Types of Surveys. Survey Process Complaint Investigations. SURVEY PROCESS: Survey Team. The Survey Process. State Licensure Surveys

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1 Types of Surveys The Survey Process Stefanie Mozgai, BA, RN, CPM Director State Licensure Surveys Federal Recertification Surveys Validation Surveys Complaint Investigations SURVEY PROCESS: Survey Team Survey Process Complaint Investigations Two nurse surveyors One pharmacist One sanitarian One building inspector One dietician Usually one surveyor for one day Focuses on the specific complaint(s) issue as opposed to a broad overview Documentation requested is similar to standard survey process May result in a full Federal survey or State survey if significant issues are identified 1

2 Hospitals in New Jersey ASCs in New Jersey Hospitals are licensed in accordance with N.J.A.C. 8:43 G ASCs can be licensed in accordance with N.J.A.C. 8:43 A Medicare Certified Hospitals must be in compliance with the Federal Conditions of Participation outlined in 42 CFR 482 Medicare Certified ASCs must be in compliance with the Federal Conditions of Coverage outlined in 42 CFR Nursing Homes in New Jersey Nursing Homes are licensed in accordance with N.J.A.C. 8:39 Licensed Facilities in NJ All licensed healthcare facilities must be in compliance with N.J.A.C. 8:43 E Medicare Certified Nursing Homes must be in compliance with the Federal regulations outlined in 42 CFR 483 2

3 Pharmacy - ASCs Pharmacy - ASCs The facility s P&Ps for the administration, control, and storage of medications shall include: The control of drugs subject to the CDS Act including: provision for a verifiable record system for controlled drugs; P&P to be followed in the event that inventories of controlled drugs cannot be verified or drugs are lost, contaminated, unintentionally wasted, or destroyed; procedures for the intentional wasting of controlled drugs including signature of a second person who shall witness the disposition. 8:43A 9.3 (b)(7) (a) A declining inventory of all drugs in Schedules I through V of the CDS Acts and amendments thereto shall be made at the termination of each shift and shall be retained wherever these drugs are maintained. 8:43A 9.5(d) (b)(2)(ii) Pharmacy - Hospitals Pharmacy - Hospitals The pharmacy and therapeutics committee, or its equivalent, shall review, approve, and ensure implementation of P&Ps addressing storage and distribution of drugs including accountability of controlled substances. 8:43 G 23.2 (a) (5) (a)(3) The pharmacy service shall inspect at least once every two months all patient care areas in the hospital, and at least once every three months all other areas of the hospital where drugs are intended for administration to patients are dispensed, administered, or stored. The pharmacy service shall maintain a record of the inspections. Identified problems shall be addressed. 8:43G (c) 3

4 Pharmacy Nursing Homes Quality Assurance - ASCs The pharmacy and therapeutics committee shall establish and enforce procedures for the inventory of controlled substances. 8: (k) Controlled substances shall be stored, and records shall be maintained, in accordance with the CDS Act. 8: (c) F425 F 431 There shall be a multi-disciplinary committee responsible for the direction of the QA program. The committee shall include at least representation from the medical staff, nursing staff and administration. The committee shall establish a mechanism to include participation of all disciplines in the identification of areas for review that affect patient care throughout the facility. 8:43A 18.1 (b) (c) Quality Assurance - Hospitals Quality Assurance - Hospitals There shall be a program of continuous quality improvement for the pharmacy service that is integrated into the hospital continuous quality improvement program and includes regularly collecting and analyzing data to help identify healthservice problems and their extent, and recommending, implementing, and monitoring corrective actions on the basis of these data. 8:43 G (a) The continuous quality improvement program shall identify and establish indicators of quality care specific to the hospital that are monitored and evaluated and encompass pharmacy and therapeutics function. 8:43G 27.5 (d) (5)

5 Quality Assessment Nursing Homes The quality assessment and/or quality improvement program shall identify problems in the care and services provided to the residents and shall include the audit of medical records. The quality assessment and/or quality improvement program shall monitor the performance of each service. 8: (a) & (b) F520 Governing Body - ASCs The results of the QA program shall be submitted to the Governing Authority at least annually and shall include at least deficiencies found and recommendations for correction or improvements. Deficiencies which jeopardize patient safety shall be reported to the Governing Authority immediately. 8:43A 18.2 (g) (e) Governing Body Hospitals Reportable Events The Governing Authority of the hospital shall have ultimate responsibility for the continuous quality improvement program. 8:43G 27.1(a) In accordance with 8:43E (a)-(d) all licensed Acute Care facilities must report to NJDOH within 3 hours after the discovery of the event: Physical Plant and operational interruptions such as: Loss of heat or air conditioning Loss or significant reduction of water, electrical power, or any other essential utilities necessary to operate the facility Fires, disasters, or accidents that result in injury or evacuation of patients or visitors 5

6 Reportable Events Plans of Correction All licensed Acute Care facilities must report to NJDOH within 3 hours after the discovery of the event: Potentially criminal events A labor stoppage or staffing shortage sufficient to require the temporary closure of a service Notice of a potential strike that a facility receives from a bargaining unit State PoCs are due ten business days from receipt of the deficiency report Federal PoCs are due ten calendar days from receipt of the deficiency report There must be one PoC for each report. State and Federal cannot be combined Plans of Correction The Survey Process THANK YOU 6