And now, I would like to reintroduce our speaker today to get us started with Part 3. Ms. Laura Dixon most recently served as a Director of Risk Management and Patient Safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as a 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 a Director, 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. Thank you for being back here with us this morning, Laura, and we invite you to get us started with Part 3. Great. Thank you, Lindsay. And you're right. This is Part 3 out of 4, and we're covering a couple of items that really came under some major changes back in 2019. Now with those changes, they changed some of the regulation, but unfortunately they haven't gotten around to updating the survey procedures, the interpretive guidelines, but I'm going to provide you information based upon what the past experience has been with it and also what is in acute, and the reason I do that is because the regulation that we're going to cover today pretty much mirrors the regulation that's in the acute manual, and I believe that's what they're going to do. They may cut off some of the stricter requirements or more broad requirements, but I really have a feeling they're just going to take that information and put it into yours. I include on slide number 2 not only my email address, but that for CMS, and yes, they do respond. It takes them a while, but they do respond, and you can send off your questions directly to them. Make sure you fully ask the question, because once they answer it, they close out the ticket, and trying to get additional information can be almost impossible, just to be very upfront with you there. All right. Here, the program I'm providing today is informational only. It is not meant to serve as providing legal advice or establishing an attorney-client relationship. Please consult with your in-house counsel, your own legal representative for any particular advice, especially as it relates to maybe a situation within your facility. Those of you who've had the opportunity to participate in GHA's previous programs know this is why we're here, so that you don't get one of these. It's that statement of deficiencies where it's at the level where you have to do that plan of correction. No provider wants to get the notice they've been involuntarily terminated from the CMS requirements or the CMS program. That's a huge financial hit for a hospital, and that's why we definitely don't want to get it. Now, these are really after some pretty egregious or things that just haven't been done, and the opportunities were there. Whether it's not providing the follow-up plan of correction, not following the plan of correction, or not even letting them have access to the facility, that can actually lead to termination from the agreement. Topics we're covering today, these are all in Appendix W. Tagged letters start with letters C, and the ones I've highlighted are the ones I'm going to hit. Provision of services encompasses a wide range of items within the manual. They clumped them all together rather than separating them out. For example, nursing services, lab, and outpatient services, that all falls under the provision of services. Then we're going to hit again on the two that were updated most recently, infection prevention and control, and discharge planning. I'm going to start right with infection prevention. Lindsay mentioned, yes, we have a few questions, so I thought I'd start us right off with a question. Lindsay? Absolutely. Let's get this one up here on your screen. You should all see this one now that says, our infection preventionist is an RN with training, an RN who has been on staff for three years, but no experience in infection prevention and control. Not sure who that person is or possibly prefer not to answer. I see several of you responding. I'll give you just another couple seconds here. By the way, this isn't a quiz. You're not being graded on it. It's simply for information. As I go through, that's what I try to hit on. What would you want to look for? In this situation, you're a preventionist. What would that person be? The preventionists, we used to call them infection control nurse. That role started to expand. Now they have identified it as infection preventionist and control. That's what their new tagline essentially is now under CMS. Perfect. I see several responses. I'll go ahead and end this here. Then for those who, I see quite a few of you who have joined in the last few moments. If you have any questions, again, for Laura, as we go throughout these polling questions that'll be peppered in throughout the presentation, you can, of course, be typing those into the Q&A at the bottom of your Zoom window or the chat option, and we'll make sure we address those throughout the presentation. Here are those results. I see a comment here in the chat saying that ours is an LPN with experience. Okay. All right. Let's talk about what we've got to do here. This is what CMS requires. Damp dates back in 2019. Well, it took them, they usually have a couple months to get it together and put out the information. It starts in your manual, in appendix W, it starts on page 490, excuse me, let me back up on that. It starts on page 495 for the manual. I have the link in the appendix. If you want to look at what that is, start on page 495. They put in 25 new tag numbers. What they also did was retired a whole bunch of them. You have to read both the memo and the actual tag numbers in your manual together in order to find out what you have to do. So hopefully we've got that accomplished through today's program. In June of 22, yes, they put out interpretive guidelines and survey procedures, but that's for acute. That's your appendix A. They are still pending for you. I checked the website daily and they still are not up there. My last interaction with CMS, it was late last year, I said, well, we hope to have it out sometime in 2025. We'll see what happens. They are supposed to put out a manual in 2025 regardless. Hopefully that will be in there. There are four revised requirements as a result of that burden reduction memo. You have to be organized and have policies. Antibiotic stewardship program, same thing, organized with policies. They included leadership's responsibilities. That is your C-suite. And then if there is a unified integrated program, like usually multi-hospital systems, you can do that. They have not yet applied those to critical access hospitals. I have a feeling they will. They're going to find this is a huge benefit for hospitals when you have this program. You can share best practices. You can learn from others on how it works. And I believe they're going to apply it to critical access. But just not yet. You have to have, and this is starting the tag numbers. They're all letter C and the four-digit number. You have to have a program that is very active all over your hospital in order for you to surveil, prevent, and control healthcare associated infections and other infectious diseases. In other words, those coming from the outside. Following nationally recognized guidelines and best practices. So we're really cutting back on the transmission. And also antibiotic resistance. Prevention and control problems. Antibiotic use issues that you have, that you've identified or you see coming up. They have to go through your quality assessment performance improvement program. Pretty much everything you have in that hospital has to go through QAPI. Again, this is one where our procedures and our guidelines are still pending. They include, in the old manual, they actually had some of the organizations that establish our national guidelines, they included those in there. CDC, of course. But they also added some of those that are specific to the particular topic. AORN, that's just surgery and recovery, perioperative services. APEC. But also OSHA. Because it includes what goes on with our staff. CDC. That's another one that they have also included. These are all the organizations that CMS references, but they don't include their guidelines. That's something, unfortunately, we have to go back and do. So let's talk about our preventionists. You as a hospital have to show that this person or persons, if you're fortunate to have more than one, that they're responsible for your program. That this individual is qualified through education, training, experience, or they've gone to the level of certification. The board has to appoint this person based upon medical staff and nursing leadership's recommendations. They approve them. And APEC has that competency manual, excuse me, model. So if you do have, say, someone who's not an RN and they're an LPN, maybe they meet this. And that's fine. We just have to demonstrate that to the surveyor when they come around. And, of course, by the way, you would do that through their personnel folder. The program has to prevent and control transmission of infections. It used to be infection control. Well, now they want us to stop it before it even shows up. So that prevention. And that means those within your facility and those that you're getting from the outside, whether it's patients coming in from a nursing home, patients coming from home, or they've just come back from a trip and they're not feeling well. Again, all of these, the guidelines, our survey procedures are pending. I do want to point out some of the essentials with this program. It did mention surveillance, prevention, and control. That means we keep our place clean, that it's a clean, sanitary environment, so that we don't even have these things cropping up. That could be mold control. Perhaps with your building, you've had a leak in the roof or in the ceiling. Then you have to watch out for that mold that's starting to contribute. We had an issue here. It was actually an apartment building where there was water that had seeped through from the roof into the ceiling areas. And when they were doing some remodeling, the people who were living there had done some remodeling, they found massive amounts of mold that led to some pretty serious illnesses for one of the people there. We also have to make sure, and this is actually in the old guidelines, no blood on the walls or floors. We're using proper hand hygiene. That's that prevention of transmission. You have to include anything you've identified to your public health. I was talking to your coordinator, Lindsay, and I asked beforehand, are you seeing an uptick in your area with the viruses? Yes, you are, whether it's RSV, norovirus, flu, whatever it is. In fact, most states have seen the uptick in the viruses, the RSV, the flu, the influenza, whatever it happens to be. They're really starting to rear their ugly head right now, and the public health authorities are putting out that information. Hey, be on the lookout for this. Same with the COVID. They're starting to see a surge in COVID in some states. How big your program is depends on how big