and control. That includes anything from maintaining a clean and sanitary environment to proper hand hygiene. So they don't want to see, you know, spills on the floor. They don't want to see blood on the walls, like in surgery or in ER. They want to make sure our curtains are cleaned, that we're doing terminal cleaning of surgical suites. And then, of course, address any issues that your public health department has identified. Maybe you have a surge in bird flu or RSV. Perhaps there's another surge going on in your community. So keep an eye on those. Usually you can sign up to get notices from your Department of Health when there is a surge going on. So as I mentioned, we have to keep the place clean. We have to keep it sanitary. And that's every area. That's everything from, again, surgery to food storage. You are expected also to have a water management program with policy and procedures, specifically Legionella. Hospitals, you need to know and recognize and contain those outbreaks when they do occur, whether it's an ICU, on a med-surg floor, wherever they are. Get a handle on them and keep them controlled. As far as how big your program is, well, that's how big of a hospital you are. How many services are you providing? And look at all departments and services, not just surgery, but look at your chemo, where you might have immunocompromised patients. Transplant, same thing, where you might have immunocompromised. Labor and delivery. It's every area that we have to include in this program. CMS, over the last several years, has really put a lot of onus on our leadership, because really the board, they have to make sure systems are there and they're working, they're operational, so we can do that job. We can track them. We can surveil them. We can control them. And that the program is successful. It works. What you're putting into place, you can keep doing. They're sustainable. And so in the guidelines, they see, you know, leadership support and accountability, that's so crucial to anything that happens, and especially with infection prevention and control. And they work with pharmacy. They work with medicine. They work with nursing to make sure this is working, what we're doing. Or maybe we need to look at another program, and that the policy and procedures are there. They address the roles, the duties of that program. Don't make those duties so onerous that no one could accomplish them, but just make sure it touches those crucial factors and can be done. The board has to make sure any of our healthcare associated infections or other diseases are addressed also through QAPI leadership. They talk about leadership's role in the guidelines to make sure not only QAPI is there, but training program covers the issues. Okay, we've got an issue with surgical site infections. Why is that happening? Do we need to go back and look at how we're doing scrubs or how we're changing dressings? Because the leaders, they are held explicitly, and it's spelled out very clearly. They're responsible for implementing a successful corrective plan. If the plan isn't working, the board's going to be held responsible. Now, there's some new things that just came out last year, and that's our public health emergency reporting system, and how often we have to report in a frequency. The secretary is like the secretary of health and human services. The hospital's current inventory and supplies, therapeutics, how many have you delivered, the current usage rate, especially for COVID-19 therapeutics, but then they expanded it. Remember back when COVID was going on hot and heavy, there was a lot of reporting healthcare facilities had to do. Well, then they kind of eased off on it. Well, they changed their mind. In fact, they renewed and revised what we had to do, that reporting data and frequency, as it relates to respiratory infections, because right now they want to make sure that we have enough insight into our supplies. What do we have so we can be prepared when a spike does actually occur? So beginning November 1 of last year, 2024, there is now a requirement for weekly reporting of the information on your infections, COVID-19, influenza, and RSV. So this is what you have to do. All hospitals, with the exception of psychiatric and rehab hospitals, or if you're critical access and you have a distinct unit, then you have to report on a weekly basis what you've got there. On those types of hospitals, psych, rehab, distinct units, they go annually in January. But otherwise, we have to submit daily data on a weekly basis. And it must be there by midnight on Tuesday. And that includes what you had each and every day of the previous week. Now, there I realized, oh, that can be pretty onerous for some of our hospitals. So I said, OK, we'll come up with a second process. And they did this because of a lot of comments that came to them. It's like, are you kidding? There's no way we can meet that requirement. So they came up with a second process. New admissions, where there is confirmed of one of those three types of illnesses. And now you report data weekly totals instead of daily data values. Now, I added the emphasis into here because that's not in the memo that came out. They also want you to report how much bed capacity and occupancy you have. What is the prevalence of your hospitalizations and ICU patients according to respiratory illnesses? But you only have to look at one day a week when you're doing that, again, as opposed to daily data. So there were some benefits. Doing that, it's a new pathway to provide that weekly reporting. There's a nice balance between the value and the burden that's placed upon facilities. And they know that there may be changes over time based upon your population, your health need, and technology that can come through. So I've just got the information here for you for 2025. This is what your data collection has to include. The one day a week snapshot and weekly total for new admissions. So I did like it that they did come up with another scenario for us for reporting because doing that daily can really be quite a burden. Back to our preventionists. They have to develop and implement your hospital-wide policies on this program, including what are we going to do for surveillance? What are we going to do with prevention and control? And of course, they have to make sure that those policies follow national guidelines. You describe what fits best for you and your patient needs. But they also have a lot of documentation that they have to do on all of those activities. And that encompasses collection and keeping pertinent information in a systematic fashion. That's why if you want to use your IT programs to help develop it, that's fine. They don't care how you do it. The guidelines actually mention an action plan to prevent our HAIs. I've got the link there for you. That could help you with this process on how to start tracking these and monitoring them. Our preventionist has a lot of other responsibilities. They work with the QAPI program on control issues. And everything, whether it's emerging diseases or those we know are already there. They also have to provide training to staff, including medical staff and contracted services. And this is the practical application of your prevention program. What are your guidelines? What are your policy and procedures? They also include auditing of the policies. They have to do that. And then work with the antibiotic stewardship program. So this is really quite a hand-in-hand process in the entire infection prevention and control. The surveyor wants to see the qualifications of your preventionist. Meaning they're going to look into the HR folder. They want evidence also that they're communicating with the QAPI program. Communicating and working with them. They want to see your policy and procedures. They want to see what kind of training is being done for the staff. And that includes competency-based training. Which means during your annual skills, maybe you want to have your ICU nurses or staff or physicians be observed putting in a central line. Changing a dressing on a central line. So we maintain that sterile environment. And they'll verify the preventionist is working with the antibiotic stewardship program. The leader of that in particular. So that brings us to the next section, the ASP. Like the prevention, you have to have an active hospital-wide program for control of these infectious diseases through antibiotic uses. And that we're identifying the use of antibiotics. Any issues, they go through QAPI. So for an active program, there's coordination with several entities. There's several processes. Infection prevention, as I already mentioned. But medical staff, nursing, pharmacy, and QAPI. Like the preventionist, they have to do documentation of evidence-based antibiotic use. And all departments and all services. And that there's sustained improvement in that use. So again, we reduce our CDEF and our MDROs. And we follow evidence-based guidelines, best practices. CDC, there are core elements for an antibiotic stewardship program. It gives examples for leadership's commitment. Has highlights of interventions and process measures that should be a priority. And the key role of pharmacists and nurses in improving antibiotic use. For nursing, it's are we giving that on time when it needs to be administered? Is it time for it to be discontinued? That's where pharmacy come into play. Or what is the most classification, generation of an antibiotic? So this is what that core elements of your program looks like. I have the link there for you. And a lot of other resources that are available. Now generally, these are geared to your larger hospitals. But they have them for smaller ones too. And this was a joint effort, not only with CDC, but American Hospital Association, Office of Rural Health, and Pew Charitable Trust. So they came up with some really practical strategies to put together this program for our smaller facilities. And that includes again, leadership's accountability and commitment. Here they have a pharmacist leader. Because again, they'll know what drugs are out there. Evidence-based action, tracking, reporting, and education. So they are trying to give us some help in making sure these programs are in place. The leader has to be appointed by the board. And here it's on the recommendation of the medical staff. This individual who's over the ASP is qualified by education and training. And should be, I won't call it, no, should be an infectious disease. That makes sense, such as your infectious disease physician. That's who they recommend highly be over your ASP, because they have to come up with your hospital-wide program based on national guidelines to monitor and improve the use of our antibiotics. Guidelines have to be dedicated, expert leadership, and this person's responsible and accountable for success. Years ago, for example, we were just applying medication and we're dosing our patients with antibiotics constantly when it was a virus. Well, we realized perhaps that's not the best way to go. Now, through all these new national guidelines, we're coming up with so many ways to treat these infections that years ago, we never would have thought of or never even considered standard of care, where now