I would like to introduce our speaker to kick us off 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 COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. 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. We thank you so much, Laura, for all of your time and information that you share with us for this series so far, and we invite you to go ahead and kick us off with our final part today. Very good. Thank you, Lindsay. We have a lot to cover today. We're covering almost 11 topics during the program today. Now, some of these are very, very short. For example, anesthesia and surgery and rehab and radiology. There's only a couple tag numbers within the manual, Appendix W, that we're going to be addressing. So that's why we decided to hold this off until the last so that, like Lindsay mentioned, if you even have questions from the previous three, it will give us an opportunity to address them at that time. My program today is informational only. It is not meant to serve as providing legal advice or establishing an attorney-client relationship. So please consult with in-house counsel, legal representative, whoever that happens to be, on a situation involving your hospital. What I can do is give you what does the CMS code regulations say you have to have in place. Well, we know that's been somewhat of a very long journey, but the critical access hospitals are so important to the healthcare community because you provide that service that normally would not be available in those smaller or even rural or even remote areas. So critical access are so crucial. And why we are doing these and why Georgia Hospital puts these on is so you don't get one of these. That is the statement of deficiencies where you have to put together a plan of correction. And no facility or even provider, I don't care if you're a radiologist, a doctor, whoever, you don't want to get noticed that you have been involuntarily terminated from the Medicare-Medicaid agreement. These are made public. And it can be not only a financial hit for a hospital and other facility, but also it can also impact your reputation. And so that's why it's great that these are being provided to you. In the manual and the appendix, I've highlighted which areas we're covering today with the addition of the new requirement on provision of obstetrical services. That came out late last year, and it is now applicable to critical access hospitals. Just a little bit of overview, if you haven't had the opportunity to listen, there is a website for critical access hospitals. It has information that is applicable to you. And for those of you who also provide swing bed services, there's numbers, contact information for your region. The website itself is for not only criticals, but also swing bed providers. It has the manuals in them. It has transmittals. That's where CMS sends out notices to their surveyors, and you, you get access to those. On what's new and upcoming, Medicare Learning Network, that's great if you have questions that you need to tap into. What are they teaching their surveyors? So that's just an example of what that swing bed provider would look for. American Hospital Association also has resources for critical access hospitals, because they know they provide that great high-level care in our rural communities. So just a few resources that I wanted to touch on before I begin. Let's start about radiology medicine. If you're going to do this, of course, it has to be provided through qualified staff. Now, you can do this by contract. You can do it by employing the individuals. It doesn't matter. Also, that includes not only doing the service, but interpretation of those films. Maybe you're using those continuous 24-hour reading services that are available. The nice thing is it does provide you 24-hour service, if that's what you want to do. You can. Again, CMS doesn't care. Of course, we don't want to expose our patients or staff to any undue radiation hazards, and we have to have services that meet what are your needs. Maybe you're in a very agricultural area, and you have some of those pretty nasty traumas that would come in. Well, you have to be able to meet those needs of those patients. Or perhaps you're next to a very major interstate where you could get some rollover accidents, some very, very bad motor vehicle accidents with multiple patients and multiple traumas. Again, that's what you have to look at. What do you have? Where are you located? And how can you meet the needs of those patients? You can offer little or whatever you need, again, to meet those needs, whether it's diagnostic, nuclear medicine. You have that ability, that flexibility to determine what you're going to offer using, of course, standards of practice. CMS won't establish that. They leave that to you, the experts in that field. And then, of course, complying with any state and federal laws, whether that's licensure, certification, having the radiology department survey to make sure it is safe. On scope, put it in writing. It should be in writing. It's not required, but should be. And of course, your board, your governing board, or that responsible individual, they have to sign off on that. If you are using those telemedicine services for radiology interpretation, they have to comply with those standards. And that means that you can agree to use those, and especially if it's another hospital, say you have a larger hospital 50 miles away or so, just have to make sure the radiologists understand that's part of telemedicine, that they have to meet all of the requirements of privileging, credentialing, review of services, et cetera. And they've already mentioned that you meet the standards according to those nationally recognized professions, whether it's ACR, is it going to be American College of Neurology, AMA, whatever it is. By the way, ACR has safety standards for MRI and contrast. It is at acr.com. I was able to download these free, and there's, again, the one on contrast media. This is the most recent one I found from 2023. I haven't seen any updates since then. There were some updates, though, that CMS put into place, and ACR, they put together a multidisciplinary committee. Again, CMS will recognize these. They put together that manual on MRI safety. It includes personnel and screening, who are you going to have doing these tests, patient populations that are special, what you have to do with those, maybe those with certain implantable devices, kiddos, pregnant patients, other objects that they may be wearing. They are the new manual. This is, again, the one from 2020. I just included in here some of the items that they were listing, but as a heads up, there is supposed to be a new safety manual coming out. I checked last week, and it is still not out, but according to their site, they are supposed to be putting out a new one. Then we have to have qualified personnel to work in there. You designate who and how many you need, because then you have to know how to use the equipment, how to do the procedures, and, of course, your staff have to meet any of their licensing requirements or certification, if they happen to have specialized services that you're providing, and again, telemedicine, they have to meet those privileging requirements. On safety, we have to make sure we don't have shielding for patients, but others, your personnel, your staff, and the facility. Usually the shielding is built into your plant, and the shielding, well, that depends on how many and what types, you know, like the thyroid cover, and also the waistband or the apron, whatever it happens to be. Included in here is our containers for radioactive materials, the waste containers, and clear signage that, hey, this is a high radiation area. Now, I didn't mention it, but since CMS works very closely with OCR, Office of Civil Rights, make sure that you have those in maybe other languages, your most common other language, because, you know, personnel, people may walk in and out unbeknownst to them where they headed. So that's why it's helpful to have. Again, the regulations didn't mention it, but you do have to have clear signage when you have a hazardous radiation area. On your policies, this is all continued, labeling, how are you going to label those materials, waste, clear identification, transportation of such between locations, and security. And that, you have to include in that policy who has access to that materials and how you're going to control that access. Who gets to get in there, who is prohibited from being in there. Usually it's easier to just say only the following classifications of individuals have permitted access to this area. And of course, periodic testing of the equipment, we want to make sure it's working using that physicist on a regular basis. We also periodically check our staff, how are they being exposed, you know, their dosimeters, storage of our nucleides and pharmaceuticals, disposal of such, whether it's the nucleides, the pharmaceutical, the waste, and again, checking of our equipment. Is it properly working? Are we over radiating or are we under radiating? Our records for radiology, they are the same thing as any other part of the medical record. So we have to maintain the reports of any exams, our results, and any consultative findings. You might want to check your state law. It may be longer than what the critical access hospital requirement is of six years. So it may be 10 years in your state. Keep it for the longer. That's what you want to do in order to make sure you're in compliance. On survey procedures, what the surveyor wants to do is they want to know who's responsible for the service. What are you providing at your main campus and do you have any off-site locations? Say you have a mobile mammography unit. How do they meet? Make sure they're meeting the standards of practice. On safety, they want to know, and how do you determine if staff are familiar with your safety policy and procedures? Do the staff know, yes, you wear the shielding and you wear your dosimeter on the outside. You tuck it in your pocket behind the apron. It won't work. Aprons. How are the aprons looking? Are they starting to fray? Are they starting to look maybe a little too worn? They will also look at your equipment reports, your maintenance reports for that equipment to make sure routine recommended maintenance has been performed. They will also look at your hazardous material. How is it labeled? How is it stored? Is it secured? And again, ask, how do you get this safely transported between areas? They will also make sure that on your personnel that the studies are done by only qualified personnel. These are the folks that the governing body has granted the privileges to do so. They'll look at the equipment the staff are using and then they'll look at their personnel folders. Are they qualified to run that piece of equipment? They talk to your staff. Can you tell me the protocols on doing this procedure? And then they're going to compare those protocols to what has been told to them. Are they adhering to them? It could be something as easy as, have they asked the patient, have you ever had a test like this done, like a contrast? Did you ever have a reaction to it? And so what kind of reaction did you have? How long ago was that? So again, are they following the protocols as written? There is a blue box memo in here. Again, if you don't do it, you're not cited. But it does talk about using a medical physicist in conduction with those who are doing the services so that if there is an issue, it can be reviewed and updated promptly. So again, if you're not doing it, you won't be cited, but it is a good idea to do it. Again, radiology was pretty short. Let's move on to rehab. Again, just like any other service, if you're going to provide it, you have to have qualified staff, whether that's PT, speech, OT, whoever it happens to be. And of course, they have to follow their state laws on licensure and any therapy requirements. This is optional. You don't have to do this directly. If you're going to do it, again, you can do directly like employees or through a contracted services. So this is like rehab therapy. Maybe you have a service in your town. Maybe not. That provides outpatient physical therapy. So again, you don't have to provide this rehab therapy, but you do have to have an order if you're going to do it, of course, to provide it, policy and procedures, everything consistent with the standard of care. In doing these services, you must follow that plan of care requirements and again, be consistent with state law, which is licensure and that everything is up to date, the equipment's safe. You know, your hydrocollator, it's not too hot. The ice that is being properly applied, not doing burns to patients. On the plan of care, this has to be done before treatment has ever started. And that depends on a couple of things on who can make that plan of care, whether it's a physician or it can be advanced practice provider. Of course, we know that's according to what the state says they can do in their scope of practice and what your hospital gives them the privileges to do. But once that plan of care is done, it can be done by PT, OT, whoever's furnishing that service. The content has to include, what are you going to do for the patient? How much, how often, how long is that going to run? It must indicate, there's a couple, one thing it must include is what is the diagnosis? And then what is the anticipated goal? So if you have a patient who's recovering from a CVA, then of course, the diagnosis is left-sided hemiplegia. And then the anticipated goal is to obtain optimal return of function for that side that