your hospital is. What's the complexity of services? You look at all departments, all services. Whether you are strictly mid-surge or do you have a mother-baby, you have a large older population where they're coming in from nursing homes and might be bringing something with them. Antibiotic stewardship program. The governing body, they appoint a person or persons to lead this program, and that's, again, based on the recommendations of the medical staff, but here it's the pharmacy. The individual has to be qualified, just like with the preventionists, through education, training, experience in infectious diseases. This can be a physician and also be a pharmacist, as long as you can show they have this education and training. Like the infection prevention, it's throughout your hospital. It's facility-wide. It also has to show coordination between everyone who's responsible for that. Infection prevention is going to be one of them. Pharmacy, nursing, all of those are going to be involved in this program. That could also be QAPI. Medicine has to also be involved. This one has quite a broad oversight in the services that are provided. We have to have our documentation. They can't avoid that. There has to be documentation. We are using evidence-based antibiotics in all departments and services, whether it's surgery, again, mid-surg, ICU, that we are using what's out there, the really good empirical evidence, and that we're improving our use of antibiotics. The goals here, we're trying to reduce C. diff and our MDROs, our multidrug-resistant organisms, where it's just what we have isn't starting to work. Control, prevention, all through this program and the leadership, we use our best practices and national guidelines. Like infection prevention, your ASP has to reflect the scope and complexity of what you do. Here, they also add a little bit more responsibility on the governing board. They have to make sure you have those systems in place, so this work can be done. Tracking the antibiotic use, that we're showing success in our activities, and that these activities are sustainable. The governing body has to make sure you have those resources available. I want to make just one quick note here in reporting National Healthcare Safety Network. This is from back in 2019 again, that we're trying to improve our antibiotic use, and that's what the program has to demonstrate, that we follow this network on reporting and tracking. Beginning last year, acute hospitals, they had to attest to reporting antibiotic use and resistance in order to get credit for this. If you're doing this as a critical access hospital, you are not required, but you can participate again to get the credit. You just have to make sure that you're eligible to participate in this program. I have the information here on how you would find it. It's under the CDC and where you get access. I think I had the link on the previous slide for you. There is one thing we have to do as a critical access hospital, and that's reporting our infectious diseases. CMS put back in those requirements on reporting on our respiratory infections. This first came out with COVID. We had some pretty strict requirements that we had to be reporting. They did revise them a little bit. They still want to make sure that as facilities, as healthcare providers, we have enough insight on these evolving infection control needs. Beginning November 1 of last year, 2024, we now have to report weekly, electronically, information on COVID, influenza, and RSV. There will be a new tag number on this regulation. It's not there yet. Overall, you do have to report by Tuesday midnight when this information has to be reported. If it is not done, you'll get an initial letter. You get an initial warning letter, just by the way, if you haven't done it for the first 28 days. I have slide 156. It talks about more information on this. If it rises to the level of a public health emergency, just be aware there may be more reporting. That will be determined at that time. I hope I didn't miss the list there. What you have to do is on your reporting, how often you have to report. It's weekly. What they're looking at is how much you had in the past week on a daily basis in order to be reporting that. We do still have to go back to reporting what we had been doing. The board and the providers, the board and the preventionist. I mentioned the board has more responsibilities they tapped on into with that improvement role. The board has to make sure our healthcare associated infections and anything else that your prevention has identified and with ASP, the antibiotic stewardship program, and QAPI leadership. They have to make sure everything is identified . The preventionist, they have to develop and put into place hospital-wide policies to do this program. Surveillance, prevention, and control. Make sure they're following nationally recognized guidelines. They have to document the program, including what activities they are doing. This person does have a lot to do. They also have to work with and collaborate with the QAPI . The preventionist has to provide training, competency-based training to everybody. Staff and contracted services on how your guidelines work and the policy and procedures. This is also those policies, the procedures, your guidelines, what you do on prevention and control. That includes they also have to audit the policies. They work with and communicate with the antibiotic stewardship program. All of that makes sense. If you're seeing an uptick in CDF, why is that happening? That's why they would work so closely with the ASP. The ASP leader, similarly, they have to come up with and put into place the policies throughout the hospital. Likewise, based on nationally recognized guidelines. The idea here is we're trying to monitor and improve our use of antibiotics. They document the activities and they work with a whole bunch of other people. They work with medical staff, pharmacy, nursing, infection prevention and control, QAPI. They work with a whole host of other units and processes in order to make this program work. Because they have to make sure, likewise, there's training and competency. This includes not just your hospital personnel, but also medical staff. Now, yes, with your preventionist, you want to make sure your medical staff is aware of what your policy and procedures are. But they specifically list medical staff here with the ASP because what you have to do is look at who's ordering the prescriptions, who's ordering these antibiotics, and that's why they really specifically mentioned medical staff in the ASP program. Again, that includes whether it's your contracted hospitalist, maybe you have a contracted service for emergency department call. We have to include them in this training. There are core elements of an ASP that the CDC has developed. They've updated them. There is also examples of leadership's commitment, C-suite, the governing board, etc. This really highlights those interventions and process measurements and priority interventions. It also spells out that key role of pharmacy and nursing to improve antibiotic use. That yes, pharmacy may know, this is the next generation of antibiotic or this antibiotic conflicts with this particular medicine. That's why that's so crucial for that collaboration. There is actually an assessment tool that there's available. They have the core elements and then your assessment tool. This is all free, by the way. You can tap into it and download it. Now, there's another option out there, and that's the one for critical access hospitals. This was a joint effort between CDC, American Hospital Association, Office of Rural Health, and the Pew Charitable. They came up with strategies to put your program for your smaller hospital into place. Leadership's commitment and accountability. Pharmacy, that you can have a pharmacist leader here with that drug expertise. Tracking, how many days are you going to be on that antibiotic? Reporting and education. This is great that they came together and pulled all of this together for us. It's right there and we can tap into it. Otherwise, CDC has some other resources. You might want to look at this if you've got a fairly new person or you're looking to maybe replace your preventionist or retiring. Now, this is nursing home focus, but so many of the issues also apply to hospitals. I like it. It's 23 modules, covers everything from covering your mouth with coughing, to point-of-care testing, and water management. It's really very comprehensive. It is free and it is flexible. For those of you who will have a nurse do this, there are C&E credits available. That's nice because it will show you how long does it run and what are you talking about, whether it's catheters or making sure you don't have a leaky roof. It's really good. Another one came up through development of Health Research and Education Trust. It's called STRIVE. It's an acronym that says states targeting reduction in infection and also engagement. STRIVE, that's the acronym. Take them in any order, no cost. Now, this is really good for your preventionist because they can use that for employee training, whether it's annual or initial. It's really nice that these resources are right there for them. Likewise, it also includes cleaning of that point-of-care testing, engaging the family to make sure they're washing their hands if they're going to touch the patient. That's what that would look like. Again, it's free if you wish to download it. Then from the CDC, this is for infection control within your staff, your personnel. Eight elements, enough resources on your immunization program, organizational culture. We're taking this serious. We don't want patients to get sick while they're here. They're already sick. Let staff know what their risk are, what are their occupational infection control and prevention risk, how you monitor performance and job descriptions with those infection risk. This is again geared to your staff on how you would keep control of it. Then just a few other resources really quick. Health and Human Services, they have an infection control video. They suggest pretty much everyone listen to this, including your risk managers. It's very interactive and how you just again tap into that to run that. Finally, they have guidelines on hand hygiene. I remember doing this in my basic nursing rotation, where that's one of the first things we learned to do, wash your hands properly, and also a guideline and a library for you. Now, the next topic I'm talking about, it's not in the actual manual, but I wanted to bring it up because of some of the issues that have arisen as a result of infection control problems that we have identified. That's vaccine storage handling and injection practices. CDC has a toolkit, they updated in 22 and amended it in last January. The amendment talks, excuse me, added in impacts, and so there's references and guidelines on handling it. But