The healthcare industry continues to experience the push toward shorter hospital length of stays, increased outpatient services, and ongoing staffing challenges. Centers for Medicare & Medicaid Services (CMS) surveyors are taking note. Recent CMS surveyor activity in the state of Kentucky has focused on staffing levels in various departments of the hospital.

Based on Kentucky data from CMS for 2015, the highest volume of citations fell into three main categories:

  • Patient rights (14)
  • Nursing services (13)
  • Emergency Medical Treatment & Active Labor Act (EMTALA) compliance (10)

Many of these citations included a component relative to staffing levels and/or use of contracted employees which contributed to the incidents that resulted in the citations. Healthcare providers should consider the areas below as you monitor compliance with CMS guidelines and as you develop your annual risk assessment. When hospitals begin a risk assessment for the targeted areas, the staffing levels and methodology should be included.

The risk assessment process for each of these items will differ slightly, due to differing requirements. The items that are consistent for each area include:

  • Policies and Procedures
    • When was the last time the policies and procedures were matched up with the conditions of participation and CMS and The Joint Commission (TJC) guidelines?
    • Do the policies and procedures align with actual day-to-day operational functions?
    • Are the policies and procedures reviewed at least annually?
  • Training and Education
    • When did formal training on policies and procedures last occur?
    • Who was included in the training program? Did it include contracted staff?
    • How frequently is the training updated? When policies and procedures are updated, are staff educated on what changed and how it impacts their jobs (tailored to the audience)?
  • Monitoring
    • Have procedures for monitoring performance relative to policies and procedures been developed?
    • If developed, what types of issues has the monitoring uncovered?
    • How were deficiencies handled? Were action plans implemented?
    • Are deficiencies identified in the monitoring being reported to the appropriate levels of management?

Risk specific considerations may include the following:

  • Patient Rights
    • Are nursing staff fully aware of all the elements within the patient rights?
    • Have nursing staff been trained on how to communicate the rights to the patients they are working with?
    • Have staff been trained on what constitutes a violation of a patient right and to whom and when those violations must be reported?
    • If a patient or family member reports a concern to staff, do staff understand when to consider the concern a grievance? Do they know the process for providing feedback to the patient’s family member?
  • Nursing Services
    • Are staffing levels being maintained at an appropriate level based on the census?
    • Does the staffing level include the appropriate mix of RNs, LPNS, and CNAs?
    • Do RNs have the appropriate balance between direct patient care and supervision of the LPNs and CNAs as required?
    • How is compliance with the patient nursing care plan monitored, with deviations reported to the attending physician?
    • Have evidence-based practices been implemented to address key patient safety areas such as CAUTI, CLABSI, falls, restraints/seclusions, pressure ulcers, etc.?
    • If evidence based practices have not been implemented, has the facility looked at consistency of practices between units?
  • Emergency Medical Treatment & Active Labor Act (EMTALA)
    • Has all staff, including contracted staff, been educated on requirements under EMTALA?
    • Has the education been tailored to the roles of the individuals?
    • When are all patients logged into the central log? Is the process designed to log them upon presentation to the ED, even if the patient has not been triaged or received an MSE?
    • Has required signage been posted in all locations where patients may access emergency services (including ambulance bays)?
    • When does the hospital ask for insurance information from patients presenting to the ED? Note that it should not occur until after the patient has received a medical screening exam and stabilizing treatment.
    • What specialties does the hospital advertise? For those advertised, is there a specialist on-call to the emergency department at all times?
    • Has the hospital documented their transfer policy?
    • Does the hospital conduct monitoring of transfer documentation to verify it aligns to the policy and CMS requirements specific to EMTALA?

The above list is not intended to be all-inclusive. Each facility may have additional risks that are unique to their location and size. Management should customize the risk assessment to meet their needs based on past surveyor reviews, existing practices and results of internal audits. Consider including Quality Managers and Compliance in risk assessments to obtain best results.

Contact your Dean Dorton advisor or a member of our Healthcare Industry Team for more information.

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