Agency for Health Care Administration

Transcription

1 Page 1 of 399 ST - H INITIAL COMMENTS Title INITIAL COMMENTS Statute or Rule ST - H Child Abuse & Neglect - Policy Adoption Title Child Abuse & Neglect - Policy Adoption Statute or Rule 59A-3.280(1) FAC; (1) FS 59A (1) Every hospital admitting or treating shall adopt and incorporate a policy that requires every staff member to report any case of actual or suspected child abuse or neglect pursuant to Chapter 395, F.S Each licensed facility shall adopt a protocol that, at a minimum, requires the facility to: (1) Incorporate a facility policy that every staff member has an affirmative duty to report, pursuant to chapter 39, any actual or suspected case of child abuse, abandonment, or neglect;... 59A-3.280(1), FAC (1), FS - Request the Child Abuse and Neglect Policy. - Review that the policy mandates that every staff member report actual or suspected child abuse or neglect to the Department of Children and Family Services Abuse Registry. - Interview staff to determine how this policy of mandated reporting is distributed to staff. - Interview staff to ascertain their knowledge of when, how, where, and what to report to DCF ( ).

2 Page 2 of 399 ST - H Child Abuse & Neglect - Report A/N to DCF Title Child Abuse & Neglect - Report A/N to DCF Statute or Rule 59A-3.280(1)(a) FAC (a) Each report of actual or suspected child abuse or neglect shall be made immediately to the Department of Children and Family Services' Abuse Registry, statewide toll free number or to the local office of the Department of Children and Family Services responsible for investigating such reports. - Request any cases of alleged child abuse/neglect from the Risk Manager. - Review for immediate and appropriate reporting. ST - H Child Abuse & Neglect -Report To Med Examiner Title Child Abuse & Neglect -Report To Med Examiner Statute or Rule 59A-3.280(1)(b) FAC (b) Any person required to report suspected child abuse or neglect, who has reasonable cause to suspect that a child died as a result of abuse or neglect, shall report his suspicion to the appropriate medical examiner. - Request and review records concerning suspected and actual child abuse or neglect resulting in death. - Verify report of such suspicions to Medical Examiner. - Review Child Abuse & Neglect Policy for the specific reporting of a death to the local/appropriate medical examiner. - Review policy for clarity as to where to report. - Interview staff for knowledge of this policy.

3 Page 3 of 399 ST - H Child Abuse & Neglect - Physician Liaison Title Child Abuse & Neglect - Physician Liaison Statute or Rule 59A-3.280(2) FAC; (2) FS 59A-3.280(2) Physician Liaison. Each hospital admitting or treating children shall designate, at the request of the Department of Children and Family Services, a staff physician to act as a liaison between the hospital, the child protective investigator and the child protection team. 59A-3.280(2), FAC (2), FS - Review documentation for a protocol re: appointment of a physician liaison. - Review documentation to ensure that, in instances in which DCF has so requested, the facility has actually appointed a qualified individual to serve as the physician liaison. (interview physician as appropriate) Each licensed facility shall adopt a protocol that, at a minimum, requires the facility to: (2) In any case involving suspected child abuse, abandonment, or neglect, designate, at the request of the department, a staff physician to act as a liaison between the hospital and the Department of Children and Family Services office which is investigating the suspected abuse, abandonment, or neglect, and the child protection team, as defined in s , when the case is referred to such a team. ST - H Child Abuse & Neglect - Policy Reporting Title Child Abuse & Neglect - Policy Reporting Statute or Rule 59A-3.280(3) FAC (3) Child Abuse and Neglect Policy Reporting. Each hospital admitting or treating children shall formulate a child abuse and -Verify the submission of the facility Child Abuse and Neglect Policy to the Department of Children and Family Services, Office of Family Safety.

4 Page 4 of 399 neglect policy and shall submit a copy of this policy to the Department of Children and Family Services, Office of Family Safety, 1317 Winewood Boulevard, Tallahassee, Florida ST - H Child Abuse & Neglect - Copy of Policy Sent Title Child Abuse & Neglect - Copy of Policy Sent Statute or Rule 59A-3.280(4) FAC; (2) FS 59A-3.280(4) Remedies. Failure to comply with these rules will result in a fine being imposed in accordance with the provisions of s , F.S (2)... Each general hospital and appropriate specialty hospital shall comply with the provisions of this section and shall notify the agency and the department of its compliance by sending a copy of its policy to the agency and the department as required by rule. The failure by a general hospital or appropriate specialty hospital to comply shall be punished by a fine not exceeding $1,000, to be fixed, imposed, and collected by the agency. Each day in violation is considered a separate offense. 59A-3.280(4), FAC , FS - Failure to comply with these rules could result in an immediate per instance, per day fine. - Surveyor should report to their Field Office Manager. - Field Office Management should review violation with AHCA General Counsel. ST - H COMPREHENSIVE EMERGENCY MANAGEMENT PLAN Title COMPREHENSIVE EMERGENCY MANAGEMENT PLAN Statute or Rule 59A-3.078(1)-(5) FAC; (1)(c) FS 59A A-3.078(1)-(5), FAC

5 Page 5 of 399 (1) Each hospital shall develop and adopt a written comprehensive emergency management plan for emergency care during an internal or external disaster or an emergency, which is reviewed and updated annually. (2) The emergency management plan shall be developed in conjunction with other agencies and providers of health care services within the local community pursuant to Section (2), F.S., and in accordance with the "Emergency Management Planning Criteria for Hospitals," AHCA Form September 94, which is incorporated by reference. At a minimum, the plan shall include: (a) Provisions for internal and external disasters and emergencies, pursuant to Section , F.S.; (b) A description of the hospital's role in community wide emergency management plans; (c) Information about how the hospital plans to implement specific procedures outlined in the hospital's emergency management plan; (d) Precautionary measures, including voluntary cessation of hospital admissions, to be taken by the hospital in preparation and response to warnings of inclement weather, or other potential emergency conditions; (e) Provisions for the management of patients, including the discharge of all patients that meet discharge requirements, in the event of an evacuation order, at the direction of the hospital administrator, or when a determination is made by the agency that the condition of the facility or its support services is sufficient to render it a hazard to the health and safety of patients and staff, pursuant to Chapter 59A-3, F.A.C. Such provisions shall address moving patients within the hospital and relocating patients outside the hospital, including the roles and responsibilities of the physician and the hospital in the decision to move or relocate patients whose life or health is threatened; (f) Education and training of personnel in carrying out their (1)(c), FS - Verify there is a plan approved by the county emergency management agency on file in the facility. PROBE: - Where is the plan located? Is it immediately accessible by hospital staff? [59A (5)] - Has the hospital tested the implementation of the EMP semiannually or in accordance with The Joint Commission guidelines? [59A (4)] - Ask staff what their responsibilities are in implementing the plan.

6 Page 6 of 399 responsibilities in accordance with the adopted plan; (g) A provision for coordinating with other hospitals that would receive relocated patients; (h) Provisions for the management of staff, including the distribution and assignment of responsibilities and functions, and the assignment of staff to accompany those patients located at off-site locations; (i) Provisions for the individual identification of patients, including the transfer of patient records; (j) Provisions to ensure that a verification check will be made to ensure relocated patients arrive at designated hospitals; (k) Provisions to ensure that medication needs will be reviewed and advance medication for relocated patients will be forwarded to respective hospitals, when permitted by existing supplies, and state and federal law; (l) Provisions for essential care and services for patients who may be relocated to the facility during a disaster or an emergency, including staffing, supplies and identification of patients; (m) Provisions for contacting relatives and necessary persons advising them of patient location changes. A procedure must also be established for responding to inquiries from patient families and the press; (n) Provisions for the management of supplies, communications, power, emergency equipment, security, and the transfer of records; (o) Provisions for coordination with designated agencies including the Red Cross and the county emergency management office; and (p) Plans for the recovery phase of the operation, to be carried out as soon as possible. (3) The plan, including the "Emergency Management Planning Criteria for Hospitals," shall be submitted annually to the county emergency management agency for review and

7 Page 7 of 399 approval.... (a)... If the county emergency management agency advises the facility of necessary revisions to the plan, those revisions shall be made and the plan resubmitted to the county office of emergency management within 30 days of notification by the county emergency management agency.... (4) The hospital shall test the implementation of the emergency management plan semiannually, either in response to a disaster or an emergency or in a planned drill, and shall evaluate and document the hospital's performance to the hospital's safety committee. As an alternative, the hospital may test its plan with the frequency specified by the Joint Commission. (5) The emergency management plan shall be located for immediate access by hospital staff. (6) In the event a disaster or emergency conditions have been declared by the local emergency management authority, and the hospital does not evacuate the premises, a facility may provide emergency accommodations above the licensed capacity for patients. However, the following conditions must be met: (a) The facility must report being over capacity and the conditions causing it to the agency area office within 48 hours or as soon as practical. As an alternative, the facility may report to the agency central office, Hospital and Outpatient Services Section, at (850) ; (b) Life safety cannot be jeopardized for any individual; (c) The essential needs of patients must be met; and (d) The facility must be staffed to meet the essential needs of patients. (7) If the hospital will be over capacity after the declared disaster or emergency situation ends, the agency shall approve the over capacity situation on a case-by-case basis using the following criteria: (a) Life safety cannot be jeopardized for any individual;

8 Page 8 of 399 (b) The essential needs of patients must be met; and (c) The facility must be staffed to meet the essential needs of patients. (8) If a facility evacuates during or after a disaster or an emergency situation, the facility shall not be reoccupied until a determination is made by the hospital administrator that the facility can meet the needs of the patients. (9) A facility with significant structural damage shall relocate patients until approval is received from the agency ' s Office of Plans and Construction that the facility can be safely reoccupied, pursuant to Rules 59A-3.077, 59A and 59A-3.081, F.A.C. (10) A facility that must evacuate the premises due to a disaster or emergency conditions shall report the evacuation to the agency area office within 48 hours or as soon as practical. The administrator or designee is responsible for knowing the location of all patients until the patient has been discharged from the facility. The names and location of patients relocated shall be provided to the local emergency management authority or it ' s designee having responsibility for tracking the population at large. The licensee shall inform the agency area office of a contact person who will be available 24 hours a day, seven days a week, until the facility is reoccupied Rules and enforcement.- (1) The agency shall adopt rules pursuant to ss (1) and to implement the provisions of this part, which shall include reasonable and fair minimum standards for ensuring that: (c) A comprehensive emergency management plan is prepared and updated annually. Such standards must be included in the rules adopted by the agency after consulting with the Division of Emergency Management. At a minimum, the rules must provide for plan components that address emergency evacuation transportation; adequate sheltering arrangements;

9 Page 9 of 399 postdisaster activities, including emergency power, food, and water; postdisaster transportation; supplies; staffing; emergency equipment; individual identification of residents and transfer of records, and responding to family inquiries. The comprehensive emergency management plan is subject to review and approval by the local emergency management agency. During its review, the local emergency management agency shall ensure that the following agencies, at a minimum, are given the opportunity to review the plan: the Department of Elderly Affairs, the Department of Health, the Agency for Health Care Administration, and the Division of Emergency Management. Also, appropriate volunteer organizations must be given the opportunity to review the plan. The local emergency management agency shall complete its review within 60 days and either approve the plan or advise the facility of necessary revisions. ST - H LICENSURE PROCEDURE (IRTP) Title LICENSURE PROCEDURE (IRTP) Statute or Rule 59A FAC Programs desiring licensure under this rule shall follow the procedure as described in Rule 59A-3.066, F.A.C., and shall comply with the provisions of Rules 59A through 59A-3.312, F.A.C., which establishes the minimum standards for the voluntary licensure as a special hospital of The Joint Commission (TJC) accredited Intensive Residential Treatment Programs for Children and Adolescents. These rules emphasize the programmatic requirements designed to meet the needs of the patient in a safe therapeutic environment and are intended to be used in licensing intensive residential treatment facilities for children and adolescents as specialty hospitals pursuant to Section (16), F.S. Unless Interview Administrator to verify if the hospital is accredited through The Joint Commission (TJC). If the Administrator confirms the TJC accreditation, request to see TJC certificate. NOTE: Refer to Tags #H0251 through #H0297 when surveying this type facility.

10 Page 10 of 399 otherwise specified, Rules 59A through 59A-3.312, F.A.C., supersede the requirements of Rules 59A through 59A-3.312, F.A.C., for the purpose of licensing intensive treatment facilities for children and adolescents as specialty hospitals. ST - H Inf Disease Exposure Rpt - Notification Title Inf Disease Exposure Rpt - Notification Statute or Rule 59A FAC; FS 59A The licensed facility shall establish a written policy and procedure for notifying EMT's, paramedics or their emergency medical transportation service employer, or other persons known to have been exposed to a patient with a selected infectious disease while transporting or treating an ill or injured patient to that licensed facility. Selected infectious diseases are defined as Acquired Immunodeficiency Syndrome; anthrax; syphilis in an infectious stage; diphtheria; disseminated vaccinia; Hansen's disease; hepatitis A; hepatitis B; hepatitis non A, non B, Legionnaire's disease; malaria; measles; meningococcal meningitis; plague; poliomyelitis, psittacosis; pulmonary tuberculosis; Q fever; rabies; rubella; typhoid fever. Each licensed facility shall designate a person or persons to notify the EMT's, paramedics or their emergency medical transportation service employer or other persons known to have been exposed to a patient with a selected infectious disease. 59A-3.251, FAC , FS - Review the facility Infectious Diseases Policies and Procedures to determine if the facility has a written policy and procedure for notifying health care workers, transportation personnel or other persons known to have been in direct contact with a patient who has a confirmed infectious disease. - Does the policy identify selected infectious diseases as defined in the regulation which require notification? - Does the policy specify who must be notified? - Interview the infection control officer(s) to determine who is responsible for this notification. - Is there documentation that this notification process is in place and has been implemented when required? Infectious diseases; notification.-notwithstanding the provisions in s , if, while treating or transporting an ill or injured patient to a licensed facility, an emergency medical technician, paramedic, or other person comes into direct contact with the patient who is subsequently diagnosed

11 Page 11 of 399 as having an infectious disease, it shall be the duty of the licensed facility receiving the patient to notify the emergency medical technician, paramedic, or his or her emergency medical transportation service employer, or other person of the individual's exposure to the patient within 48 hours, or sooner, of confirmation of the patient's diagnosis and to advise him or her of the appropriate treatment, if any. Notification made pursuant to this section shall be done in a manner which will protect the confidentiality of such patient information and shall not include any patient's name. ST - H Inf Disease Exposure Rpt - Notify 48 hr Title Inf Disease Exposure Rpt - Notify 48 hr Statute or Rule 59A-3.251(1) FAC 59A The licensed facility shall establish a written policy and procedure for notifying EMT's, paramedics or their emergency medical transportation service employer, or other persons known to have been exposed to a patient with a selected infectious disease... These procedures shall include at a minimum the following: 59A-3.251(1), FAC , FS - Is there documentation that either verbal or written notification of exposure to a selected infectious disease was provided within 48 hours of a confirmed diagnosis? - How does the facility ensure that all involved health care personnel or other persons known to be exposed were notified? (1) Notification of exposure to a selected infectious disease, either verbal or written, must take place within 48 hours of a confirmed diagnosis.

12 Page 12 of 399 ST - H Inf Disease Exposure Rpt - Written Title Inf Disease Exposure Rpt - Written Statute or Rule 59A-3.251(2) FAC [59A The licensed facility shall establish a written policy and procedure for notifying EMT's, paramedics or their emergency medical transportation service employer, or other persons known to have been exposed to a patient with a selected infectious disease... These procedures shall include at a minimum the following:...] 59A-3.251(2), FAC , FS If notification of exposure to a selected infectious disease was accomplished verbally, ask for documentation to verify that there was a follow-up written notification within 48 hours of a confirmed diagnosis. Review all cases of exposure and notifications for the past year. (2) Verbal notification of such exposure to a selected infectious disease, must be followed by written notification within 48 hours of a confirmed diagnosis. ST - H Inf Disease Exposure Rpt - Persons ID Title Inf Disease Exposure Rpt - Persons ID Statute or Rule 59A-3.251(3) FAC [59A The licensed facility shall establish a written policy and procedure for notifying EMT's, paramedics or their emergency medical transportation service employer, or other persons known to have been exposed to a patient with a selected infectious disease... These procedures shall include at a minimum the following:...] 59A-3.251(3), FAC , FS - Verify that all EMT, paramedic, or other persons known to have had contact with the patient during treatment or transport were identified. - Is there documentation that the EMS provider was notified regarding this information? -Review transport records for individual crew members and proper notification of individuals.

