PLAN OF CORRECTION. Provider's Plan of Correction (Each corrective action must be cross-referenced to the appropriate deficiency.)

Transcription

1 ID Prefix Tag (X4) R000 R200 Provider's Plan of Correction (Each corrective action must be cross-referenced to the appropriate deficiency.) Submission and implementation of this Plan of Correction does not constitute an admission of or agreement with statements and conclusions set forth on the Statement of Deficiencies. This Plan of Correction is prepared and executed to comply with all applicable regulatory requirements which mandate submission of a Plan of Correction. Definition of governing body will be amended from current definition of Human Services Director to Human Services Board. The Human Services Board is comprised of four individuals who also participate on the County Board. The hospital administrator will submit monthly written reports to the Human Services Board that include the following: Completion Date (X5) 1) Summary of issues related to patient care 2) Summary of issues related to contracted services 3) Summary of issues related to patient complaints, actions taken, and resolution/status 4) Pending or received federal and state regulatory concerns and citations 5) Apprising governing body of issues related to any other pertinent hospital programs 6) Evaluation and approval of medical staff appointments At least annually, the governing body will review and approve the hospital s policies and procedures. Additionally, one member of the Human Services Board will participate on the hospital s QAPI Committee. This individual and the hospital s Quality Assurance Coordinator shall provide written summary reports of QAPI activities to the Human Services Board on a quarterly basis. The QAPI summary report will include QAPI data, subsequent actions, and outcomes. Specific areas will 1

2 include but not be limited to contracted services, infection control, discharge planning and social service assessments, and medical records integrity. Hospital policies related to the governing body will be reviewed and revised by the governing body and the hospital administrator to reflect compliance with (1). Hospital administrator and Human Services Director. R207 Chair of the governing body (Chair of the Human Services Board) and the Human Services Director. The governing body, defined as described below, shall meet at least six times per year. The chair of the governing body shall ensure that minutes of meetings are retained for a period of not less than seven years. Definition of governing body will be amended from current definition of Human Services Director to Human Services Board. The Human Services Board is comprised of four individuals who also participate on the County Board. The hospital administrator will submit monthly written reports to the Human Services Board that include the following: 1) Summary of issues related to patient care 2) Summary of issues related to contracted services 3) Summary of issues related to patient complaints, actions taken, and resolution/status 4) Pending or received federal and state regulatory concerns and citations 5) Apprising governing body of issues related to any other pertinent hospital programs 2

3 6) Evaluation and approval of medical staff appointments At least annually, the governing body will review and approve the hospital s policies and procedures. Additionally, one member of the Human Services Board will participate on the hospital s QAPI Committee. This individual and the hospital s Quality Assurance Coordinator shall provide written summary reports of QAPI activities to the Human Services Board on a quarterly basis. The QAPI summary report will include QAPI data, subsequent actions, and outcomes. Specific areas will include but not be limited to contracted services, infection control, discharge planning and social service assessments, and medical records integrity. Hospital policies related to the governing body will be reviewed and revised by the governing body and the hospital administrator to reflect compliance with (2)(b)1. Hospital administrator and Human Services Director. R233 Chair of the governing body (Chair of the Human Services Board) and the Human Services Director. The governing body is responsible for approving the policy revision outlined below and for ultimately ensuring ongoing compliance with the policy as written. The Social Services Manager is developing a discharge planning protocol that will be incorporated into policy and includes essential items to ensure consistency in the discharge planning process. These items include: 1) Referral sources for post-discharge needs 2) Information and education to provide to the patient 3