this particular toolkit covers a vast array of information for storing a vaccine on your site. Cold chain, what are the recommendations of the manufacturer? Temperature range, but check your state. They may also have certain requirements. Again, they updated it with impacts information for you. There is also a training that's included in that toolkit, so staff know where stuff is. Where are your vaccines? How do we store them? You want to add this also when a new one comes on board. Keep these procedures close to where the units are, so the staff doesn't have to run around and try and find it. Then of course, injection practices. We've talked about this repeatedly, but we still have some problems coming up. What are the unsafe ones that put not only our patients, but you at risk? It's not just in one site, it's across the board with our settings and our care. It's part of your standard precautions. They worked with what's called the Healthcare Infection Control Practices and Advisory Committee to come up with these recommendations. There were eight of them total. I'm not going in depth, I'm just going to list them for you. Aseptic technique, of course, so we don't have any equipment that gets infected. We don't administer meds from one syringe, multiple patients. You'd think that was common sense, but it still comes up. Infusion administration sets for one patient only. Single-dose files when possible. You don't administer meds from a single dose to multiple patients nor combined leftovers for multiple use. Multi-dose files, if you must use them, and they said if you must use them, then both needle, cannula, syringe, everything has to be sterile. You have to start over. New needle, new syringe, everything. Don't keep multi-dose files in the patient treatment areas. Store according to Fancher's recommendation. Discard if you're not sure about the sterility or you're starting to see particulates in it. Then of course, we don't use our bags, common source for multiple patients in order to serve as an IV flush. There's also a quick video. If you're doing some of the training, you want to break it up a little bit. There's a nice injection safety video. It runs four minutes and you're done. We're out of infection prevention and control. Now we're going to the provision of services. Again, there were three areas I'm going to talk about this round, nursing, outpatient services, and laboratory, those three areas. Let's start off with another question, Lindsay. Okay. Let's get that one up here on your screen. This question asks, and you can check all that apply here to your organization, our critical access hospital provides, laboratory, radiology, OB services, a dedicated behavioral health unit, ICU or CCU, and or routine medical and surgical services. We have one question come in as well, Laura, that asks, what qualifies as training CIC? I would go to the CDC training, that APEC one that I mentioned early on. That's really good training. That's where the experts are. CMS won't tell you what that training encompasses, but they want to see that at least they have some training. They've had that outside experience coming in to get them up to speed, and make sure that they're following those nationally recognized guidelines. That's why I think APEC and CDC has some really good ideas for you on what they want. You could have someone who's done this for years, just not been identified as a preventionist. That's their experience part. They probably have had training. How would you describe it? That's what I would put. They've worked with this person for so many years, side-by-side at another hospital. That's where their training occurred as opposed to a certification. Certification is the clear-cut way to do it. May not be easy, may take a bit of time, but if they show they are certified, that's sufficient for CMS. Yes, I'm certified in infection prevention. Perfect. I'll end this and show those results. Great. Good. Everybody's, wow, quite a bit over. Just a few of you have behavior. That's good. Moving on. These are the areas, again, I mentioned that we were going to touch on. Not too many tag numbers here. Laboratories, he only has one. But those are the areas on what we're covering on this round. Let's start with patient services. What you do? We provide diagnostic and therapeutic services you'd normally see in a physician's office, or say, in the emergency department that you would normally provide. That means we have to have enough supplies that you typically find in that ambulatory setting. Whether it's putting in a cast, setting a bone, or the routine, history and physical, specimen collection. How is your health status? Doing that variety of conditions in order to treat them, whether it's asthma, NMI, or maybe it's a surgical component. Now, granted, we don't do surgery in outpatient, I mean, in a physician's office, but what you normally find as far as supplies. We have for your outpatient department, this is your outpatient department, enough services and staff and equipment so that we can provide them safely, following those standards of practice. I've said it before, and I'm sorry, I'm going to repeat it. CMS does not establish the standard of care. They leave it to the experts, the AMA, Marin College of Orthopedic Surgeons, Marin College of Radiology, whatever it happens to be. But they do have to be integrated with, those services for outpatient have to be integrated with inpatient. Lab, radiology, maybe it's another service, a diagnostic service. You can do it by contract or directly, whatever suits your needs. So again, radiology, reading those films could be through a contracted services. Physicians and non-physician practitioners have to be there though, to be able to treat patients at your hospital. And that's when these outpatient services are provided. And those outpatient services that can only fall within their scope of practice. So, we wouldn't expect a non-physician practitioner to do everything a physician can, we just have to make sure it's within their scope of practice. Now that's outpatient. On inpatient, we know we give acute care. The average length of stay, average for one year is 96 hours. And they recognize that they generally provide less specialized services. That's why the length of stay can be met. They're going to look at information. CMS will look at information to make sure those who need inpatient are actually admitted. And that we have to certify Medicare patients are either going to be discharged or admitted to the hospital within 96 hours. And that's usually when they're coming in from outpatient. They just simply don't see it in the best interest of the patient to send them off when you can care for them locally. So, maybe they're in observation and you're just not too sure, is this patient going to get better? Are they going to get worse? Now, normally if they get worse, it was years and years and years ago where the, okay, we got to send you off to a hospital 50 miles away in order to take care of you. Well, now with these criticals, that's not the case. You can take care of them in their hometown. They can be there locally. And usually that's done within 96 hours average. On census, they do know you're going to have seasonal variations, your ups and downs. And you're not required to keep a minimum number on site. You can have no patient and still continue to be in operation. For compliance, what they're going to look at, what's your ED volume? And how much are you treating patients outpatient? How many certified beds? How many of those also, or other beds, are observation beds? What's your annual average occupancy? Your average inpatient beds, both quarterly and annually? And what's the percentage of ED patients that you end up admitting? So there's a host of information that they're going to look at in order to calculate your census. So to ensure compliance, please don't have a huge number of observation beds. You're a 25-bed hospital. If you have 20 of those being observation, they're going to kind of find out why do you have this many observation beds, as opposed to transfer or discharge or admit. We don't want, they don't want transfer of patients from the ED to another hospital when you can do this. And data does show, this is from CMS, the data will show half number of those who visit the hospital of your nature. They're admitted more than they're in a non-rural hospital. If you admit, this is from CMS, if you admit 8% of your emergency department patients annually, then you're compliant, and then they're done. They won't go any further. And if you're looking for where that information came from, I have it here, it's on page 137 of your current manual, and you'll see the two bullet points there. So that's if you're looking to find out where that information came from. Now, I want to clarify something that came up from a question a week or so ago. So we're a 25 bed hospital, we're a critical access hospital and we have 10 swing beds. We were told we can only have 15 acute beds, and that's correct because swing beds are part of your total 25 bed count. How you use those beds is up to you, but that's the maximum you could have. If you have 10 swing beds, only 15 acute, then additionally can be used for acute care services. Off to laboratory, one tag number is all, because they made it pretty short and sweet. You do your basic labs, and that's for the immediate diagnosis and treatment. Of course, they have to meet CLIA standards. They're going to be surveyed under CLIA. You can contract it out. Yeah, if that's the case, they would say you're having a reference lab also, make sure they have a current CLIA certificate, get a copy of that CLIA certificate. We have to have a written policy. We want to make sure all labs are recorded in the record. And also, how are you going to preserve that specimen? How are you going to make sure it's still usable from when you obtain it, you transport it, it's run, and then you're getting the results back? Whether it's blood work or a tissue sample, whatever that happens to be, your policies have to spell out how that's going to occur and who's responsible to make sure it does occur. These are the six mandatory tests that you must perform. Urine dip, hemoglobin metacrit, glucose, occult blood for stool, pregnancy test, and primary culturing. What you're doing here really is you're doing the culture and then getting it ready to go off to that certified lab if you are not doing that on-site. So that's the six mandatory tests that you must have. The scope, complexity, you may want to expand it. Maybe you're doing other testing or other services. For OB, of course, you'll have your pregnancy test, but maybe you want to have testing on-site if for RH, for vagabond that moms may need to have given any discrepancy between the blood types. So again, laboratory is pretty short and sweet on what they require. Now, this one takes up a little bit more room and that is nursing. So