13 Page 13 of 399 (3) Identification of EMT, paramedic, or other known persons to have been in contact with the patient during treatment or transport, if notification is made to the EMS provider. ST - H Inf Disease Exposure Rpt - Included Info Title Inf Disease Exposure Rpt - Included Info Statute or Rule 59A-3.251(4) FAC [59A The licensed facility shall establish a written policy and procedure for notifying EMT's, paramedics or their emergency medical transportation service employer, or other persons known to have been exposed to a patient with a selected infectious disease... These procedures shall include at a minimum the following:...] 59A-3.251(4), FAC , FS Review both written and verbal notification documentation to ensure that the required information as outlined in the regulation was provided. (4) Both written and verbal notification shall contain at a minimum: (a) Name of disease; (b) Signs and symptoms of clinical disease; (c) Date of exposure to the selected infectious disease. (d) Incubation period of disease. (e) Mode of spread of disease; (f) Advisement of appropriate diagnosis, prophylaxis, and treatment, if any.

14 Page 14 of 399 ST - H Inf Disease Exposure Rpt - Confidential Title Inf Disease Exposure Rpt - Confidential Statute or Rule 59A-3.251(5) FAC [59A The licensed facility shall establish a written policy and procedure for notifying EMT's, paramedics or their emergency medical transportation service employer, or other persons known to have been exposed to a patient with a selected infectious disease... These procedures shall include at a minimum the following:...] 59A-3.251(5), FAC , FS - Does the facility policy and procedure for notification of exposure to selected infectious diseases require confidentiality of patient information? - Is the patient's name excluded from both written and verbal notification? (5) Confidentiality of patient information must be maintained. The name of the patient shall not be disclosed. ST - H LICENSURE PROCEDURES - Licenses Posted Title LICENSURE PROCEDURES - Licenses Posted Statute or Rule 59A-3.066(7) FAC 59A-3.066(7) Licenses shall be posted in a conspicuous place on the licensed premises, and copies of licenses shall be made available for inspection to all persons. In the case of a single license issued for facilities on more than one premises, a copy of the license shall be retained and posted in a conspicuous place at each separate premises. 59A-3.066(7), FAC (7), FS - Request the administrator to identify the area(s) of the facility where the license is posted. - Verify that the license posted is current. - Confirm that copies of licenses are made available for inspection to all persons. - If a single license applies to multiple premises, verify that the license is retained and posted in a conspicuous place at each separate premises.

15 Page 15 of 399 ST - H LICENSURE PROCEDURES - Number of Beds Title LICENSURE PROCEDURES - Number of Beds Statute or Rule 59A-3.066(10) FAC; (4) FS 59A-3.066(10) No licensed facility shall continuously operate a number of hospital beds greater than the number indicated by the AHCA on the face of the license (4) The agency shall issue a license which specifies the service categories and the number of hospital beds in each bed category for which a license is received. Such information shall be listed on the face of the license. All beds which are not covered by any specialty-bed-need methodology shall be specified as general beds. A licensed facility shall not operate a number of hospital beds greater than the number indicated by the agency on the face of the license without approval from the agency under conditions established by rule. 59A-3.066(10), FAC (4), FS - Review facility file prior to survey; note capacity and previous survey report. - Review facility census reports to verify that the facility is not continuously operating a greater number of beds than indicated on the license. - If the hospital meets the definition of specialty hospital set forth in s (29), F.S., ensure that the hospital is not providing services or regularly serving any population group beyond services/groups specified in license. PROBE: If questionable, count the number of beds during the walk-through and verify any discrepancies. The location of beds needs to be documented for the file using a sketch of the facility's floor plan, notes of building numbers, etc. ST - H LICENSURE PROCEDURES - Leased Beds Title LICENSURE PROCEDURES - Leased Beds Statute or Rule 59A-3.066(11) FAC (11) Hospitals shall not lease a portion of their licensed beds to another entity or facility, except for hospices licensed pursuant to Chapter 400, Part IV, F.S. - Determine if the hospital is leasing a portion of their licensed beds to another entity and if so, what services that entity provides. NOTE: Management contracts are permissible.

16 Page 16 of 399 ST - H LICENSURE PROCEDURES - Residential Program Title LICENSURE PROCEDURES - Residential Program Statute or Rule 59A-3.066(12) FAC (12) The collocation of any residential program on the premises of a licensed hospital requires prior approval from the agency, based on the following criteria: (a) Health, safety, and welfare cannot be jeopardized for any individual; (b) The essential needs of patients must be met; and (c) The facility is staffed to meet the essential needs of patients. - Verify that the required agency approval is on file if another residential program is operating on the premises of a hospital. Examples may include: --a crisis stabilization unit --a Chapter 400 licensed nursing home --substance abuse NOTE: Check with the Central Office before citing a deficiency for this tag. ST - H PATIENT RIGHTS & CARE - Initial Assessment Title PATIENT RIGHTS & CARE - Initial Assessment Statute or Rule 59A-3.254(1)(a) and (b) FAC (1) Patient Assessment. Each hospital shall develop and adopt policies and procedures to ensure an initial assessment of the patient's physical, psychological and social status, appropriate to the patient's developmental age, is completed to determine the need and type of care or treatment required, and the need for further assessment. The scope and intensity of the initial assessment shall be determined by the patient's diagnosis, the treatment setting, the patient's desire for treatment, and response to previous treatment. (a) Such policies shall: - Review written policies and procedures to determine if they contain all of the elements required by the regulation. - Review sample of patient medical records to determine assessments. Are the care and services appropriate with the assessed needs. Are all appropriate facets of care covered including nutritional and evaluation for discharge planning? Probes - Surveyor should review open records on a sample of units to evaluate patient rights and care. - Interview appropriate staff involved in care.

17 Page 17 of Specify the time period preceding or following admission within which the initial assessment shall be conducted; 2. Require that the initial assessment be documented in writing in the patient's medical record; (b) The initial assessment shall determine the need for an assessment of the patient's nutritional and functional status, as well as discharge planning needs, when appropriate; ST - H PATIENT RIGHTS & CARE - Reassessment Title PATIENT RIGHTS & CARE - Reassessment Statute or Rule 59A-3.254(1)(c)-(d) FAC (c) The hospital shall have policies and procedures to ensure that periodic reassessments of the patient are conducted based on changes in either the patient's condition, diagnosis, or response to treatment; (d) The hospital shall ensure that care and treatment decisions are based on the patient's identified needs and treatment priorities; - Review written policies and procedures to determine if they include provisions for periodic reassessment of the patient. - Review patient medical records to determine if reassessments were conducted when there were changes in the patient's condition, diagnosis, or response to treatment. - Determine if the patient's care and treatment decisions were based on the patient's identified needs and treatment priorities. For example, if the patient medical record has documentation that the patient wishes to forgo certain tests, is this documented and respected? - Review a sample of closed and open medical records. Open records give the surveyor a better opportunity to review the record, interview staff, and observe/interview patient/facility staff as appropriate. ST - H PATIENT RIGHTS & CARE - Indiv Treatment Plan Title PATIENT RIGHTS & CARE - Indiv Treatment Plan Statute or Rule 59A-3.254(1)(e) FAC (e) An individualized treatment plan shall be developed for - Review written policies and procedures to determine if they include provisions for how the individualized treatment

18 Page 18 of 399 each patient based upon the initial assessment and other diagnostic information as appropriate. plan is developed. - Review the patient medical record to determine if the treatment plan is individualized based on the initial assessment and other diagnostic information as appropriate. ST - H PATIENT RIGHTS & CARE - Coord of Care Title PATIENT RIGHTS & CARE - Coord of Care Statute or Rule 59A-3.254(2)(a)-(d) FAC (2) Coordination of Care. Each hospital shall develop and implement policies and procedures on discharge planning which address: (a) Identification of patients requiring discharge planning; (b) Initiation of discharge planning on a timely basis; (c) The role of the physician, other health care givers, the patient, and the patient's family in the discharge planning process; and (d) Documentation of the discharge plan in the patient's medical record including an assessment of the availability of appropriate services to meet identified needs following hospitalization. - Review written policies and procedures to determine if they include provisions for identifying which patients require discharge planning, when the discharge plan is to be initiated and the role of the patient, family, and health care providers. - Include in the patient sample patients who will be discharged during the survey, including those who may require discharge planning. - Interview patients about their knowledge of discharge plan to determine if it corresponds to the documented plan. - Review the sampled inpatient medical record, as well as patients who will be discharged during the time of the survey. - Were the physician, the appropriate health care disciplines, the patient and family involved in the plan? - Look to see if the discharge plan includes arrangement for post-discharge services prior to discharge (i.e. home health services, specialized rehabilitative services, etc.). This should include appropriately licensed facilities as needed. - Is discharge planning sufficient to prepare the patient for discharge to another setting without interruption of necessary care and services? Is the discharge plan appropriate for the post-hospital services needed? Interview the person responsible for discharge and coordination. ST - H PATIENT RIGHTS & CARE - Patient/Family Educat Title PATIENT RIGHTS & CARE - Patient/Family Educat Statute or Rule 59A-3.254(3)(a)-(b) 1-2 FAC

19 Page 19 of 399 (3) Patient and Family Education. (a) General Provisions. Each hospital shall develop a systematic approach to educating the patient and family to improve patient outcomes by promoting recovery, speedy return to function, promoting healthy behaviors, and involving patients in their care and care decisions. (b) Each hospital shall provide the patient and family with education specific to the patient's assessed needs, capabilities, and readiness. Such education shall include when indicated: 1. An assessment when indicated, of the educational needs, capabilities, and readiness to learn based on cultural and religious practices, emotional barriers, desire and motivation to learn, physical and cognitive limitations, and language barriers; 2. Instruction in the specific knowledge or skills needed by the patient or family to meet the patient's ongoing health care needs including: a. The use of medications. b. The use of medical equipment. c. Potential drug or food interactions, and nutritional intervention or modified diets. d. Rehabilitation techniques. e. Available community resources. f. When and how to obtain further treatment; and g. The patient's and family's responsibilities in the treatment process. 59A-3.254(3)(a), FAC 59A-3.254(3)(b)(1)-(2), FAC - Review written policies and procedures for provisions addressing patient and family education. The policies and procedures should address an interdisciplinary process for patient and family education, based on the patient's assessed needs, capabilities, and readiness. The education must be presented in a language the family and patient understand. -The written education should, when indicated, address instruction in the specific knowledge or skills needed by the patient or family to meet the patient's ongoing health care needs including: a. The use of medications. b. The use of medical equipment. c. Potential drug or food interactions, and nutritional intervention or modified diets. d. Rehabilitation techniques. e. Available community resources. f. When and how to obtain further treatment; and g. The patient's and family's responsibilities in the treatment process. - Review the patient medical records to see that education was provided to the patient according to the established policies. - Ask patients what education they have received from staff. - Review a sample of educational materials used for patient education. - Patient education may be provided in many forms - written, verbal, television, computer based, and in individual and group settings. ST - H PATIENT RIGHTS & CARE - Discharge Instruction Title PATIENT RIGHTS & CARE - Discharge Instruction Statute or Rule 59A-3.254(3)(b)3. FAC

20 Page 20 of Information about any discharge instructions given to the patient or family shall be provided to an organization or individual responsible for providing continuing care. - Review written policies and procedures for provisions addressing how discharge instructions are communicated to organizations or individuals responsible for providing continuing care. - Review the patient medical records for evidence of this communication according to the written policies and procedures. - For example, if the patient was given discharge instructions and is being discharged to a nursing home, look to see how the hospital communicates these same discharge instructions to nursing home staff. - Interview appropriate parties involved. ST - H PATIENT RIGHTS & CARE -Refuse Tx, Adv Directi Title PATIENT RIGHTS & CARE -Refuse Tx, Adv Directi Statute or Rule 59A-3.254(4)(a)-(b) FAC 4. Patient Rights. Each hospital shall develop and adopt policies and procedures to ensure the following rights of the patient: (a) The right to refuse treatment and life-prolonging procedures as specified under Section , F.S.; (b) The right to formulate advance directives and designate a surrogate to make health care decisions on behalf of the patient as specified under Chapter 765, F.S. The policies shall not condition treatment or admission upon whether or not the individual has executed or waived an advance directive. In the event of conflict between the facility's policies and procedures and the individual's advance directive, provision should be made in accordance with Section , F.S. - Review written policies and procedures for provisions for the patient's right to refuse treatment and life-prolonging procedures. Also, review these policies to determine if they address how patients are informed of their right to formulate advanced directives. - Patients may choose to formulate advance directives or not. If the patient has existing advance directives prior to hospital admission, the hospital must obtain a copy for inclusion in the medical record. - Some hospitals' religious or moral beliefs may conflict with the patient's advance directive. Section of the Florida Statute for Advance Directives, titled "Transfer of a patient", states "A health care provider or facility that refuses to comply with a patient's advance directive, or the treatment decision of his or her surrogate, shall make reasonable efforts to transfer the patient to another health care provider or facility that will comply with the directive or treatment decision. This chapter does not require a health care provider or facility to commit any act which is contrary to the provider's or facility's moral or ethical beliefs."

21 Page 21 of 399 ST - H PATIENT RIGHTS & CARE - Advance Directives Title PATIENT RIGHTS & CARE - Advance Directives Statute or Rule 59A-3.254(4)(b)1. FAC [59A-3.254(4)(b) Patient Rights. Each hospital shall develop and adopt policies and procedures to ensure the following rights of the patient... Policies shall include:] 1. Provide each adult individual, at the time of the admission as an inpatient, with a copy of "Health Care Advance Directives-The Patient's Right to Decide," effective , which is hereby incorporated by reference, or with a copy of some other substantially similar document which is a written description of Chapter 765, F.S., regarding advance directives; - Request a copy of the facility information that is provided to patients upon admission for Advance Directives. - Review this to determine if it provides a written description of state law regarding advance directives and includes the hospitals policies for respecting advance directives. - Inquire as to the procedures in place to ensure that such information is provided to adult individuals at the time of admission. - During patient interviews, ask the patient if he or she has been provided information regarding advance directives upon admission. - To view the document, "Health Care Advance Directives - The Patients' Right to Decide," on the AHCA website: ST - H PATIENT RIGHTS & CARE - Adv Directive Policy Title PATIENT RIGHTS & CARE - Adv Directive Policy Statute or Rule 59A-3.254(4)(b)2, FAC [59A-3.254(4)(b) Patient Rights. Each hospital shall develop and adopt policies and procedures to ensure the following rights of the patient... Policies shall include:] See surveyor guidance under tags H0025 and H Providing each adult individual, at the time of admission as an inpatient, with written information

22 Page 22 of 399 concerning the health care facility's policies respecting advance directives; and ST - H PATIENT RIGHTS & CARE-Adv Directive In MedRec Title PATIENT RIGHTS & CARE-Adv Directive In MedRec Statute or Rule 59A-3.254(4)(b)3. FAC [59A-3.254(4)(b) Patient Rights. Each hospital shall develop and adopt policies and procedures to ensure the following rights of the patient... Policies shall include:] - Review patient medical records for evidence of the existence of an advance directive of the patient (i.e. in physician progress notes or nursing progress notes might state the patient has a "living will"). If this evidence is found, look to see that there is a copy of the patient's advance directive contained in the medical record. - Interview patients and/or representatives about advance directives. 3. The requirement that documentation of the existence of an advance directive be contained in the medical record. A health care facility, which is provided with the individual's advance directive, makes the advance directive or a copy thereof a part of the individual's medical record. ST - H PATIENT RIGHTS & CARE - Add'l Policy/Procedur Title PATIENT RIGHTS & CARE - Add'l Policy/Procedur Statute or Rule 59A-3.254(4)(c)-(h) and (5) FAC [59A-3.254(4) Patient Rights. Each hospital shall develop and adopt policies and procedures to ensure the following rights of the patient:] (c) The right to information about patient rights as set forth in section , F.S., and procedures for initiating, 59A-3.254(4)(c)-(h), FAC 59A-3.254(5), FAC - Review written policies and procedures for patient's rights. - Ask staff how patients are informed of their rights and review written information given to patients. - During patient interviews, ask the patient if he or she was informed of his or her patient rights, and, if so, how.