4 3) Coordination of care (including appointments) 4) Hand-off communication to community providers to ensure consistency in the discharge planning process 5) Documentation of activities related to discharge planning Social workers and nurses will be trained on the protocol. The Hospital Administrator or designee will conduct random periodic audits of five patient medical records weekly to verify compliance with documentation of discharge planning. R294 Hospital administrator, Social Services Manager, and Director of Nursing. Hospital administrator and the Human Services Director. Hospital Administrator or designee will appoint an Infection Preventionist to oversee the implementation of the Infection Control Program. The infection control program will be implemented across departments and monitored by the Infection Preventionist. The Infection Preventionist in conjunction with the Hospital Administrator will identify and define the roles and responsibilities of other department heads and staff regarding the implementation of the Infection Control program and their roles in responding to an outbreak of communicable disease, an episode of infection, or the threat of a bio-hazard attack. Hospital Administrator will create a job description outlining the role and responsibilities and qualifications of the Infection Preventionist. Hospital Administrator and Infection Preventionist will review and revise all current policies and procedures on Infection Control to ensure compliance with and provide staff training on these policies. 4

5 Hospital Administrator and Infection Preventionist will determine the role and responsibilities of other department heads in the tracking and monitoring of outbreaks of infection including outcomes and the steps taken to contain the outbreak. Infection Preventionist will develop and implement a training program for all staff that will include infection prevention and control practices. Annual training topics will include routes of disease transmission, hand hygiene, sanitation procedures, transmission-based precaution techniques, as well as the required OSHA training. Hospital Administrator and Infection Preventionist will define the elements of the surveillance system including the tracking system, which is responsible for collecting what data across departments, the type and frequency of trending and reporting required by departments. Hospital Administrator and Infection Preventionist Infection Control will be a part of the QAPI program. Reporting of trends related to antibiotic use, acquired infection by both staff and patients, bacteria monitoring by the laboratory, will be presented and analyzed to identify trends, performance issues, and effective practices to reduce the incidence of infection. Reporting will be monthly to the QAPI Committee through June 2015 and then quarterly thereafter. The QAPI Committee will use reported data to plan and implement and evaluate/revise interventions. Infection Preventionist or designee will audit a random sample of 30% of staff training records quarterly for compliance with education and training related to Infection Control. Results of the audit will be submitted to and reviewed by the QAPI Committee to analyze staff compliance with training and to problem solve any issues or trends related to compliance. 5

6 R328 QAPI meetings will be held on an ongoing basis. For the period of March 2015 through June 2015, meetings will be held monthly. Effective July 2015, meetings will be held at least quarterly. Hospital policies related to the QAPI program will be reviewed and revised by the human services director and the hospital administrator to reflect compliance with (4). Specifically, the human services director and hospital administrator shall ensure that the hospital policies address the following: 1) Frequency of QAPI meetings and alternate plan when committee members are unable to attend 2) Mandatory attendance at QAPI meetings by appropriate staff who comprise the QAPI committee 3) Documentation of QAPI activities including actions, goals, and follow up 4) Inclusion of all hospital departments and services including contracted services 5) Method and consistent forms to ensure documentation of multidisciplinary QAPI activities including maintenance of data, development and implementation of action plans, review of effectiveness of QAPI activities, and revision/re-evaluation of implemented actions 6) Use of multiple available data sources to evaluate patient care quality including medical records, hospital information systems, peer review organization data, and third party payer information 7) Selection of appropriate individuals who comprise the QAPI committee including representation from the governing board, medical staff, contracted service providers, hospital administration, and all departments 6

7 8) Inclusion of a member of the governing body (one member from the Human Services Board) on the QAPI committee 9) Process for intervention by governing body if hospital fails to comply with QAPI policies and requirements R329 The QAPI committee will receive training on the revised policies. The governing board will receive training on QAPI requirements. Policies will be implemented by the QAPI Committee via their initial monthly and then quarterly meetings. The Governing Board is responsible to ensure implementation of revised policies. Hospital Administrator and Human Services Director. Chair of the governing body (Chair of the Human Services Board) and the Human Services Director will monitor through the meeting minutes of the QAPI Committee and Governing Body. Further monitoring will occur via QAPI Committee participation by one assigned member of the Governing Board. Hospital policies related to the QAPI program will be reviewed and revised by the Human Services Director and the Hospital Administrator to reflect compliance with (5)(a). Specifically, the Human Services Director and Hospital Administrator shall ensure that the hospital policies address the following: 1) Process to ensure that QAPI committee uses data to initiate changes that improve quality of care and promote more efficient use of facilities and services 2) Method and consistent forms to ensure documentation of multidisciplinary QAPI activities including how data is used to initiate changes to improve quality of care and efficiency 3) Process to ensure that QAPI committee emphasizes identification and analysis of patterns of patient care and recommended changes 7