this is nursing throughout. Again, we have to make sure the service is up to snuff and it's meeting what our patients need. This is where you do have to have an RN. RN has to provide or assign care to each patient and according to what that patient needs, what is their acuity level? Maybe there are certain qualifications or special training that you want for that particular staff on a floor, ICU, or if you have a combined critical care unit, CCU. Do you want them all to have ACLS and whatever else they need to have? Same with the ED. The ED, those nurses, what do you want for their special qualifications? That's up to you. The state may also define what additional qualifications or training the staff have to have in a particular unit. Again, I was all critical care. You put me on OB and I'm probably going to be lost and probably wouldn't be safe. That's where you need to evaluate what each unit has to have. The service has to be well-organized and someone is responsible for the direction of that service. Now, it is expected to be an RN. If they say we expect it to be an RN, it needs to be an RN. How you call them is up to you, whether it's DNO, CNO, nurse manager, whatever. But this person is responsible to make sure there's nursing policy and procedures, that they're developed, they're reviewed, updated when needed because they are responsible for the overall management and evaluation of care. They have to make sure there is supervision of the staff. If they want to do it, that's that's up to you, but it sometimes helps to maybe have a mid-level manager in between there who can also provide care and yet supervise and make sure staff is performing safely. They have to make sure the director, and just for ease of terms, the director has to make sure there's ongoing review and analysis of nursing care. Again, they don't have to do it personally, but they have to make sure it's done and then there's a reporting to them of any concerns or issues. Any agency nurse you use, they have to be oriented and supervised. You do have to have some level of nurse available for care when you have one or more inpatients, whether it's an LPN, RN, or if you're going to a higher level prepared nurse such as a master's prepared. They have to make sure you have enough staffing for those services, enough supervision and non-supervision so we get the care done. Competent, trained, educated, oriented, and licensed. So you can look. Most nursing boards have a verification for licensure that will tell you when that person's expired or if they're current or if they're under any restrictions. All nursing staff have to know about the policy and procedures. Where are they? What do they encompass? And how do you assign and coordinate care? You may have a phenomenal LPN who really could serve as an RN, but for the training and licensure, that maybe you want to give them a tougher patient. That's fine. Again, this is one you have to have a way to do that. You're going to assess the patient's care and say, yes, this individual can handle it. First off, they're going to talk with that RN. Usually it's the CNO and they want to find out how are needs assessed, how do you determine them for your patients. Then based upon that, then how are you going to assign care and provide that care? It's one thing to assign an RN to a very critical patient, but maybe there's another individual helping with provision of care, whether that's giving them a bath or helping them be mobile. How do you train your staff? How do you orient your staff? How often does that occur? Who is doing this orientation? That's what they want to find out. They're going to then watch care being delivered. Is this staff, do you have an adequate number of staff? They also want to see your staffing schedules. They want to make sure staff are following policy and procedures and they'll look at files. Are they licensed? Is there any additional certification that you have required or the state has required? If so, is it current? When did they last go through that? An RN, or if your state permits it, a physician assistant can supervise nursing care and evaluate nursing care for each patient. That includes swing beds. If your state permits it, a physician assistant can also do that. Otherwise, just common sense, care provided according to what the patient needs. Care plans, you don't have to have them for outpatients, IED, like emergency department observation. You don't have to have those, but you may find it beneficial if this is a person that has to show up frequently because maybe they live in a remote, very remote area. They only get in when they're so ill, but they don't meet the level of needing admission, just some observation. That may be beneficial for those patients who come back more often. Otherwise, we know we follow acceptable standards, even for down to medication administration. The surveyor wants to see your written staffing plans. How does this person, whether it's an RN or PA, how do they supervise and evaluate care for each patient? Then they're going to talk to the person who supervises and evaluates that care. What they want to find out is how do you do that? How do you supervise the care provided by your staff? Are you doing rounds with them? Do you check documentation? Do you have interaction with them? Are you starting to hear complaints? What are the patients saying? What about bad outcomes? Are there events that are occurring? All of these are just some of the questions the surveyor may ask. That's unfortunately not in our survey procedures, but you can see where they're going. How do you make sure that you're properly supervising or this person is being supervised in the performance of their day-to-day care? Medications, drugs, and IVs fill in under nursing services, which of course makes sense because that's who's doing it. All drugs, IVs have to be administered under the supervision of an RN, provider, or PA, again, if the state law allows the PA to do that. Yes, we need a signed order, and that's what the surveyor do. They look through the charts. They want to see that there's a signature, a date, and a time on all orders. They're written within standards of care and consistent with any federal and state laws. Now, for your federal laws, of course, that's DEA. Are they meeting those requirements? Do your state have a particular requirement, say, on antibiotics? My state did. They put out some recommendations that also on controlled substances, that maybe for controlled substances, you can give a patient an ED so many days' supply. For surgical patients, you give them so many days' supply, and then you reevaluate the patient intensely and perhaps move them on if that's the case. Our policies have to be written for administration according to following standards of care. Again, they mention multiple resources. Specify who can administer meds. Do you allow, does your state allow medication aids to administer medications? If so, which ones? Signed order by someone who's authorized to do so. You have to have a policy on verbals and standing orders. Who can take them? Who can initiate standing orders? What's the requirements for co-signature by the provider who put that in? What conditions can those orders be done? What is the minimum content for the medication order? We know that's name, dose, route, frequency. There may be more that you want, like when does it stop? How about the parameters for the administration? Are there any height and weight requirements? The minimum content we know is name, dose, route, frequency. Of course, make sure that if you're allowing self-administered meds, which again, you can, totally your decision. If that is, then what are the policies on that and the practices? Training for administering medications, just basic safe practices, timing of meds, IV medications, who's going to be allowed to do that? What meds are going to do that? Documentation and assessment for those patients. Now, I talked earlier about what are the contents of an order. This really lists out what actually has to be in that order. Now, some of these are applicable, like exact strength, dosage calculations, quantity, duration. Some of that involves the height and weight of the patient, those type of items. But otherwise, date and time, name, dose, frequency, route, et cetera. Of course, who's ordering it? Verbal orders, if you're going to allow them, okay, the regulation does require we have to have something written and signed in order for that to be an actual order. You're not precluded from using verbal orders. So again, right now, the regulation says I have to have a written and signed order, but you can use verbal. If you're doing that, your policy has to stress how it's going to do it. I'm going to get to that in just a minute. But the practitioner has to then follow up and make sure they're authenticating it. So here's the minimum requirements for what goes into a verbal order. When can it be used and any limitations or flat out prohibitions? How do you establish the identity of that person issuing the verbal order? The elements required for that process. Protocols. In other words, how do I know for sure that's the verbal order that was given? We do it simply by feedback. Who can receive it? Who can act on it? And of course, prompt documentation. If you require the unit clerk to simply hand the phone to the RN to take that verbal order, that can be your process. Because most hospitals don't allow a unit clerk to take verbal orders. They want the nurse to have that. Not necessarily a nurse taking care of the patient, but a nurse who can take that verbal order. Standing orders. A little bit different. Similarly, you have to have a policy in the minimum contents or how it's developed, approved, monitored, evaluated, and maybe updated. Standing orders. Who can initiate that standing order if it's needed and under what circumstances? I'm in CCU. I'm already admitted. My standing order is saved for ventricular tachycardia lasting more than so many beats. This is what you do. Same thing for low heart rate. Maybe you or those of you working in PACU, a patient gets a vagal response and their heart rate drops. What is the standing order in order to treat that response? We still have to have it authenticated by that practitioner who's responsible for the patient. Now, that could be the PA who is also working with the physician or advanced practice provider, whoever it happens to be. You have to have in your policy the timeframe and who does it and what do they do to authenticate that standing order. Blue Box has some information on verbal and standing orders. I mentioned these before. You're not cited if you're not following what's in here, but it's some really good information for us. They understand no standard definition for a standing order. Whatever you call it, that's it. Protocols, standing orders, whatever it happens to be. Again, briefly on self-administered medications, optional. That's