was infected. If there's any changes, of course, we have to go along with those policy and procedures. And what are we going to do? Perhaps unfortunately, this patient has another continuation of the stroke, and now it's maybe hemiplegia from the waist down in addition to one side. So that's what we have to keep an eye on, that plan of care. Yeah, rehab's pretty short. Now we're going into visitation. This is the one area, as far as patient rights, where that's addressed in the critical access manual. Remember, if you've had an opportunity to listen to perhaps the patient rights section, that's a different program. See, the critical access don't address that much. They still have to do something, but they don't address it to the extent of visitation. Now CMS and Office of Civil Rights have shared jurisdiction when it comes to especially non-discrimination. And these regulations on visitation just flat-out bars discrimination on the basis of those protected classes. Now CMS and OCR, they work very closely here, and OCR, they will enforce any prohibited discrimination based on religion and any of the other protected classes. CMS enforces them as they relate to other bases of discrimination. So really, these two entities work hand-in-hand to prohibit that discrimination. And that includes visitation. So we have to have policy and procedures on how you're going to do this. Now that can include any reasonable restrictions or limitations on visits. There was a JAMA article that they mentioned in the regulation that does encourage open visitation in ICU. You don't have to do that. That's just an encouragement to help the patient who is so sick perhaps gain some return to normalcy by hearing familiar voices, seeing familiar faces. This visitation includes both inpatients and outpatient, and it talks about the role of that support person for both. But that patient may want that support person, if they're getting ready for pre-op or some procedure, sitting there with them, maybe when they're in the ED. So again, you have to have those policies on how that's going to occur. On reasonable restrictions, again, you can have them. Maybe it's perhaps that you got a court order restricting contact with a particular patient, or you've got that visitor who's very disruptive or threatening to your staff and others. You can do that for a substance abuse treatment program. If you're concerned that those well-meaning visitors, and I'm including family, friends, neighbors in that visitors, they want to help them along, ease them through this. Maybe they have a lot of pain and we're limited on what we can order. You can do that. Maybe patient's just having a test and it's good to not have somebody in there or let them rest after those testing. Maybe it's an infection control issue, or the roommate also needs rest. And then maybe you want to restrict kids under a certain age. Sometimes it's nice when little kids can come visit, but sometimes the children can also, especially if it's a school year, can bring in some nasty bugs with them. And we also have to protect the patients and your staff. So those are some reasonable restrictions. If you're going to do that, you must apply them universally across the board. So what goes for patient A goes for patient E on restrictions, reasonable restrictions. You have to have your staff trained on what those policies are. They have to be aware of them. And what role are they going to have in controlling visitors? Now you could have a visitor that is very disruptive. And so including your policies, how is the staff to handle that? Do they call security? Is this person so disruptive that they're concerned about their safety and well-being that maybe you need to call law enforcement? have in there what they do, support your staff in that, and give them that authority to say, okay, we're done here, you need to leave the premises for visitors. The surveyor will verify, first off, you do have your policy and procedures, and then they're going to look at them, because what they're looking at are those restrictions. They want documentation staff is trained, and the best way you can show that is if you're doing your annual skills lab, have them sign in on a sheet, and to show they were there during that presentation. Just make sure staff are aware of it, comfortable with it, and also, they can describe the policy. When can I, as a floor nurse, restrict visitation for a patient who just had some major surgery and needs some downtime? What can I do? What is my authority in restricting that visitation? We also have to notify patients of what your visitation policy is. It's usually in your notice that you give to the patient when they show up, and include in there any restrictions. Now, this can be a very broad restriction, if that is easier, and then be able to provide it to that patient when needed, know that we reserve the right to restrict visitation when it's in the patient's best interest, and also, if there's any issue of security or infection control, et cetera. Overall, the patient does decide who gets to come visit them, and we can't discriminate based upon that protected class, whether it's same-sex family. We just can't discriminate on there. You may have a very good reason for not allowing that one particular person in there, but it has to be a valid reason. By the way, you may also need to allow another person to come in and assist the support person if they happen to have a disability. The support person is in a wheelchair. They're confined to a wheelchair. They may have to have another person come in and help them get in and out of the hospital and the room, so you may have to allow that, and that is separate from the right to visitation. This was a recent frequently asked question on visitation, so it does, in a way, it's nice because it helps free up your staff. They're not so much responsible, but we may have to allow that third person in. On the support person, it could be totally different from the durable power of attorney that's spelled out in the advance directive. It can be anybody that the patient said, they're my support person. They exercise those visitation rights on behalf of the patient, and we have to accept that designation, whether it's verbal or in writing. Of course, we all know writing's best. If you're joint commission, they call this individual a patient advocate. It's the same thing, essentially. On incapacitated patients, you don't have any advance directives, you have everything in writing, which would be great. Anybody who shows up and says, I'm their support person, we have to accept that, and you can't demand documentation to support it, unless, of course, there's more than one. This person, they exercise the rights, and we give them the notice, so as I just mentioned, if there's more than one person that show up, then you can ask for that proof, that documentation. Have a policy on how you're going to resolve it, and then any refusals to recognize one support person, document in the record, along with why. Why is it? You may have a very darn good reason, like maybe it's elder mistreatment or child mistreatment, or maybe you're concerned about human trafficking, that there's just something that's not sitting right with you, so have that information for your staff. You may want to consult with the risk manager, if that's you, or your in-house counselor, how do we do this, because this just isn't sitting right. We're just concerned about it. Other visitation requirements, of course, the patient can say, you know what, I'm done, go away, everybody, leave me alone. They can change their mind whenever they want. Just document, again, that you've given them the notice, usually you do that, you can do it on your registration form, that they've been given a copy of their visitation policy or practices. The surveyor will look at what is your notice for visitation rights, they'll look at the records to make sure it's somewhere in there, and then they may even stop your staff and say, do you know what a support person is, what does that mean for your patient? Have you identified that person, or has one been identified for you? If you are going to prohibit visitation, we know we cannot restrict simply because of these five classes, race, color, sex, religion, it's only four. Sex includes, by the way, gender identity, orientation, etc., so it's a very broad term. If you restrict it to two visitors every hour, then the patient gets to pick that, who is going to come visit them. Have that culturally competent training programs also, especially if you're in the area where there has maybe multiple cultures involved. We need to recognize those, and again, to the level it is safe and it's non-discriminatory, that's how we have to practice it. All right, moving on now to clinical records, this is a little bit more broader scope than what we've covered so far. I'm going to start off with a couple items like HIPAA, OCR, and timely access, and how that overlaps. Well, first off, the Office of Civil Rights. There's information available to patients on their HIPAA rights. Now, a lot of us have been around for how many years has HIPAA been in place, and patients, some of them are very familiar with what HIPAA says. Well, they added to that just a little while ago on access, so patients now have access and a right to access that information. They can inspect their records, and of course, we know they can request any format that they want it in, whether it's hard copy or electronic, and they have a right of access within a reasonable amount of time, so that's why just some of the rights, which we know have been around for a while, they get a copy within 30 days of the request, unless, of course, they're off-site and you have to go get them or go find them. You can charge for records, no retrieval fee, but it's the paper that you're charging for. Also, there's also an inclusion in there when you can deny that request to send them along, but you can't refuse to give a copy because there's an outstanding bill. That's not new, by the way. That's been around. Generally, under HIPAA, we have to provide access upon request. Now, that's a reasonable time frame you have in there. Now, you may require them to ask for access in writing. Now, this is provided that you tell the patient ahead of time of this requirement. Actual measures that cause any delay or barriers to getting access will not be permitted. For example, requiring them to physically come in and request with proof of identity. That's over the line. Using a web portal to request. Not everybody has access to the internet. I have an older sister who lives in northeast Iowa. She does not have internet. Number three, if you have to have the mail in the request because that's going to delay their access to that. Now, again, you may require it, but you may just want to say, yes, I know this patient. They want to look at their records. That's good enough for me. And, of course, it's our current record. What's going on with them at this time? So that's why hospitals, you may need to look at your policy, educate your staff and physicians, on everybody, on access. And have a way if patients want to look at their record while they're inpatient. And, again, oral or written requests. Again, some of them will have them sign that access request. Now getting a copy of your records. We know they have that right to get them in the form and format they want it. The regulation talks about having an agreement between you and the patient or the representative. How do you want this done? And if it's not available in the way they want it, then we have to do it by hard copy. You know, if they say, I want you to put it on this and shoot it over across the country and get it confirmed back, you can say, you know what, we'll give you a hard copy and you can take it from there. You can get it to where you need it. One thing they do look at is timeliness and the entire record. 