we're getting better at this. The ASP leader documents the program, and of course, the surveyor wants to see it. What are your activities on controlling and monitoring your antibiotic use? They work with, they communicate with a host of other individuals, which like medical staff, nursing, pharmacy, infection preventionists, QAPI. Like the preventionists, they have to do education and training. All personnel, all staff, all medical staff, all contracted employees. What are our guidelines and our policy and procedures on antibiotic use? Now, if you're part of a system of separately certified hospitals, you have a governing body over at least two or more of them. You could have a unified infection prevention and control and antibiotic stewardship program for all of the hospital, as long as your state law or local law says that's okay. The board again is responsible. They have to make sure each hospital meets all of the requirements in this section. Here's what has to be there. The program has to make sure each hospital's unique circumstances, populations are taken into account. That the policy and procedures for this unified program meet the needs of each hospital, no matter what they do or where they're located. There has to be a mechanism to make sure issues specific to a particular hospital are taken into account and addressed no matter what the size, no matter what the practice. Again, we have to have someone who's qualified to be responsible to communicate this unified program, and they have to make sure policy and procedures are in place and implemented, and they have to make sure education and training is done. The surveyor wants to see documentation on this communication, on the policy, on the training documents, maybe a sign-in sheet to show who was trained and when was it done. There's one other thing, and that's the interoperability program. This talks about electronic reporting for payment. I don't talk about payment issues, but I did want to bring this up because it is so closely tied to infection prevention. Most of the hospitals acute, you're going to participate. Criticals, you have to be eligible to participate. It talks about our antibiotic use resource surveillance measure for electronic record that began in January of last year. There is more information on what you have to report and how often. I did want to mention it since it did involve infection prevention and control. Finally, one more resource, and that's our infection control worksheet. This was one CMS developed back when they were looking to revise the whole program. Don't use it anymore. Never used it for critical access, but it's a really good tool for gap analysis. They covered all of these. They added most of them to the new regs, not all of them, but most of them, but to give you an idea what they're looking at. I'm going to move now on to discharge planning, our next major component of the program today. In 2019, again, major changes. Because what they wanted to do was try and look at the processes and practices so we prevent unnecessary readmissions. It implemented the requirements of the IMPACT Act so that, again, we could reduce these readmissions that didn't need to occur. They updated it back in June of 23, where they talked about when you have this effective discharge planning process, that really looks at what are the patient's goals and treatment preferences, but we also include not only the patient, but who's going to take care of them right there. Because sometimes that's a gap that didn't get met. What the requirements is that we have to have a discharge and transfer, of course, when applicable, but we have to send everything along with it, because sometimes they found patients being transferred to other facilities and critical information was missing. The course of illness and treatment, what were those patients' goals at admission on your hospital? This information is going to those appropriate post-acute care providers, agencies, suppliers, those outpatients who are going to be responsible for taking care of the patient, whether it's home health or home visit PT. They identified six areas of concern that were either missing or just flat out wrong, and medications was the first one that they noticed. Medication reconciliation hadn't been done or was inadequate. Durable medical equipment wasn't available or ordered. There were skin tears on a patient when they were transferred to another facility that this other facility had no idea was there that they had to take care of. Communication with these post-acute care providers. Those patients with serious mental or substance use disorders, or even complex behavioral needs, that information wasn't communicated. Then finally, just what does the patient want when they're leaving? We're up to already question number 2. Lindsey, would you put that up for me? Absolutely. Okay. You should see this question now that says that a 200-bed hospital E's discharge coordinator is a semi-retired social worker, and he has been in that position for four years without issue, no complaints, or unplanned readmissions. Would this be a possible citation for hospital E? Your options here, yes, no, or do not know. As we are a little bit further through the presentation, I do see that several of you have joined after we did our initial introduction today. Just another reminder, if you have questions for Laura, as we go throughout the presentation, make sure that you're typing those in either the Q&A option found there at the bottom of your Zoom window, or you can submit them through the chat as well. With this being the final session in the series, I want to make sure that we're addressing any questions that you have. Even as we get towards the end of today's session, if you have a lingering question, maybe from a previous session, don't hesitate to type those in as well. Okay, we've gotten some responses all over the place here. Oh, good, because, you know, it could be this person would be just fine. And so we're going to talk about, okay, they're not an active working individual, but perhaps they've been in this position for decades and really know what they're doing and are very good at it. So let's talk about this. But before I do start, just want to let you know there's new tag numbers and standards. No interpretive guidelines or survey procedures. They didn't get around to that. Hopefully, and I'm keeping my fingers crossed, they will eventually. Now, I want to point out, these are the tag numbers. Some of the previous tag numbers remain. They're modified with new standards, but again, they didn't update or have any survey guidelines. The new tag numbers, the new ones they put in actually overlap and repeat many of the requirements in the previous ones. And I asked them, I asked CMS, are you going to clean this up? And they said, yes, we hope to do so with the new manual. So for now, on these tag numbers, on these slides, you will see some of those that have two tag numbers because they repeat themselves. Now, how that happened, I wish I had an answer to that, but I don't know. So here's one that didn't change. You have to have a process that meets what does the patient want? What are their goals when they leave? What are their preferences for who provides that ongoing care if needed? But we also include not only the patient, but those who are going to take care of them or that support person. The plan has to be consistent, the plan to put together with those goals and preferences, because you want to make sure it's an easy transition from hospital to where they end up. And then we cut those factors that maybe could lead to preventable hospital readmissions. So first, we have to start at an early age. What's our patient? Which one of those patients are going to have adverse consequences if we do not do any discharge planning? We just send them on their merry way. So we have to do an evaluation. We have to do one of discharge planning for those that, yep, they're going to have a problem when they leave us. Not maybe a problem, but they're going to need ongoing services. The patient and the representative can also request that evaluation, or the physician can request the evaluation. Now, the plan is different. You have to develop a plan and put it into process, get it started. If the patient requests it or the physician requests it, then, of course, regularly reevaluate the patient's conditions. So we say, oh, did something come up that maybe we need to go back and look at that plan? We also have to look at our overall process, how we do this on a regular basis, and really just make it ongoing. Is it still working? Look at a review of some of the previous discharge plans you've done. For sure, include anybody that was readmitted within 30 days, because we want to make sure our plan's meeting those needs, those post-discharge needs. As an acute hospital, you have to help the patient, their family, whoever it is, select a post-acute care provider. Now, this is where they're not going to go home, all right? This is where they maybe have to go to a long-term care, a nursing home, wherever it is. In doing so, you give them data on quality measures and how that particular facility uses their resources. Are they good or not? And it must be relevant and applicable to what the patient wants, their goals, their treatment. It includes home health agencies, skilled nursing facilities, inpatient rehab facility, or a long-term care. Those are the four that you must provide the data to that patient. Now, take, for example, you have a patient. They're going to need some maybe skilled nursing until they can go home. They've had a bad fracture or a bad accident, and they don't need acute care. They're not that sick anymore, but they're not ready to be home independent. And so you have to help them pick it. Is it one that the patient knows or maybe a family member's there or a friend? Have them look at that. Maybe they want to look at that data, but you share that data. And by the way, if you know that place, your discharge coordinator or whoever knows it and has some concerns about it, you can share. Maybe this is a better one. They've got better outcomes for those who happen to have your condition. Patient wouldn't know that, but you have to share that with them to make sure they're going to the safest area. If the patient adamantly puts their foot down and say, no, I'm going to go there no matter what, okay. We have to respect their decision on their treatment. Otherwise, we do a timely evaluation to make sure arrangements are ready to go before discharge. We don't want to delay that discharge if at all possible. The surveyor is going to look at discharge tracers on open and closed records. They have certain questions they will ask, like, okay, is this done? Is this done? When was it done? Was there any delay? And if so, why? We have to have an evaluation for, as I mentioned, those at risk, if the patient or physician requests it, and include what is the likelihood they're going to need those services, whether it's home health or transportation for dialysis. Are they going to need any special equipment at home? Will the home need to be modified like a ramp? Include an assessment in there. Can the patient take care of themselves? Or does