what you want to do. You have to have an order, policy and procedures on when and how it's going to be done. This can include meds that the patient might bring from home. Perhaps they just bought a new inhaler and not sure when it's going to go out. Sometimes it's better to have that inhaler bedside or maybe it's something as simple as hemorrhoid cream. It's better to have it bedside for immediate use. We just have to make sure that the patient knows how to handle it and how to secure it. In training, medication training, education, we do that during orientation. If you require continuing nursing ed, safe handling and preparation, are they washing their hands before they're doing that? What are the side effects of that medication? What do you expect or what can you expect from an adverse drug reaction? Are there dose limits on that medication? How do you use the equipment associated with it? How do you run that IMED pump? What do you do if you're starting to get that beeping goes off? In other words, can they do that initial assessment of the pump to see is it actually broken or is it something I can fix real quick? Of course, any policy and procedures. That's all training on medication administration overall. There's our third question, Lindsay. Okay, let's get that one up here on your screen. I do see several questions are as well. I've been reading through here. This polling question says, with medication administration, our facility requires, in your options here, five rights, seven rights, or nine rights. I'm going to scroll up here in the chat, Laura, and see. Okay. This first question says, so is 15 the maximum number of acute patients that can be admitted as a critical access? No, no, no, no, no. This was from a particular hospital who they had 10 dedicated swing beds. That's what they had. The maximum that hospital could have for acute is 15. So just look at how many swing beds do you have, if you're doing swing beds, and then the balance can be your acute. You may have three swing beds, and the rest can be acute. So look at what you're certified to have in that respect. Overall, swing beds are part of the 25 bed count. So just look at that from what you are allowed to have for your inpatient beds. Okay, go on, I'm sorry. I was going to say, there were several questions, or a question, and then some folks, thank you so much in our chat, who are kind of clarifying that as we've gone along as well. So I appreciate you all chiming in there. That's wonderful. And then just more clarification, I think you just addressed this, it said, are you saying that if you specify a certain number of beds will be acute, you can't use those beds for swing beds, and vice versa? No, not necessarily. No, again, they're going to look at, when the surveyor shows up, unless agreement with CMS says, we're just going to have three swing beds, and that's it, no more, ever, then that's what they're going to look at. But if they come on site, and you happen to have a patient who needed swing bed services, they don't have to leave that bed, they can stay in that bed. But then you have to count that bed in your total number of acute beds that you do have. It's all in one, it's a big clump of numbers. That's what they look at. It's just how are you going to divide that up on that particular day? So that's what they're looking at. They just don't want you to go over the 25 bed max. That's what they're looking at. Perfect. They did, I want to qualify, I think before back in 2001, because I went back and tried to find that regulation. Back in 2001, I think they did say, okay, you can only have this many acute and this many swing. But now they have taken that away. And now they look at the total number of your beds. Yeah, you may have 10 swing beds and 15 inpatient or three swing and the rest acute. So that's what they're trying to give you guys a little bit of a break here. Perfect. And then this question is just asking, is this session going to address PRN pain orders? I hadn't, but I'm happy to take any questions on PRN, because that can be part of the routine standing orders. You just have to follow and I'm always looking at, like Demerol and those narcotics, where there was a lot of confusion a couple years ago, where it says give 25 milligrams every so many hours to relieve pain. Some of these patients were getting a lot of narcotics at one time. And so they had to qualify. What do you mean by that? It used to be I could give 25 milligrams Demerol IM every four hours for the relief of pain. Now I can titrate that up to 25 milligrams if needed. But again, your policies have to stress what does that include for medication administration? CMS won't get into too much on pain control. They leave that to how do the societies, the experts like American Society of Pain Management, how did they identify proper pain control and then using good practice on ordering the PRN narcotics. If you've worked in or have pain patients where they've been on long term narcotics, they can walk around with so much of this stuff in their system that put most of us in a coma. But they're used to it. They've got that resistance to it. So you have to evaluate that on your policies, what your patients need, and then good practices. CMS won't do that. Perfect. Okay. And this last question I see asks, for insurances that limit conversion from observation to inpatient, how would we address that? Okay, I think you're maybe Medicare Advantage could be one of them. You follow what the insurance policy says. Because that is different. That is, I am surprised CMS allowed it. But that's what they have done. And again, that's on the insurance policy, under your advantage to handle it. They may say they only have to be, you know, inpatient for one day and you can convert them to swing. But your traditional Medicare, Medicaid traditional, they do have those certain requirements. And I don't feel I can get into the individual insurance policies. I think that would open up a whole can of worms. And I really don't want to do that. Understood. Okay, I'm gonna go ahead and end this poll and share those results here. Awesome questions, by the way. Yeah, just a few of you are doing nine rights. That's, that's, that's great. I mean, it's a lot of work. I don't don't question it. Base safety practices, the five rights, that's what at least CMS wants to see those five rights, and then have that culture of safety. Do your staff feel like they can question an order when it comes across without getting their head bit off? And who do they go to when that is? Then there's the process of administration. That's different. There are five steps to that one, ordering, transcribing a verification that's usually done in the pharmacy. Same with the pharmacy dispensing and getting it up to you. And then nursing, administration, and monitoring the patient, of course, reporting if things aren't going the way it is. On the nine rights, I do want to point out with those of you who might have not been might have not been familiar with those. There are sources that say eight or 10 rights. I don't want it to be cumbersome or overwhelming to where they won't do it. But CMS at least says the five rights, patient, drug, route, time, dose. That's what they want to see for the five rights. The rest, they'll leave that to you. But then we have timing of medication. So we've got the order pharmacies filled, and it's up there. Now, this is where nursing takes over. That's where your policies have to address those timing based upon what the medication is and why you are using it. There are four things in the policy that you have to include. Which medications are not going to be time-based? Which ones are time-based? What can you do outside the normal dosing administration windows? And then going back and evaluating those timing policies. So I wanna start with the meds that are not eligible. These are the ones you don't put into a scheduled time. This is one where you have to have exact time for that therapeutic effect, by cause of diagnosis or what you're trying to treat. Stat drugs, that's a good example. Loading dose, pre-op. Maybe you're going to have a serum drug level, your peaks and troughs or your ditch level, whatever that happens to be. Your PRN meds, those aren't on a schedule. And investigational drugs. Investigational drugs have to go through a whole series of IRB, through the IRB in order for that to occur. And that's why they didn't include investigational drugs and meds, not in that scheduled boat, so to speak. And then there's everything else. Those meds that are on a repeated cycle for frequency, whether it's daily or QID. This is where we're trying to get that therapeutic blood level. And that's why your policy has to spell out standardized times. This is because pharmacy needs to know when to get it up there. When the nurses have to assess the patient and review the blood work, what's going on? How's my peak and trough? Oops, peaks way up there. And so is the trough. Maybe I need to get a hold of the physician and tell him. The policies have to address, on these medications that are eligible, when are you going to give that first dose? When can the nurses use judgment for the next dose? When did you miss a dose? Or it just got omitted for whatever reason. Those you can give outside your scheduled dosing times. This is all part of what your policy must address. And then we have to go back and evaluate this policy. Are we adhering to our policy? We want to track errors on timing. Maybe that's part of your PI process. Why are we missing that 10 p.m. dose? Or why is it so easy to miss the first dose in the morning? What's going on that it continually happens? Is it because pharmacy couldn't get it to the nursing floor in time? Or is it the patients wake up and they're hungry and trying to take a pill with it makes them nauseate. So they can't take it. What is it? There are three time schedules for administration. I'm gonna go through. Time critical, hour before or after, and two hours before or after. And I have to hand it, CMS worked really closely on these medications in order to come up with this common sense approach. Used to be, and I always say used to be, back in the ancient days when I was practicing nursing, that if you missed it by 30 minutes, didn't matter the medication, didn't matter how long they had been on that medication, if you didn't get it to them in time, you were out of compliance and had to do an incident report. Well, they realized, no, that's not the case. That patients, A, if they've been on a home, don't do that at home. They don't follow it so rigidly. And secondly, maybe there's a good reason that we're gonna be a little early or a little later past that scheduled dosing time. So thank you, CMS, they did recognize this was necessary. So let's start with the time critical ones. These are the ones, yep, we still have to stay with that 30 minute timeframe. Here you have medications