30 days, unless it's stored off-site. State law may be shorter. So, again, this is when you just want to confirm whether or not your state has a shorter period of time. The entire record or a portion, whichever one they want. And don't forget, it must include discharge planning documents. They must be included in there. Lindsay mentioned we have, there's only about three questions. And here's our first one. I'll have Lindsay put it up and give you time to answer it. Okay. I'm going to read this top part to you and then I'll put your options up here. And it says that Hospital D recently updated its EMR and now patients can access their medical records whenever they wish. The process requires that the patient to have a computer or access to one. J.D. is an elderly patient with no computer or internet access and he has asked to review his records and arranged for a time at the hospital to do so. The HIM administrator refused his request. Will Hospital D be cited here? And you should now see these options on your screen. Yes. Although no other patient has made such a request and so no accommodation, we're not sure. It looks like we do have just a couple of questions that have come in, Laura. The first one asks for radiology, is the IAC accrediting recognized instead of the ACR? Usually it is. It depends on, as far as accreditation, you would want to check with your state on that, which one they recommend. But CMS just says, you know, folks who work there and everything has to meet those requirements of what the accrediting organization is. It's like joint commission. Does your state recognize that for that certification? Okay. And then this last question asks, what are the regulations on support animals? I only chuckle because bringing a peacock in as a support animal, to me, it's a little bit overboard. There is some. And if you don't mind, Lindsay, I want to look that up and I will send you a couple of the resources. I mean, it has to be a reasonable support animal. I know the airlines went through that quite a bit when literally somebody tried to bring, I thought it was a peacock or something on board with them to keep them company. And they said, nah, not going to allow that. And a dog, a small animal, yeah, that's okay. But some get a little outlandish. They're even some of those miniature horses that they have designated as support animals. And again, let me look that up and get you some of those resources. Absolutely. And Tina, I took that email came from you, or I'm sorry, that question came from you. So if you wouldn't mind sending an email to education at gha.org, we'll be happy to follow up with you with that additional information. I'll go ahead and share. On that last question, I can only do it from the federal government saying, for whatever state law that would be different, which I would not have access to, but I can look it up with the federal government and said, okay, yes, there's going to be a little visit with them. Because this has really started to come around patients and CMS has even now said, look, we're up and coming. Computers have been around for a very, very long time. And really, number one, we need to refill that request in less than 30 days, we should be able to. And we can't frustrate those efforts to get them. And that's exactly what Hospital D, the HIM officer was doing was saying, nah, we're not going to make that accommodation. But yeah, we have to do that. And that's where they overlap with OCR. They know now, OCR is the one who issues the fines, by the way. If patients don't get them timely, they'll file a complaint. One in every 10 has been related to not getting the records. And so now OCR is stepping up and say, we're done. The first and second fines alone, this was a couple of years ago, we're 85,000 each. And it just keeps going up. Here they didn't give films, radiology films, to the tune of 100,000. And same thing, this was in January of just last year, that they didn't give the records, they didn't give access to the records. And that's starting to cost them 160,000. Now, this is per violation. So if they had several other patients who made that same complaint, that's going to be 160,000 times every single complaint, if that's what it was. And some of the delays in here that you start reading these issues, you can think, why aren't you turning over these records? What's the problem? And by the way, if you contract with a service, make sure they're aware of those requirements, but you don't want to face a fine because your contractor didn't help you meet those requirements. So make sure that they are also living up to that expectation. That's it for CMS OCR overlap. Now I'm going to go right into what the conditions of participation are for records. Well, we know we have to maintain a system according to what our policy and procedures are that we can for the patient record. Who is that author? Who made that entry? How are we protecting the security of our medical records? Because we have to make sure they're not lost, stolen, altered. That's a part of the security, or else somehow reproduced in an unauthorized manner. We limit access to those records to only those who are so authorized. That means you need to have somewhere authenticated signature, however that is your decision. Owner codes. Who owns that code and who has access to it? Signature stamps. Now in signature stamps, I don't know if I really covered this further in this session, but in signature stamps, it used to be they were not allowed. So be very, very careful. In those situations where the physician has such a disability that their signature is illegible, they may allow a signature stamp with very tight controls. In other words, that's the only person who has access to it. Otherwise records are adequately protected and authorized, and they had to make sure that the governing body is aware of how you're doing that. Cross-reference for inpatient and outpatients, and if they do transfer to swing beds, if you do do that, have the one record but some way to divide that series of care so we know when did they leave acute inpatient and when were they transferred to swing bed. Each record has to include, according to what's applicable for their situation, anything from mission to discharge. That means progress notes, nursing notes, any diagnostic studies and their results. Fetal monitoring strips, that has to be still a part of that record. And discharge summary. On the retention, six years. So you have to be able to pull that record going back six years, 24-7. Again, check your state law for retention, keeping the actual physical copy, it may be longer. The surveyor is going to look and make sure, yes, there's a record for every patient, whether inpatient or outpatient, as in ED. They're going to see how are they maintained, where are they stored, is it protected from damage, fire, flood, to the extent you can. Like you get hit with a tornado, an F5 tornado, things aren't going to stay in place, but at least you're going to have it protected to the extent you can. Theft. They will also make sure it's confidential, that confidentiality is protected. So if you see them walking up and down the hallways, they'll look to see are computer screens left up for when nobody's there to keep an eye on them? How long is that screen visible? How well is it visible? And then make sure there's enough personnel in the HIM department in order to meet the needs. So if you're very busy, who can get those records, who can get them accessed? The record itself has to be legible and accurate, of course, accessible, and systematically organized, so that what works on the med-surg floor is the same way it's going to be organized on another unit. Accurate and complete means everything's there, from orders to evaluations to what care did you actually give in response to orders or the patient needs. How did the patient respond to that treatment and that care? In other words, if I'm giving, say, maybe I'm giving five milligrams of morphine IV for chest pain, did I document patient is reporting relief of chest pain or the easing of chest pain? Maybe we're giving a medication, Lasex, for congestive heart failure. How did their lungs sound beforehand? How were they after? What's the urinary output? That's what they want to see, is how are they responding to treatment? We have to have a director of the department that is appointed by the board and one unified service. So, what happens in ER is still documented in your system the same way as if that patient is in ICU. The record must also have information on our patient other than the care we gave them. Who is it? What social data, meaning perhaps what is their cultural background, their address, telephone number, information like that? Consent forms that are properly completed, a pertinent medical history, an assessment of where is this patient, what do they need, and then the brief summary of the care. What happened to them? Where did they end up? And any instructions for when they went home, a copy of them. On informed consent, they want evidence that they are properly executed, and that's for any procedure or surgery that the medical staff has said, we need to have an informed consent. Also, any federal state laws. For example, if you're doing research, there are certain consent forms that are very extensive with research that you have to complete that we can show that, yes, they were given to the patient and their representative on what happened, what's going on with this procedure. Enough information so that they can make an informed decision to give that consent or refuse that procedure. Just some example of some of the procedures. The American College of Surgery may have a list. I haven't been able to find a more current list. This was one that I was able to find. And again, just some examples, but that's up to your medical staff. Does this thing need an informed consent? As far as being properly completed, well, there are certain things that are required. Who's doing this? Who's the patient, for starters? What's the name of your hospital? What's the name of the procedure? Who is doing it? And the signature of the person that's giving that consent. You also have to have in there that you've given an explanation of this procedure. Now, you can also include the signature of person witnessing the consent. That's helpful because really all they're doing, they're verifying that was the patient's signature. I saw this patient sign it. That's all they're signing off on. Who explained it? You can include that. That's helpful. And then the date and time. Now, that is required. The date and time of the consent is required to be added to that. You have to have enough information in the record to justify why were they admitted and how they progressed. That means something to support the diagnosis. The chest x-ray shows pneumonia in both lower lateral lungs. How do they respond to services, as I mentioned before? And we also have to then keep them confidential. Take precautions to make sure folks who have no business being in that record do not get access. So don't forget, OCR will find you if they find this has not occurred. Retention is six years against state, maybe longer. Now, I want to talk briefly about what's called the security rule. January 6th, they did talk about some proposed rulemakings, and it talked about modifying some existing standards. The idea here is so that they can improve confidentiality of electronic PHI. And we want to increase the cybersecurity for that. Because we know that we're now in an environment where we've had increased breaches and cyberattacks. And sadly, it's become almost a daily conversation with us. It's almost a norm when you start hearing about a cyberattack or a security breach. Now, normally, normally, CMS does not make these changes more than once every 12 months, so that we can keep an eye on them. However, given the concerns, they put out these new proposed changes to the HIPAA security rule to tighten them up. So what you have to do is you have to evaluate your risk and vulnerabilities within your hospital and your system, your electronic system, then put measures in place that are reasonable to protect against those reasonably anticipated threats to the security or integrity. You have to implement policy and procedures to prevent, detect, contain, and correct any violations that you do find. Do an accurate and thorough assessment of potential risk and vulnerabilities. Because these could come from anywhere. Unauthorized disclosure, whether it's accidental or malicious, that could happen. Modification, destruction of information, unintentional errors or omissions, disruptions in your whole IT system, whether it's natural, like again, a fire or something that happens, or manmade, somebody puts a virus in your system. If you don't exercise due care and diligence in your security, it could also occur. So under the risk analysis, and I'm just going to do this briefly, there is information in the appendix on what to do, how to start it, etc. Your IT person is probably going to be well versed in this. Hopefully they are. Look at the scope of your analysis, any electronic media that you might have, a web page. Gather what information you have and look at it. Look at any potential threats and document it. Write those down. Look at what your current measures are, and how likely is it that you're going to have a threat put against you or implemented against you? What is the impact that if it does occur, what's going to be shut down? What's your level of risk and then document that analysis. They want to see that documentation. And it doesn't have to be medical records, by the way, it could be something within your IT system that could wipe out a diagnosis on a chest x-ray. As far as resources, OCR knows there's not one single way that will guarantee your compliance. Office of Civil Rights, the Office of National Coordinator for Health Information Technology, there is a new tool. But as of last October, quick caveat, they know it doesn't capture all the technical vulnerabilities. It is just one method that you can use as a gap analysis. So on this tool, it's an analysis that will map your current practices and assess if you're meeting it, that will use that risk analysis tool when you have no other protected health information asset inventory or technical detail. Now this particular tool that they have, it's based upon another cybersecurity framework. It doesn't include your EPHI inventory. And then again, it doesn't capture the entire spectrum that OCR wants to see. It's a starting point. By the way, OCR won't do an analysis because that needs to be unique to you and your hospital. And last October, again, they recommend it is inefficient. And again, it doesn't address those technical issues. They know there's gaps in it. And at least they identified it, that we can be prepared. Well, now for that bad news, let's move on to the discharge summary. This talks about what happened to the patient while they were in your facility. Where did the patient end up? What's their follow up care that they're going to need? Like, you know, they're to follow up with their physician in 10 days, or they'll go to long term care, maybe swing bed. It's required for all states. And it's also before and after any swing bed admission. So if they are going to swing bed, yes, you have to do a discharge