8 to maintain consistently high quality patient care and effective, efficient use of services 4) Method and consistent forms to ensure documentation of multidisciplinary QAPI activities including how committee identifies and analyzes patterns of patient care and recommended changes to maintain consistently high quality patient care and efficiency 5) Procedure to conduct and document root cause analysis for patient care incidents/adverse events/sentinel events and how RCA findings are used to plan, implement, and evaluate changes to prevent future similar occurrences The QAPI committee will receive training on the revised policies. The governing board will receive training on QAPI requirements. Hospital Administrator and Human Services Director. R332 Chair of the governing body (Chair of the Human Services Board) and the Human Services Director. Definition of governing body will be amended from current definition of Human Services Director to Human Services Board. The Human Services Board is comprised of four individuals who also participate on the County Board. The hospital administrator will submit monthly written reports to the Human Services Board that include the following: 1) Summary of issues related to patient care 2) Summary of issues related to contracted services 3) Summary of issues related to patient complaints, actions taken, and 8

9 resolution/status 4) Pending or received federal and state regulatory concerns and citations At least annually, the governing body will review and approve the hospital s policies and procedures. At least annually, the governing body in conjunction with clinical and administrative staff will evaluate the hospital s quality assurance program. One member of the Human Services Board will participate on the hospital s QAPI Committee. This individual and the hospital s Quality Assurance Coordinator shall provide written summary reports of QAPI activities to the Human Services Board on a quarterly basis. The QAPI summary report will include QAPI data, subsequent actions, and outcomes. Specific areas will include but not be limited to contracted services, infection control, discharge planning and social service assessments, and medical records integrity. Hospital policies related to program evaluation will be reviewed and revised by the governing body and the hospital administrator to reflect compliance with (6). Hospital administrator, director of nursing, and Human Services Director. R431 Chair of the governing body (Chair of the Human Services Board) and the Human Services Director. The standardized treatment plan content has been deleted from the hospital s treatment plan templates. Current patients treatment plans have been revised to reflect specific, individualized problems/diagnoses, goals, interventions, and 9

10 treatment modalities. Hospital policies related to patient treatment plans will be reviewed and revised by the Hospital Administrator and director of nursing to reflect compliance with (6)(c). The governing body will provide final approval on revised policies prior to implementation. Specifically, the Hospital Administrator and director of nursing shall ensure that the hospital policies address the following: 1) Initiation of the nursing care plan upon admission 2) Input by social services, the physician, and other relevant disciplines within 24 hours with completion of the multidisciplinary coordinated care plan within 48 hours 3) Inclusion of physiological and psychosocial factors and method by which the treatment plan is updated to reflect changes in the patient s status 4) Discharge planning as a goal for each patient 5) Inclusion of short term and long term goals that are measurable and achievable and specific to the patient s needs and desired outcomes 6) Inclusion of interventions that are patient-specific and developed in collaboration with the multidisciplinary team including at minimum the physician, social services, and nursing 7) Process by which documentation of goal attainment or revision occurs to reflect progress or changes in the patient s status and treatment needs 8) Documentation of review of treatment plan at least every seven days The treatment plan team will receive training on the revised policies. The Hospital Administrator or designee will conduct random periodic audits of 10