where giving it early or later, that 30 minutes will impact what we're trying to achieve, that pharmacological effect or that therapeutic effect. Policies have to include, are they always time critical? Such as antibiotics, anticoagulants, insulin, anticonvulsants, you kinda wanna keep the blood level up there. With these, these time critical ones, you have an hour, 30 before or 30 after. So you really have an hour's window of time. It's ordered at nine. You can give it at 8.30, you can give it at 9.30, and you're still okay within that timeframe. But then there's the others, that non-time critical. These are one where it's a little earlier or a little later since that prior dose, it's not really gonna impact the outcome. Here you have meds that you can give before, an hour before or an hour after. So you have a two hour window of time. Usually that's TID, BID, you have that gap. Then you have those that you can have more time, two hours before, two hours after, for four hours total. These are the ones given daily, maybe weekly or even monthly, where you do have that give in the administration, and it's not going to really impact that therapeutic effect. They still have to have it, but it's not really gonna impact it that much. What do you do if you miss it, or it is outside the timeframe? That's what your policy has to address. What do the nurses, what are you supposed to do? What are the nurses to do? If the patient's ill, they just can't swallow it right then, maybe the patient's down an X-ray, or it's simply not there for another reason. You dropped it on the floor, and there's not a second one available. Okay, what do you do in that situation? And then also, what can the nurses do using their own judgment of rescheduling those missed and late doses? We do have to still report them to the attending. They need to know, by the way, they were down an X-ray. We didn't get that medication administered at that time. What do you want us to do? Now, your policy on those parameters can simply be, call the physician. Ask, what do you want me to do? Or when can they use their professional judgment in making that retiming? Otherwise, they are very concerned about opioids, CMSs. So are the accrediting organizations. And that's why we need to carefully monitor them. What we do and the extent of monitoring, it's going to depend on a few things, but I'll get to that in a minute. Right now, what they really want to do is our respiratory status and our other vitals, BP, pulse ox, or entitled CO2, if you've gone that direction. And then just how are they normally? Are they confused? Are they seem more somnolent than what you would expect? Are they itching? Perhaps they're agitated. Maybe that's their adverse reaction to that medication because opioids are a high risk medication. ISMP, Institute of Safe Medication Practices, they have a list of those in the acute setting. It is long, that's why. I just put the first page up there for you. Insulin is a high alert medicine because of how rapidly a patient can terribly respond. Same with your intrathecal or epidural medications. They just react so much faster. But opioids, they take some time in the manual to talk about opioids in particular. They include a recommendation from the Patient Safety Movement Foundation, specifically patients on IV opioids and what that foundation recommends. Continuous pulse ox, another one, if they're on O2, so they're getting nasal cannula or a mask, it's better to have entitled CO2. It reacts faster. Plus with that oxygen, we may be knocking out some of the respiratory drive. So that's why we need that entitled CO2 with IV opioids and supplemental oxygen. Attach that monitoring to a notification system for the staff. Somehow to do that where if my CO2 starts to rise, that my nurse is alerted or someone at the station is alerted and then an escalation protocol. I'm tied up, I can't get to that patient. Who is it gonna go to next? Is it going to be the daily charge nurse or is it another nurse on the unit? I think 60 seconds, I believe 60 seconds is too long because patients can really have a bad effect when they're perhaps apneic for 60 seconds. Maybe you wanna shorten that a little bit, but the movement did mention 60 seconds in particular. Another, they have best practices for you on monitoring after prescribed opioids. I have to find this one. These are all free, by the way, that I've tried to put up there for you. If there's something you have to pay for, I always warn you ahead of time, but these are all ones you can access and monitoring after prescribed opioids. One thing to keep in mind also, usually you'll find this on the floor, your reversal agent, your Narcan, your Naloxone, whatever it happens to be, whatever you're gonna have handy, make sure that's located in a readily accessible location. Talked about the risk factors. Those who are at greater risk for not only respiratory, depression, but other adverse events with it, failure of kidney or liver, sleep apnea, snoring, that's not been diagnosed as sleep apnea. How old are they? Are they very old and cascadic or debilitated? Thoracic or other incisions. Thoracic incisions, especially if they have a chest tube, that hurts. And taking deep breaths and coughing really hurts. And so that's why they included those in there. Smoking, other cardiac or pulmonary diseases. But they're an opioid naive, first time getting it. In addition, they're getting antihistamines and or benzodiazepines that can potentiate those opioids. Asthma, obese patients, those who are very heavyweight, it's difficult for them to take those deep breaths. So these are just some of the risk factors you wanna take into account when you're identifying how often and how am I going to monitor this patient? Of course, we assess their sedation level. They need to know or expected to know, how does the patient respond? Please tell me patient, have you taken this narcotic before? How'd you react to it? Did it work for you? I mean, if it's nausea, okay. Sometimes the opioids can cause nausea. But I said, yeah, I remember taking that once and the next thing I know, I woke up in an ambulance. Probably not the medication you wanna take with it. Educating family too. Is your loved one, is your family member acting different after that? Are they, do you see them not breathing or they're starting to pick at things? They can tell you when that happens. Policies address the how and the manner that you're going to monitor that patient. Again, this is always, always can permit upon the professional discretion of that individual. Because nurses, you're trained to assess patients. So are the physicians. How are they responding? Is this different than what you would expect? Likewise, if you have a patient who's on long-term opioids, they may react totally different than your opioid naive. They separate out IV medication administration because, well, for a couple of reasons. We know it acts 10 times faster than IM or even oral. And so that's why they have separated IV medication administration. Always choose the right route, how you're going to do it, whether it's blood or medications. Are you gonna allow PICC lines to administer blood? Policies to address who can give these items, whether it's IV meds or blood and what type of access. Trace the lines. Make sure you have the right connection. You have the right line, the right medication. And also that the pump is properly programmed and it's working. So again, you, those who probably work on the floor, this is not unusual. How many pumps do you have? How many bags are hanging and what's going on? On monitoring the patient, there's a couple of ways to do that. They just list these or reference them in the manual. I put up examples of them. This is Pacero. It talks about, you know, how oisy they can awake. Are they frequently drowsy? No response. Then there's the Richmond scale. I don't endorse any one of these. It's up to you which one you wanna use. Richmond goes a little bit more into detail. And so that may give you more information on how well your IVs and especially your sedation is working for that patient. I actually found a site where you can do a comparison to it through Medscape. We'll give you what are the scales for reporting opioid-induced sedation. So this is just for opioids. But if you're looking to, hey, is there a better way we can do this or a different way? I'd start there. See which one fits into your particular facility. But ISMP does say, please use a standard scale so that what happens in the floor is going to happen maybe in recovery or ICU. So they know it and they're comfortable and we have trained them. And speaking of training, yes, we have to have policy and procedures and we have to train them. The policies are expected to address monitoring their flu and electrolyte balance, especially with blood, monitoring those who receive high alert meds, how often, what are you going to use, what are you going to evaluate and watch for over sedation and depression, especially with opioids in post-op patients. The longer the period of anesthesia, the more vulnerable they are to over sedation with IV opioids. So just keep that in mind. We always had to look, was that a half an hour procedure once we got them induced until the surgeon was done and we're bringing them out? Was it a four hour procedure where there was a lot going on? On blood, they do separate this out also. We know we have to have the correct patient, the correct blood product. The CMS standards, they call for two qualified persons to do this check, one who's actually administering it. Joint Commission, the National Patient Safety Goals say you can have one person hang the blood if you use barcoding. Policy and procedures have to spell out how often and what you're monitoring with that blood administration and what are you going to document? It also has to spell out how you identify, treat and report any reactions. Blood transfusion reactions can be devastating. That could kill a patient. So that's why we need to spell out how are you going to identify it? Just briefly, I know once there was one time when a surveyor was really going in and talking to nurses, you're hanging blood, what are you looking for, for a reaction? And a couple of them couldn't do it. They couldn't identify what do they look at? How often do they check the patient and what are they to monitor in that? So just make sure those who are hanging blood are familiar with those requirements. And again, your policy needs to spell that out on what needs to be done. So we're off meds. Let's talk about the nursing care plan. You have to develop and keep a current plan for every inpatient. And I want to stress that, inpatient. Observation, they're not required, but you may find it beneficial. Especially again, if they're coming in more frequently and they didn't require admission. You don't have to, but it may be beneficial. It starts on admission and we update it as