summary for their inpatient care. Once they're labing swing bed, yes, you have to do a discharge summary of that swing bed state. You can delegate it if it's permitted by state law, if they they're allowed to do that. There are discharge planning standards, we've already touched upon those. The surveyor, they want to verify that the staff has those procedures that require consent. And that they are have the consent forms themselves of all of those required elements. They will look at open and close records. They want about 10% of your average daily census. They'll make sure that they're complete and accurate the records themselves. And that consent policies, they include those requirements, any state law, or if you're an accrediting organization also. Now, here's some suggestions. When you are discharging a patient, by the way, you might want to think about making that appointment before discharge. Because if you know the inpatient physician is not their PCP, and they are saying you'll see it follow up with your physician within three days, and they can't get an appointment for money, it's going to lose that effect. That's why sometimes it's helpful if you can do it. Make sure the physicians or providers are doing their summary, getting it done as soon as possible. Because you as the hospital, you have the duty to get that summary into the hands of the PCP for that first visit. They need to know what happened to them if they of course they weren't the admitting physician. And if possible, as I mentioned, try to make that appointment within four days. These are not required by CMS except for that discharge summary. But otherwise, you can't do that. Still, the medical records are a history and physicals now. You can do it, the physician can do all of it, or he can delegate it. As long as the state law says they can do it. And that your policy and procedures say a PA maybe can do that history and physical. But the physician still has a responsibility and must co-sign off on that HMP if that's what's occurring. The surveyor will look at your bylaws to determine when it must be done. And that it's on the chart before the patient goes to surgery, absent an emergency. This is a huge issue with Joint Commission, CMS, any other accrediting organizations. They want to make sure we know something about that patient before they go in. Now CMS has answered some questions for us in the past. And these are some that they answered for me. And since they were kind of all over the board with some of it, I decided to combine them. So does the patient need HMP done when they're put in swing bed? When they've already had one at the same hospital while they were acute? And no, they don't have to have an additional HMP when they swing from acute to swing bed. However, if they came in from outside your facility, yes, they do need to have that HMP done. Is it required for an observation patient? Yes. I like it when they make them short and sweet. We document how did the patient respond? All orders, nurses notes, any complications that come up? Anything else you need to know? How are they responding? So they're on ibogenomizine. How's their peaks and troughs? How's their lab levels doing? All records promptly filed and completed. So again, we need to have as a complete of a medical record on any given day as possible. That's why it must include all orders, promptly authenticated, all nurses notes, all reports of treatment, including complications, any healthcare associated infections, our medication records, including whoops, he reacted to it, labs, radiology report, vitals, anything else you need to know on how to monitor that patient. Entries are date and time authenticated. That's why your medical staff policies have to spell out who does that. Policies identify how they also do that. Is it signature, initials, key code, whatever it is. Again, if you're using rubber stamps, they have to sign off. They are the only one using it. They cannot delegate it. So unless it is a complete physical requirement for that provider, it's best just not to use them because sure enough, they'll get lost. On computer codes and signatures readily available and secure so that they can't be altered. Sanctions for improper use of these items, whether it's a code or a stamp and policies in place implemented, make sure that your health system, your health record system is acceptable. On authentication, every entry has to be authenticated. You decide how you're going to do that. So in other words, the author has to make some specific action on every entry to make sure it is done. Now that's, of course, the entire progress note, just authenticated it at the end. And the timing, make sure that that is noted and it is correct. Auto authentication, this is when you do it before you transcribe it, that is not consistent with those requirements. We talked briefly about confidentiality. So we know we have to maintain it. Safeguard against loss, destruction, unauthorized use, alteration, or dissemination. Limited access. We release only when we have that proper authorization. And however you're going to do it, whatever you've worked out between you and the patient. On release, have policy and procedures that govern it. And also conditions for release. Just don't forget HIPAA, don't forget HITECH, and our breach notification. And again, you have to have written consent for release, not access. This is one on reproductive health. I did want to bring it up because it came out mid last year. This is from the Office of Civil Rights and Health and Human Services. They have incorporated this. It's not part of the standards, but you still have to abide by them. Here, these talk about any records relating to reproductive health that you might have in your possession. And it prohibits the use or disclosure for the purposes of another entity to conduct a criminal, civil, or administrative investigation into or to impose liability, whether that's criminal, civil, or administrative. And this is for any person. It's on any person that might present to you to seek, obtain, to provide, to facilitate reproductive health where it's lawful in your state. And we probably know this is the result of DOBS, where there were some states, some of the law enforcement, and other agencies were reaching out to providers in other states to say, we want those records on patient so-and-so. We know they came into your state wanting an abortion. And so we want those records. And that's why the government had to step in and say, no, no, no, no, no. It's legal in that state. You cannot exert your authority across that state line in order to prosecute that person, whether it's the patient or you as the individual. And so again, it also prohibits disclosing the name of that person who did receive the care. So this only applies when you believe, or your business associate agrees, has determined that one of the more following exist. Now here you had to be compliant by December of last year. You have time to update your Notice of Privacy Practices. That's February of next year. I have the link, by the way, to this entire rule. So here's what you have to do. Number one, this care has to be lawful in the state where it was provided. And under the circumstances it was provided, meaning that it couldn't have been provided by someone who is not licensed to provide that care. It is protected, and it's either protected or required, either according to the federal law or the U.S. Constitution. In other words, each state has the right to determine what goes on within their state. It was provided by someone other than a covered entity that receives a request given under the belief that this care was lawful. It's okay. Unless you know as an entity or provider that you have factual knowledge or can show substantial basis it was not lawful. So in other words, you have records that care was provided in your state by an unlicensed individual, you know that, then that information is not protected. So here's permitted disclosures. You can use it to defend yourself in a professional action, whether it's through the Board of Medicine or a lawsuit. You can use that to protect yourself. Also, to the Director General. When they come around and do audits for health care oversight, you have to turn it over in that situation. But what has to be in place, and this is coming from the entity requesting the records, if you get a request for this information and it has potentially reproductive health care related documents in there, you have to make sure there's an attestation from that requesting entity that they're not going to use it for reproductive use. And this implies to whether it's a judicial administrative procedure, law enforcement, anything. So again, if you are your Board of Medicine is asking your physician to turn over this record, they have to sign that attestation. It's not going to be used for improper purposes. There is an example of that attestation. This is the model attestation they put together. So that's what the other entity has to fill out. So that was a big one. I did want to put that out. So now I want to talk about information blocking. Now the final rule came out in June of last year. And really what this is trying to do is it's a disincentive for health care providers to block information. It's part of the CARES Act. And they found that providers were blocking information under certain circumstances. And so unfortunately they had to put this law out. Blocking is when you interfere with access, exchange, or use of electronic health record, unless of course you made an exception, where you as a provider know that blocking is something that interferes with a person's right to have access or exchange of their information with someone else. And it could also impact your participation, what's called the interoperability program. It's not part of the manual yet. But the rule is still out there. So here's what it doesn't apply to. Psychotherapy notes. Under HIPAA we know that's not new. It's been around. And that's recorded by someone who is a mental health care professional taking care of that person, whether it's in an individual therapy sessions. Number two, when you put that information together in anticipation of a lawsuit or civil criminal administrative proceeding, those don't fall into this category of blocking. So it's one of those two. And you can do what you need to do. So there are four exceptions where, again, it is not blocking. You can block access in these terms. Prevent harm, it's a privacy exception, a security exception, or simply infeasible. You can't do it. Now I'm going to go through this in the interest of time fairly quickly. I'm going to go through these slides. If you do download them, they will help you through it. To prevent harm, you have to do two things. One, it's a reasonable practice to reduce that harm. And this is to the patient, by the way. And it's no broader than necessary to reduce that harm. The risk has to be determined on a case-by-case basis in the professional judgment of that health care provider. And it's based on what information you know or reasonably suspect is wrong. It's misidentified. It's corrupt because of a technical failure or some other reason. Now, when this does happen, so the risk of harm is there, the patient, there has to be a way for the health care provider to make sure it's consistently applied and have that determination reviewed. And understand it could be potentially reversed. Organizational policies, they have to be in place. They must be written based upon that relevant clinical technical data and expertise. And determination has to be based upon those facts and circumstances you reasonably know at the time you make that determination. So that's harm. Privacy, again, it's nondiscriminatory. It conforms to all your policy and procedures. And there has to be a specific criteria when you're restricting the access here. And by the way, you have to have training on when that occurs and documentation on that criteria. So if you get an authorization that doesn't satisfy all the elements for restricted access, what you can do is, here, sign this one off. That does meet the requirements and we're good to go. But what can't happen is that an improper encouragement or inducement to that patient to withhold their consent and uniform policies to address those restrictive practices. So let's say you get a request not to share information. You can agree if there's no improper encouragement. Like, hey, I'll give you 50 bucks if you don't share it with the other side's attorney. You can't do that. But if there is a requirement by law to share it, then you have to share it. If you decide that, you know what, you've asked me not to share it, I'm going to terminate it. The person has to agree, either orally or in writing, document it when it's orally, and that I'm telling the person I'm not limiting access to this. It's going to be available because I have to. Then the security exception. Here we do it, of course, to protect the security, and it's directly related to that confidentiality, the integrity of it, and that's why we have to tailor it to that specific security risk. It's done in a consistent manner, and your organization policy has been in place. So it must be in writing, prepared on the basis of you're responding to a direct threat or one that you have assessed to being present, aligns with one of the other consensus-based standards, and it provides that time frame and other parameters to identify and respond to these incidents. So that's the security. If you don't have a policy on it, then you have to do a case-by-case basis, and it's necessary to mitigate that risk