23 Page 23 of 399 reviewing and resolving patient complaints; (d) The right to participate in the consideration of ethical issues that arise in the care of the patient; (e) The right to personal privacy and confidentiality of information including access to information contained in the patient's medical records as specified under Section , F.S.; (f) The right of the patient's next of kin or designated representative to exercise rights on behalf of the patient; (g) The right to an itemized patient bill upon request as specified under Section , F.S. (h) The right to be free of restraints consistent with the rights of mentally ill persons or patients as provided in Section , F.S. (5) In addition to the provisions of this section, the hospital complies with Section , F.S., which remains in effect. Section is the Patient's Bill of Rights A patient has the right to: Be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy. A prompt and reasonable response to questions and requests. Know who is providing medical services and who is responsible for his or her care. Know what patient support services are available, including whether an interpreter is available if he or she does not speak English. Know what rules and regulations apply to his or her conduct. Be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis. Refuse any treatment, except as otherwise provided by law. Be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care. To know upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate. This right only applies if a patient is eligible for Medicare. Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care. Receive a copy of a reasonably clear and understandable, itemized bill and, upon request to have the charges explained. Impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. Treatment for any emergency medical condition that will deteriorate from failure to provide treatment. Know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research. Express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency. A patient is responsible for: Providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health. Reporting unexpected changes in his or her condition to the health care provider. Reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her. Following the agreed-upon treatment plan recommended by the health care provider. Keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider

24 Page 24 of 399 ST - H EMERGENCY CARE - Signage Requirements or health care facility. His or her actions if he or she refuses treatment or does not follow the health care provider's instructions. Assuring that the financial obligations of his or her health care are fulfilled as promptly as possible. Title EMERGENCY CARE - Signage Requirements Statute or Rule 59A-3.255(1)(a)-(c) FAC (1) SIGNAGE REQUIREMENTS. (a) Each hospital offering emergency services and care shall post, in a conspicuous place in the emergency service area, a sign clearly stating a patient's right to emergency services and care as set forth in Section , F.S. The sign shall be posted in both English and in Spanish. (b) Each hospital offering emergency services and care shall post a sign identifying the service capability of the hospital. The categories of services listed on the sign may be general in nature if the sign refers patients to another location within that facility where a list of the subspecialties is available. The sign identifying the service capability of the hospital and the additional listing of subspecialties, if a separate subspecialty list is maintained, shall be in both English and in Spanish. (c) The signs required by this rule section shall be posted in a location where individuals not yet admitted to the hospital would reasonably be expected to present themselves for emergency services and care. Conspicuous place is defined as: a place where it is likely to be noticed by all individuals entering and in the emergency service areas. - Verify that the sign stating a patient's right to emergency services is in a conspicuous place, is clearly readable, and that it is in both English and Spanish. NOTE: At a minimum, the sign must specify the right of any individual who presents to the emergency department area to receive: - medical screening, examination and evaluation to determine if an emergency medical condition exists, and if it does - the care, treatment or surgery by a physician necessary to relieve or eliminate the emergency medical condition within the service capability of the facility. (review ) - Verify that there is a sign, located in a conspicuous place, listing the service capability of the hospital, and that this sign is in both English and Spanish. - Compare the services capability sign for consistency with the Agency listing of the hospital's emergency services capability on the face of the hospital's license. NOTE: This sign may be general in nature; i.e., 'This hospital offers the following services: obstetrics, neurosurgery, pediatrics, etc.'

25 Page 25 of 399 ST - H EMERGENCY CARE -Txfr Proc Persons Responsible Title EMERGENCY CARE -Txfr Proc Persons Responsible Statute or Rule 59A-3.255(2) - (2)(a) FAC (2) TRANSFER PROCEDURES. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and procedures shall incorporate at a minimum: (a) Decision protocols identifying the emergency services personnel within the hospital responsible for the arrangement of outgoing and incoming transfers; 59A-3.255(2), FAC 59A-3.225(2)(a), FAC - Review the policies and procedures relating to emergency services to determine: (a) does the policies specify the personnel positions authorized by the By Laws to conduct an appropriate transfer; (b) does it require documentation in the medical records of the reason(s) for the transfer; (c) does it specify the need to ascertain from the receiving facility that " it agrees to accept the patient ", has space and qualified personnel available for the necessary services; (d) does it require documentation of: the name, position title of the person at the receiving facility with whom the transfer conversation took place, date and time the transfer conversation took place, and nature of the conversation that transpired. - Draw a sample of 10 records involving patient transfers to check for evidence that these protocols are in effect. When reviewing the sample of records, the surveyor should be able to fully understand the rationale for the transfer, and the benefits vs. risks should be specified. Review the Transfer Log and examine for the following: - Appropriate transfers. Transfers to offsite testing facilities and return. Death from /due to significant adverse outcomes. Refusals of examination, treatment, or transfers. Patients leaving against medical advice (AMA) or left without being seen (LWBS) and the potential relation to inaccurate triage coding and payor source. Returns to the Emergency Department within 48 hours. Look for excessive wait times prior to commencement of medical screening exam. Review the Transfer Log and Central Log for indicators of acuity levels of patients in the emergency department, that may explain justifiable reasons for delayed medical examination and review excessive wait times prior to commencement of medical screening. PROBES Is a protocol established that identifies personnel positions that are responsible for arranging both incoming and outgoing transfers? (Transfer arrangements must be made between hospital ER personnel.)

26 Page 26 of 399 ST - H EMERGENCY CARE-Txfr Proc Conditions/Informed Title EMERGENCY CARE-Txfr Proc Conditions/Informed Statute or Rule 59A-3.255(2)(b)1. FAC [59A (2) TRANSFER PROCEDURES. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and procedures shall incorporate at a minimum:] (b) Decision protocols stating the conditions that must be met prior to the transfer of a patient to another hospital. These conditions are: 1. If a patient, or a person who is legally responsible for the patient and acting on the patient's behalf, after being informed of the hospital's obligation under Chapter 395, F.S. and of the risk of transfer, requests that the transfer be effected; or 59A-3.255(2)(b), FAC 59A-3.255(2)(b)(1), F.A.C. - Is a protocol established that details the conditions that are to be met prior to the transfer of a patient to another facility. - Is a protocol established to ensure that when a patient requests a transfer, the patient has been fully informed of the hospital's obligation to provide emergency services and care and of the associated risks involved in the patient's decision to be transferred to another facility? ST - H EMERGENCY CARE - Txfr Proc Written Certificat Title EMERGENCY CARE - Txfr Proc Written Certificat Statute or Rule 59A-3.255(2)(b)2. FAC 59A-3.255(2) TRANSFER PROCEDURES. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and Is there an expressed written physician certification (not implied)? Is there a protocol established to ensure that a physician certifies all transfers?

27 Page 27 of 399 procedures shall incorporate at a minimum: (b) Decision protocols stating the conditions that must be met prior to the transfer of a patient to another hospital. These conditions are: 2. If a physician has signed a certification that, based upon the reasonable risks and benefits to the patient, and based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the individual's medical condition from effecting the transfer; or ST - H EMERGENCY CARE - Txfr Proc Signed Certificati Title EMERGENCY CARE - Txfr Proc Signed Certificati Statute or Rule 59A-3.255(2)(b)3. FAC 59A-3.255(2) TRANSFER PROCEDURES. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and procedures shall incorporate at a minimum: (b) Decision protocols stating the conditions that must be met prior to the transfer of a patient to another hospital. These conditions are: - Is there a protocol specifying the qualified medical persons who may sign a certificate of transfer when the physician is not physically present in the emergency services area? - This protocol should be consistent with the professional practice acts at 64B-8 FAC. - Verify that when someone other than a physician authorizes the transfer, that the consulting physician subsequently signs the certificate within the 72-hour time frame. 3. If a physician is not physically present in the emergency services area at the time an individual is transferred, a qualified medical person may sign a certification that a physician with staff privileges at the transferring hospital, in consultation with such personnel, has determined that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility

28 Page 28 of 399 outweigh the increased risks to the individual's medical condition from effecting the transfer. The certification summarizes the basis for such determination. The consulting physician must sign the certification within 72 hours of the transfer. ST - H EMERGENCY CARE - Txfr Proc Closest Hospital Title EMERGENCY CARE - Txfr Proc Closest Hospital Statute or Rule 59A-3.255(2)(c) FAC; (3)(e) FS 59A-3.255(2) TRANSFER PROCEDURES. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and procedures shall incorporate at a minimum: (c) A provision providing that all medically necessary transfers shall be made to the geographically closest hospital with the service capability, unless another prior arrangement is in place or the geographically closest hospital is at service capacity as stated in Section (3)(e), F.S (3) EMERGENCY SERVICES; DISCRIMINATION; LIABILITY OF FACILITY OR HEALTH CARE PERSONNEL.- (e) Except as otherwise provided by law, all medically necessary transfers shall be made to the geographically closest hospital with the service capability, unless another prior arrangement is in place or the geographically closest hospital is at service capacity. When the condition of a medically necessary transferred patient improves so that the service capability of the receiving hospital is no longer required, the receiving hospital may transfer the patient back to the 59A-3.255(2)(c) FAC (3)(c), FS - Review the policies and procedures relating to emergency services to verify that there is a protocol established to ensure that the closest geographical hospital having the service capability is contacted first in transfer cases where another prior arrangement is not in place. - If another prior arrangement is in place, review records to ensure that transfers are made in accordance with such agreement. - Draw a sample of records involving patient transfers to check for evidence that this protocol is in effect. Review the Transfer Log / Manual to determine if in accordance with 59A-3.255(b)(c)(1)-(2) FAC (See H0047) the Manual includes Decision Protocols for: when to transfer a patient; who is authorized by the facility's policy or Decision Protocol to conduct / arrange for the transfer with the receiving facility; Does the Manual contain a list of receiving hospitals with the specified hospital's special care capabilities, telephone number and contact person? Is the Transfer Manual readily accessible to Emergency Department Staff?

29 Page 29 of 399 transferring hospital and the transferring hospital shall receive the patient within its service capability. ST - H EMERGENCY CARE - Records of Transfers Title EMERGENCY CARE - Records of Transfers Statute or Rule 59A-3.255(2)(d) FAC; (4)(a)1 FS 59A-3.255(2) TRANSFER PROCEDURES. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and procedures shall incorporate at a minimum: (d) Protocols for maintaining records of patient transfers made or received for a period of five years. Patient transfer information shall be incorporated separately in transfer logs and into the patient's permanent medical record as stated in Section (4)(a)1, F.S. 59A-3.255(2)(d), FAC (4)(a)(1), F.S. - Verify that there is an established policy that provides for the maintenance of transfer records for 5 years. - Draw a sample of 10 transfer cases to verify that records of transfers are maintained both in a transfer log as well as in the patients' medical records. Review the medical records of the transferred patients to determine if they contain: available history, documentation related to the individual's emergency medical condition, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent (4) RECORDS OF TRANSFERS; REPORT OF VIOLATIONS. (a)1. Each hospital shall maintain records of each transfer made or received for a period of 5 years. These records of transfers shall be included in a transfer log, as well as in the permanent medical record of any patient being transferred or received.

30 Page 30 of 399 ST - H EMERGENCY CARE - Records of Transfers Title EMERGENCY CARE - Records of Transfers Statute or Rule (4)(a)2. FS (4)(4) RECORDS OF TRANSFERS; REPORT OF VIOLATIONS.- (a) 2. Each hospital shall maintain records of all patients who request emergency care and services, or persons on whose behalf emergency care and services are requested, for a period of 5 years. These records shall be included in a log, as well as in the permanent medical record of any patient or person for whom emergency services and care is requested. - Verify that there is a policy in place to ensure that a medical record is maintained on every patient seeking emergency care and that the record is incorporated into the patient's permanent medical record for a minimum of 5 years. - Draw a sample of records to verify that complete medical records are maintained for each patient presenting to the emergency department. (Sample should be selected from the Emergency Department Logs.) ST - H EMERGENCY CARE - Inventory Reporting Title EMERGENCY CARE - Inventory Reporting Statute or Rule 59A-3.255(3)(b) 1-3 FAC Inventory Reporting. (b) Every hospital offering emergency services and care shall report to the agency for inclusion in the inventory those services which are within the service capability of the hospital. The following services, when performed on an infrequent and short time limited basis, are not considered to be within the service capability of the hospital: 1. Services performed for investigative purposes under the auspices of a federally approved institutional review board; or 2. Services performed for educational purposes; or - Review the hospital's current license to determine what emergency services are provided and have been reported to the Agency as being within service capability of the hospital. - Draw a sample of records to determine actual services being provided. (If, during the review of sample records, the surveyor determines that the hospital is providing a service that is not included on the inventory, then a deficiency should be cited.)

31 Page 31 of Emergencies performed by physicians who are not on the active medical staff of the reporting hospital. ST - H EMERGENCY CARE - Addition of Service Title EMERGENCY CARE - Addition of Service Statute or Rule 59A-3.255(3)(c) FAC (c) Any addition of service shall be reported to the agency prior to the initiation of the service. The agency will act accordingly to include the service in the next publication of the inventory and to add the service on the face of the hospital license. - If the agency has reason to believe that a hospital offers a service and the service was not reported on the inventory, the agency (Central Office) will notify the hospital and provide the hospital with an opportunity to respond. The agency shall arrange for an on-site visit prior to the agency's determination of capability, with advance notice of the on-site visit. - If, after investigation, the agency determines that a service is offered by the hospital as evidenced by the patient medical records or itemized bills, the agency shall amend the inventory and the face of the hospital license. ST - H EMERGENCY CARE - Exemptions Title EMERGENCY CARE - Exemptions Statute or Rule 59A-3.255(4)(a)1-3; (3)(d) FS 59A Emergency Services/Exemptions. (4) Exemptions (a) Every hospital providing emergency services shall ensure the provision of services within the service capability of the hospital; at all times; 24 hours per day, 7 days per week either directly or indirectly through: 1. An agreement with another hospital made prior to receipt of a patient in need of the service; or 2. An agreement with one or more physicians made prior to the receipt of a patient in need of the service; or 59A-3.255(4)(a) 1-3, FAC (3)(d)(1), FS - Review the hospitals current license to determine what emergency services are provided. - Draw a sample of 10 records from the Central Log to determine actual services being provided. Review the Emergency Department Transfer Log to identify services not provided by the hospital (that are within its service capability) for which patients were inappropriately transferred. Ascertain if a Transfer Agreement is in place. - Review the emergency department on call schedule to verify that 24/7 on call coverage is provided for all emergency services listed on the hospital's license. (This requirement can be met by in-house physician coverage or through a specific agreement with another hospital for a particular service. General transfer agreements would not meet this requirement.)

32 Page 32 of Any other arrangement made prior to receipt of a patient in need of the service (3)(d)1. Every hospital shall ensure the provision of services within the service capability of the hospital, at all times, either directly or indirectly through an arrangement with another hospital, through an arrangement with one or more physicians, or as otherwise made through prior arrangements. A hospital may enter into an agreement with another hospital for purposes of meeting its service capability requirement, and appropriate compensation or other reasonable conditions may be negotiated for these backup services. ST - H EMERGENCY CARE - Exemption Application Title EMERGENCY CARE - Exemption Application Statute or Rule 59A-3.255(4)(d) FAC (4) Exemptions (d) When a hospital has been providing 24 hour per day, 7 day per week coverage either directly or indirectly through an agreement with another hospital or physician(s) for a specialty service as evidenced by the inventory and hospital license, and the circumstances significantly change such that the hospital can no longer provide the service on a 24 hour per day, 7 day per week basis, the hospital must apply for an exemption from the agency. Ask the facility if they have been granted any exemption and if so contact the Agency's Hospital and Outpatient Services Unit to determine if the facility has been granted an exemption for any emergency services.