they progress through their stay. But we don't have to forget, we must include transfer and discharge. Consider what are the goals of that care, whether it's psychosocial or physiological. And again, discharge planning. Did that patient come in with an incomplete suicide attempt? They're going to have perhaps many more requirements in that care plan than you do for a patient who comes in for pneumonia. That develops interventions, nursing interventions, based upon the identified needs. It has to be a part of the record. You can do it as part of the interdisciplinary plan, but you still must have a separate nursing care plan. That still has to be there. And the surveyor will make sure it's there. It started soon after admission and somebody's looked at it throughout this stay, at least looked at it. They're there for two days. You're probably not going to have too many changes. They're there for two weeks. Yes, they do expect to see a revision and that somebody has looked at it. So that's nursing. We never did get away from the nursing care plans and they can be as simple or as complex as what that patient's care needs. So now we're moving into our final segment, the discharge planning. And again, this is part of that update. We don't have survey procedures. We don't have guidelines yet. They're still pending on them. I have included in here some information from the acute, because again, their requirements, your requirements pretty much say what the acute say. You have to have an effective process in order for this to be considered compliant. We're literally looking at what does the patient want from their care? What's their goals and treatment preferences? And we include their representative. They have to be included, not only the representative, but the patient in this process. We can't just sit back and do this. We have to include the patient in this. So you have to have a way to identify early on those patients who may have a bad outcome or consequences at discharge if we don't do this, if it's not done and done appropriately. We have to then provide an evaluation of those patients we've identified who are going to have a bad outcome or if the patient representative wants one or if the physician requests an evaluation. Now we have to do discharge planning regardless. It's the evaluation that we really have to look at. It must be done timely because we wanna make sure things are done when the patient's ready to leave. So we don't wanna have that delay. Include an evaluation if they're going to need post-hospital services, whether that's home health, hospice, going into swing bed, or maybe going back to long-term care. We have to determine also, are they where the patient's located, where the patient lives? Because if this patient needs home health and there's nobody in the vicinity to provide it, we have to find an alternative. That's what we have to do. The plan, you need to document what you found in your evaluation in the record and make sure you're talking it over with that patient and the representative. You have to arrange for development and initial implementation of the plan if the physician wants it done. So if the physician says, okay, you've done your evaluation, great. yeah, we know they can't go home, home health's not there. Then the physician said, okay, great, let's put a plan together and get it started on placing them maybe somewhere else. Maybe they go to intermediate care swing bed until they can't go home. But the physician has to request the implementation of the plan. This overall has to be done by somebody who's qualified, an RN, a social worker, somebody else who's qualified, and then have regular re-evaluations of their condition. Perhaps, hey, they improve faster than we expected, and they can go home, and then they can come back in. So we have the daughter, the son, family member, whoever it is can bring them in and do this care, we're good. You also have to review your overall process on a regular basis. That means go back and look at what you've done in the past. Go back for a sampling of records, especially if that patient is readmitted within 30 days. You may have a chart, everybody, you discharged within 30 days, or focusing again, just on those readmitted. What did you miss? What did we miss? What happened at home that we can plan for on the next round? Anything else to prevent that readmission, that's why discharge planning really came around. So we avoid those preventable readmissions. One thing we also have to do is help them if they have to have a post-acute provider, like long-term care, home health, SNF, inpatient rehab, then we have to help them select that provider. We share data on quality and resource measures. We give it to them, let them look it over, and make sure that is relevant to their situation. Where do they wanna go? And what's their goal for care? That's why they put together the Care Compare resource. It's nice, it has doctors, hospitals, nursing homes, whatever it happens to be. And the patient just plugs in where they're located. Is it five to 10 miles away, 25 miles away, wherever it happens to be from their current locations, and it pops up everything. It also has in there the data that these facilities have to report on their quality measures and use of resources. There are two segments to it. One is what they have to report, and then there's also patient comments. They include that. And it's anywhere from one star to five stars on how well they rank. So it's a really great resource if you are assigned that task to work with the patient representative or the patient only, and finding that resource, what's available to them. So when we do discharge them, this is really transfer. This is when you can't provide that service or with the evening swing beds. Send along what that next care provider needs to know, their course of illness, their treatment, what were their goals and treatment plans, their preferences for that patient. You have to do a discharge planning evaluation. It must be in the record, and you use that to do your plan. So again, if you've identified this patient's coming in and they live remotely, maybe not too many people around, or they need additional services, then okay, what's that evaluation entail? Now I have some additional points for you. You can use telehealth to meet these requirements. It doesn't have to just be all your folks. You can use telehealth. You're not required to include in your discharge planning a list of those four areas. Acutes have to, but you as a critical, you don't. Just have to make sure, help them select the appropriate provider. That means you still share the data on quality measures and the cost, efficiency, all that information that they have to report. I would follow Appendix A guidelines closely. If I were you, I have them. I believe I put them in the appendix. If not, I'm gonna talk about them here, but that will help. The only difference is you don't have to include that list in their discharge planning. Just help them select the right one. And you know what's good out there. You know which ones in your community or nearby are the ones you would recommend for what they need. The person, the patient may only know from that list. Oh yeah, I remember that. That's where a friend of mine was. So I'll go there. Maybe that's not the best for what they need. In June of 23, they put out a memo and it talked about hospitals. We really have to have an effective process here. Focus on their goals and treatments. That was the first one they put out there. And include the patient and their caregiver because that caregiver may be the one at home changing those dressings, helping them get up and down off the toilet. We have to discharge or send them where it's applicable and all necessary information. That we knew. Here's what they found. When CMS went back and was doing some of these audits since the new rule went into place, they found some pretty consistent deficiencies and missing information. And that's why they found sending all this information off at that time can help prevent those readmissions. When it is missing, a post-acute care provider may not be prepared for their care, whether it's home in their actual unit. They weren't aware of that stage three decubitus on their rear end when they took them in. So they weren't prepared to take care of them. They also mentioned in that memo, any accrediting organizations, keep an eye on those common issues because they have to make sure that that discharge is still in compliance with CMS conditions of participation. Now you can develop your own policy and procedure on how you're meeting these requirements, but nonetheless, we still have to meet them. So here were the six areas of concern that they found on their surveyors. It was missing or just flat out wrong. Medications, medication and reconciliation. We still have some concerns and issues with that. It's not done or it's not done properly. Durable medical equipment. Wasn't ordered in time. Wasn't available. Didn't get to their location when the patient needed it. We saw this a lot with babies where the patient, the baby had to have those lamps, the billing lamps, once they got home. Patient gets home, no billing lamp. Doesn't show up for hours or even a day. The condition of the skin, whether it's tears or started a decubitus. Communication was lacking between those post-acute care providers and what the patient needed. Also, those patients who happened to have substance use disorders or complex behavioral needs, those weren't communicated. And therefore, the next level was long-term care, nursing home, wherever it was, they weren't ready to take care of that patient. And then the basic preferences and goals for care. No, that's not what I wanted. This is what I wanted for my treatment or for my goals. I've just got some suggestions to do. It's not part of the regs, just this is some suggestions. Always give them that list of those post-acute care providers that participate in Medicare and serve their area. If they're in managed care, make sure that that's in their network so that they can choose the appropriate one. Tell the patient, you get to choose who you want. We just can't limit qualified providers. Now, it may not be the one you would choose and you might have some serious concerns with them, but if the patient flat out said, that's where I wanna go, okay. And you also have to, this is one thing you have to do. You have to disclose a financial interest if you have it in home health or in a skilled nursing hospital. You have to disclose it, that's all. That's all you have to do. I do wanna talk about a potential new rule. It's part of the outpatient prospective payment. Now, this doesn't modify EMTALA. You think, why are you bringing EMTALA? Because there's a couple of others. There is a new condition of participation that will come up and it talks about discharge planning. And right now, it only references acutes. It may