to the information, and that there's no other alternatives available. And then finally, infeasibility. You can't do it because your building burned down or you had some kind of an attack. Let's say you did happen to get an attack. I'm sorry, you were a virus was uploaded, and you can't access the records because you're shut down, your system's shut down. That would be an infeasibility exception. Again, under the circumstances, like the type and purpose for what they needed, it's just you can't get it. The cost to comply is just outrageous. Maybe you don't have the resources financially to get that. And in determining, it doesn't matter, by the way, if that request was facilitated by a competitor, you can't do that. Responding to those requests for blocking, if you don't fulfill a request, for access first. If you don't fulfill the access or exchange, you have to give a written reason, and you have 10 business days to do that. So if I'm not going to send these records off to a certain individual, I have to tell the patient why. So that's blocking. All right, so now back to retention. These are the tag numbers. Six years from the last state of entry, but watch other requirements. Not just your state, but look at OSHA, FDA, EPA, they may have longer time periods. However you do it, whatever you can do to either give the copy or make it reproducible. Now AHIMA, they have a practice brief on retention periods. That ties in with destruction. There's also federal and state. I have the link there for you on how long you want to keep them. Notification, this is also new. If you use electronic record that follows all the exchange standards, you have to be able to show that your system can send out a notice to post-acute care providers or any other entity that the patient wants you to have sent out this information on what happened with this patient. Now there are some proposed regulations that are coming down also on HIPAA, and these haven't taken effect yet, but just some really key ones that affect us. That patients can inspect their record in person, take notes, take photos. We're all really good with our cell phones now. They want to shorten the time from 30 down to 15 days as the maximum. When you give it without charge, there are some state laws that do require that, and they want to expand that. They also change the wording, and this really goes perhaps maybe to your behavioral health patients or those in the emergency department. When you can disclose information for safety and security purposes, right now it's at serious and eminent. They want to decrease that level, that bar, to serious and reasonably foreseeable. So these are proposed. They have not gone into effect yet. So I'm keeping an eye on these to see if, in fact, they do. Okay, that was a long one. Let's move on now to some of the shorter ones. Surgical, starting with surgical, if you provide them, of course, in a safe manner by somebody who's qualified and has privileges. You have enough equipment and supplies for what you're going to do, and that your department is organized and staffed. You follow any federal and state laws, standards of practice by your nationally recognized organizations. If you're doing outpatient surgical, that's great, but they have to follow the same standards as inpatient, and scope of services must be in writing and approved by the medical staff. The OR has to be supervised by someone who is experienced. Your policy and procedures address that qualification of the supervisor. Now, if you're using an LPN or OR tech as scrub nurses, that's fine, but they have to be under the supervision of an RN who can step in and take over if need be. So, in other words, they can't be scrubbed in on another surgery. And, of course, wearing the correct attire that covers the hair. By the way, AORN has some really good guidelines on that. You do have to be a member for AORN, so hopefully you have the ability to have your supervisor of the OR staff be a member of them because they have some really good standards that could help. On policies, we know we have to have one on aseptic technique, surveillance, scrub techniques, what do you consider an infected, non-infected case, housekeeping requirements between cases and terminal cleaning, and then patient care requirements like workup, consents, releases, safety practices, patient identification, duties of the scrub and circulating. These are all some of the policies you have to have in place. Safety practices, doing those surgical counts, scheduling patients, personnel policies that are unique to the OR. What are you going to do about resuscitation and maybe DNR status that you want to have a policy on? Taking care of specimens, who's going to tag them, how are they going to get sent out, when do you get that report back? And then handling malignant hyperthermia. And then protocols for any of your procedures you do, they may be specific or general, and what equipment materials do you have to have to carry out that duties? Sterilization, disinfection procedures, operating rheumatira, I mentioned that, handling those biomedical wastes, and how do we do it? Each one has to have a complete HMP done before surgery. You can delegate all or part of it as long as the state law and your policies abide by that. If that's the case, if they're delegating it, the surgeon still has to sign off and assumes responsibility. Now, the only exception to that HMP is when it's in an emergency. There, they use your progress notes, something enough to identify what's going on with this patient, that minimum critical information, vitals, their status, et cetera. Of course, we know we have to have informed consent on anything inpatient, outpatient. And by the way, we have to tell the patient who's actually doing the surgery, no-go surgery. And if someone else, other than the primary surgeon, is doing important parts of that surgical procedure, even if the surgeon's standing right there. Now, the content of the informed consent is very similar to what you would expect. Name of the patient, hospital, the procedure, who's doing it or important parts other than the surgeon, and what are those significant tasks? And they list them, open, close, dissect, remove, implant, et cetera. Now, on April 1st, it did talk about including in the consent wording, when other providers and applicable students will perform tasks or evaluations and examinations considered invasive. And that's for educational and training purposes. What I'm talking about here are those rectal, the breast, the pelvic, the prostate exams that might occur outside of that normal surgical procedure. Because they were finding out these were being done and the patients were not consenting to it. So right now, that information, that requirement is only in appendix A for acutes. But I have a feeling they will disseminate it down because you may have students in there, whether it's EMTs, maybe there's a medical student that's coming in to get a little extra practice, or you've got a resident who you're doing a residency with. Well, that's included as far as long as that procedure is for educational purposes and it's outside the normal scope of that surgical procedure. Otherwise, we include the, what is the nature and purpose of that treatment or the risk complications, probability that this is going to work, signature of the patient, date and time it was obtained. And I'd have a statement who explained it to that patient. That's usually your person who's doing the procedure. I mentioned the witness. That's all they're signing off on. They're witnessing the signature. Overall, enough information so the patient can make that informed decision. By the way, if you have a form that's not in their primary language or is so above and beyond their ability to comprehend and they still sign off, that's not informed consent. So you may have to have an interpreter present. And again, healthcare literacy. One way you can think about getting confirmation of how they're, do you understand what's going to happen? Tell me what's going to occur. Tell me your understanding of this. And that can really give you some eye-opening experiences when they say, I don't know what's going to happen. Over to PACU. Enough provisions so that we take care of immediately post-op. They do mention ASPAN, American Society of Post-Anesthesia Care Nurses. A separate room, limited access. Your policy and procedure specify transfer requirements to and from PACU. Our assessment includes how awake are they? How are their vital signs? What's their color? If you don't have, or if they're not going back to PACU, then they have to have close observation by the RN in their room. We have to have an R register. That includes who came in, what was done, how long did it take, who was in there, everything that occurred with that procedure. This is the register and the age. This is what it should include. I'm sorry, but if CMS says it should include it, have a way to document this information. Op report, we've all seen them. That name and identification of the patient. When did the surgery occur? How long did it take? Who was in there? What was the pre and post-op diagnosis? What type of anesthesia? Complications, if any. And how did you do this procedure? What was the findings? Did you take out anything? Did you put anything in, whether it's a graph or a device? And a description of the surgical tasks performed by others, whether it's opening, closing again, and even implanting. The surveyor is going to verify access to not only surgery, but PACU is limited. They'll verify you're doing enough cleaning between cases and terminal cleaning. Proper attire for cases is being done. Those working must only wear clean surgical equipment and equipment that you have it available for rapid routine sterilization, your immediate use sterilization. They will make sure equipment is for monitoring, that it's being inspected and tested. And usually what they'll do is I need to see your maintenance records for this equipment. They're going to look at your sterilized packages. How were they packaged? How were they handled? Are they labeled? Are they done in a way and stored to keep that sterility? And what do you do on expiration? They want to see the policy on that. Surveyor's busy, by the way, in surgery. They want to see the organizational chart. Who's the lines of authority and delegation? Who do they go to if they need help? They'll verify that if you're using non-RN techs, or if they're performing circulating duties, that you've got medical staff policy and procedure. And again, you have an RN immediately available to step in. They'll look at medical records also, because what they're looking for is H&P, consent forms, and the surgical report, that it is signed and dated. They will check your equipment. They will go in here. They want to see your intercom system. They want to make sure the monitor's in there, the resuscitator, defibrillator. They'll go and check your suction equipment. And they'll make sure you have a trach set. Not a cricoidotomy, but a trach set. So again, surveyors are quite busy when they come into surgery. Surgical. Designate who can do the surgeries, whether it's a doctor, podiatrist, whoever it is. They have to conform with all the policy and procedures and be within their scope. Privileges, look at them every two years to make sure they're still current, that they're not doing something that's not on the list, or they are doing something, excuse me, that isn't on the list. Keep a roster of those surgical privileges, plus keep a list of those surgeons who have had those privileges suspended. Your scheduling person needs to have that available. On determining them, well, your bylaws have to determine that criteria. Who is going to do what? And when they want to go and ask for additional privileges, because they have to make sure that there's competency to do each, and that they're done by those appropriate physicians. We appraise their privileges, education, training, experience, and competency. Make sure that that's also through your QAPI program, and you're adhering to policy and procedures. Surveyor will look at a written assessment of a surgeon's training and experience. They were going to look at that. They're also going to look at their health status. They want to make sure that there's no issue that would compromise their ability to perform those surgical services. You have to specify privileges for each physician who does, or practitioner who performs a task, whether it's an RN first assist or your surgeon. If the task does require supervision, that means they're in the same room working on the same patient. Anesthesia, there's only a couple tag numbers, but they follow with surgery. There must be an assessment, a pre-anesthesia assessment before the surgery starts, and by someone who's qualified to actually provide that anesthesia. What is the risk? What type of anesthesia? Their medication and allergy history? Any potential problems they think is going to crop up? And what's their condition prior to induction? And then they have to go evaluate them after anesthesia. We have to have that follow-up report on all inpatient and outpatients before they leave by someone who can administer anesthesia. At a minimum, their cardiopulmonary level of consciousness, any follow-up care that's needed, or any complications that occur during anesthesia or in PACU. You designate who could administer it according, of course, what their state law says they can do, and they have listed out who is only under CMS. Anesthesiologist, an assistant, maybe a supervised trainee, that's a key, supervised. Maybe you want a dentist or CRNA, whoever