somebody have to be there? Maybe the patient can get around home fine, but somebody has to come in and set up their pill dispenser. Or maybe it's someone to come in and make sure that their weight is good, their linens are clean, they're not having any skin breakdown. So if they are going to home, the guidelines do give us information to determine can that patient return home or do they need to go elsewhere. If they go elsewhere, the discharge coordinator, or whoever this person is going to be, they are expected to have knowledge of that facility to take care of that patient, to provide those services. And also talk about the ability to pay for any out-of-pocket expenses. Now, Medicare, Medicaid, if that's the case, on what they pay or their insurance plan. But are there other out-of-pocket services that may not be covered that the patient would require? They are expected to have knowledge about other community resources like the Center for Independent Living. The idea is return them to where they came from. Is it going to be home? Or are they going to go to maybe an inpatient rehab and then to their senior assisted living? That's the idea. There is a checklist that patients can, we can provide to patients. I've got three of them. This is actually in the manual. It's a blue box. You're not cited if you don't do this, but it's a good resource that if you want to hand it to the patient. The evaluations include will they need post-hospital care like PT? Is it available in their area? Is their policy, their insurance going to cover it? Can they get to that service if they so need it? Or are they too far away? Of course, we have to have documentation in the record. We want to make sure that the plan is being prepared accordingly and that the results are discussed with the patient and the representative. Either the evaluation or the plan has to be developed under the supervision of an RN, a social worker, or another qualified individual. Our retired social worker, they may actually fit that requirement that they are qualified, they've done this, they've done it for years, they have a good handle on the resources and it's worked fine. They may actually be qualified to do that. The evaluation has to be done timely and you have to discuss what you've come with with that patient. And of course, in the record, because we have to use that for any discharge plan. For discharge, you have to discharge, transfer, refer, and of course, send everything along with them. What do we send? Well, pretty much everything that's relevant to their care, their care and their treatment. What were the discharge goals for care after they've gone home or left? And treatment preferences at the time of discharge. Do they want to go to their daughters? Do they want to go to a skilled nursing? Do they just adamantly want to go home? We send enough information so that these post-acute care providers can take care of them, suppliers, agencies, outpatient service providers. And providers, there is a requirement that talks about these services. So that's why we give that list to them, that list of the post-acute care providers to them, those that participate in Medicare, those that serve their geographic area. Home health, they do have to request to be on the list. If the patient has a managed care network, just make sure that the list you give them, they're in their network. If the patient decides to go out of network, that is their choice. They just have to be notified that it's not in their network as far as payment issues. We have to inform patients that they get to choose them, who supplies them, who takes care of them, and we have to respect what is their preference. We can't limit anybody who's qualified, whether it's a provider or a supplier. But what you must do as a hospital, you must disclose any financial interest you have in a skilled nursing facility or home health agency. You just have to disclose it. Our hospital owns this skilled nursing facility. That's all you have to do. I mentioned that the plan has to be under the supervision of a qualified person, RN, or a social worker, or someone else. Here's the others' qualification. They have experience in discharge planning. They have knowledge of what factors affect that patient's function, whether it's clinical or social. They have to know what resources are out there to meet those needs. And they have to have some assessment skills. So again, our retired social worker is probably just fine in that situation. Anyone who performs or supervises the plans must have knowledge of clinical, social, some type of insurance understanding, not maybe background, but understanding, and what other factors we need to take into account for this patient. Patient's in a wheelchair. They weren't in a wheelchair when they left, when they got to your hospital. Now they are. So what do we have to do for the home? And also, when we evaluate how the discharge plans and the needs can be met. The physician can request the plan. We have to arrange for initial implementation. So work with the family, the patient, get them ready for that post-hospital care. And then go back and look at the plan, reassess it. Is there anything that happened to this patient's condition that might alter that plan? Maybe not. Surveyor, they want to see records. They want to see how the plans were developed, when were they developed, who's responsible, and they'll talk to staff. Did you know when and how you had to, A, assess the patient, and then reassess that person? And I mentioned including home health and your SNFs. The requirements here are that they have to participate in Medicare, be in the area where the patient is located. And again, if it's a managed care, let the patient know that. Provide a list and disclose if you have any financial interests. So again, home health and SNFs, you can provide them that list. Otherwise, we transfer, refer them where it's necessary to take care of them. Information to send along, I'm not going to go through all of these, but it really sounds like a lot of the record. What was their condition at discharge, the medication list, any outstanding lab results that you're still waiting on? Maybe you drew a late Chem 6 and the results aren't back. Make sure that those are pending. We'll get them sent over to them. Please send the advance directives if you have them. And then any follow-up appointments, referrals that they're pending and are still waiting to have happen. As a last resort, you have to look at your own discharge process. Do it on an ongoing basis. It is part of your QAPI program because what you want to do is make sure, did it respond to the patient's needs? Look at the plan when you have a readmission. Was that a preventable readmission or not? Did the patient go home, they were fine, 29 days out, they have an MI. You can't prevent that. But maybe there was something, there was a slip and fall. Could we have prevented that readmission if we had done better planning? And was the plan really responsive to their needs? Was home health able to get in and see the patient? I want to point out one thing. There is a new rule that came out as part of discharge. It will go into the discharge planning program area. It was part of the previous administration and it really focused on maternal care, not solely but focused on maternal care. We have to have written policy and procedures for transfers. And this includes intra-hospital transfers, whether it's from ED to inpatient, or units of the same or even different hospitals. You know, you may transfer from the medical floor to ICU. What they're looking at is that it's an appropriate level of care. So they included this, again, they did focus on maternal care, but not solely. So as of January 1, when this went into effect, as far as the process, you have to do annual training to staff who are involved in this process. Hospital policies and procedure for transferring patients. Make sure staff are doing the same thing, regardless of what type of transfer. Staff know about changes in protocols, and they do these transfers safely because we're trying to minimize errors. This has to be in place by July 1 of this year. So, like with infection prevention and control, there is a discharge planning worksheet. Similarly, they did it back before they redid the rule. It's a good gap analysis. You're not required to use it, but it's a helpful tool. So, those are our two big areas. Now I'm going to start focusing on some very localized, very specialty areas for the hospital, starting with our tissue, eye, and organ procurement. And we're up to number three. We're good on time, Lindsay. So, if you want to put that up. Absolutely. Okay. So, you should see this one on your screen that says Hospital D is a large teaching facility with an OPO agreement in place. One of the stipulations in the agreement requires a medical resident to obtain consent from a family for organ, tissue donations. On occasion, the OPO is not notified of a death or imminent death. Could this result in a citation from CMS? Yes or no? And if you have any questions for Laura, now is a great time for you to be typing those in so we can make sure that we address those. I remember back in the days, I sound like my mom when I say when I was a girl, back in the days of bedside nursing where we would have a patient where it's like, yeah, this isn't going to, this is bad. This is what's going to happen. And fortunately, I had one patient in particular, he had always expressed his desire to his family that he wanted to have whatever could be used be donated upon his death. And so, it was nice to know that now they have these organizations because prior to that, the staff had to make that conversation. And sometimes it was a really tough conversation. It's like, wait a minute, he's not even dead and you want to start taking pieces out of him? But now that we have this new rule and this new resource, the Organ Procurement Organization, it does help in this process. I don't know how many of you might recall a couple years ago, there was an idea floated where it was going to be mandatory. If you had a viable organ, you didn't have a right to say no. Fortunately, that did not go through because there are some of the religious communities who say no, no, no, you can't do that. That violates our religious beliefs. And so, that did not ever come to fruition. And so, yes, those of you who did answer, by the way, thank you for those who do participate. So, it wasn't so much the medical resident was doing it, it was actually noticed to the OPO. So, what you have to do is you have to have written policy and procedures and a written agreement with this organization to address organ procurement. That includes timely notification to the organization if either death is imminent or the patient has already passed away because the organization determines suitability of that organ for transplant. In the one particular situation I was mentioning, this patient came in septic. And they said, I'm sorry, there's nothing we can utilize or can take advantage of because of his systemic infection. So, in that situation, it was unfortunate we couldn't meet his request. The standard itself sets out what has to be in your written agreement. In other words, there are