33 Page 33 of 399 ST - H EMERGENCY CARE - Changes for Exemption Title EMERGENCY CARE - Changes for Exemption Statute or Rule 59A-3.255(4)(f) FAC (4) Exemptions (f) Each hospital shall immediately report any change in the conditions which led to the granting of an exemption. - Contact the Agency's Hospital and Outpatient Services Unit to determine the circumstances that existed at the hospital at the time the exemption was granted. - Verify with the Hospital and Outpatient Services Unit that the hospital has not reported any change in the circumstances that led to the granting of the exemption. - Verify from record samples and from review of the medical staff roster that the circumstances that existed when the exemption was granted have not changed. ST - H EMERGENCY CARE - Emergency Services Personnel Title EMERGENCY CARE - Emergency Services Personnel Statute or Rule 59A-3.255(6)(a)1. FAC; (9) FS 59A-3.255(6)(a)1 Service Delivery Requirements. (a) Every hospital offering emergency services and care shall provide emergency care available 24 hours a day within the hospital to patients presenting to the hospital. At a minimum: 1. Emergency services personnel shall be available to ensure that emergency services and care are provided in accordance with Section (9), F.S (9) "Emergency services and care" means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if 59A-3.255(6)(a) 1, FAC (9) FS - Review the volume of ER patients and verify that there is adequate medical and nursing personnel qualified in emergency care to provide the emergency services listed on the hospital's license as within its service capability, and to meet the needs of the patients requiring those services. - Review patient records to determine if all patients presenting to the emergency department and requesting emergency care are provided a medical screening, examination and evaluation. (The hospital must determine through screening, triage and assessment, if an emergency medical condition exists, and if it does, must provide the care, treatment or surgery by a physician necessary to relieve or eliminate the emergency medical condition within the service capability of the facility.) NOTE: Emergency services and care is defined as "medical screening, examination, and evaluation by a physician,

34 Page 34 of 399 an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of the facility. or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of the facility." Chapter (9), F.S. defines Emergency Medical Condition as "a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1. Serious jeopardy to patient health, including a pregnant woman or fetus. 2. Serious impairment to bodily functions. 3. Serious dysfunction of any bodily organ or part. With respect to a pregnant woman: 1. That there is inadequate time to effect safe transfer to another hospital prior to delivery; 2. That a transfer may pose a threat to the health and safety of the patient or fetus; or 3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes." ST - H EMERGENCY CARE - On-Call Physician Available Title EMERGENCY CARE - On-Call Physician Available Statute or Rule 59A-3.255(6)(a)2. FAC 2. At least one physician shall be available within 30 minutes through a medical staff call roster; initial consultation through two-way voice communication is acceptable for physician presence. Review Physician on-call Policy & Procedures / By Laws to determine if systematic procedures are in place to ensure there is an on- call physician available to the emergency room at all times. - Verify that there is an on-call physician available to the emergency room at all times. - Review a sample of records to ensure that the physician on call responds within the 30 minute time frame. ST - H EMERGENCY CARE - Specialty Consultation Title EMERGENCY CARE - Specialty Consultation Statute or Rule 59A-3.255(6)(a)3. FAC

35 Page 35 of Specialty consultation shall be available by request of the attending physician or by transfer to a designated hospital where definitive care can be provided. Review rosters designating medical staff members on duty or on call for primary coverage and specialty consultation are posted in the emergency services care area. ST - H EMERGENCY CARE - Medical Records with Txfr Title EMERGENCY CARE - Medical Records with Txfr Statute or Rule 59A-3.255(6)(b) FAC (b) When a patient is transferred from one hospital to another, all pertinent medical information accompanies the patient being transferred. Review patient records to determine if the appropriate medical information accompanied the patient transferred. NOTE: Individuals being transferred to another hospital must be accompanied by necessary medical information. Necessary documentation should include available history records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or physician certification. ST - H EMERGENCY CARE - Txfr Manual Outgoing Title EMERGENCY CARE - Txfr Manual Outgoing Statute or Rule 59A-3.255(6)(c) 1-2 FAC (c) Every hospital offering emergency services and care shall maintain a transfer manual, which shall include in addition to the requirements in paragraph (2) of this rule: 1. Decision protocols for when to transfer a patient; 2. A list of receiving hospitals with special care capabilities, including the telephone number of a contact person; Verify that the hospital maintains a transfer manual. - Does the manual address decision protocols for when to transfer a patient? - Is a list maintained of recipient hospitals having specialized service capabilities? The list should include telephone numbers and contact persons. - Is a list of on-call specialists maintained (including telephone numbers)? - Are protocols in place to address procedures that must be followed when a transfer request is received from another hospital?

36 Page 36 of 399 ST - H EMERGENCY CARE-Txfr Manual Incoming & Update Title EMERGENCY CARE-Txfr Manual Incoming & Update Statute or Rule 59A-3.255(6)(c)3-4, 59A-3.255(6)(d) FAC [59A-3.255(6)(c) Every hospital offering emergency services and care shall maintain a transfer manual, which shall include in addition to the requirements in paragraph (2) of this rule:...] 3. A list of all "on-call" critical care physicians available to the hospital, including their telephone numbers; and 4. Protocols for receiving a call from a transferring hospital, including: a. Requirements for specific information regarding the patient's problem; b. Estimated time of patient arrival; c. Specific medical requirements; d. A request to transfer the patient's medical record with the patient; and e. The name of the transporting service. (d) Both transferring and receiving hospitals assign a specific person on each shift who shall have responsibility for being knowledgeable of the transfer manual and maintaining it. 59A-3.255(6)(c)(3), FAC 59A-3.255(6)(c)(4)(a)-(e), FAC 59A-3.255(6)(d), FAC - Verify that a specific person on each shift has responsibility for being knowledgeable of the transfer manual and maintaining it. - Is a list of on-call specialists maintained, to include telephone numbers? - Are protocols in place to address procedures that must be followed when a transfer request is received from another hospital? -Does the transfer manual and protocols consider specific medical requirements and treatment times? -Interview the person responsible for the transfer manual. -Review transfers to receiving facilities; were all protocols followed? Review a selection of patient records of patients received from other hospitals. Consider the inventory of services provided by the hospital being surveyed. -Interview emergency department staff to determine knowledge of the on call physician list and of the transfer coordination process. ST - H EMERGENCY CARE - Written Policies/Procedures Title EMERGENCY CARE - Written Policies/Procedures Statute or Rule 59A-3.255(6)(e) FAC

37 Page 37 of 399 (e) Each hospital offering emergency services and care shall maintain written policies and procedures specifying the scope and conduct of emergency services to be rendered to patients. Such policies and procedures must be approved by the organized medical staff, reviewed at least annually, revised as necessary, dated to indicate the time of last review, and enforced. - Verify that there are written policies and procedures approved by the medical staff that identify emergency services responsibilities that have been dated to indicate the time of last review. - Review the inventory listed in the Emergency Department, license, and the emergency services policies and procedures for scope of care provided. ST - H EMERGENCY CARE - Policy/Proc Physician Direc Title EMERGENCY CARE - Policy/Proc Physician Direc Statute or Rule 59A-3.255(6)(e)1. FAC [59A-3.255(6) (e) Each hospital offering emergency services and care shall maintain written policies and procedures... Such policies shall include requirements for the following:] Review the policy providing for direction of the emergency department by a designated physician member of the organized medical staff. Interview the physician director regarding the provision of medical care and services. Review the credential file of the physician director of the emergency department. 1. Direction of the emergency department by a designated physician who is a member of the organized medical staff. ST - H EMERGENCY CARE - Physician Coverage Title EMERGENCY CARE - Physician Coverage Statute or Rule 59A-3.255(6)(e)2. FAC (e) Each hospital offering emergency services and care shall maintain written policies and procedures... Such policies shall Review the physician coverage schedule. Consider the inventory of services offered. Interview the physician designated to direct the emergency department, for the provision of physician coverage.

38 Page 38 of 399 include requirements for the following:] 2. A defined method of providing for a physician on call at all times. ST - H EMERGENCY CARE - Nursing Supervisor Title EMERGENCY CARE - Nursing Supervisor Statute or Rule 59A-3.255(6)(e)3., FAC [59A-3.255(6) (e) Each hospital offering emergency services and care shall maintain written policies and procedures... Such policies shall include requirements for the following:] 3. Supervision of the care provided by all nursing service personnel with the emergency department by a designated registered nurse who is qualified by relevant training and experience in emergency care. Review the personnel record of nursing supervisor in charge or designee. Review a sample of nursing personnel for training and experience. Interview the nurse in charge for required competencies and training. Review the policy and schedule for supervision personnel by a qualified designated registered nurse. Observe supervision of nursing personnel in the emergency department. ST - H EMERGENCY CARE - Other Personnel Title EMERGENCY CARE - Other Personnel Statute or Rule 59A-3.255(6)(e)4., FAC [59A-3.255(6) (e) Each hospital offering emergency services and care shall maintain written policies and procedures... Such policies shall include requirements for the following:] Review a sample of personnel records for adherence to duties, responsibilities. Interview the emergency department director for clarifications of personnel assignments of duties/responsibilities.

39 Page 39 of A written description of the duties and responsibilities of all other health personnel providing care within the emergency department. ST - H EMERGENCY CARE - Formal Training Program Title EMERGENCY CARE - Formal Training Program Statute or Rule 59A-3.255(6)(e)5. FAC [59A-3.255(6) (e) Each hospital offering emergency services and care shall maintain written policies and procedures... Such policies shall include requirements for the following:] 5. A planned formal training program on emergency access laws, and participation, by all health personnel working in the emergency department. - Is there an established policy that provides for formal training of emergency department staff on emergency access to care laws? - Sample review of ED staff for training on the emergency access laws. Interview health personnel working in the emergency department regarding training on emergency access laws; to include physicians and contracted staff. ST - H EMERGENCY CARE - Control Register Title EMERGENCY CARE - Control Register Statute or Rule 59A-3.255(6)(e)6. FAC [59A-3.255(6) (e) Each hospital offering emergency services and care shall maintain written policies and procedures... Such policies shall include requirements for the following:] 6. A control register adequately identifying all persons seeking emergency care be established, and that a medical - Verify there is a policy that requires a control register be established and a medical record maintained on every patient seeking emergency care. - Verify EMS report on all patients delivered by ambulance is a part of the patient medical record The form HRS 1894, is no longer in the EMS F.A.C.; 64E-2001(17) and 64J (5) Transporting vehicle personnel shall provide recorded information to the receiving hospital personnel at the time the patient is transferred that contains all known pertinent incident, patient identification and patient care information. Components of a complete EMS report are also defined.

40 Page 40 of 399 record be maintained on every patient seeking emergency care that is incorporated into the patient's permanent medical record and that a copy of Florida EMS Report, HRS 1894, as required by Rule 64E-2.013, F.A.C., be included in the medical record, if the patient was delivered by ambulance... Observe how emergency department staff receive EMS information upon patient arrival. -Interview ED staff for hand off of care from EMS. NOTE: The purpose of the central log is to track the care provided to each individual that comes to the hospital seeking emergency services and care. The hospital has the discretion of maintaining the central log in a manner that best meets the needs of the patients. ST - H EMERGENCY CARE - Control Register Info Title EMERGENCY CARE - Control Register Info Statute or Rule 59A-3.255(6)(e)6. a-e, FAC [59A-3.255(6) (e) Each hospital offering emergency services and care shall maintain written policies and procedures... Such policies shall include requirements for the following:] 6....The control register must be continuously maintained and shall include at least the following for every individual seeking care: a. Identification to include patient name, age and sex; b. Date, time and means of arrival; c. Nature of complaint; d. Disposition; and e. Time of departure. - Review the emergency department control log covering at least a one year period. - Check for completeness, gaps in entries or missing information. Review for the required a-e items. Seek clarification from the appropriate staff, for any missing portions, from the emergency department director or designee. ST - H EMERGENCY CARE - QA Review Title EMERGENCY CARE - QA Review Statute or Rule 59A-3.255(6)(f), FAC

41 Page 41 of 399 (f) Every hospital offering emergency services and care shall have a method for assuring that a review of emergency patient care is performed and documented at least monthly, using the medical record and pre-established criteria. - Interview QA person or ED Director. - Verify there is an established policy providing for, at a minimum, monthly quality assurance reviews of the care provided to patients in the emergency department. ST - H EMERGENCY CARE - Lab Services Available Title EMERGENCY CARE - Lab Services Available Statute or Rule 59A-3.255(6)(g) 1, FAC (g) Every hospital offering emergency services and care shall ensure the following: 1. That clinical laboratory services with the capability of performing all routine studies and standard analyses of blood, urine, and other body fluids are readily available at all times to the emergency department. - Verify that lab services are available at all times to the emergency department that includes routine studies and standard analyses of blood, urine and other body fluids. - Review medical records to determine that lab tests are processed timely. ST - H EMERGENCY CARE - Adequate Supply of Blood Title EMERGENCY CARE - Adequate Supply of Blood Statute or Rule 59A-3.255(6)(g)2. FAC [59A-3.255(6) (g) Every hospital offering emergency services and care shall ensure the following:...] 2. That an adequate supply of blood is available at all times, either in-hospital or from an outside source approved by the - Review policies and procedures to determine acceptable levels of blood inventory. - Check inventory to verify that an adequate supply of blood is available. - Verify that blood typing and cross-matching capability is readily available to the emergency department. - Verify that blood storage facilities are readily available to the emergency department.

42 Page 42 of 399 organized medical staff, and that blood typing and cross-matching capability and blood storage facilities are readily available to the emergency department. ST - H EMERGENCY CARE -Diagnostic Radiology Services Title EMERGENCY CARE -Diagnostic Radiology Services Statute or Rule 59A-3.255(6)(g)3. FAC [59A-3.255(6) (g) Every hospital offering emergency services and care shall ensure the following:...] - Verify that a policy exists to ensure that diagnostic radiology services are available at all times to provide routine studies to the emergency department. - Review patient records to determine if radiology services are provided in a timely manner. 3. That diagnostic radiology services within the service capability of the hospital are readily available at all times to the emergency department. ST - H EMERGENCY CARE - Other Services Available Title EMERGENCY CARE - Other Services Available Statute or Rule 59A-3.255(6)(g) 4.a-q, FAC [59A-3.255(6) (g) Every hospital offering emergency services and care shall ensure the following:...] 4. That the following are available for immediate use to the emergency department at all times: a. Oxygen and means of administration; b. Mechanical ventilatory assistance equipment, including Conduct observations in the emergency department. - Verify that items a. through q. are present and available for immediate use in the emergency department. - Check to see that the equipment and supplies used in the emergency department are suitable for all sizes of patients treated. - Verify that equipment is checked on a scheduled basis in accordance with the hospital's preventative maintenance program. - Check expiration date on supplies to determine if supplies are current.

43 Page 43 of 399 airways, manual breathing bag, and ventilator; c. Cardiac defibrillator with synchronization capability; d. Respiratory and cardiac monitoring equipment; e. Thoracenteses and closed thoracostomy sets; f. Tracheostomy or cricothyrotomy set; g. Tourniquets; h. Vascular cutdown sets; i. Laryngoscopes and endotracheal tubes; j. Urinary catheters with closed volume urinary systems; k. Pleural and pericardial drainage set; l. Minor surgical instruments; m. Splinting devices; n. Emergency obstetrical pack; o. Standard drugs (as determined by the facility), common poison antidotes, syringes and needles, parenteral fluids and infusion sets, and surgical supplies; p. Refrigerated storage for biologicals and other supplies requiring refrigeration, within the emergency department; and q. Stable examination tables. ST - H EMERGENCY CARE - Radio Communication Title EMERGENCY CARE - Radio Communication Statute or Rule 59A-3.255(7)(a)-(b) FAC; FS 59A-3.255(7) Each hospital offering emergency services and care have the capability to communicate via two-way radio with licensed EMS providers and their primary communications centers. The two-way radio communications system must meet the following provisions: (a) Conform to the State EMS Communications Plan applicable to emergency room or department communications; and (b) Any new communications system or an expansion of an 59A (a)-(b), FAC , FS Verify that there is a radio control system in place that has the capability of radio communication between the hospital and EMS and between other hospitals and that it is in working order.