go to you, but right now it's only an acute. You have to have written policy and procedures on discharge transfers. And that includes intra-hospital transfers of inpatients. That can be ED to inpatient. If you're going to the same unit, but it's in a different hospital. What they're looking at is the appropriate level of care that is needed. So that's the essential elements. We don't have any tag numbers, nothing on it yet, but it is coming. If your policy and procedures address this already, you're ahead of the game on it. And then just one more quick suggestion that I wanna put out there for you. There were three worksheets CMS had years and years ago, and it was before they put the new hospital improvement rule into place. And it talked about discharge planning, infection prevention and control, and their performance improvement. They never used them in a critical access hospital survey. They're no longer used, period, because now they have the new rules. But if you're looking at a self-assessment, wanna do a gap analysis, these things are great because they spell out everything that they're going to look at. Now, some of the things they put in the final rule, what's in these worksheets, they may not have included in the final rule, but it's always something to keep an eye on. So I've got it for all three areas, infection control, discharge planning, and QATI. The discharge planning one, I believe, is the longer one. So that's the one they were really, that and infection prevention and control, they were really honing in on those two. So we've got a few minutes left. I wanna talk about our final situation. We have a 69-year-old, multiple comorbidities, bad diabetes control, high blood pressure, peripheral vascular disease, and cataract. KR is not a healthy person, needless to say. He doesn't wanna go to extended care upon discharge and no family around. He's this individual, somewhat of a hermit. They do order home health, but once he gets home, he says, nope, you can't let him in, uh-uh. 14 days later, two weeks later, this person's found unresponsive outside by a neighbor who just, every once in a while, they go by and check on him. He was readmitted. He had a CBA that was determined, but he does not survive. He does pass away. Do you think our hospital's gonna be sited? And if so, for what? Now, again, we have to keep in mind, this is discharge planning and preparation for this patient to go home. So what do you think, if anything, might occur in this situation? And do you have any other suggestions what they could have done for KR, if anything? So Lindsay, I see you've got that put up there. I'm not gonna flip through. I do wanna just show them a couple of the other resources in here in the appendix. I have 26 pages. I am not going through all 26 pages, but I've tried to include, for example, here's what that infection control worksheet would look like. Great assessment tool. How would you comply with those standards? And then I have additional links in there for you to make it easy. So with that, Lindsay, are there any additional questions you'd like me to cover? There are a few questions. I'm gonna pull those up here while I have everyone give you a couple more seconds to put in your responses here to that following question. Okay, so this first question asks, should we have a policy for patients who are using medical marijuana, pharmacy and or nursing? Yeah. You can have a policy. This is such a sticky wicket because some states do permit medical marijuana. A lot of the hospitals, I know in my area, Colorado allows medical and recreational marijuana and that's been such a sticking point. They say, well, the state law says it can't do it. And the hospitals say, I understand that. We are federally funded. It is not permitted, period. And that's what they stick to. They stick to that. We do not allow nor will we prescribe medical marijuana in our hospital. So that's where I really have to defer you to your in-house counsel or some legal representative. How does that play in with your hospital and with your state law? Because yeah, some find extremely beneficial, like a coma, chemotherapy, it is beneficial. And if your hospital and your council says they wanna bring in their edibles to help them through this, we're not going to prohibit it. We just won't provide it or we won't order it. So that may be something you can discuss with your in-house counsel that yes, it's beneficial. It helps this patient and improves their outcomes. But the federal law said, eh, eh, that's what you have to work. That's how I would approach it with your counsel. You're not gonna prohibit it. You're just not going to prescribe it nor provide it. Okay, and then another question here is, when you were discussing nursing care plans, should that include information about transfer and discharge? Is that not included in the case manager notes or the interdisciplinary notes? Or do you mean that they need to state, should leave the PAV at time of discharge and this goes into the drivers of health? Is transportation available? Who, how, connecting the dots from there. Discharge planning has to be part of the nursing care plan that discharge planning will be completed by and then who does it? That's fine. We just have to do that discharge planning. I can only go off some of my experience that that's how they did it. They did identify this patient may have issues at home once they're there because of mobility or sight. They're blind, they can't get around and they've had this procedure done. They need someone with them to monitor their meds. And then whoever does the discharge, the coordinator then steps in and takes over on that component, how that's going to be done. But discharge planning has to be considered in the nursing care plan. Patient's going to go home after this procedure. That's the discharge plan and the nursing care plan. And like again, discharge planning coordinator will take over from there and take it. It just has to be in the medical record that discharge planning and the processes was determined is in the medical record somewhere, whoever coordinates it. Perfect. Okay, and then I do see a question. Sandra, I see your question regarding infection control. And Laura, this may be something that we want to take offline. It's a much more specific IP question. So for IC questions, so we can certainly follow up with Sandra. Sandra, if you want to email education at gha.org and I'll be happy to work with Laura to get you some responses back for that. And then I will end this poll and share those results here and it looks like I did have another response here in the chat that says that we have good response with APS referrals to go in and assess the patient when they refuse the need of discharge plans. And we also call the PCP if the patient has one and get them to talk with the patient on the three to five day follow-up visit to express that need as well. I think that's excellent. Sorry, I didn't know if I was mean or not. That's an excellent suggestion. Because again, we have one thing I always, I asked him, is this patient competent? Does a physician or anybody have any concerns with his ability to make a rational decision? And yes, he was, he did. So that was the first question I asked him because he's got diabetes, he's got high blood pressure, he can barely walk and barely see. Was this a person who really had it together? And he did. And so I said, well, here's the one concern. Did we take into account working with him to find a safe alternatives? Overall, they did get cited. They did not. If you did say they got cited, that's okay. That's okay, because you're really thinking out there and that's great. What else could we have done? So I like that suggestion of adult protective services. Somebody telling the PCP, this guy won't let us do a thing with him. We can't arrange anything. He refused to let home health in. What do you want us to do? Now, there is also a point that the patient assumes responsibility for their own care as long as they're competent and he was. And so they had to understand, okay, I don't agree with your choices. I think it's dangerous. Here are the potential outcomes, but that's your decision. And they were smart and they documented a lot on this patient and what they tried to do. And this happened. You know, again, we don't agree with it. We may not like it, but we have to respect their decisions. So yeah, there were citations, but they did step up there, really looked at their district planning process to make sure, did we miss anything? And they did. Unfortunately, the individual died. So thank you, everyone. Good responses. I like how you're starting to think a little bit more outside the box, bringing in some more factors to this. That's wonderful. And with that, thank you, Lindsey. I will follow up with you on that last question. Perfect. And I have asked for those who have any additional questions. I've been communicating with a few folks individually here in the chat, but if you do have any additional questions or maybe just a more, that you feel very specific questions to your organization, you can always send those over to education at gha.org. I did just put that email address there for you in the chat. So you can go ahead and send those over to us today if you'd like. And then I did just now post a final reminder that you will receive an email tomorrow morning if you've been with us for the previous sessions, then hopefully you've seen those emails come through, but it will come from educationnoreplyatzoom.us. So if you don't see it in your inbox tomorrow morning, then possibly just check those junk or quarantine spam folders. And if you'd like to just go back and access the recording of today's session and you don't receive that email for any reason, you can just use the same Zoom link that you use to join us for the live presentation today to also access that recording. And just remember that the link to the recording is available for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented for us today. But I did go ahead and provide that link there for you in the chat now to have as a resource as well. And again, if you have any additional questions at all, don't hesitate to reach out to us at education at gha.org. We'll be happy to work with Laura to get some responses back over to you in a timely manner. Thank you all so much for joining us for part three today. And we look forward to having you back with us next week as we wrap up this series. And thank you so much, Laura, as always, for your time and information. And we hope you all have a wonderful afternoon. Thank you, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

risk management

patient safety

hospital regulations

infection prevention

discharge planning

antibiotic stewardship

infection preventionists

quality improvement

nursing service regulations

medication administration

opioid monitoring

CDC guidelines

patient discharge