definitions of death. What is the criteria for referral? Also, that the written agreement includes the organization has access to your death records. Joint Commission, there's a similar standards in the transplant safety standards. The organization, they have their own regulations. They're in Appendix Y. So, you have to have that written agreement. There's definitions that CMS includes, which is great. If you want to use them, just put them right in your policy or even the agreement. But you must do the one call rule. In other words, make one call to the organization if the patient has died or if death is imminent. You are not required to initiate an agreement if you do not have an OR or a ventilator. So, it's either one of those if you don't have one of the others. But you are required to enter to an agreement with any hospital that wants one. If you don't have a ventilator and an operating room, then you may just have notice. That's it. This patient is dying. On the items, the board has to approve the policy, integrate it into your QAPI. The surveyor wants to see it. They want to make sure all of the required information is included. And they also want proof that, yes, you have called the organization to notify them of death. Generally, they'll look into the medical record to verify someone has made that call. From organs to tissue and eye, there has to be an agreement with at least one of them. One tissue and eye bank. That organization can do all three. They can do organs, tissue, and eye. They can act as the gatekeeper. And they will notify the tissue or eye bank that you have selected as a hospital. They determine suitability for that transplant. And the nice thing is, if your organization does it, your OPO, then you don't have to have the separate agreement. Everything is done under that one agreement. The hard part is the family notification. So once the organization, the OPOs, identified that potential donor, of course, we have to tell the family, there is an option for you to donate. You, the hospital, and the organization, you decide how and by whom the family is approached. Because the organization recognizes that your staff may have a very great relationship with these grieving families and might be a little bit softer or easier to hear it from someone they know and they trust. But either way, you have to work with the organization in educating your staff on what has to be done. And as I mentioned, they can review death records to make sure that they were notified on each and every occasion. On initiation of the request, it's either somebody or staff, who's agreed to, or through the organization, a representative, because they have to have a course completed in order to actually make those requests. They do encourage discretion and sensitivity to not only the circumstances, but the beliefs of the family and the patient. The surveyor wants to see also a complaint file for any relevant complaints that might have come up with the OPO or any organ donation. So that means we train our staff. The consent process, using discretion, who is the designator, what is their role, getting quality improvement, make sure they are notified of any problems, and what is the role of that OPO. We train all new ones, new staff, and anytime you change something or there's a problem that has come up, why are we getting all these complaints from family, from say this particular unit or this particular time frame. We have to cooperate with the OPO. The surveyor will verify your policies do so, that you do work with them. You have to maintain our potential donors so that testing and placement can take place, have policies so that we can maintain the viability of organs. And believe it or not, they actually included this in the interpretive guidelines. We ensure the patient is declared dead within an acceptable time frame. That hasn't been an individual who's been dead for too long, but yes indeed that they're dead within that time frame. So it's a very short section, which now I'm going to move on to surgery and PACU. They've somewhat combined these two components of care. Yes, they're different, but they didn't combine them. So starting with surgery, of course, if you're going to do it, it has to be well organized. Outpatient surgery, it's the same quality of care for inpatient. We each have to follow standards of practice, whether it's AMA, AORN, American College of Surgeons, whatever it happens to be. We integrate this process into QAPI. The surveyors, they go into OR rooms. Of course, if they're busy, no they won't. But they do have to have access to the surgery and PACU, and they want to make sure otherwise access is limited to only those who need to be in there. In other words, we just don't have strangers walking in and out of our surgical area. The surveyor wants to make sure we're conforming to aseptic and sterile technique. Are things being packaged and secured in a proper manner? Is appropriate cleaning between cases and terminal cleaning? Do you have enough equipment for rapid sterilization? Is the room of a good size for that procedure being performed? How about temperature and humidity? Are we controlling them? American Society of Anesthesiologists, AORN, there's policy and procedures on many. I know with AORN, you do have to be a member to get access to those resources. Services have to be appropriate to what you're offering and must be supervised by an experienced RN or MD. Have specialized training. These folks have to have training in surgery and management of the service. They will look at the job description to verify that. ILPNs and ORTECs, they can serve as scrub nurses, but there has to be an RN supervising them, and that means the RN has to be able to step in and physically intervene and provide care if absolutely needed, which may be your circulating nurse, but it is a qualified RN. Again, an LPN or ORTEC can assist if the state law permits it, but again, the RN has to be there to step in and immediately respond to emergencies. Privileges for our surgeons, they are delineated for everyone performing anything according to their competency, and you have to keep a list, a roster, specifying each surgical privilege for those doing surgery. Privileges are reviewed every two years, and you also have to keep a current list of suspended surgeons, those who are not allowed to schedule or perform surgery. On surgical tasks, we have to identify for each person performing a particular task. That can be a physician, can be an RN for assist, but we have to specify them, and that's based on compliance with what they do under state law. If the task requires that they be under the supervision of a physician, okay, but they have to be in the room working with the patient. They can't be in another room. There are several surgical policies that we need to have in place, from attire, handling biomedical waste, what are the patient care requirements from safety to consents, housekeeping between and after procedures, sterile surveillance, scrub technique, even outpatient surgery, and post-op planning, and they go on. There's just not a few of them. There's a whole bunch of them. What are the duties of our scrub nurses? Surgical counts, scheduling, resuscitative techniques and DNR policies, care of specimens and malignant hyperthermia, protocols for all procedures, sterilization and disinfection, and what do you have for an infected and non-infected cases? And of course, we definitely have to have our fire prevention. There is a very detailed section on use of alcohol-based skin prep and how to prevent these OR fires, because it's a fuel source, and it is a delicate balance between preventing infections and preventing fires, because some of you may have seen the issues where a patient was horribly burned as a result. This was a patient who was undergoing just a routine procedure, and the alcohol-based skin prep caught fire. I just want to do some on history and physical. This was actually in a couple places within the entire manual. HMP no older than 30 days, updated prior to surgery. Healthy outpatients, you can do that pre-assessment as opposed to a history and physical. Otherwise, it's on the chart before the patient goes to surgery, unless it's an emergency, and policies specify what is an emergency. On the exception, that's the assessment. It must be completed and documented after registration, but before we do anything before surgery, that requires anesthesia. You don't have to do the comprehensive HMP unless the medical staff decides, no, outpatients, you still get a full history and physical. Again, healthy outpatients. Guidance is pending on this one, and we know we have to have a consent properly executed in the record before surgery, unless it's an emergency. There are actually informed consents in three different sections in that entire 500-some-odd-page manual. Surgery, which is what we're talking about, medical record, and patient rights. Each is different. It is not repeated, so that's why we cover all three during this five-part session. This is the one. What I'm talking about is what's in the surgical section. Anesthesia consent is recommended. You don't have to do it, but your hospital policy may say so, but it is recommended. Otherwise, you set out the elements for a well-designed process. What are your optional elements you're going to include? Mandatory elements were in the medical record section, and that specifies what must be in your policy, who can obtain it, what procedures. You have to have consent form, including those defined by the American College of Surgeons. Your policy makes sure, of course, it's on the chart before they go to surgery, unless it's an emergency. It spells out in the policy what needs to be in the consent form, who can obtain it, who's responsible, what procedures require informed consent, and if the consent's outside your hospital, say at the surgeon's office, well, how do you make sure that gets into the record? That's what needs to go into your policy. We have to also disclose others doing important tasks, like residents, first assist, technicians. That can include opening and closing, taking out tissues or doing grafts, administering anesthesia, that's also part of it, if it's like a local, putting in devices, placing invasive lines. Those are important surgical tasks, and we have to have that in writing, and that's usually under optional or well-designed list. Now, we did talk about this a couple programs ago, but I like to bring it up because this is the only part it's in. It's in the surgical section. April 24 memo talked about doing those exams without patient consent, that where you have people who are being supervised in training programs, education-related programs, and these are exams outside medically necessary procedures, and it came from an article in the Annals of Surgery, where a growing number of states have regulated doing sensitive exams on anesthetized patients, and there's the article. This is a nurse from Arizona. She checked into her hospital. She was having stomach surgery, and before the procedure, she specifically told her physician, I don't want any med students directly involved in my care. I don't want them in there. Well, sure enough, afterwards, a resident came up to her and