44 Page 44 of 399 existing communication system shall be approved by the Department of Management Services, Division of Communications, prior to purchasing Emergency medical services; communication.-each licensed hospital with an emergency department must be capable of communicating by two-way radio with all ground-based basic life support service vehicles and advanced life support service vehicles that operate within the hospital's service area under a state permit and with all rotorcraft air ambulances that operate under a state permit. The hospital's radio system must be capable of interfacing with municipal mutual aid channels designated by the Department of Management Services and the Federal Communications Commission. ST - H EMERGENCY CARE - No Discrimination Title EMERGENCY CARE - No Discrimination Statute or Rule (3)(f), FS (f) In no event shall the provision of emergency services and care, the acceptance of a medically necessary transfer, or the return of a patient pursuant to paragraph (e) be based upon, or affected by, the person's race, ethnicity, religion, national origin, citizenship, age, sex, preexisting medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services, except to the extent that a circumstance such as age, sex, preexisting medical condition, or physical or mental handicap is medically significant to the provision of appropriate medical care to the patient. Verify that the policies and procedures pertaining to triage of patients are consistent with this provision. Interview emergency department staff and patients regarding the emergency department admissions process.

45 Page 45 of 399 ST - H NUTRITIONAL CARE - Dietetic Department Title NUTRITIONAL CARE - Dietetic Department Statute or Rule 59A , FAC 1. All licensed hospitals have a dietetic department, service or other similarly titled unit which is organized, directed and staffed, and integrated with other units and departments of the hospitals in a manner designed to assure the provision of appropriate nutritional care and quality food service. - Review the hospital-wide organizational chart and the dietetic department organizational chart. - The dietetic department should be directed by a full-time individual who oversees the food service operations and possibly nutritional care. - There should be staff designated for food service, such as supervisors, cooks, cold food preparation workers, porters, etc. - There should be staff designated for nutritional care, such as registered dietitians, registered dietetic technicians, diet clerks or diet aides, etc. - There should be adequate kitchen space and resources available to provide quality food service (unless the food is prepared offsite). - Observe staff to verify according to the organizational chart. ST - H NUTRITIONAL CARE - Dietetic Dept Director Title NUTRITIONAL CARE - Dietetic Dept Director Statute or Rule 59A (1)(a) (a) The dietetic department is directed on a full-time basis by a registered dietitian or other individual with education or specialized training and experience in food service management, who is responsible to the chief executive officer or his designee for the operations of the dietetic department. -Review the hospital-wide organizational chart and the dietetic department organizational chart. Verify that the dietetic department director is responsible to the CEO or his/her designee for the operations of the dietetic department. Review the position description of the dietetic department director to determine if he or she works full-time. Occasionally, the dietetic department director will also be designated as director over another department. If this situation exists, verify that the dietetic department director works full-time by the facility's definition of Full Time Equivalents. Determine also if there is adequate direction of the department in this case through quality outcomes (kitchen sanitation, competent staff, and food quality). -Review the credentials of the dietetic department director. If the dietetic department director is a registered dietitian,

46 Page 46 of 399 ST - H NUTRITIONAL CARE - Registered Dietitian verify current registration. If the dietetic department director is not a RD, then review past education, training, and experience. Determine if the dietetic department director's education, training, and experience are adequate for the size and complexity of the hospital dietetic department services. For a large organization, the education of the dietetic department director should be equivalent level of the RD (i.e. Bachelor's degree). The education of the dietetic department director, if not a RD, should include food service management. The dietetic department director responsibilities may include: Managing food service employees o Orientation, work assignments, supervision of work and food safety. o Personnel performance. Budgeting. Menu planning, recommending supplies to be purchased, maintaining essential records of cost, menus, personnel, etc. Participation in regularly scheduled conferences with the administration and department heads. Quality improvement or Performance Improvement. Management of auxiliary services, such as catering. Title NUTRITIONAL CARE - Registered Dietitian Statute or Rule 59A (1)(b), FAC (b) If the director of the dietetic department is not a registered dietitian, the hospital employs a registered dietitian on at least a part-time or consulting basis to supervise the nutritional aspects of patient care and assure the provision of quality nutritional care to patients. The consulting dietitian shall regularly submit reports to the chief executive officer concerning the extent of services provided. - Request information on all of the staff designated to provide nutritional care, such as registered dietitians (RDs) and dietetic technicians, registered (DTRs). - Request the position descriptions and credentials of all these staff. - Interview the RDs and the nutritional care staff who assist them, as available, to verify their employment and nutritional care responsibilities. - The intent of the regulation is to ensure that there are enough RDs on staff to assure the provision of quality nutritional care to patients. Having one RD on staff does not necessarily meet the requirement. - Staffing of RDs should be in accordance with the hospital size, patient needs and complexity of patients served. DTRs often work in partnership with RDs to assist in the nutrition care process. Further information about RD and DTR credentials and their roles can be found at the Academy for Nutrition and Dietetics website at - If there are consultant registered dietitians, request to see the contract to determine if she or he supervises the nutritional aspects of patient care and provides adequate services for quality nutritional care to patients. Additionally,

47 Page 47 of 399 ST - H NUTRITIONAL CARE - Registered Dietitian Svcs request the consultant reports submitted to the CEO for the past 6 months to verify services provided. - Quality nutritional care may include: Providing timely nutritional assessment according to facility policies and procedures and standards of practice and document this in the patient medical record. Providing diet instructions and counseling according to facility policies and procedures and standards of practice and document in the patient medical record. Developing regular and therapeutic diets to ensure they meet the nutritional needs of the patients to the greatest extent possible. Developing and implementing in-service education programs for dietary services and nursing personnel. Developing nutritional care policies and procedures. Participating in interdisciplinary care planning. Participating in committees related to nutritional care. Participating in quality improvement or performance improvement. Title NUTRITIONAL CARE - Registered Dietitian Svcs Statute or Rule 59A (1)(c)1-6, FAC (c) Whether employed full-time, part-time or on a consulting basis, a registered dietitian provides at least the following services to the hospital on the premises on a regularly scheduled basis: 1. Liaison with administration, medical and nursing staffs; 2. Patient and family counseling as needed; 3. Approval of menus and modified diets; 4. Required nutritional assessments; 5. Participation in development of policies, procedures and continuing education programs; and 6. Evaluation of dietetic services. - Interview the registered dietitians to verify their involvement in these nutritional care responsibilities. - Review the written policies and procedures regarding nutritional care to determine if these services are provided and for evidence of the RD participating in their development. - Request the personnel record of the dietitian(s). Verify these services are included in their job description. - Review the regular and therapeutic menus to determine if the RD has approved them. - Review patient medical records to determine if required nutritional assessments were completed and patient and family counseling was provided according to policies and procedures and standards of practice. - Review staff continuing education programs to determine the RD's participation. - Interview the RD(s) about how they act as liaisons with other departments or services related to patient care. - Review committee information that the RDs participate in. - Request documentation regarding how the RD evaluates dietetic services, and participation in the hospital-wide QI or PI programs. - If the facility employs multiple RDs, these responsibilities may be shared or delegated to one or more individuals. - The "Clinical Nutrition Manager" may be delegated the responsibility of development of policies and procedures and evaluation of dietetic services.

48 Page 48 of According to 59A-3, a registered dietitian must provide required nutritional assessments and patient and family counseling as needed. ST - H NUTRITIONAL CARE - Annual Dietetic Review Examples of patients who may require a nutritional assessment include: - Patients requiring artificial nutrition by any means (i.e., enteral nutrition (tube feeding), total parenteral nutrition, etc.) - Patients whose medical condition, surgical intervention, or physical status interferes with their ability to ingest, digest or absorb nutrients; - Patients whose diagnosis or presenting signs/symptoms indicates a compromised nutritional status (e.g., anorexia nervosa, bulimia, electrolyte imbalances, dysphagia, malabsorption, end stage organ diseases, etc.); - Patients whose medical condition can be adversely affected by their nutritional intake (e.g., diabetes, renal diseases, etc.). Title NUTRITIONAL CARE - Annual Dietetic Review Statute or Rule 59A (1)(d)(1)-(5), FAC (d) At least annually, a registered dietitian conducts a review and evaluation of the dietetic department to include, but not be limited to: 59A (1)(d)1-5, F.A.C. 1. A review of menus for nutritional adequacy; 2. A review of tray identification methods, patients who are not receiving oral intake, and the elapsed time between the evening meal and the next substantial meal; 3. A review of the counseling and instruction given to patients and their families with special dietary needs; 4. A review of committee activities concerning nutritional care. 5. A review of the appearance, palatability, serving temperature, patient acceptability and choice, and retention of nutrient value of food served by the dietetic department. Look for documentation that these evaluations have occurred annually. - Request information to verify that the current regular and therapeutic menus have been reviewed for nutritional adequacy annually. There is no directive as to how the RD reviews the menus for nutritional adequacy. Common practice is that they will have a computerized nutrient analysis of their menus, although this is not required. - Request information about their review of tray identification methods. The dietetic department may conduct audits on the accuracy of their tray identification system. - Interview the RD about how he/she tracks patients who are not receiving oral intake. Look to see how they track this, in writing or electronically. The dietetic department must track patients who are not receiving any oral intake without enteral or parenteral support for several days, so that the RD can ensure that these patients do not experience weight loss or nutritional deficiencies during their hospital stay. - Interview the RD about how he/she reviews the elapsed time between the evening and the next substantial meal. - Interview the RD about how he/she reviews patient and family diet counseling and instruction. Ask for written information about how this evaluation is done. Common practice is that they will audit the number of diet counseling/instructions ordered by physicians or per policy against the number of diet counseling/instructions actually completed. They may also track the types of diet counseling/instructions done. - Interview the RD regarding the committees he/she participates in and ask about how she/he reviews the committee

49 Page 49 of 399 ST - H NUTRITIONAL CARE - Dietetic Services Contract activities. Ask for written documentation about this review. - Interview the RD about how she/he reviews the quality of food served by the dietetic department. This review includes reviewing the appearance, palatability, serving temperature, patient acceptability and choice, and retention of nutritive value. Ask for written documentation of this review. Common practice is that they conduct test trays to evaluate the food palatability, appearance and serving temperature, although not required. Common practice for evaluating patient acceptability and choice is by patient interviews and patient satisfaction surveys, although not required. Title NUTRITIONAL CARE - Dietetic Services Contract Statute or Rule 59A (1)(e), FAC Nothing in this section shall prevent a hospital from employing an outside food management company for the provision of dietetic services, provided the requirements of this section are met, and the contract specifies this compliance. - Ask the Dietetic Department Director if the hospital contracts with an outside food management company. - If the hospital contracts an outside food management company, ask to see the current contract. - Review the contract to determine if it includes provisions that the requirements of this section are met. ST - H NUTRITIONAL CARE - Sufficient Personnel Title NUTRITIONAL CARE - Sufficient Personnel Statute or Rule 59A (1)(f), FAC (f) The dietetic department, service or other similarly titled unit employs sufficient qualified personnel under competent supervision to meet the dietary needs of patients. - Observe the dietetic department personnel performing various operations of the department including food preparation, food storage, tray service, sanitation, diet order processing, medical nutrition therapy, etc. - Interview dietetic department personnel about their assigned duties. - If concerns are identified, review credentials and training records of personnel and related dietetic department policies and procedures. Also, if concerns are identified, review how staff are supervised in their duties. - Evaluate processes and outcomes of the various dietetic department operations to determine sufficient, qualified personnel. Poor outcomes from insufficient or unqualified staff might include poor quality meals, unsanitary kitchen

50 Page 50 of 399 ST - H NUTRITIONAL CARE - Dietetic Staff Instruction conditions, late meals, and inadequate medical nutritional therapy Title NUTRITIONAL CARE - Dietetic Staff Instruction Statute or Rule 59A (1)(g)1-6, FAC (g) Personnel in the dietetic department receive, as appropriate to their level of responsibility, instruction in: 1. Personal hygiene and infection control; 2. Food handling, preparation, serving and storage; cleaning and safe operation of equipment; 3. Waste disposal; 4. Portion control; 5. Diet instruction. 6. The writing of modified diets and the recording of pertinent dietetic information in the patient's medical record. - Review staff development or in-service records to determine that dietetic department personnel have received instruction, as appropriate in: Personal hygiene and infection control Food handling (also known as food safety), food preparation, serving and storage Cleaning and safe operation of equipment Waste disposal Portion control Diet instruction The writing of modified diets and the recording of pertinent dietetic information in the patient's medical record. - Review job descriptions, if necessary to determine which areas of instruction are necessary for personnel. For example, a cook would not require instruction in recording pertinent dietetic information in the patient's medical record; conversely, a dietetic technician would not require instruction in cleaning and safe operation of equipment, if he/she does not use kitchen equipment. - Interview personnel during observations of the dietetic department regarding their training, particularly if there are concerns about their competence. - This instruction should be provided to new personnel during orientation, and updated when processes and policies change. This instruction is not required quarterly. ST - H NUTRITIONAL CARE - Qrtrly Training & Records Title NUTRITIONAL CARE - Qrtrly Training & Records Statute or Rule 59A (1)(h), FAC

51 Page 51 of 399 (h) Personnel in the dietetic department receive at least quarterly in-service training of which a record is kept by the dietetic department. - Review staff development or in-service records to determine that dietetic department personnel have received at least quarterly in-service training. - Interview personnel during observations of the dietetic department regarding their duties and training. - The in-service topics may include those specified in 59A (1)(g)(1)-(6), F.A.C. but these are not required to be conducted quarterly. ST - H NUTRITIONAL CARE - Dietetic Policies Title NUTRITIONAL CARE - Dietetic Policies Statute or Rule 59A (1)(i)1-4, FAC (i) The dietetic department, service or other similarly titled unit is guided by written policies and procedures that cover food procurement, preparation and service. Dietetic department policies and procedures are developed by the director of the dietetic department with nutritional care policies and procedures developed by a registered dietitian, subject to annual review, revised as necessary, dated to indicate the time of last review, and enforced. Written dietetic policies shall include at least the following: 1. A description of food purchasing, storage, inventory, preparation, service, and disposal policies and procedures. 2. A requirement that diet orders be recorded in the patient's medical record by an authorized individual before the diet is served to the patient. 3. The proper use and adherence to standards for nutritional care as specified in the diet manual which is at least in accordance with the Recommended Dietary Allowances (1989) of the Food and Nutrition Board, National Research Council and National Academy of Sciences. 4. A requirement for patients who are on oral intake and do -Review the dietetic department policy and procedures to determine if they were developed by the dietetic department director. -Review the nutritional care policies to determine if they were developed by the Registered Dietitian (RD). Look for the date of the last review of all of the policies, which must be done annually. -Determine if the dietetic polices include the topics from Make observations of the dietetic department operations throughout the survey to determine if these policies are enforced and reflect current practice. If there are concerns identified regarding the enforcement of these polices, interview the dietetic department director and/or the RD about this. -These dietetic polices should reflect current standards of practice, particularly in nutritional care. -For #1: Review the written policy regarding food purchasing, storage, inventory, preparation, service, and disposal. Make observations in the food storage areas, of food preparation, food service, and food disposal. Does the dietetic department have enough food to serve the menu and maintain a week's supply of non-perishable food? Does the dietetic personnel appear to be following the written policies for food preparation, service, and disposal? Is quality food served? If the dietetic personnel do not appear to be following the written policies, interview them about their instruction and training for their job duties. Additionally, interview the dietetic department director regarding the enforcement of these policies. -For #2: Review the written policy regarding how diet orders are recorded in the patient's medical record by an authorized individual before the diet is served to the patient. During the review of sampled medical records, look for a written diet order by an authorized individual. Verify the diet orders of these same patients in the dietetic department to determine that they match. Interview the RD about how diet orders are written and by whom. Interview other staff