11 R456 five patient medical records weekly to verify compliance with documentation of discharge planning. Hospital Administrator and Director of Nursing. Hospital Administrator will monitor overall compliance and EMR Coordinator will complete audits of 5 treatment records per week for compliance for the first 90 days of transition and then 30% quarterly thereafter. EMR Coordinator under the direction of the Hospital Administrator has developed a new treatment plan that has removed the ability for the staff to delete any part of the treatment plan, includes tracking of who is entering information in the treatment plan, and added a status button. The new treatment plan is scheduled to go live on February 20, The interim approach includes staff updating the treatment plan by documenting goal met or issue resolved following the problem statements rather than deleting the area of concern from the treatment plan. Director of Nursing and EMR Coordinator to provide staff training on the new treatment plan prior to go live date of February 20, Hospital Administrator and EMR Coordinator and Director of Nursing Hospital Administrator will monitor overall compliance and EMR Coordinator will complete audits of 5 treatment records per week for compliance for the first 90 days of transition and then 30% quarterly thereafter. 11

12 R462 Hospital Administrator or designee will review and revise the facility policy and procedure Psychiatric Clients with Medical Conditions to ensure compliance with (c)(4)(i)(B) and provide training to RNs and medical team regarding policy and procedure and any revisions. Hospital Administrator, Health Information Manager EMR Coordinator or designee will audit at a minimum of 30% of all new admissions to ensure that H&P is completed or scheduled according to policy and procedure and follow up with the Advanced Practice Nurse Practitioner (APNP) or RN as necessary to schedule the H&P. EMR Coordinator or designee will track compliance and submit monthly to the QAPI Committee through June 2015 and then quarterly thereafter. R510 Hospital Administrator or designee will review the Pharmacy contract and ensure that all elements of the contract are being met by the current pharmacy. The Hospital Administrator or designee will maintain at minimum weekly contact with the pharmacy consultant to ensure that pharmacy is actively participating in all required committees and completing all required monitoring including serving on the QAPI Committee, participating in the Medication Advisory meeting, completing weekly counts, and completing a Monthly Pharmacy Review. Consulting pharmacist will ensure that all reports are submitted in a timely manner including the submission of the weekly medication reconciliation count the day the count is completed. Consulting pharmacist will provide the facility with a monthly Pharmacy Review report. Pharmacy to provide facility with updated and revised Policy and Procedure manual. Pharmacy to establish contract with Med Call and create a Policy & Procedure in conjunction with the Hospital Administrator and Director of Nursing regarding the utilization of the Med Call Pharmacist to provide pharmacy services after 11 12

13 pm including the review of all medication orders for new admits within a 2 hour timeframe. Consulting pharmacy in conjunction with the Hospital Administrator or designee will review the contingency system week of February 8 th to ensure the system is accurate. Consulting pharmacist will provide training to nurses on February 12 th, 2015, regarding the revised policy and procedure, proper documentation and use of forms. Hospital Administrator or designee will review with nurse staff the policy regarding Medication Administration including the use of incident reports to document medication given outside of the prescribed timeframe. Hospital Administrator or designee will provide the Governing Board with an updated and revised proposal related to the purchase and implementation of an Automated Medication Dispensing System for medication dispensing. Pharmacy agrees to share in the cost of the purchase and implementation of the system. Hospital Administrator, Consulting Pharmacist Hospital Administrator or designee will maintain minutes of 1:1 meetings with consulting pharmacist and submit a monthly summary to the QAPI Committee regarding the status and effectiveness of pharmacy services. Hospital Administrator or designee will conduct random and routine audits of the Weekly Count Reports to ensure completion, timeliness of submission to the facility, as well as completion of any necessary follow up indicated by the report. QAPI Committee to review the monthly reports submitted by the pharmacy and make recommendations based on the information within the reports. Director of Nursing or designee to track all medication related incident reports 13