said, oh, by the way, you're having your period. Nobody would have known that unless they had done the exam, so she took action, and CMS then recognized, you know what? This is not right. We need to do something, so they updated the guidelines in the surgical section that when you have, whether it's medical, APPs, someone other than who you would expect for a surgery you'd expect, that they're doing exams or invasive procedures for execution and training that you have to have consent. You have to tell the patient, hey, this could occur, and the patient has a right to say, no, uh-uh, you're not going to do that, and they talk about which of these procedures are breast, pelvic, prostate, rectal exams. Maybe your state also has another one that, you know, a patient has a right to say, no, you're not going to do that. ACOG back in 2011 already had a policy on this, their ethics committee, where they specifically said doing a pelvic exam on a woman who's asleep where there's no benefit to her and done solely for teaching only with specific informed consent before a surgery, so now as of January 2019, June 2019, excuse me, some states actually said you can't do that without specific consent, and I have a feeling that list is going to grow exponentially. So here's just some suggestions. Make sure staff know this, and especially your surgical staff, whether it's your surgical scrub, nurse, the circulator, whoever it is, I don't care. Look at your policies and procedures. You may need to update them. Look at your consent forms and train your staff on what the requirements are, because if this is occurring and there's no consent, the nurses have that professional obligation to speak up and say something. AORN, they talk about standards to help with some of these policies. Again, you do have to have a membership to obtain them, but it's a huge benefit if you can have your surgical lead have that membership. Back to our normal systems, our equipment. You have to have a call-in system, monitor and defibrillator, some kind of suction equipment, a trach set, cricoid thyroidectomy is not a substitute. PACU, now we're out of surgery, we're heading over to PACU. You have to have enough provisions for that immediate post-op care, following standards of practice, ASPEN, that's a really good example. I have that in the appendix for you. A separate room with limited access and policies, they have to specify transfer requirements to and from PACU. When is that patient stable to come into PACU? When are they stable to leave PACU? We have to have an assessment, of course, their level of activity, pain, what are their vitals, how's their color, their Aldrete score for pain. If they're not sent to PACU, then there has to be close observation until the patient's regained consciousness by a qualified RN. For example, they're down to maybe have a shunt put in, then they go back to the floor, ICU, or whatever it happens to be. A qualified RN needs to be with them to maintain them, make sure they're waking up, their airway's maintained, etc. You are expected to have policies on the minimum scope and frequency of monitoring in that PACU setting, consistent with standards of care, because they are very concerned with opioids. There's over sedation, respiratory depression. We know once they're out of PACU, we're not watching them as closely, because they're not in one room. We don't have that availability for eyes on or close eye inspection. That's why we have to have that assessment to prevent those complications. The surveyor will watch your care you give in PACU. They want to make sure we're watching our patients and we're assessing them before they are transferred back to the floor or they're being sent home. They'll look to make sure you have a way to monitor needs once they are in PACU or going to another unit. And then they're going to talk to your staff. How are you visually monitoring that patient and keeping an eye on them? How do you know what to look for? What do you look for in a particular patient? We have to have an OR register that identifies who, what, when. In other words, patient name, date of surgery, length of surgery, who was in there, who was working, the type of anesthesia, what were the findings, and age of the patient. Joint Commission, I just put this in here as a reference. It's pretty much the same. Of course, we know the surgeon has to do an operative report immediately after surgery. What did you do? What did you find? What did you take out or put in? And it's signed by the surgeon. It must include patient information, ID, time of surgery, who was in there, diagnosis pre and post, what did you do, any complications that you encountered, graphs, and then any significant tasks done by others. Now there is a list in there. It's very similar to important tasks provided by others. That could be something as simple as surgical PA completed the closure of the external wound. Just a quick description of what that other person did. So staying in the surgical arena, I'm going to move now on to anesthesia and question four. And again, I think we're very good on time, Lindsay. So if you want to go ahead and put that question up. Sorry, Laura, it would help if I came off the beat, wouldn't it? Let's get that question up here on the screen. So our anesthesia providers include, and you can check all that apply to your organization here, anesthesiologist, CRNA, supervise only, CRNAs, no supervision required, or anesthesiologist assistant. I don't see any pending questions at this time, so I know we're about halfway through. So if y'all have any questions, please make sure you're typing those in. And as far as what providers, that's totally up to the hospital on who they want to allow to provide those services. CMS won't tell you. If you're going to use a non-physician, then of course you have to abide by the rules on supervision and monitoring of those folks. Okay, we've got some good results there. Good. Wow, you're good. Yeah. So CMS has quite taken on much more care in hospitals, especially in your smaller critical access. So for anesthesia, just like any other service provided in a well-organized manner under a direction of a qualified physician, now here they do say it has to be a physician. Like any other service, it's integrated into QAPI, and the medical staff determines what are those director's qualifications. They will look at the job description, the surveyor will, they want to see what elements did they look at. And this is wherever anesthesia is provided, whether it is actually in surgery or is it in the emergency department. All they're doing is they're supervising, they're overseeing the delivery of anesthesia in those non-OR settings. There is a state exemption, we know, for supervisions of CRNAs in 26 states. So it is still out there, that half of them. But there were some changes to the standards, and so one of them happened to be you're expected to have policy and procedures, especially on meds, that might fall into that continuum where you're going from analgesia over to anesthesia. I always think of morphine. Policies consistent with our national guidelines and specify the qualifications of those who can administer analgesia, not anesthesia. So not only do we have to spell out who can administer anesthesia, but that analgesia, when it's starting to creep toward that side of anesthesia, they added definitions for us. Put them in your policies if you want to, you won't be cited if you do. Anesthesia, we know that's where we blunt or take away that pain perception. We take away our movements, both voluntary and involuntary, and also memory and level of consciousness. Anybody who's had Versed knows exactly what that feels like, that loss of memory. Analgesia, that's where we do to provide pain relief, whether it's a block or something, but the patient doesn't lose consciousness. Again, all of this is on a continuum. So in your surgery, say you're going to be doing a shoulder surgery, and you're going to do a block, a stellate ganglion block to help with that pain. Well, that's analgesia, but it's curging toward anesthesia. And so that's why you want to have that clear definition of who can do it. MAC, we know that's monitored anesthesia care by a qualified provider. Can be a CRNA or an anesthesiologist. This means you can convert to a general or go up to a regional if you need to. Deep sedation, that's where there's enough depression of consciousness where the patient can't be easily woken up, but they do respond to repeated or painful stimulus. So deep sedation, deep analgesia, that's included in a MAC. As far as pain, there are three areas. They're not subject to anesthesia administration or supervision requirements, like a local. This is where, of course, we go in to stop pain stimuli. Medium sedation, something that they can still respond, but it will decrease their anxiety like a Valium. And then there's moderate or conscious sedation. Here the patient responds purposely to verbal commands, where before, you know, they didn't, they were, you know, it was painful stimulus. Here they respond to verbal commands or maybe touching them. So that's moderate or conscious sedation. Either way, in anesthesia, you have to be able to rescue the patient if need be. We know sedation can go from they're still kind of awake and moving around to they're completely out where you have to bag them, airway management. That's why procedures to rescue patients becomes deeper than what we intended it to be. Maybe you have a very fragile elderly individual and they respond very quickly, very dramatically to that anesthesia that we hadn't anticipated, where any other person of the same age might not have responded. Overall services are under one anesthesia service under the direction of a qualified physician, no matter where it's provided, again, whether it's an OB, ER, or surgery. There is no bright line. We know that between anesthesia and analgesia. There is references that we follow, of course, our national standards, ASA, they are the national ones for anesthesia, but don't forget GI and endoscopy in particular where they're providing some sedation. You have to determine as a hospital if you're going to allow anesthesia outside of the OR suite, whether it's ED or procedure room. The standard, it does mention supervision requirements for those who administer it. Policies have to establish minimum qualifications and supervision. That includes moderate sedation. Here the medical staff will credential standards, nursing standards exist to make sure staff are qualified and competent. We know as nurses, if you're going to be working in PACU or you're going to be working in some of those procedure areas like endoscopy, ACLS, maybe you have to have that. Your policies have to look at your adverse events or errors. Maybe other indicators, is there something we're missing, a step that we can prevent that from happening going forward. Again, we're still in anesthesia. It's organized according to scope of service. And you only administer it by those who are qualified to do so. Whether it's an anesthesiologist, an oral surgeon, a CRNA, or an anesthesiologist assistant. The anesthesiologist assistant, they are under immediate available supervision. The state exemption, which