52 Page 52 of 399 not have specific dietary requirements, that at least three meals or their equivalent be provided daily, with not more than a 15 hour span between the evening meal and breakfast. involved in the process of how the diet order is communicated to the dietetic department. Observe these same patients during meal service to determine if they receive the ordered diet. -For #3: Review the written policy regarding the proper use and adherence to standards for nutritional care as specified in the diet manual. The diet manual should be a current edition, including the latest standards of nutritional practice. -This rule requires that the nutritional standards be at least in accordance with the Recommended Dietary Allowances (RDAs) (1989) of the Food and Nutrition Board, National Research Council and National Academy of Sciences. The RDAs have since been replaced by the Dietary Reference Intakes (DRIs). Although the state law does not require hospitals to use the most current RDAs, they are required to use the most current nutritional standards under the federal law. -Ask to look at the diet manual that is used by the dietetic department. Review the hospital menus to see that they reflect at least the 1989 nutritional standards. Look to see if the therapeutic and modified diets reflect the standards in the hospital diet manual. -Also, review patient education materials to determine if they are based on current nutritional standards. -For #4: Review the written policy regarding meal service times, to determine that there is not more than a 15 hour span between the evening meal and breakfast. Observe meals to determine if they are served on time according to the policy. Interview patients regarding the timeliness of meals and the span of time between the evening meal and breakfast. -If there are concerns identified regarding the enforcement of these polices, interview the dietetic department director and/or the RD about this. ST - H NUTRITIONAL CARE - Dietetic Policies Title NUTRITIONAL CARE - Dietetic Policies Statute or Rule 59A (1)(i)5-16, FAC (i)... Written dietetic policies shall include at least the following and enforced: 5. A requirement that temperatures for holding and serving cold foods be below 45 degrees F, and for hot foods be above 140 degrees F. 6. A requirement that a supply of non-perishable foods sufficient to serve a hospital's patients for at least a one week period be available. - #5 Review the written policy regarding the holding and serving temperatures of cold and hot foods. The current Florida Food Hygiene Code requires that cold food be held at 41 F, rather than 45 F. Observe cold food held under refrigeration and during meal service. Look at the refrigerator thermometers. Ask the dietetic department personnel to take temperatures of cold foods on the tray line and elsewhere to demonstrate their knowledge and skill (it is permissible for the surveyor to take temperatures, if the situation warrants). Is the cold food held under proper temperature? Observe food held hot on the tray line, in the oven, on the stove, and in warming equipment. Ask the dietetic department personnel to take temperatures of hot foods on the tray line, or elsewhere to demonstrate their knowledge and skill (it is permissible for the surveyor to take temperatures, if the situation warrants). Is the hot food

53 Page 53 of A requirement that written reports of sanitary inspections be kept on file, with a record of actions undertaken to comply with recommendations. 8. A description of the role of the dietetic department in the hospital's internal and external disaster plans. 9. Menus. 10. The role of the dietetic department in the preparation, storage, distribution and administration of enteric feeding, tube feeding and total parenteral nutrition programs. 11. Alterations in diets or diet schedules, including the provision of food service to patients who do not receive regular meal service. 12. Ancillary dietetic services, as appropriate, including food storage and kitchens on patient care units, formula supply, cafeterias, vending operations and ice making. 13. Personal hygiene and health of dietetic personnel. 14. A description of dietetic department policies and procedures designed to provide for infection control including a monitoring system to assure that dietetic personnel are free from communicable infections and open skin lesions. 15. A description of the identification system used for patient trays and other methods for assuring that each patient receives the appropriate diet as ordered. 16. Safety practices, including the control of electrical, flammable, mechanical, and as appropriate, radiation hazards. held at proper temperature? If there are concerns, ask to review their temperature logs if they have them (not required). - #6 Review the written policy regarding the supply of non-perishable foods sufficient to serve a hospital's patients for at least a one-week period. Obtain the patient census. Review all dry food storage areas. The one-week supply of non-perishable food does not have to be stored separately; however, some hospitals may separate and secure their non-perishable food supply for inventory control. The hospital must have measures in place to minimize the risk of tampering or other malicious, criminal, or terrorist actions on their food supplies. Observe the non-perishable food supply to determine if sufficient to serve the hospital patients for at least a week. Food stored in the refrigerators and freezers cannot be included in the one week non-perishable supply, unless the food can be stored at room temperature without spoiling or making the food unsafe to eat. If the hospital does not have a policy regarding their one-week supply of non-perishable food, use the hospital ' s regular menu as a guide for portions and food groups, to evaluate whether the hospital has sufficient one week non-perishable food supplies on hand to serve their hospital patients. - Ask the dietetic department personnel how they periodically rotate this food supply, to ensure that quality is maintained. - #7 Review the written policy regarding how written reports of sanitary inspections are kept on file and acted upon to comply with recommendations. The Department of Health no longer conducts quarterly kitchen sanitation inspections. However, the local jurisdiction (county or city) may continue to require food permits and sanitation inspections. - Ask the hospital who is conducting sanitary inspections. Review the sanitary inspection reports conducted in the last year. Ask if the kitchen has been inspected by any regulatory agency for food safety and sanitation in the past year. If so, request the sanitation reports Review the dietetic department's corrective actions for any sanitation citations included on these reports. The dietetic department's corrective actions should be in writing, in any format they chose. - #8 Review the written policy regarding the description of the role of the dietetic department in the hospital's internal and external disaster plans. - This policy may be part of the hospital-wide internal and external disaster plans. These plans should address how the dietetic department utilizes staff, equipment, food, and supplies during various types of internal and external disaster situations. - See also Comprehensive Emergency Management Plan at H If there are concerns identified regarding these polices, the surveyor should consult with a Life Safety Code surveyor.

54 Page 54 of #9 Review the written policy regarding menus. This policy may include how menus are planned for regular, modified and therapeutic diets; the type of menus (non-selective vs. selective; restaurant style); the menu cycle; how menus are revised; how menus are reviewed for nutritional adequacy; and how menu items are substituted, etc. - Review the hospital regular and therapeutic menu cycle. Observe a meal to determine how the menu is followed. If the hospital uses a selective menu, interview dietetic department personnel about this process. Look at patient meal trays to determine if their menu selections are honored within their dietary restrictions. Interview patients about their menu selections. - #10 Review the written policy regarding the role of the dietetic department in the preparation, storage, distribution, and administration of enteral feeding, tube feeding, and total parenteral nutrition programs. Many hospitals do not store their enteral formulas in the dietetic department. The enteral formulas may be stored in Central Supply and/or Pharmacy. Ask the RD if any enteral products or infant formulas are prepared in the dietetic department. If they prepare enteral products or infant formulas, observe this process for sanitary technique and accuracy of preparation. Observe how enteral products once prepared or opened are stored. Interview the RD about his/her role in nutritional assessment of patients receiving enteral nutrition support (tube feedings) and making recommendations for nutrition support. Parenteral Nutrition (PN) mixtures are usually prepared in the Pharmacy Department, not the dietetic department. Interview the RD about their role in nutritional assessment of PN patients and making recommendations for nutrition support. - Nursing personnel usually administer enteral and parenteral nutrition. Interview the RD about their role in the distribution and administration of enteral and parenteral feedings. Observe patients receiving enteral and parenteral feeding. Check the type and amount of formula the patient is receiving to determine if it corresponds to the health care practitioner's order. - #11 Review the written policy regarding the diet alterations and schedules, including the provision of food service to patients who do not receive regular meal service. These policies may include how diets are altered according to physician's orders and how they meet patient's nutritional needs. They may also include how early and late trays are served for patients in which test/treatments/procedures may interfere with regular meal service. They may include how supplemental feedings and snacks are provided and how small frequent meals are served to patients requiring these. Observe the process of diet alterations and schedules, such as late tray service and supplemental feedings. - #12 Review the written policy regarding the dietetic department's ancillary dietetic services, as appropriate, including food storage and kitchens on patient care units, formula supply, cafeterias, vending operations and ice making. This may also include catering and restaurant services. Interview the dietetic department director about any ancillary dietetic services provided. Observe the ancillary services that involve patient care to determine if they reflect the written policies.

55 Page 55 of #13 Review the written policy regarding personal hygiene and health of dietetic personnel. This policy may include dietetic department personnel's requirements for their cleanliness, clothing, shoes, hair, nails, jewelry specifications, tobacco use, eating and drinking, and hand washing. - Observe the personal hygiene of dietetic department personnel to determine if it reflects the policy. - Observe dietetic department personnel for any signs or symptoms of infection or with conditions that cause persistent sneezing, coughing, or a runny nose or discharges from the eyes, nose, or mouth. - #14 Review the written policy regarding infection control including a monitoring system to assure that dietetic personnel are free from communicable infections and open skin lesions. - The policy should address those signs and symptoms that would exclude dietetic department personnel from working in any area of a food service establishment in any capacity in which there is a likelihood of such person contaminating food or food-contact surfaces with pathogenic organisms, or transmitting disease to other individuals. Some of these signs and symptoms include boils, infected wounds, sores, vomiting, diarrhea, jaundice, sore throat with fever and an acute respiratory infection. Additionally, the policy should include that if the dietetic department director has reason to suspect that an employee has contracted any disease in a communicable form or has become a carrier of such disease that can be transmitted by normal food service operation, the Department of Health shall be notified immediately. - The policy should include that dietetic department personnel must report these signs and symptoms to the dietetic department director. - Observe dietetic department personnel for any signs or symptoms of infection. Interview the dietetic director about how he/she monitor dietetic personnel for signs and symptoms of communicable infections and open skin lesions. - #15 Review the written policy describing the identification system used for patient trays and other methods for assuring that each patient receives the appropriate diet as ordered. - Some hospitals use printed menus identified with the patient name and room number and diet order. Others use computer printed menus or tray slips identified with the patient name, room number and diet order. Observe the tray identification system used for patient trays during meal service and tray delivery. Interview the dietetic department director and/or RD about this system. Interview patients about the accuracy of their meal trays. - #16 Review the written policy regarding safety practices, including the control of electrical, flammable, mechanical, and as appropriate, radiation hazards. As you make observations of the dietetic department, make note of potential hazardous conditions, such as frayed electrical cords, a radio put on a shelf over a sink with a cord plugged into the wall outlet; paper stored near a gas stove burner, and meat slicer without protective knife guard when not in use to protect employees from injury. Look to see if the policy addresses safety practices for preventing scald burns, injuries

56 Page 56 of 399 ST - H NUTRITIONAL CARE - State Hygiene Code from equipment use (slicers, mixers, food processors, etc.), falls (from slick floors, tripping over objects), and heavy lifting. Observe dietetic personnel for their safety practices during their work duties to determine if the policy is followed. Title NUTRITIONAL CARE - State Hygiene Code Statute or Rule 59A (1)(i)(17), FAC (i)... Written dietetic policies shall include at least the following and enforced: 17. Compliance with Chapter 64E-11. F.A.C. - #17 Hospitals are no longer defined as a foodservice establishment according to Florida Statute Section ; therefore, hospitals would no longer have to comply with 64E-11. However, some local jurisdictions might continue inspections under their local code. Their local code can require that the hospital follow the state hygiene code (64E-11, FAC). In these cases, the hospital must have a policy regarding how the dietetic department ensures proper food hygiene according to Chapter 64E-11, FAC AHCA cannot enforce 64E-11, FAC - AHCA has the authority to enforce the rules related to food safety and sanitation included in the hospital rule, Chapter 59A-3(1)(j-p). [See H0076]. Refer to the AHCA-HQA-Field Operations Survey Findings-Referral Matrix when food safety and sanitation concerns are identified. - [FYI: If the hospital is federally certified, they must use the current Food and Drug Administration Food Code as their guide for their hospital food safety program. Federally-certified hospitals must have written policies that address food safety and sanitation standards, which must be incorporated in the hospital-wide infection control program.] ST - H NUTRITIONAL CARE - Environment & Equipment Title NUTRITIONAL CARE - Environment & Equipment Statute or Rule 59A (1)(j)-(p), FAC (j) The dietetic department is designed and equipped to facilitate the safe, sanitary, and timely provision of food service to meet the nutritional needs of patients. (k) The dietetic department shall have adequate equipment (j) Determine from observations of the various functions in the dietetic department, if it is designed and equipped to facilitate safe, sanitary, and timely provision of food service to meet the nutritional needs of patients. For this requirement, look for poor outcomes, such as unsanitary conditions in the kitchen, hazardous conditions, patient complaints about poor quality food, inadequate diets, and a pattern of weight loss or nutritional deficiencies in

57 Page 57 of 399 and facilities to prepare and distribute food, protect food from contamination and spoilage, to store foods under sanitary and secure conditions, and to provide adequate lighting, ventilation and humidity control. (l) The dietetic department shall thoroughly cleanse and sanitize food contact surfaces, utensils, dishes and equipment between periods of use, shall ensure that adequate toilet, hand-washing and hand-drying facilities are conveniently available, and provide for adequate dishwashing and utensil washing equipment that prevent recontamination and are apart from food preparation areas. (m) The dietetic department shall ensure that all walk-in refrigerators and freezers can be opened from inside and that all food and nonfood supplies are clearly labeled. Where stored in the same refrigerator, all nonfood supplies and specimens shall be stored on separate shelves from food supplies. (n) The dietetic department shall implement methods to prevent contamination in the making, storage, and dispensing of ice. (o) The dietetic department shall ensure that disposable containers and utensils are discarded after one use, and that worn or damaged dishes and glassware are discarded. (p) The dietetic department shall hold, transfer, and dispose of garbage in a manner which does not create a nuisance or breeding place for pests or otherwise permit the transmission of disease. patients. (k) To determine if the dietetic department has adequate equipment for food storage, preparation and distribution, look for the following examples: Walk-in refrigeration or freezer units that are overstocked to the extent that there is insufficient airflow food, food is not properly cooled, proper temperature is not maintained, and may cause injury to dietetic personnel. Food not prepared properly, due to lack of appropriate equipment, such as pureed food not prepared to have a smooth even texture. Cold or hot food not held at proper temperature due to lack or poor design of holding equipment. Meal trays not served timely due to insufficient tray delivery carts or equipment. Meals are not served at palatable temperatures due to lack of or poor design of equipment to retain heat or cold. Poor nutrient retention of food due to lack of proper preparation with appropriate equipment for quantity food service. (l) During observations in the dietetic department, look at the physical environment for evidence of: stagnant air ventilation, poorly lit areas, and High humidity conditions resulting in mold growth on equipment, walls, vents, etc. - During observations in the dietetic department, look for evidence of: Adequate toilet facilities Conveniently available hand washing sinks, equipped with a sanitary method for hand drying. Adequate dishwashing and utensil washing equipment that is located apart from the food preparation area. Most hospitals have mechanical dishwashers and 2 or 3 compartment sinks for large equipment washing. Some may have pot washing machines. Look to see if this equipment is operational and designed to accommodate the volume of dishes and utensils used. Observe that the soiled dishes are kept separate from the clean dishes, so that they are protected from contamination. (m) All walk-in refrigerators and freezer unit can be opened from the inside. This is to prevent an individual from being locked inside the walk-in units. Check each walk-in door. Ask the dietetic department personnel to demonstrate how they open the door from inside the unit if it is locked on the outside. There should not be any locks installed by the hospital on the outside of the door to prevent the door from opening from the inside of the unit. All food and non-food supplies are clearly labeled with their identity. Look for separation of non-food supplies and specimens stored on separate shelves from food to prevent contamination. (n) Prevention of ice contamination during making, storage and dispensing. Look at the icemakers and ice storage bins in the dietetic department to see if they are clean on the interior and exterior surfaces. Dietetic personnel should dispense ice with dispensing utensils, such as scoops or tongs that are stored on a clean surface or holder between use, and in a manner to protect it from contamination. Observe storage holders for ice scoops to determine if they are clean. Dietetic personnel should not touch ice for consumption or display with bare hands or contaminated gloves.