14 R529 and submit a report monthly to the QAPI Committee for review and recommendations based on trends. Hospital Administrator or designee will ensure the completion of an incident report form for any pharmacy issues that impact patients such as medication administered outside timeframes due to medication not available in a timely manner. Incident reports will be reviewed and monitored weekly by the Hospital Administrator and Director of Nursing. Critical incidents will be reviewed and monitored by the Hospital Administrator and Director of Nursing at the time of the incident or as quickly as reasonably possible. Incident report data will be reviewed in aggregate by the QAPI Committee and included in minutes and reports to the Governing Body. Consulting pharmacist will provide monthly reports to the QAPI Committee regarding utilization of contingency, Med Call system, dispensing of medication to treat infections, and other specialized reports to be determined by the Hospital Administrator or designee. Hospital Administrator or designee with the assistance of the consulting pharmacist will review and revise the Drug Formulary policy and procedure and provide to the medical staff for signature and approval. Specifically, the policy will address creation of a drug formulary which when implemented will be incorporated into the new policy. The policy will be reviewed and formally approved by the medical staff. Hospital Administrator, Consulting Pharmacist Hospital Administrator or designee will provide the revised policy and procedure to medical staff for review, approval, and signature. Hospital Administrator or designee will ensure that the facility has a revised and updated pharmacy policy 14

15 R838 and procedure manual. Hospital Administrator or designee will review and revise policy and procedure SOC-1308 Social Services Assessment to ensure compliance with (2)(d). Hospital Administrator or designee to provide training to Social Service staff on the policy and procedure. Social Service Assessment to be converted from paper format to electronic format with go live date of 2/6/2015. All Social Work staff to receive training on the utilization of the new Social Service Assessment on 2/5/2015. Hospital Administrator, Social Service Manager R841 Social Service Manager or designee will audit 5 charts per week for compliance with the policy and procedure. The Social Service Manager or designee will track compliance to determine trends and follow up with Social Service staff to ensure compliance. Hospital Administrator and Social Service Manager to evaluate current level of Social Work coverage and implement a schedule to provide Social Services daily effective 01/31/2015. Social Service Manager, Director of Nursing, and COTA to develop and implement a group programming list and binder materials for quality and meaningful program/therapeutic options. Group programming to be provided seven days per week to be facilitated by Social Work, nursing, COTA, and CNAs. Groups will be therapeutic and reflective of the current needs of the population being served. Social Services Manager and Director of Nursing or designee to provide CNAs and nursing staff training on group dynamics and how to run therapeutic groups. Training will be provided at minimum as part of new hire orientation and a training refresher provided at least annually. Hospital Administrator, Director of Nursing, and Social Service Manager to review and revise policy and procedure Multidisciplinary Client Education NPC-129, Multidisciplinary Collaboration NPC-128 to ensure compliance with (2)(e)3. Social Service Manager, COTA, and Director of Nursing to review 15

16 and revise form Group Flow Chart and provide training to C.N.A.s, nursing staff, and Social Work staff regarding documentation and tracking of group participation. Hospital Administrator, Social Service Manager R847 Social Service Manager or designee to audit 5 charts per week for compliance with documentation of participation in group programming and provision of 1:1 services according to the treatment plan. Tracking and trends to be provided monthly report to the QAPI Committee through June 2015 and then quarterly thereafter for review and action planning as necessary. Plan/action plan implemented to prevent recurrence: Social service staffing has been revised to include a social worker on site on weekends (Saturdays and Sundays for a total of fifteen hours). Additionally, an on call protocol is being established for social services to triage discharge planning calls/issues on evenings and weekends. Nursing staff is being trained as backup for discharges on weekends and evenings when social service staff is not on site. The QAPI committee will review readmission data for psychiatric hospitals to benchmark the hospital s readmission rate against similar size hospitals with comparable patient populations in Wisconsin and regionally. Data will be used to identify additional potential areas for improvement. Interventions will be developed and implemented and evaluated as indicated. Baseline readmission rate data will be analyzed with future readmission rates to evaluate effectiveness of social service staffing changes. The Hospital Administrator or designee will conduct random periodic audits of five patient medical records weekly to verify compliance with documentation of discharge planning. 16

17 Hospital administrator, social service manager, and director of nursing. Hospital administrator and the Human Services Director. The individual signing the first page of the SOD (CMS-2567) is indicating their approval of the plan of correction being submitted on this form. 17