I touched upon, this is where the governor sends a letter to CMS. I have consulted with medical and nursing boards. This is the best interest of our patients and our citizens if we do not have supervision. Because now we have a wider base of anesthesia providers, especially in our smaller communities or smaller hospitals. And they request the exemption and recognition of withdrawal from that request effective upon submission. So I have the link here, 25 states now. You may have a slide that says 24. My research yesterday showed that it's now 25. Massachusetts came on board late in 2024. So now it is 25. We're halfway there. Utah and Wyoming, there's a partial opt-out for critical access. And those specified rural hospitals, where, again, they simply can't get one, and this is the best way to do it. All right. Services and policies, of course, meet the needs of the patients. And our resources, what do we have available? What is pre-anesthesia and post-anesthesia responsibilities? Because there are certain ones before and after. And that includes, the policy includes, who gets consent? Are you going to get a separate consent? Infection control prevention measures. Safety in all areas. In other words, monitoring the patient. And how are you going to meet the needs? Protocols for life support, CPR, respiratory emergencies. Any reporting requirements. Documentation and equipment requirements. Monitoring testing of your anesthesia equipment, who's going to do it? How often is that going to be done? They may want to see documentation of that, by the way. And then pre- and post-anesthesia responsibilities. For pre-anesthesia, this is the responsibility, it's the assessment. Somebody who's qualified to administer it, this is non-delegatable. In other words, the physician can't delegate that to an RN. It's done 48 hours before surgery, at least. Inpatient and outpatient procedures. And regional, general, and MAC. It is not required for moderate, but you may still want to do an assessment. Something to say. Who does that? Well, someone who can actually administer the anesthesia. Whether it's an anesthesiologist, CRNA. An assistant can do it, but they have to be under the supervision of the anesthesiologist who's immediately available if a question comes up. Now, this is the pre-assessment. A dentist can also do it. Somebody who's qualified under state law could do that. You can't delegate it to someone who's not qualified. And it starts, the time for that 48 hours, that starts at the first dose of medication for administering or inducing anesthesia. Some can be collected before that 48 hours, but never over the 30 days. Like let's say you've got a patient where you're going to be putting in a temporary pacemaker or replacing a permanent pacemaker. The patient saw the cardiologist 15 days before they came in. That's fine. You can use some of that information in collecting the data for your 48 hours. But then again, you have to do that pre-assessment. You have to do the history, any anesthesia, drug, or allergy history, talk and examine the patient. The remainder, again, you can do it within that 30-day timeframe. What is their ASA risk? That could change, by the way, as you know. Any potential problems, maybe they've had something going on in that 15 days that you've got to be ready for, like a bad IV access, or it's just a difficult IV access. Anything else that the standard of care says you need to do. Then you develop a plan. What type of medications are you going to use? How are you going to maintain this patient? And what post-op care will they need? Of course, risk and benefits of that anesthesia. The surveyor wants to look at a sample of your records, both inpatient and outpatient, those who have had anesthesia. Because what they're looking for is that evaluation done by that qualified person. They will determine that two anesthesia evaluations included that all required assessments and elements, and that it was done within 48 hours before that first dose. ASA, American Association of Nurse Dynesticists, they have those pre-anesthesia assessments. I like ASA. I respect that they put the information available to the general public. The anesthesia evaluation, it's the interview with the patient, their history, it's an appropriate physical exam, you know, you may want to open them out, okay, how's it looking in there? They'll look at maybe some other data, whether it's labs or x-rays. They have to then assign an ASA status, and they put together the plan, talk about the risk and benefits with the patient or their representative. Nurse Dynesticists' standards, very similar, there's a section on that assessment, and they also have a lot of good resources, like practice documents and guidelines, joint physician statements, so they also have quite a bit. I believe there's stuff you may need to be a member, but under ASA, you do not. Interoperative record, this is for anesthesia. You have to have policies on interoperative anesthesia, and also the record, those who have general, regional, or MAC. It must have, of course, hospital name, ID number, who administered the anesthesia, and then the techniques. Now, they include a patient position, because sometimes, you know, the anesthesiologist wants one position, the surgeon comes in and flips them over. We just have to make sure that that is documented. Any IV lines or airway devices that we're going to insert. The record, what medications did we give, IV fluids, blood, how were their parameters with oxygenation, ventilation. It is time-based documentation that continuous records any adverse reactions or problems that happen to come up during the surgery. So once you're done with surgery and they're out, we have to go back and do a post-anesthesia evaluation, again, by somebody who's qualified to give anesthesia. No more than 48 hours after that anesthesia-required procedure. We do it according to policy and procedures and any state law that is required. The policies have to be approved by the medical staff and reflect current standards of care. It's in the chart, again, within 48 hours of those who receive services. Inpatient and outpatient, you may have to call your outpatient surgery patient, see how are they doing. It doesn't have to be done by the same person who administered, but by someone who is qualified to actually administer the anesthesia. Now, nurses may call after the fact and just say, how's your nausea doing? Are you keeping your fluids? Are you able to move around, et cetera? But the anesthesia post-assessment is separate, and that has to be done by a qualified provider. Out in the evaluation, it starts from the time they're moved into PACU or somewhere else, like maybe ICU. And normally, we can't do it while they're going to recovery because they're not awake yet, and they can't participate. If you have same-day surgery, you can do it again after discharge. If your policies and procedures say sure, state law says it's okay. If they're intubated, you still have to do it. Just document the patient can't participate. If they require long-acting anesthesia, that may go beyond 48 hours, document it. And note, full recovery has not yet occurred. And this is what the assessment includes. Are some respiratory function, their rate, any cardiovascular functioning issues, their mental status, pain, temperature, nausea and vomiting, and how are they doing hydration? Are they still on IVs, or can they now take orals? The surveyor will look at your records. They want to make sure it's in the chart, your evaluation, and it's done by somebody who's qualified, that it was done within 48 hours, and all of those elements are documented in that assessment. ASA does have guidelines on post-anesthesia. That is a time-based record. We know that for anesthesia, medications, IVs, everything, and any post-anesthesia visits. So they do have guidelines. Okay, moving on to outpatient services. It's optional. You don't have to do this if you don't want to, but you have to meet the same standards of practice. Comply with all the conditions, both on and off campus, and integrate it into your QAPI. They have to be appropriately organized and integrated. So if you have any old records, they have to make sure they're available. Radiology and labs are done timely. Anesthesia, pain management, everything, they're all included into that record because we have to coordinate the care and make sure there's enough information in the record to provide safe outpatient care. Have enough personnel, whether professional or non-professional. That's, of course, what are you doing? Are we talking invasive radiology? Are we talking outpatient surgery? Or are we talking physical therapy? Put in writing the qualifications and competency of each person, and that's normally in their job description. And policies and procedure make sure the person's responsibility is spelled out. How many you need, that's up to you, just to make sure it's appropriate for the care that you're providing. Have enough supervisory staff to make sure it's immediate availability for an RN. The previous regulations said bedside. They took out bedside. Because that includes, or that references inpatient. So now it's just availability of an RN for care. You determine how to organize your own department, but define in writing what are the qualifications and competencies of each director. Surveyor wants to see how you're organized, who's responsible for direction. They want to look at your policy and procedures, who is also responsible to make sure these policies are met. Who is also responsible to make sure these policies are carried out. And what are the prescription descriptions of those who are responsible for services. So as far as an outpatient RN and those areas, which ones need an RN? MRI? Maybe not necessary. Ambulatory surgery? Yeah. Criteria in the outpatient department. What is your acuities? What services are you providing? What are the standards of care? What are the standards of practice say you have to have? Here you can look at these every three years, as opposed to every two years. The street nursing officer, they have to review your policies and approve them and then make sure there is an alternative staffing plans. So if you know you're going to be extremely busy, are you ready for it? Who's going to be in there providing that care? Any services are provided according to orders. Somebody who's responsible for taking care of that patient. Of course, licensed in the state. The order is within their standard, their scope of practice. And that the medical staff, it's that physician can write that order. Then they're approved by the board. Whether privileging and credentialing by the hospital or not, whether or not that's required. Again, these are outpatient services. But you want to verify that person's licensed and you can check the license. Don't forget your OIG, Office of Inspector General. They have a list of excluded individuals who are not allowed to write orders because of their exclusion. Usually it's because of Medicare and Medicaid fraud. We always follow standards of practice, whether it's AMA or American College of Surgeons. Again, optional. You just have to comply. And enough services, equipment, staff, orders have to be made by someone