58 Page 58 of 399 ST - H NUTRITIONAL CARE - Equipment Maintenance (o) Disposable containers, intended for single-use are discarded. Dishes and glassware are in good condition. Check the dietetic department's dishes, glassware, and eating utensils to ensure they do not have breaks, pits, chips, scratches, scoring, crazing, decomposition, distortion, and other similar imperfections. The dishes, glassware, and eating utensils should be easily cleanable and smooth. (p) Garbage is held, transferred, and disposed of in manner that does not create a nuisance or breeding place for pests or otherwise permit transmission of disease. Check that garbage is held in leak proof, nonabsorbent containers covered with tight fitting lids. Check the dumpsters and compactors located outside to see that they are kept clean and maintained in good repair. Look for leaks from the containers, foul odors present and pests observed around the dumpster or compactor would indicate lack of cleanliness and good repair. See also housekeeping section for the storage and removal of garbage (H0124). - Interview dietetic department personnel who are directly responsible for these procedures. Ask about their training and how they report problems to management. Review the related written policies if there are identified problems and interview the dietetic department director and/or RD about the policy development and/or enforcement. Title NUTRITIONAL CARE - Equipment Maintenance Statute or Rule 59A (1)(q), FAC (q) All matters pertaining to food service shall comply with Chapter 64E-11, F.A.C. Information on specifications, operation and maintenance of all major and fixed dietetic department equipment shall be maintained. A preventive and corrective maintenance program on such equipment shall be conducted and recorded. -Hospitals are no longer defined as a foodservice establishment according to Florida Statute Section ; therefore, hospitals would no longer have to comply with 64E-11. However, some local jurisdictions might continue inspections under their local code. Their local code can require that the hospital follow the state hygiene code (64E-11, FAC). In these cases, the hospital must have a policy regarding how the dietetic department ensures proper food hygiene according to Chapter 64E-11, FAC. AHCA cannot enforce 64E-11, FAC -AHCA has the authority to enforce the rules related to food safety and sanitation included in the hospital rule, Chapter 59A-3(1)(j-p). [See H0076]. Refer to the AHCA-HQA-Field Operations Survey Findings-Referral Matrix when food safety and sanitation concerns are identified. -Request to see the information regarding the specifications, operation, and maintenance of all major and fixed dietetic department equipment (i.e. range, convection oven, floor mixer, slicer, refrigerator, freezer, dishwasher, fryer, steamer, beverage dispensers, etc., if they have these). -Request to see the preventative and corrective maintenance program for this equipment (the Maintenance department may have these records). -During observations in the dietetic department, make note of any essential non-operational equipment.

59 Page 59 of 399 ST - H NUTRITIONAL CARE - Written Orders If concerns are identified, interview the dietetic department director about the preventative and corrective maintenance program. Title NUTRITIONAL CARE - Written Orders Statute or Rule 59A (1)(r), FAC (r) Dietetic services are provided in accordance with written orders by the individual responsible for the patient and appropriate information shall be recorded in the patient's medical record. Such information includes: 1. A summary of the dietary history and a nutritional assessment when the past dietary pattern is known to have a bearing on the patient's condition; 2. Timely and periodic assessments of the patient's nutrient intake and tolerance to the prescribed diet modification, including the effect of the patient's appetite and food habits on food intake and any substitutions made; 3. A description or copy of diet information forwarded to another organization when a patient is discharged. During review of patients' medical records, verify diet orders, diet consults, diet instructions are written by the individual responsible for the patient (physician, physician assistant, or Advanced Registered Nurse Practitioner). - Review nutritional assessments in the medical record, if applicable. Not all patients will have a nutritional assessment conducted. Most hospitals have a system in which patients are screened upon admission for nutritional problems (based on criteria the hospital establishes from their hospital population). If the patient is identified to have a nutritional problem, based on the hospital criteria, then the patient is referred for a nutritional assessment. Review the dietetic department policy related to this, to know their admission nutrition screening criteria. - Look to see if the nutritional assessment includes a summary of diet history, if relevant, and obtainable. - Review the medical record to see if timely and periodic assessment of the patient's nutrient intake, when applicable. If a patient is identified as having poor meal intake and at nutritional risk, often the RD will conduct a food intake study to determine how many calories, protein, and other nutrients were consumed. - Review the nutrition progress notes to determine if they addressed the patient's tolerance to the prescribed modified diet, including appetite, and cultural, religious and ethnic food habits. Also, note if any substitutions were made or should have been made to accommodate the resident's appetite and food habits. - Review the medical records of discharged patients and look for a description or copy of diet information that was forwarded to another organization, such as a nursing home or assisted living facility. - If there are identified concerns, review the written nutritional care polices. - Also, interview the Registered Dietitian about identified concerns. ST - H NUTRITIONAL CARE - Order Confirmation Title NUTRITIONAL CARE - Order Confirmation Statute or Rule 59A (1)(s), FAC

60 Page 60 of 399 (s) Within 24 hours of admission and within 24 hours of any subsequent orders for diet modification, the diet order is confirmed by the practitioner responsible for the patient receiving oral alimentation. - Review the written policies regarding the dietetic department's system of how they confirm orders for diet modification by the practitioner responsible for the patient receiving oral alimentation. Oral alimentation is the act or process of affording nutriment (something that nourishes or promotes growth, provides energy, repairs body tissues, and maintains life) or nourishment through the gastrointestinal tract. Diet modification would be any diet other than a regular diet, with regular consistency. - Review medical records to determine if this process is occurring within 24 hours of admission and within 24 hours of any subsequent orders for diet modification. - Interview dietetic department personnel who are directly responsible for this process. - Also, interview the Registered Dietitian about identified concerns. ST - H NUTRITIONAL CARE - Quality Control Title NUTRITIONAL CARE - Quality Control Statute or Rule 59A (1)(t)1-7, FAC (t) The hospital has appropriate quality control mechanisms to assure that: 1. All menus are evaluated for nutritional adequacy. 2. There is a means for identifying those patients who are not receiving oral intake. 3. Special diets are monitored. 4. The nutritional intake of patients is assessed and recorded as appropriate. 5. Effort is made to assure appetizing appearance, palatability, proper serving temperature, and retention of nutritional value of food. 6. Whenever possible, patient food preferences are respected and appropriate dietary substitutions are made available. 7. Surveys of patient acceptance of food are conducted, particularly for long-stay patients. - The dietetic department should have written policies about how they implement these quality controls. - Review these corresponding policies. - Interview the leadership position who supervises the dietetic department director about their knowledge of these quality control mechanisms Interview the Registered Dietitian about how menus are evaluated for nutritional adequacy. There is no directive as to how the RD evaluates the menus for nutritional adequacy. Common practice is that they have a computerized nutrient analysis of their menus, although this is not required. Request documentation to show that these menus are nutritionally adequate. Refer to H68-2. Interview the Registered Dietitian about how they identify those patients who are not receiving oral intake. Look to see how they track these patients in writing or electronically. Patients who are not receiving oral food intake may not be receiving any nutrition orally or receiving enteral and/or parenteral feedings. Ask the RD what he/she does when patients are not receiving oral food intake without enteral and/or parenteral feedings for several days. Refer to the guidance under H Interview the RD about how they monitor special diets. Ask about the quality controls to ensure that the patient receives the correct diet. During meal observations, do patients ordered special diets receive the correct diet? - 4. Interview the RD about how nutritional intake of patients is assessed and recorded as appropriate. From patient

61 Page 61 of 399 record reviews, were patients' nutritional intake assessed and recorded according to the dietetic department's policy? Patients would require assessment of nutritional intake based on nutritional needs Interview the RD and dietetic department director about how they ensure food is served with an appetizing appearance and proper serving temperature, and retains nutritive value. Common practice is that they conduct test trays and conduct meal rounds to interview patients to evaluate the food palatability, appearance and serving temperature, although not required. Ask to see written documentation of their quality control. During meal observations, did the patient meals look appetizing? From patient interviews, did patients complain about the appearance, taste, or temperature of the food? Refer to H Interview the RD and dietetic department director how they ensure that patient's food preferences are respected and that there are appropriate substitutions made available when a patient refuses food. - During observations in the hospital and dietetic department, look at the system in place to obtain and document patients' food preferences. During meal observations, look to see if patient's food preferences are respected. From patient interviews, ask patients if their food preferences are honored and what happens if they refuse food. Ask them if they are offered a similar substitution if they refuse food Interview the dietetic department director and RD about how surveys of patient food acceptance are conducted, particularly for long-stay patients. Some hospitals may conduct a written questionnaire for the patient or family to complete, although there are other methods to assess patient food acceptance. - Request documentation on this process. Interview a few long stay patients to determine if hospital personnel surveyed their food acceptance. During meal observations, did the patient meals look appetizing? From patient interviews, did patients complain about the hospital food? If so, ask who they complained to, and whether the issue was resolved. - If concerns are identified, interview the dietetic department director and/or RD. Also, interview the leadership position who supervises the dietetic department director about identified concerns with quality control mechanisms. ST - H PHARMACY - Procedures Title PHARMACY - Procedures Statute or Rule 59A (2), FAC (2) Each hospital shall develop and monitor procedures to assure the proper use of medications. Such procedures shall address prescription and ordering, preparation and dispensing, administration, and patient monitoring for medication effects. For purposes of providing medication services, each Class I -Interview the Pharmacy Director (i.e., Chief Pharmacist) and determine who the Consultant Pharmacist of Record is as required by the Florida Board of Pharmacy Permit. -Verify that the required institutional, community pharmacy permit(s) and pharmacist licensure(s) are current. -Determine that the hospital has a Pharmacy and Therapeutics interdisciplinary committee that meets regularly and that committee minutes are available.

62 Page 62 of 399 and Class II hospital shall have on the premises, and each Class III hospital shall have on the premises or by contract, a pharmacy, pharmaceutical department or service, or similarly titled unit, and, when applicable, shall present evidence that it holds a current institutional or community pharmacy permit under the provisions of the Florida Pharmacy Act, Chapter 465, Florida Statutes. -Determine that the facility has Pharmacy Policy and Procedures to ensure that the safe dispensing, prescription ordering, preparation, administration and proper monitoring of medication and that these policies are periodically reviewed. -How are Pharmacy Services involved in development and implementation of these policies and procedures? -How do the Pharmacy Services as provided meet the needs of the patients, ensure optimal selection of medication, minimize medication errors, identify adverse drug events and monitor all patients' drug regimens? -How are the facility pharmacists an integral part of the patient care activities? -Verify that Pharmacy Services are a part of the hospital Quality Improvement (QI) program. US Food and Drug Administration: American Society of Health System Pharmacists: National Institutes of Health: Florida Statutes Chapter 465: US Pharmcopeial Convention: ST - H PHARMACY - Formulary Title PHARMACY - Formulary Statute or Rule 59A (2)(a), FAC (a) Each hospital shall maintain a hospital formulary or drug list which is developed and maintained by appropriate hospital staff, which shall be regularly updated. The formulary shall include the availability of non-legend medications, but does not preclude the use of unlisted drugs. Where unlisted drugs are used, there shall be a written policy and procedure for their prescription and procurement. Selection of medications for inclusion on the formulary shall be based on need, effectiveness, risks, and costs. - Determine that the hospital has a drug formulary developed by appropriate hospital staff and that the Pharmacy Department is involved in the process. - What are the criteria for placing a drug on the formulary? - Do the criteria include need, effectiveness, risks, and costs? - Does the facility have a pharmacy policy for use of non-formulary drugs? - How often is the formulary drug list revised and updated? - How is the formulary drug list made available to the facility professional staff? - Does the Pharmacy Department monitor formulary drugs for safety and/or recall, and disseminate this information to the hospital professional staff? - Does the policy preclude the use of unlisted drugs? US Pharmcopeial Convention:

63 Page 63 of 399 ST - H PHARMACY - Auth to Prescribe Medications Title PHARMACY - Auth to Prescribe Medications Statute or Rule 59A (2)(b), FAC (b) Each hospital shall ensure that individuals who prescribe or order medications are legally authorized through the granting of clinical privileges. - How is the Pharmacy Department notified when a staff professional is granted or denied clinical privileges by the Governing Body regarding authorization to prescribe medication? - Review the Pharmacy Department policy regarding staff clinical privileges. - Is there a Pharmacy procedure in place to ensure that only authorized hospital staff can prescribe or order medications? Florida Statutes Chapter 465 ST - H PHARMACY - Preparing & Storing Title PHARMACY - Preparing & Storing Statute or Rule 59A (2)(c), FAC (c) All drugs shall be prepared and stored under proper conditions of sanitation, temperature, light, moisture, ventilation, security and segregation to promote patient safety and proper utilization and efficacy. - Review Pharmacy Policies and Procedures for drug storage to ensure they are consistent with professional principles. - Is the Pharmacy Director and/or designee monitoring implementation of these policies and procedures? - Tour the drug storage area to determine that drugs and biologicals are stored in accordance with manufacturer's directions and State and Federal requirements. - Determine that employees provide pharmaceutical services within the scope of their license and education. - Are all drugs checked by a pharmacist prior to dispensing? - Are pharmacy records of sufficient detail to monitor procurement, distribution and control of all medication products used in the hospital? - Does the Pharmacy Policy regarding storage specify that only staff licensed in accordance with Federal and State law can have legal access to facility drugs and biologicals? - All drugs and biologicals must be kept in locked storage areas accessible only to staff who in accordance with their

64 Page 64 of 399 license and practice act may have access to facility drugs and biologicals. - Review documentation that medication storage areas are periodically inspected in accordance with facility policy. US Food and Drug Administration: ST - H PHARMACY - Labeling Title PHARMACY - Labeling Statute or Rule 59A (2)(d), FAC (d) All medications shall be appropriately labeled as to applicable accessory or cautionary statements and their expiration date, shall be dispensed in as ready-to-administer forms as possible, and in quantities consistent with the patient's needs which are designed to ensure minimization of errors and diversion. - Review the Pharmacy labeling policy and determine how the Pharmacy ensures that outdated, mislabeled or otherwise unusable drugs and biologicals are not available for patient use. - Spot-check patient drug labels to ensure they conform with applicable state law; State law regarding patient's full name, prescriber's name, strength and quantity of drug dispensed. - Are appropriate accessory and cautionary statements including expiration date, lot and control number on the label as required? - Verify through observation, staff interview, and record review as required that the dispensing operation including labeling is performed under the supervision of a Pharmacist. - Is this supervision in accordance with applicable State laws and in a manner to promote patient safety? US Food and Drug Administration: ST - H PHARMACY - Prescription Review Process Title PHARMACY - Prescription Review Process Statute or Rule 59A (2)(e), FAC (e) The pharmacist shall review each order before dispensing the medication, with the exception of situations in which a licensed independent practitioner with appropriate clinical privileges controls prescription ordering, preparation and administration of medicine. The pharmacist shall verify the - Review Pharmacy policy to determine the facility prescription review process. - Interview staff pharmacists to verify that prescriptions or medication orders are reviewed by a pharmacist prior to dispensing. - How are medication orders reviewed by a pharmacist when the medication is removed from an automated dispensing machine or an on-site licensed pharmacy which is not open 24 hours a day, seven days a week?

65 Page 65 of 399 order with the prescriber when there is a question. - If concerns are identified regarding the prescription or drug order, are these concerns clarified with the individual prescriber? US Food and Drug Administration: American Society of Health System Pharmacists: ST - H PHARMACY - Preparing & Dispensing Title PHARMACY - Preparing & Dispensing Statute or Rule 59A (2)(f), FAC (f) All medications shall be prepared and dispensed consistent with applicable law and rules governing professional licensure and pharmacy operation and in accordance with professional standards of pharmacy practice. - All compounding, packaging, and dispensing of drugs must be conducted by a registered pharmacist or under the supervision of a registered pharmacist, performed consistent with state law and in accordance with professional standards of practice. - Review pharmacy dispensing policies and procedures to ensure that the dispensing process is in accordance with applicable laws and promotes patient safety. - Interview pharmacy and hospital staff to determine how drugs and biologicals are prepared and dispensed and do observation of on-site dispensing operations. - Determine if medications are dispensed in a timely manner, i.e., for the next dose of medication as ordered by the physician. American Society of Health System Pharmacists: ST - H PHARMACY - Patient Medication Profiles Title PHARMACY - Patient Medication Profiles Statute or Rule 59A (2)(g), FAC (g) A medication profile shall be developed and maintained by the pharmacy department for each patient and shall be available to staff responsible for the patient's care. The medication profile shall include at least the name, birth date, - Review the Pharmacy policy regarding patient profile information. - Interview pharmacists and do on-site observation to verify this information is maintained and updated for all current patients. - How is this information made available to facility health care staff involved in medication management?