you happen to want to use. On CRNAs, anesthesia assistants. A CRNA can do it. They operate under the supervision of that operating practitioner or an anesthesiologist who's immediately available. An assistant, they can only administer under the supervision of an anesthesiologist immediately available. We know the state exemption for CRNAs would be exempt from that supervision. The governor sends a letter to CMS after they consult with medicine and nursing boards. They look, this is the only way they're going to get access to this quality anesthesia care, and it's in the best interest to opt out of that supervision requirement. I like that they give us some definition of what they determine immediately available. They're physically in the OR or L&D. They're prepared to step in and hands-on intervention, and they're not doing something else that could prevent them from immediately intervening. We have to discharge patients from surgery in PACU to a responsible adult. Any exceptions, that's determined by your attending provider and documented in the record. The surveyor will make sure there are policies to make sure that this is governed and that's in place. QAPI, this is interesting. Here's our second question. Lindsay, if you want to put this up while they're providing all their answers. QAPI was interesting. CMS made a whole bunch of revisions to quality assessment performance improvement a couple of years ago. They then updated the acute manual. Well, they forgot to update your manual. Now, I have a feeling, that's just my belief, that the regulations, they so follow each other like almost word for word that when the new critical access manual comes out, they're probably going to take the interpretive guidelines and survey procedures, which aren't in yours yet, that are in the acute and will put them in yours. I believe that's what they're going to do because there's so much overlap in these two items. Lindsay, did you want to see how we're doing or if there's any questions you want me to answer? Yep, there are a few questions and I have those options there up on the screen for you about your QAPI program. You can check all to apply to your organization here. Then, I'll come over here to the Q&A first and ask how soon do verbal orders have to be authenticated by the provider? As soon as possible. That's the way CMS listed them. As soon as possible. Your hospital determines that. How long? In ruse, it's a medical staff. 24 hours that they are signed off as soon as possible. Now, let's say your provider gives it. He or she goes on vacation. The partner's covering it. Partner can sign off on them. That's fine. As soon as possible. Don't let those things sit out there unsigned. Don't let those happen. 24 hours, 48 hours, depending on how soon the provider can get in. With informed consent, do you have to add the name of the persons who will be helping with the procedure? For example, RNFA or can you just add the title of the persons assisting? Yeah, you can do that. Say, I may be using an RN first assist to help me with this case. That's totally fine. Now, if you have the benefit of knowing it, that's great. But I've seen that on so many of them where we use an RN first assist, a PEA physician assistant to help me with this process. That's fine on the informed consent. Okay. Then, let's see. Are there any specific documents considered discharge planning documents? No. Not under CMS. No. All right. The last question I see here is what case management documents are required to be included in the medical record or where do the insurance approvals and denials need to be located? That one CMS won't touch. But usually, you can put that in your demographic information wherever you feel it would fit. it could be a miscellaneous. CMS won't tell you where they absolutely have to be, just that it's consistent in the hospital. Where are you going to put them? Perfect. I'll go ahead in this poll and share those results. Good question. Required, goodie, goodie, goodie. QAPI, like I said, they rewrote them back in 2019, and really what they did for your manual is they took out that reactive. Now they want it to be a proactive approach, so that we're looking at things saying, is this the best way to do it? Then if so, how can we take care of it? New tag numbers, new requirements. We still are waiting our guidelines and survey procedures. If you have a state flex program, great. They have some resources for you on that. But generally, you have to put into place, get it going, maintain it, and effective ongoing hospital-wide data-driven program. In doing this, you may want to look at some things such as adverse event. I like it, CMS did give us their definition. That's what you can add to your policy if you want. Adverse, this is not what we anticipated. Untoward, undesirable event that could cause injury or death to the patient. Error, now, that's what we had planned to do, didn't turn out. It can be a wrong plan, can be the wrong medication, whatever it is. It usually includes problems in our practice, our procedures, and then they narrow it to a medical error where it's one in the delivery of healthcare services. That's usually what we're going to see. Under QAPI, you have to put together under your design and scope according to the complexity of your hospital. What do you provide? It has to be ongoing. All departments are involved, all services, including by contract. If you are using contracted radiology interpretation services, they have to be included. You have to use objective measures to evaluate it. Those process, the forms, the functions, not something anecdotes. These are the measures we expect you to meet. It has to look at those indicators to improve the outcomes, to reduce or prevent errors, adverse events, healthcare acquired conditions. Usually in the transition of care. In that case, you're trying to reduce readmissions. Your governing board is responsible for this program and they have to make sure it meets all of the requirements. It's ongoing. It meets those indicators. It has been implemented hospital-wide. Your activities focus on measures to improve the outcomes and that you have a way to analyze and track your performance. Set priorities. Is it high volume, high risk, or maybe you just know it's a problem-prone area? By the way, a high volume can be something as dietary. Are your dietary practices, whether you're providing meals to your staff and others, are they meeting those requirements? That's high volume. High risk, that could be your neonatal unit or your OB services that you're providing. Look at your, maybe for example, your ED readmissions. Balls, that's huge. That can be one of those high risk and high volume, depending on the severity of injury. To collect our data and analyze it, that's what we have to do. Look at our indicators that we want to track, whether it's patient care, maybe it's going to be something within your community that you're keeping an eye on. And if you happen to participate in a patient safety organization and you're work-crowded from that, because that's where we take, oh, this is what happened, this is what we did and what we're going to make it proved, how we're going to help. Well, CMS knows that you voluntarily submit that information, that work product to this organization. It is privileged. The surveyors cannot demand disclosure. If they want to see something on that, you have to get alternative documentation to show yes, you're in compliance. Now, this act came back way back in 2005. I mean, we're talking 20 some odd years ago. And it really outlined that privilege. So we keep this information confidential. That could be statements of a provider or says, yeah, I messed up. That was my error. I was totally off base with that. We want to keep those confidential. But if it's not part of that work product, in other words, you compile it because you have to do it for external obligations like National Practitioner Data Bank, that's not going to be protected. If you have an adverse drug event and you have to send that information to the FDA, that is not going to be protected. Overall, what you have to be able to show is that your QAPI program has, you can maintain it and you have evidence that it is effective. You have to give the surveyors some information in that QAPI program without disclosing your work product. So be prepared also to show you have a relationship with that patient safety organization. They will verify that that relationship does exist. Now here's some guidelines on it. Pretty much again, the regulations are short, sweet and to the point. Here are the interpretive guidelines for the acute. If you want to consider going ahead and adding them until CMS can get around to updating yours. It's only as a reference. So first off, they want to make sure you have an effective ongoing system to identify your problematic issues, whether it's an event, a policy or a practice. With that, you've taken action to remedy it along with follow-up. Were those actions, did they actually work? Did they improve it? And are they sustainable? You have to have a way that you can systematically examine the quality of care you've provided. Maybe improvement projects that are ongoing for all services. What are the complexity when you're determining your parameters for that quality? It should include somehow you can continually collect and analyze your data. Corrective actions, they're in place. And again, to improve your outcomes. You evaluate your program data itself to make sure, yes, indeed, we're looking at our priority areas and we're taking action. In doing your prioritization, I always like to start with health outcomes. Did this actually improve our patient's outcome? Is it safe? Did we give good quality care? And again, that's based on your complexity. Look at your high risk, ICU, ED, L&D or your high volume. I did mention food preparation, but that can include hand hygiene. You can do something as simple as hand hygiene. Everybody's supposed to be doing it. Medication administration, because bad outcome could be across the board. What is your problem prone area? Maybe you know something within your hospital you really wanna beef up. It could be security, security within your building. Incidents, that's how often it occurs. The prevalence, how widespread. And then severity, how bad is it gonna be if it happens? In the guidelines, and okay, these are in the queue. They separate projects from activities. Projects, that requires a lot of pre-planning with your objectives. So in other words, you wanna improve the throughput of your emergency department patients from this amount of time down to this amount of time. And we're going to study it from here to here. Your activities, okay, how are you gonna do that? In other words, how are you gonna track when a patient's in their first triage, they're back in the room, they're discharged. Then you're gonna analyze it. Were there times of peaks and troughs in this timing? What was going on? Was it related to weather? Was it related to maybe an outbreak of flu or RSV? What did you put into place to make sure that this is gonna happen? And can it work, monitoring it? And are you gonna put it in all departments? What about your dedicated resources depending on what you're doing? That's scope and complexity. Do you have enough staff? Does staff have time to do this? Are you gonna use IT to help collect and analyze this data? And then education and training so that these projects, these activities can be done and done well. Now there's a new rule on QAPI and OB patients. Now, I wanna point this out. There's slightly different wording if you're part of a system with an acute, but essentially it's the same. Now, this is for hospitals that provide OB services. Your OB service leadership has to engage in QAPI including collecting data and monitoring for OB patients. If you participate or you have a maternal morbidity review committee in your state, your jurisdiction, wherever it is, that's great. Just leadership, OB leadership or someone they designate has to make sure there's a process to incorporate publicly available information and data from that committee into your QAPI program. So again, if it's there, go for it. Secondly, you have to incorporate quality data including patient care data. Again, if you offer OB, you have to have a way that your program can assess and improve outcomes and disparities for patients, OB patients. The effective date, this will go into effect. You must be doing this by January 1 of 2027. It has to be implemented then by July of 27. Now, this is the first time that CMS has required hospitals to use your program to address health disparities. There are four minimum requirements here. One, you analyze data and indicators by your diverse subpopulation. And this again is among your OB patients. Measure, analyze and track your data, your indicators on those outcomes in providing your care and your outcomes. Analyze, prioritize outcomes and disparities because what they want you to do is develop and put into place actions to improve those outcomes. Track your performance also. And then four, do at least one performance improvement project to improve these outcomes for disparities among your program annually. So again, that's the first time they have done this. Continuing here, you have to provide annual training to the relevant staff on these policies and procedures. And that includes transferring. If you're discharging an OB patient, that's a transfer. In other words, staff have to follow the same procedures and they have to be informed of any changes in your protocols. And we want to make sure these are done safely. So again, this