who's, again, responsible for the care of the patient. So as I start to wind down, we just have a couple more topics, starting with emergency services. This is what happens any place within your hospital. You have to, of course, meet the needs of the patients and make sure specific services are organized and directly directed appropriately. We follow standards of practice and organized under a qualified member of the medical staff. And the medical staff determines what is that person's qualifications. Are you going to have the ED, chief medical officer, chief ED, or are you going to have the chief medical officer for the hospital be responsible? That's up to you guys. They're integrated with other departments, whether it's lab, medical records, communication between departments. You have to have immediate availability of not only equipment, but services, other resources. And look at how long does it take to transfer between departments. Is that appropriate or is it taking too long? Other departments, you have to provide emergency care at all times. And that, again, take into consideration, how long does it take to transfer this patient from point A to point B? How long does it take to get equipment and supplies or staff to the emergency department, that's where it's going to be specifically, to provide those services? So this is part of this new plan. And I'm going to briefly touch on it as a last topic. But again, as of July of this year, you have to have enough provisions and protocols. And those protocols are based on nationally recognized guidelines for the care of the patient emergency situation. This includes OB emergencies, complications, and immediate post-delivery care. Again, this was part of that prior administration's rule that really focused on OB care. These are kept at the hospital, your supplies, everything, and it's readily available to treat these cases. That must include equipment, supplies, and medications to treat cases. They are kept there and readily available. That includes drugs, blood, blood products, equipment, supplies, and a call-in system for each patient in the treatment area. So if you get a patient, let's say you're on the L&D floor, and all of a sudden, your patients start to exhibit postpartum bleed. You have to have all of this stuff available within your hospital to treat that postpartum bleed. It could also be a post-surgical bleed. We were taking care of a patient. She was getting ready to go home the next day, and she had had a vaginal surgery. And she was saying just that night, she called my tech in and said, you know, I'm feeling some drainage. Would you mind checking it out? And she was having a massive, delayed postoperative bleed. And so we had to have all of these products, services, everything available in order to treat that emergency condition. Staff training is new. This is another new requirement. Which staff has to be trained annually on the protocols and what you need? The governing body, they have to identify and document what staff has to have that training. You also have to document that in their personnel records, and that staff has to be able to demonstrate competency on those topics. You use findings from QAPI to say, oh, maybe we need to update our staff on this or update it to something on an ongoing basis. So this is all new. These will be a part of the conditions of participation once they get around to updating them. Just briefly on urgent care, you can have them on campus, you can have them in your physician's offices if that's the case, they comply with the conditions. I put it here because if you hold out only providing urgent care services and maybe other, be very careful that you publicize it. This is urgent care. It is not emergency services. Now, to most of the lay people, what's the difference? That's the same thing. But we know they're very different because an urgent care doesn't meet the definition of a dedicated emergency department under EMTALA. And that's why it's so crucial to make sure it's a clear delineation of, this is urgent care. This is for your scrapes. You couldn't get into your physician's office and the kid has a temperature or the kid is coughing, something like that, or you're coughing, you're not feeling well, or you scraped your hand and you need to have a few stitches. So that's what you need to be very clear, it's urgent care. Services have to be supervised by somebody who's qualified by the medical staff. And supervision is more an immediate form of oversight at all times. They can, of course, be briefly absent from the department, but they're expected to be in-house for that supervision. And medical staff put out the criteria. What are the qualifications for that supervision? That may be specialized training. Otherwise, enough personnel, whether it's medical and nursing, that they're qualified in emergency care, you determine the category and numbers. The medical staff determines the criteria for qualifications on each staff, do periodic assessments, make sure they're still up to snuff, and work with your local emergency preparedness officials when you do have a possible disaster. The surveyor will verify you have enough medicine and nursing personnel. There's a clear chain of command, and they'll talk to staff. By the way, do you know where or how to take care of an injury to an extremity, like splinting? What about central nervous system injuries? What are you going to be looking for? And blood and IV fluid requirements, prevention of infection, that's kind of what they're going to be talking about. So now we're on to one of the shorter segments. There's only a couple tag numbers. Now, rehab has a lot of tag numbers, but there's not much information in there. So I'm going to start with rehab. If you do provide this, whether it's rehab, PTO, speech, whatever it is, as with any other segment, it has to be staffed and organized so we have safe care delivered. Those are qualified according to what state law says they have to have, and the medical staff. They have to meet standards of their national associations. And if you're going to do this, like anything else, again, it's integrated into the hospital-wide QAPI. Rehab organized to provide the scope of services. You have to have proper equipment and personnel, have the scope defined in writing, and policy and procedures approved by the medical staff. Each service has to function within their lines of authority and responsibility with enough qualified staff for each patient for the initial plan, and then also supervise and support a personnel. So in PT, you've got your registered physical therapist, but you may have a PT tech who's doing all the other ancillary processes. Surveyor will look at your policy and procedures. Are your scope of services defined in writing? If you're provided by contract, great. They want to see the contract. Again, enough members and enough qualified staff. They will also look at records. Who evaluated this patient? Who initiated the treatment? Then they'll look at a sample of personnel folders. They're looking at licensure, certification, any ongoing training that might be required. There has to be a director of rehab, someone who's knowledgeable and experienced to supervise and administer services. They have to be able to show through education, experience, or training that they're so qualified. Part-time, full-time, whatever your services demand. And likewise, a surveyor wants to see their job description. They will look at timesheets. Are they dedicating enough hours to this supervision? And then they'll talk to the director. How did you make sure you have enough of this training, education, or experience to do the actual supervision? With any process, we have to have an order. Somebody who's qualified, licensed to take care of that patient, and also the medical staff says, yes, you can order PT or rehab services. Privileges are granted according to state scope of practice, and all records have to have that order. Provision of services according to a written care plan, and that's only after somebody who's qualified can write that order, but you have to have a plan of care. The type, amount, frequency, and duration of treatment, and any changes according to policy and procedure. Switching over to respiratory. Again, meet the needs of the patient following standards of practice. They're organized according to your scope and complexity. It should be in writing and approved by the medical staff. There is a director who's a physician. They have knowledge, experience to supervise these services. That may be a pulmonologist, and then you have to have enough therapists, technicians to do the actual provision of services. They have to be qualified to do those procedures, and the amount of supervision necessary that needs to be in writing. So here's just what you have to have for delivery of services on respiratory. That includes assembly and operation, preventing maintenance, safety practices, CPR, storage, and access to medication. ABGs, who's going to analyze them? Who's going to draw them? How are they going to respond to adverse events? Percussion and vibration. Mechanical ventilation. That's probably where they spend a lot of their time, maintaining those ventilators. Aerosol, therapeutic gases, et cetera. Quite a bit that you have to have required policies on. So with our time left, I want to talk about obstetrical services. Again, this is going to be new to the conditions of participation. I am going to start right now with your hospitals, your acute hospitals. It is not part of your published manual yet because this came out after the fact. I don't have tag numbers yet, but it's going to cover some of the areas we've touched briefly on. Overall, obstetrical services, well-organized according to nationally recognized practices. This is for pregnant, birthing, and postpartum patients. If you have outpatient services consistent with inpatient care, the quality of care, this will all go into effect January of next year, 2026. You have to have organization of your OB services according to the scope of what you're offering. Integrated with other departments. That may be surgery. That may be lab, x-ray, or radiology. Your L&D rooms, whether it's combined or separate, they have to be supervised by an experienced RN, nurse practitioner, EA, or physician. OB privileges have to be delineated for all practitioners providing OB care according to their competencies. Services have to be consistent with the needs and resources of what you have. Policies governing OB care designed to achieve and maintain high standards of care. This also includes any equipment you have, provisions and protocol. Provisions are like your medicines, your OB packs. Again, this requirement will go into effect January of 2026. On equipment, you must have the following equipment readily available and maintained to treat cases and to meet the needs according to your volume. That's a call-in system, cardiac monitor, fetal doppler, or monitor. On provisions and protocols, enough so that you can take care of these emergencies. You can respond to the emergencies or complications. Could be other patient events that maybe your QAPI program has identified. I've already talked equipment, but this includes your medications