was just went into effect lately, I think December of last year is when they put out the notice on it. And you have until the 2027 year to be compliant in it. So you have a little time. Overall with QAPI, I always put this into place. If you want to do an overall gap analysis for, we've already touched infection control and discharge planning. But if you want to do it for QAPI, it's there. We never used them for years, but it's a good tool if you want to have a quick one. Briefly on organ tissue and eye procurement. If you're doing this, you have to have written policy and procedures on doing it. You have to have an agreement with an organization, organ procurement organization. If, if you have an OR and a ventilator. What you must do is timely notify this organization if you have a patient whose death is imminent or if they have already died. Because it's up to that organization to determine if they can use those organs for donation. That agreement has to address criteria for referral. In other words, imminent death or death. They have to include definitions of imminent death and timely notification. And the organization determines the suitability. If they can, the organization can also help with tissue and eye bank notification of potential donors. Timely notification, that's must be in the agreement. Who is going to do the request to the family? They have to have training with it. And by the way, they get access to your death records. Usually on the schedule that's arranged, whether it's monthly or however often. For you, you have to make sure that you have ways to keep that organ viable, whether it's eye, tissue or an internal organ. You just have to have a way to do that. Your policy, the board has to approve your procurement policy. Integrate it into QAPI. This is beneficial because if there's complaints you're getting from the organization, whatever it is, that needs to be addressed. The surveyor wants to see that agreement. They will review it, make sure all the information is in there. It's a very long list that they want to make sure like definition of an imminent death. How, what does it consider timely? And again, access to the records. Here's imminent death under the definition. And in the interest of time, I'm not going into too much, but we know it's a bad brain damage where they have to be related. The MD, they evaluate brain death within one hour and they've ordered according to the family's decision, removing all life sustaining therapies. Your tissue and eye bank, you have to have an agreement with each one. The organization can be the gatekeeper. They can notify that tissue and eye bank that your hospital has identified. Again, they determine suitability. You don't have to have a separate agreement if the organization does that, if they also do tissue and eye procurement. But once there is a potential donor that the organization has identified, they have to tell the family. The family can opt out, of course. And you, the hospital, and the organization decide who's going to approach the family. Now, these organizations, their people have to be trained. They have to go through that training. But sometimes your providers, they have a better relationship with the family. And maybe that's a better one to do it, to approach that person. But again, if it's from that organization, they have to have a completed course that the organization has approved. That's why use that discretion, sensitivity, even their religious beliefs. They may say, nope, absolutely not. Surveyor, they will interview the requester. How do you approach the person? How do you approach the family? They'll look at the training program and they wanna see a complaint file for any relevant complaints. Staff have to be trained. What is the consent process? Who's going to do this? How do you make sure that everything has been documented and maintained? That's why you wanna change, train your employees. Definitely on orientation, or if there's an issue that keeps cropping up in your QAPI. Of course, policy and procedures. You develop those with the organization. This is one area where you can reach out to them to work with your policy and procedures. But you do have to cooperate with them, maintain the donor while testing is being done. How are you going to maintain the viability of those organs? And the surveyor will verify that you have worked with that organization. Okay, on to swing beds, I believe we'll be just fine here. These are long-term care services. You have to meet certain conditions if you want to provide them. So you can use these beds interchangeable from acute to SNF. It's a reimbursement, that's all it is. It's really a reimbursement identification. They will survey them if you're having a full survey, if there's a complaint, or you actually wanna go and get approval. The interpretive guidelines, survey procedures are all in appendix PP. I don't have a crossover for that. I've tried to identify where those would be located, but that's an appendix PP. It's a very long manual, by the way. And by the way, the bulk of it is that first part resident rights. Four changes in 2019 applicable to you. By the way, your appendix only has a regulation. Again, the interpretive guidelines, survey procedures are in appendix PP. Number one, before you had to help your person obtain routine 24-hour dental care. Well, now it's all part of your conditions of participation. You probably have policies on it. So they took it out because it's duplicative. Activity programs, this is where a lot of questions come up, that and the next one. Before you had to provide an ongoing program to really help this person in their choice of activities. And that was based on the comprehensive assessment. Well, they took it out because technically they're not to be long-term residents. This is an interim. But if you do have them there for a long period of time, you have to do something for them. What do they need? Where are they at? How can we promote their independence? Getting them up and moving. And this was the other one, the social worker. 120 beds or more, you had to have a full time. You don't have 120, you're limited to 25. So they took it out. And then the resident performing services. So this is services performed for your benefit as the facility. Now, it's all in the patient rights section. If the patient wants to do it, great, but you can't require it. You have to determine is it gonna be voluntary or is it gonna be paid? If it's paid at the prevailing rate, it's in their care plan. They took it out. But again, if you have someone who, they're bored and they want something to do, you say, hey, we have these towels. If you wanna fold them, we're happy to pay you for it or whatever it happens to be. Great. Or if they'd have some other service, playing piano on a Sunday morning or during the day, it's up to you, but that's what you can do. I'm gonna pass on this question, Lindsay, in the interest of time, if that's okay with you. Sure. Okay. Requirements. I mentioned before, you have to have discharge orders from acute. You have to have the progress notes available and a discharge summary. And then admission orders into swing bed because that's what they are doing. They're discharged from acute, admitted to swing bed. They don't have to change the record, just have a separator if it's in the same facility. Medicare. This is straight traditional Medicare. They require a three-day qualifying inpatient stay, either you or another qualified hospital before they go into swing bed. Only Medicare patients. Medicare Advantage, they may be different and you'll have to work with them on it. The surveyor, they're going to look at least two swing beds. If you don't have any, they'll look at some closed swing bed records. No length of stay restriction. That it is to be transitional. No transfer agreement between you and a nursing home. You don't have to use the minimum data sheets for recording their assessment. If it's there, okay, but you don't have to use it. You can use the same record, just a divider with admission orders, discharge from acute and mid to swing. For eligibility, you have to be certified no more than 25 beds. They will screen you to make sure that you're eligible for this. The regional office makes that determination. You have to comply with those SNF rights that I mentioned, and it's very long, from rights to nutrition to social services. There is a section on facilities who participate as a regional, I'm sorry, rural primary care hospital. I have that in there if that's what you happen to be. So resident rights, again, they're huge. And the representative acts again on their behalf. Informed of treatment in the language they understand. Informed of changes to their plan of care. They could choose to or refuse to perform services for your benefit. They could choose their own physician who meets those requirements. Licensed and comes to your facility. They can use and retain personal possessions as long as space permits. They can share a room with the spouse if both consent. They access to their family and friends. They get to receive and send mail. Personal privacy and confidentiality. And by the way, on mail, you give them access, but they have to pay for that stationary or postage. You don't have to provide that at no charge. They get to have written and telephone communications. They have the right to make sure their records are secure and they can refuse release. What you have to do is you have to notify them any changes, charges, excuse me, that are not covered by Medicare or Medicaid at the time of admission and periodically if they're gonna be there for a while. Tell them if they become eligible for Medicaid. You have to give them a copy of their rights. And again, there's a very long section on these patient rights. Swing bed is normally a 90 minute session in and of itself, by the way. Transfer, that means they're leaving your facility and going elsewhere. And what they did in these is they really tightened the restrictions so that we don't dump them. When we have those high care difficult individuals that we're not dumping them. And so the basis is that we can't discharge them or transfer them unless we have to do it to meet their needs. You cannot provide that care. Maybe they need Whirlpool and you don't have it. Then that would be okay to transfer them. They don't need the services anymore, they're recovered. If others are going to be endangered according to their behavior or clinical status, and that can include your staff. Health of the individuals, I already mentioned that. They don't pay after you've given them enough time or you have to close down, you have to close your facility. You cannot transfer if that resident or the representative has filed an appeal, unless of course it's a danger to others and then document it. There is specific documentation that you've tried to meet their needs. You can't do it, you've made reasonable accommodations. It can't be done safely or it's not meeting the needs. And that's the basis for the transfer. If you are going to transfer them, we have to send information along so that the new person taking care of them knows about the person. What's their contact information of their representative? Do they have advanced directives and they have a copy? You send a copy. What were the care plan goals? A discharge summary, enough information so they can reach out to the practitioner at your site if they have questions. So if we're going to do this, if we're going to transfer, we have to give them notice or even discharge well in advance. Why are they being transferred or discharged? The date it's effective, where they're going. Here's your appeal rights, by the way, and a phone number. And that's the name and phone number of the state office for long-term care admin. Their job again is to protect the rights of these individuals. If you have an intellectual developmental disability or mental health disorder, same thing, give them the information on the state agency that covers it. And of course, an advance notice before you close. We have to give them time to be prepared for this transfer or discharge. Changes, if you just want to move them to another part, you can't do it unless the resident agrees. Of course, we can't do it because, well, we want to, they have to be closer, that's a good reason. And we want to make sure the patient understands for your safety. Other rights, freedom from abuse and neglect, and exploitation, stealing a property, unnecessary restraint and seclusion, including medical, chemical restraint. And we can't use restraints for convenience or discipline. We can't employ individuals who are found guilty of abuse, neglect, exploitation, theft. That's why those background checks are so crucial. Your state nurse agency, your state board, they will have this information. And by the way, that includes if the court determines that this person has no business being in taking care of patients. Sometimes the nursing board will do that also. Have policies to prohibit that, that it does occur. By the way, if they pled nulla contendere to a charge, that's the same as pleading guilty. So that's the same thing. On abuse and injury especially, no later than 24 hours after you get the allegation, two hours if they're serious bodily injury. That goes to the administrator of the facility, the state agency, maybe adult protective services if the state gives them jurisdiction. You have to investigate it thoroughly. So we prevent this from happening. You report your results within five working days. And the guidelines again are in appendix PP. Overall, you provide medically related social services to