and supplies. So what are you going to have for medications to treat your OB emergencies? And then as far as staff training, there are five requirements. You have to develop policy and procedures to make sure relevant staff are trained on those specific topics to improve care. Number one, training concepts must reflect the scope and complexity of your hospital. Are you a level five neonate? Now, in my state, a level five neonatal, that's like children's hospital, that's the highest level attainable. Level one, if you've got really good healthy babies, they're in and out fairly quickly. So what are your complexity of services? You're using evidence-based best practices to improve the delivery of care. Use the findings from QAPI to inform staff. Hey, this is what we found as an issue or a concern that we're having. So we're going to train and add or revise and update our training. Number two, make sure your relevant staff have been identified. New staff also with initial training. Number three, the governing body identifies and document which staff have to have initial and ongoing training on the topics identified. Number four, document their records. Training has been successfully completed, but then number five, staff have to be able to demonstrate that knowledge on any topics so identified. You have some time in this one. They know it's not going to happen overnight. This, you must be effective up and running by January of 2027. So again, this is part of the Biden-Harris administration and CMS said, yep, we're going to include a lot of these requirements now. There are similar ones for critical access hospitals. That will also include when maybe you need to transfer a patient. And critical is not so much for transfer, but I mentioned these in the discharge protocols. This was part of that new requirement. And by the way, QAPI, which we talked about, I believe a week or so ago, this is the first time CMS took the step to include OB services in responding to emergencies as part of a mandatory QAPI. It's the first time they've done that. All right, we're up to our final discussion. So I'll go ahead and read this one and then have Lindsay put up the questions. Very busy multi-specialty hospital, mainly an older population. We have a patient post-lobectomy, scheduled to go home. And on the day of admission, of course, temperature goes up to just 100. Patient's been on antibiotics for five days. Discharge planning was completed with the idea the patient's going to go to the daughter's home and then have home health come in for respiratory care and follow-up visits. Daughter works at a neighboring care center. She has three young school-age children that are in the house. Four days post-op, she's home now. Fever goes up. It's up to 102.5. Patient's getting very tired. Pulse axis running 85 to 90 on room air. Not very good. One of the three kids was home from school with a sore throat and a headache. Home health recommended, you know, really patient P, you need to be away from the kids. But that's hard because, you know, kids want to see grandma. 10 days post-discharge. Patient's now back in the emergency department, RSV, and acute respiratory distress. Any issues you see here? I just put out a few. Infection prevention and control. Talking to the family. Adequacy of our discharge planning. Was the resident a good choice or the best choice? Was this readmission avoidable or anything else you want to bring up? Because again, you know, sometimes going to a family member is fine with adequate precautions. And so I see Lindsey's put them up. Lindsey, we're really good on time this time. So I'll go ahead and open it up to you, see if there's anything else. And then I'll just close us out with just a couple of comments on some of the resources. Perfect. Hey, I see several of you putting in your responses here. I see some of you have selected other comments. So if you'd like to share those comments, you can of course type that into the chat. I'll be happy to share those with the group. And then if you do have any questions for Laura, again, I know today is the final session in our series. So please don't hesitate to go ahead and type those in to either that Q&A option found there at the bottom of your Zoom window, or if for some reason you don't have that as an option, you can of course type your questions into the chat. And it may not be for this particular session, but if you have a question lingering from one of the previous sessions, we're happy to address those as well. One question that just came in, Laura says, for the OPO policy, is it appropriate for the board to delegate that approval authority to management? The board will be responsible for it no matter what. So they can delegate it. It's just the board has to recognize, yeah, you're gonna be responsible to know what's in there. They cannot pass off that responsibility. Yes, they can delegate getting it done, the review of it, et cetera, et cetera. But the board has to know what's going on in the hospital, and that includes that agreement. And it could just be something that they're going to do during their review of all the contracts or the agreements and that, oh yeah, we looked at this. Yep, yep, we're good, okay. That's it. As long as the board, and I wanna clarify, the board minutes need to really show they have or were involved in knowing that, yes, this policy or the agreement has been done and reviewed. Perfect. Okay. Let's see, I see just a comment here, I think, related to the discussion that says, I would not have been comfortable sending the patient home with a new low-grade fever. Should a culture have been done to ensure the appropriate antibiotic was chosen? Correct, yeah, that's a good catch on that, especially on infection prevention and control. That, yeah, perhaps the daughter's wasn't the best choice. And we still had pretty much a fairly, to me, this patient was label, label, label, yeah, fragile, that's a better word, fragile. She's an older individual, just had part of a lung taken out for crying out loud, and she had that low-grade fever. Maybe another area would have been a better option. Unfortunately, they lived in a metropolitan area, so swing bed for a critical access hospital was not available. I don't recall if there was a smaller hospital, like under 100 beds, that did have swing beds, that maybe that would have been a better choice for her to go to until we got that fever back to normal. Because she would eventually have gone back home-home, as opposed to the daughters. Otherwise, include the daughter in this, it's like, this is crucial, I know the kids wanna see grandma, but not right now. Or, would it have been an option to really stress infection prevention from wearing mask? I don't know. I don't know, when you got little kids, how hard is it to keep that mask on? Was that an option? And then getting the kids out of the room, and then the mask could come off. So I like all of your comments, you're all right on E and right on target with what the issues were here. They did not get reimbursed for the revisit when she had to be readmitted. They did feel, yeah, this was probably preventable, which, yeah, maybe one or two more points on it. So I do wanna point out one thing. Now, you're going to see in here, and on the slides that Lindsay provided, I have a whole bunch of resources, like 30 pages of them, so I'm not gonna go through them. I've tried to include as many of the websites as possible. So here's just an example of some of those. There are several pages of websites, whether I covered it on this session or any of the previous four. So you might wanna keep this just as an option for some of those websites. Again, you may have to, some do require memberships, but I try to point out the ones where you don't have to have memberships. How much of this is now available? I can't answer that. With some of the changes going on nationally, I really can't say which one of these will be available to you at this point in time. Otherwise, if you do have a question that comes up afterwards, please reach out to Lindsay. Lindsay's great about getting them to me, and I'll respond back to the levels that I can. Again, I can't provide legal advice, and I can't address anything as far as payment issues. So Lindsay, I'll turn it back to you to maybe give them, what, 12 more minutes of their afternoon or their morning. Yeah, absolutely perfect. Thank you so much, Laura. I'm just gonna post some final follow-up information here for you in the chat. And as Laura just mentioned, if you do have any questions, please don't hesitate to reach out to us at education at gha.org. And I'm more than happy to get those questions over to Laura, and she, in turn, is very wonderful about being very generous with her time and her knowledge here. So we are very thankful for going above and beyond in doing that. You should see there in the chat now, this is a final reminder. You will receive that email tomorrow morning. I hope that you have been receiving those emails throughout the series, but just note that it does come from educationnoreplyatzoom.us, and that email will, of course, include the link to the recording of today's session and a link to the slides that Laura has presented. But that link for the slides is there now for you in the chat as well. And as I mentioned, whenever we open today's session, if you are joining us as a member of the Georgia Hospital Association, I do ask that you also pay special attention to a follow-up email that you should receive this afternoon that will include links to the recordings of all sessions, the slides, and then especially information related to the continuing education credits that we are offering to GHA members for the completion of this series. And again, you should receive that email in your inbox this afternoon. If you do not receive that by tomorrow, I encourage you to reach out to us at educationatgha.org. We'll be happy to make sure that you have all of the CE information that you need. And if you are joining us as a member of a partner state hospital association, unfortunately, GHA is only able to offer CEs to GHA members, but I do know that several other states are offering CEs for this series. So please reach out to your contact within your state hospital association to obtain that information as well. And again, don't hesitate to reach out to us with any questions at educationatgha.org. Thank you so much, Laura, for your time and your information that you've shared with us throughout this series. I see comments here in the chat just saying that it was a wonderful series and appreciating your information that you've shared. So I hope you all have a wonderful afternoon. We appreciate you all being with us and for your questions and participation throughout the series. We hope to have you all back with us for future webinars. Thank you so much, Laura. Hope you all have a wonderful afternoon. Thank you, Lyndsay. Thank you, everyone. I appreciate the comments. Thank you. Okay, bye-bye.

risk management

patient safety

hospital operations

infection prevention

discharge planning

surgery

anesthesia

outpatient services

emergency services

antibiotic stewardship

patient-centered care

emergency procedures

OB services

quality improvement