keep them alert and oriented, keep them active, physical, mental, psychosocial. Again, patient activities directed by a qualified practitioner, that was deleted. Education requirements, those were also deleted for you. On resident assessment, you have to do a very comprehensive assessment, care plan and discharge planning. You're not required to use a resident assessment instrument that usually comes when they're coming from a nursing home. But there are multiple elements of that assessment you must do. Who they are, what's their routine, what's their cognitive ability, how's their mood, what's their vision and communication. Discharge planning, that's part of your assessment. How can they move? Are they, do they have to have a walker? What's their skin condition? Continent, are they incontinent? What medications? These are just all part of that assessment. It's a very long assessment that we have to make sure is being included in that assessment. And again, documentation of summary information on that additional from the minimum data sheets. Good, you don't have to use them if you don't want, but sometimes it's good to have that information. Document that the patient participates in the assessment or not and do direct observation. Here again, you're trying to develop that care plan to get them onto the next phase. The assessment has to be done within 14 days of admission. That's what's in the regulation, you'll read that, but that doesn't apply to you. Do it timely, because again, this is a short-term stay. Of course, if there's a significant change, you would do that, another of those assessment. Specialized services, these are for your mental illness, developmental disabilities. And when they're doing the assessment or services needs, if your provider disagrees with it, they have to indicate why. Why do they disagree? And with any patient, there has to be a care plan. What are the objectives and how we're gonna meet them? Goals for admission, where do they wanna end up? And preferences for discharge. It must be developed within seven days after you do your assessment. Now, if they're not gonna be there that long, of course, get it done sooner. And include if the patient refuses treatment. If you're part, if your swing bed is part of an interdisciplinary care team, that's great, because you wanna include all of those services that are available, whether it's the attending physician or a dietician, who's gonna be there. Update as necessary and make sure that they're culturally competent, qualified to meet those standards of quality. Yes, you have to have a discharge summary. That's a recapitulation of their swing bed stay. What was their status at the end of it? Medication reconciliation, and what's gonna happen when they go home? What's the discharge plan? Then specialized rehab services, if this is what you have to have, PT, OT, respiratory. All of these require an order. And how are you going to get them? Are they gonna be in-house, out-house? Where is it gonna be provided? Dental, yes, they deleted it. I included it because if you happen to have patients who need dental care, you have to do something with them. How are you gonna do it? Is it going to be that maybe the dentist can come in and help? Are we gonna get that swing bed resident over to a dentist? By the way, you can charge Medicare patients, you can charge them for routine and emergency dental services, but have a policy if somehow we happen to lose our dentures or partials. So we don't charge the resident. Again, this is where it's on, it's on us. Also, how do we refer them to get them done within three days, if at all possible, and watch their nutrition? On assisted nutrition and hydration, this is your NGs, your J-tubes. You use your assessment to make sure they're keeping that body weight and electrolyte in balance or balance, enough fluid intake. They have parameters here for us. What is considered significant and severe loss? And I'm gonna wrap this up with some obstetrical services. Again, this is going to be some new conditions of participation. Totally new, it's not in your current manual. It's under if you offer OB services well-organized and provided according to national standards. That includes physical and behavioral health of your pregnant, birthing, and postpartum patient. If you offer outpatient OB, well, again, consistent with the quality of care for inpatient according to complexity of services. This is effective January of next year. You have to have an organized OB services appropriate to your services offered, integrated into other departments, whether it's ED or maybe it's med-surg if the baby didn't survive and you want to get mom off your OB unit. L and D rooms have to be supervised by an experienced individual, RN, certified nurse midwife, advanced practice provider or physician. Privileges must be delineated for those who are providing them according to their competencies. Services consistent with the needs and resources you have. Policies governing OB care have to meet the highest available standards of medical practice and care and it also covers equipment, provisions, and protocols. Again, effective January 1st of next year. The following equipment has to be kept and readily available to treat your OB cases and according to your scope and volume. A call system, cardiac monitor, provisions and protocols enough consistent with taking care of patients in an OB emergency or those having complications, immediate post-delivery care. I always think of a septic mom who is going septic after the delivery. Toxic, other patient events that you QAPI. I've already identified the equipment. You have to have that call in the monitor, both cardiac and the fetal monitoring. You have to have enough supplies and medications to handle these emergencies. There are five requirements for staff training and you have to have policy and procedures to make sure relevant staff are trained to improve delivery. Training concepts reflect the scope and complexity of services that you've identified those evidence-based best practices. You must use findings from your QAPI program to inform your staff of what training, whatever revisions are going to occur and on an ongoing basis. You provide relevant staff and new staff with training. Governing body, they have to identify and document which staff has to complete this training. You put it into their personnel records of successful complaining and they have to do a return demonstration. They have to be able to demonstrate the staff know what the topics are. Now, the nice one is you have a little bit more time. You have January 27 to make sure that these are in place. Again, this is the first time they've really hammered in on this specific type of care being provided for a patient that is non-behavioral health. They did it for behavioral health, but now they're doing it for the OB patients. That brings me to my last issue. And there's only four minutes left. So Lindsey, do you want us to go through this one or not? I'll leave it to your discretion. Well, maybe we have a few questions here that we can answer and then we can just give some final wrap up comments if that's okay. Perfect, okay, that's fine with me. Okay, so this first question asks, back to medical records releases, what about behavioral health integration components of the rural health clinic record? Will those have to be segregated for release? Yes, you're gonna follow your normal HIPAA routine. So if, okay, so you said you're part of a rural health, is that what it was? Yeah, it says what about behavioral health integration components of the rural health clinic record? Yep, okay, yeah, you'd wanna make sure that those are identified and kept separate because those are the behavioral health. These again are the ones that are by your healthcare provider, your mental health professional, because sometimes you'll get your PCP who will come and say, yeah, the patient's kind of depressed with what's going on. That's not included in those. These are the actual behavioral health provided by a behavioral health professional. That's the ones they're concerned about. So yeah, you'll wanna keep those separate. That's again, part of those exceptions to information blocking where you can, as long as they feel that that could be a hazard to that individual, the patient. Mm-hmm, okay, and then previously you said that the surgical scope of service needs to go through medical staff. For a critical access hospital, should all scope of services go through medical staff or do they need to go through the board? These are the board, and I take it when you mean the scope of services, that's anything and everything that you would be doing. The surgical ones have to go through the surgical committee and of course, then the board would approve those. But the surgical committee or medical staff determines which ones they're going to be doing and which ones require a consent form. I think I'm hearing that question correctly. If not, please correct me. Monique, if you have additional questions for that, just let us know. And then this final question that I see here is, with swing patients, do critical access hospitals have to comply with minimum water temperature requirements in the state regulation for nursing home residents? For example, water temperature maximum in the state regulation requires water to be less than 110 degrees, and do critical access hospitals have to comply? Yeah, for swing beds, I believe you do. I believe you do, especially for swing beds, because that's what you're falling under, is the regulations, that's where they came from, was from the long-term care manual. Okay, I don't see any other questions. I know we are right at time. Do you want to maybe go over if there's any other resources or anything in here? Yes, I think that'd be a great idea. Now, bear with me, there is roughly, there's some pages of resources, but I have a lot of websites that I've tried to include for you. You probably have a lot of these anyway. Be aware, there are some, you must be a member to access the data, like AORN, American College of Surgeons. Some of that information, yes, is only through membership. Now, Anesthesia, American Society of Anesthesia for Patient Safety, I love them because they give out their standards. You can access them for free, so you don't have to be a member. Here's some of those proposed regulations I mentioned under HIPAA, excuse me. They were pretty extensive, and some just simply don't apply to you. AHIMA model release, that's the American Hospital Healthcare Information Association. They have some model releases. Again, the anesthesia guidelines I happened to mention, these are all free. Deep sedation, a lot of just basic resources that if you want to tap in, use your staff on these too, as it applies to their department, like PACU, surgery, rehab, whatever it is. Make sure that they're aware of them, and perhaps they can help pull up information if you're looking at your policies and procedures. And so again, 30 some pages, and I won't go through a volume for you. But thank you, Lindsay. Thank you to everyone who's participated. I'm sorry we couldn't get to our last session, our last question there. But if anyone has questions on it, I'm happy to address it offline. Absolutely. Thank you so much, Laura. You've already gotten just wonderful comments and responses in regards to the series as a whole. So we just appreciate all of your time and the information that you've shared with us, and for being so thorough throughout each session. I did just post some final information there for you all in the chat. Again, if you've joined us for our previous sessions, hopefully you've received these emails, but you should receive that email tomorrow morning from educationnoreplyatzoom.us. That will include a link to the recording of today's session and the slides that Laura did present for us. That link there, though, for the slides is in the chat now as well. So you can go ahead and pull that up and have that as a resource. And just remember that the link to the recording is available for 60 days from today's date. And then as Laura did just mention, if you do have any questions, you can always reach out. You see her contact information there on the screen, but I would encourage you to reach out to us at education at gha.org. And I'm happy to get those questions over to her and then follow back up with you with her response as soon as possible. And as I mentioned at the opening of today's session, if you are a member of the Georgia Hospital Association, please do pay special attention to a separate email that you will receive this afternoon that will include additional information regarding the continuing education credits available for this series. And if you are joining us as a member of a partner state hospital association and you have questions or interest in CEs, please do reach out to your contact within your state hospital association as GHA is only able to provide CEs to GHA members, but your state may very well be offering those CEs for the series as well. We thank you all so much for joining us for all four parts and for your questions, your engagement with us. And again, thank you to Laura, and we look forward to having you all back with us for future sessions and hope you all have a wonderful rest of your day and week. Thank you so much, Laura. Thank you, everyone. Thank you, Lindy. Bye-bye.

Laura Dixon

risk management

patient safety

healthcare regulations

CMS guidelines

critical access hospitals

compliance

HIPAA

cyber threats

QAPI program

quality improvement

patient outcomes

informed consent

patient discharge

healthcare compliance