66 Page 66 of 399 sex, pertinent health problems and diagnoses, current medication therapy, medication allergies or sensitivities, and potential drug or food interactions. American Society of Health System Pharmacists: ST - H PHARMACY - After Hour Process Title PHARMACY - After Hour Process Statute or Rule 59A (2)(h), FAC (h) The hospital shall develop and implement a process for providing medications when the pharmacy is closed that ensures adequate control, accountability, and the appropriate use of medications. If the pharmacy is not computerized and/or not open 24 hours a day, 7 days a week, how is the patient medication profile implemented and the information made available to facility patient care staff - If the pharmacy does not provide 24 hours a day, seven days a week service, review the Pharmacy Policy for after-hours Pharmacy entry by non-pharmacist health care professionals. - Who is designated to remove medications from the Pharmacy when a pharmacist is not on-site? Medications only in amounts sufficient for immediate patient needs should be removed. - Review required documentation (i.e., log) of any after-hour Pharmacy entry by a non-pharmacist. - Is there documentation of pharmacist review of this removal activity and that the removal correlates with current medication orders in the patient medication profile? - Is a pharmacist responsible for reviewing after hour medication supplies to ensure they are adequate and thereby minimize the need for non-pharmacist after hour's entry into the pharmacy? American Society of Health System Pharmacists: ST - H PHARMACY - Emergency Drugs Title PHARMACY - Emergency Drugs Statute or Rule 59A (2)(i), FAC (i) The hospital shall ensure there is an adequate and proper supply of emergency drugs within the pharmacy and in designated areas of the hospital. - Review Pharmacy policy regarding emergency drugs and their availability in patient care areas. - How are these drugs secured and who has the responsibility for monitoring drugs these drugs? - If used, are they immediately replaced by Pharmacy services?

67 Page 67 of If crash carts are used, who monitors the crash carts and how are supplies other than drugs replaced on the crash carts? - Who has the responsibility of periodically reviewing and updating what emergency drugs and supplies are available in the patient care areas? American Society of Health System Pharmacists: ST - H PHARMACY - Controlled Drugs Title PHARMACY - Controlled Drugs Statute or Rule 59A (2)(j), FAC (j) Receipt, distribution and administration of controlled drugs are documented by the pharmacy, nursing service and other personnel, to ensure adequate control and accountability in accordance with state and federal law. - Determine if there is a system, delineated in the facility Pharmacy Policies and Procedures that tracks movement of all scheduled drugs from point of entry into the hospital to point of departure. - Review the system of documentation of administration to the patient or destruction by nursing and medical staff. Determine Pharmacy responsibility of reviewing records of receipt, disposition and reconciliation of all scheduled drugs. - Does the system of review provide capability of readily identifying loss or diversion of all controlled substances? - Has the Pharmacy had a problem with loss or diversion of controlled drugs? - If so, how was it investigated and reported in accordance with State and Federal laws? - If the facility has not had a problem with loss or diversion of controlled drugs, is there a Pharmacy Policy and procedure to follow in the event that a problem is identified? American Society of Health System Pharmacists: ST - H PHARMACY - Drug Administration Title PHARMACY - Drug Administration Statute or Rule 59A (2)(k), FAC (k) The hospital shall ensure that the administration of drugs shall take place in accordance with written policies, approved - Review Pharmacy policies regarding drug administration. - Do their policies include drug delivery systems such as automated dispensing machines?

68 Page 68 of 399 by the professional staff and designed to ensure that all medications are administered safely and efficiently. - In addition to review of the patient profile do the policies address reporting and monitoring of adverse drug reactions, drug interactions, high risk medications, sound-alike drugs, including drug recall, etc.? - How are identified drug concerns and/or safety information provided to the facility patient care staff responsible for medication administration? American Society of Health System Pharmacists: ST - H PHARMACY - Consultant Pharmacist of Record Title PHARMACY - Consultant Pharmacist of Record Statute or Rule 59A (2)(l), FAC (l) Each hospital's pharmacy shall be directed by a licensed pharmacist, who may supervise satellite pharmacies, and who may be hired on a contract basis. The director of the hospital pharmacy, or other licensed pharmacists who are properly designated, shall be available to the hospital at all times, whether on duty or on call. - State law requires that a hospital Pharmacy has a Consultant Pharmacist of Record. This pharmacist may be the Director of Pharmacy or a designee, but this pharmacist must be licensed as a Consultant Pharmacist by the Florida Board of Pharmacy. - The pharmacist may be full-time or part-time in a small hospital, but is responsible for the overall administration of pharmacy services and development of the Hospital Pharmacy Policy and Procedures. - There must be sufficient staff to provide quality pharmacy services. Pharmacy services may be full-time 24 hours, seven days a week or part-time in small hospitals. - Quality pharmacy services include accurate and timely medication delivery, providing appropriate clinical services and participating in the hospital QI program. - Pharmacy services must meet the needs of the patient population. American Society of Health System Pharmacists: ST - H PHARMACY - Administration of Drugs Title PHARMACY - Administration of Drugs Statute or Rule 59A (2)(m), FAC (m) Administration of drugs shall be undertaken only upon the orders of authorized members of the professional staff, where - The Hospital Pharmacy must ensure that medication orders are accurate and that medications are administered as ordered.

69 Page 69 of 399 the orders are verified before administration, the patient is identified, and the dosage and medication is noted in the patient's chart or medical record. - If medications are returned to the pharmacy, is the reason for the return evaluated by a pharmacist (medication refusal, order change, medication error, etc.)? - Does the Pharmacy Department periodically observe medication administration? If so, review the documentation. American Society of Health System Pharmacists: ST - H PHARMACY - Investigational Medications Title PHARMACY - Investigational Medications Statute or Rule 59A (2)(n)1-5, FAC (n) Investigational medications shall be used only in accordance with specific hospital policy which addresses: 1. Review and approval of hospital participation in investigational studies by the appropriate hospital committee; 2. Requirements for informed consent by the patient; 3. Administration in accordance with an approved protocol; 4. Administration by personnel approved by the principal investigator after they have received information and demonstrated an understanding of the basic pharmacologic information about the medications; and 5. Documentation of doses dispensed, administered and destroyed. - Review the facility Pharmacy Policy and Procedures for use of investigational medications. - Has a process been implemented that investigational medications are safely controlled and administered? - Does the Pharmacy have a copy of the researcher's Institutional Review Board approval? - Procedures for use of investigational drugs are implemented as follows: hospital review committee approval, patient informed consent form, Pharmacy monitoring and dispensing, patient care staff education regarding possible concerns and/or side effects. - Is a research contact person and a designated Pharmacy contact person available 24 hours, seven days a week? Interview staff and do on-site review? American Society of Health System Pharmacists: ST - H PHARMACY - Monitoring System Title PHARMACY - Monitoring System Statute or Rule 59A (2)(o)1-4, FAC (o) Each hospital shall have a system for the ongoing monitoring of each patient for medication effectiveness and - Review the Pharmacy Policy and Procedures for reporting adverse drug reactions and medication errors. - Is a report immediately sent to the Pharmacy?

70 Page 70 of 399 actual or potential adverse effects or toxicity which includes: 1. A collaborative assessment of the effect of the medication on the patient based on observation and information gathered and maintained in the patient's medical record and medication profile; 2. A process for the definition, identification, and review of significant medication errors and adverse drug reactions are reported in a timely manner in accordance with written procedures. Significant adverse drug reactions shall be reported promptly to the Food and Drug Administration; - Review Pharmacy documentation of prompt investigation and reporting of findings to appropriate health care personnel and the hospital QI Committee. - Interview facility staff (Nursing, Pharmacy, Medical) regarding their awareness of the facility policy on reporting and documentation of medication errors and adverse drug reactions. - Is the Pharmacy Department proactive in the identification of adverse drug events (i.e., observation of medication pass, review of indicator drugs for change of dose, discontinued drug or drug held, etc.)? - How does the Pharmacy do on-going evaluation of the reporting system and is the reporting system non-punitive? - What sources of drug information are available in the pharmacy? - Is this information (i.e., Drug Interactions, ADR, Dosage, etc.) hard- copied or computerized? - How is drug information made available to the facility patient care staff? American Society of Health System Pharmacists: US Food and Drug Administration: 3. Information from the medication monitoring is used to assess the continued administration of the medication; 4. Conclusions and findings of the medication monitoring are communicated to the appropriate health care personnel involved in the patient's care. ST - H PHARMACY - Written Policies & Procedures Title PHARMACY - Written Policies & Procedures Statute or Rule 59A (2)(p), FAC (p) Each hospital shall have written policies and procedures governing the selection, procurement, distribution, administration, and record-keeping of all drugs, including provision for maintaining patient confidentiality. The policies and procedures shall be reviewed at least annually, dated to indicate time of last review, revised as necessary, and enforced. - How are the Pharmacy Policy and Procedures maintained and available to patient care staff? - Are they hard-copied or computerized? - Ask the Pharmacy Director to provide documentation that their policies which cover all areas of Pharmacy services including, medication availability, administration, record keeping, drug recall, etc., are reviewed annually and revised as necessary? - Do the Pharmacy policies reflect Pharmacy services as currently provided? US Food and Drug Administration: American Society of Health System Pharmacists :

71 Page 71 of 399 ST - H PHARMACY - Parenteral Nutrition Title PHARMACY - Parenteral Nutrition Statute or Rule 59A (2)(q), FAC (q) Parenteral nutrition services, when provided, shall be designed, implemented, and maintained to address assessment and reassessment of the patient, initial ordering and ongoing maintenance of medication orders, preparation and dispensing, administration, and assessing the effects on the patient. - If the Pharmacy Department provides Total Parenteral Nutrition, review the Pharmacy Policy and Procedures. - Does the facility have a nutritional support team and does a pharmacist participate? - Is the parenteral nutrition prepared by Pharmacy or is it ordered from the manufacturer already prepared? - If possible, observe the preparation (prepared under IV hood). - How does pharmacy monitor the effectiveness if there is not a nutritional support team? - Does the Pharmacy Department have a pharmacist certified in parenteral nutrition? US Food and Drug Administration: American Society of Health System Pharmacists: ST - H SURGICAL DEPT - Policies & Procedures Title SURGICAL DEPT - Policies & Procedures Statute or Rule 59A (3)(a)1-5;(b)-(g) FAC (3) Surgical Department. Each Class I and Class II hospital, and each Class III hospital providing operative and other invasive procedures, shall be organized under written policies and procedures regarding surgical privileges, maintenance of the operating rooms, and evaluation and recording of treatment of the patient. All surgical department policies and procedures shall be available to the AHCA, shall be reviewed annually, dated to indicate time of last review, revised as necessary, and enforced. These procedures shall require: (a) The determination of the appropriateness of the procedure 59A (3), FAC 59A (3)(a)1-5, FAC 59A (3)(b)-(g), FAC Observe a surgical procedure. Did you observe anyone discuss the risk and benefits of the surgical procedures prior to obtaining informed consent for the procedure? Were alternative options discussed with the patient prior to obtaining consent? Did the patient receive a pre-anesthesia evaluation prior to the surgical procedure? Was the patient assessed prior to being discharged from the hospital? Did the physician discharge the patient prior to the patient leaving the facility? Interview the patient. Did the patient understand the risk and benefits of the surgical procedure prior to signing the consent form? Was the patient seen by the physician after surgery?

72 Page 72 of 399 for a patient to be based on: 1. The patient's medical, anesthetic, and drug history; 2. The patient's physical status; 3. Diagnostic data; 4. The risks and benefits of the procedure; and 5. The need to administer blood or blood components. (b) The risks and benefits of the procedure are discussed with the patient prior to documenting informed consent and includes alternative options, if they exist, the need and risk of blood transfusions and available alternatives, and anesthesia options and risks. (c) A preanesthesia evaluation of the patient shall be performed prior to surgery, except in the case of extreme emergency. (d) Plans of care for the patient are formulated and documented in the medical record prior to the performance of surgery and shall include a plan for anesthesia, nursing care, the operative or invasive procedure, and the level of post-procedure care. (e) The measurement of the patient's physiological status is assessed during the administration of anesthesia and the surgical procedure. (f) The post-procedure status of the patient is assessed on admission to the recovery area and prior to discharge from the recovery area. (g) The patient is discharged by a qualified practitioner. Do charts have pre anesthesia evaluations? Does the patient's record contain the physician's determination of appropriateness of the procedure based on the patient's medical, anesthetic and medication history, physical status, diagnostic information, risks and benefits of the procedure and the need to administer blood? Does the patient's record show evidence of a pre-anesthesia evaluation? Does the patient record show evidence of a plan of care prior to the surgical procedure? Did the anesthesiologist document the measurement of the patient's physiological status assessment during the administration of the anesthesia? Did the physician document a post-surgical procedure assessment prior to discharging the patient? - Do charts reflect measurement of patient's status during and after anesthesia? Interview the patient. Did the patient understand the risk and benefits of the surgical procedure prior to signing the consent form? Was the patient seen by the physician after surgery? Interview staff to determine who is allowed to discharge from recovery room. REVIEW: Policy and Procedure if concern such as practice differs from what staff tells you. Are policy and procedures reviewed annually and revised as needed? (May be a face sheet stating policies reviewed and signed by staff.) Based on what you observed, heard in interview and reviewed in the patient's record, did the facility follow its own policies and procedures? Risk benefit information may be documented in the patient's medical record. If non-compliance is identified; review risk management and quality improvement requirements. ST - H SURGICAL DEPT - Distinct Location Title SURGICAL DEPT - Distinct Location Statute or Rule 59A (3)(h), FAC (h) Each hospital's surgical department shall be organized functionally and physically as a distinct entity within the Observe a surgical procedure. Obtain permission from one patient to follow them through their procedure, arrival to the surgical area/or from their patient's room to the surgical area. Follow their path through the pre-op, operation, and

73 Page 73 of 399 hospital. The operating room and accessory services shall be located in a manner to prevent through traffic, control traffic in and out, and maximize infection control. post-op (please ensure that you dress as required for the area you will be in). Observe the surgical area, prior to the beginning of the procedure to ensure the facility is following infection control standards. Interview the surgical staff. How do inpatient and outpatient flow through the surgical department? Is this department the only place where surgical procedures are performed. If not, how are the other ORs incorporated into the hospital's surgical department? What are the facility's policies and procedures regarding infection control in the surgical department? How do they prepare the surgical department in between surgical procedures to ensure infection control? Does the facility have policies and procedures regarding the staff's use of surgical scrubs? How does the surgical department ensure they adhere to the facility's infection control policies and procedures? Interview the infection control personnel and inquire how they ensure patients do not acquire an infection after the surgical procedure, especially for outpatient procedures? Request a list of facility acquired infections after a surgical procedure. Ask what infection control standard the facility is using. Keep in mind, we have no specific requirements. We are looking to see that the hospital follows its own policy and if there are infections, that they investigate for causes. Record review. Review the facility's policies and procedures regarding HICPAC website (CDC) infection control. ST - H SURGICAL DEPT - Designated Physician & RN Title SURGICAL DEPT - Designated Physician & RN Statute or Rule 59A (3)(i), FAC (i) Each hospital shall designate a physician as medical advisor to the surgical department and a registered nurse to direct nursing services within the operating rooms of a surgical department. Review: List of surgical staff. Select the physician and registered nurse to ensure they have been appointed to their positions, have the qualifications for the positions and have their responsibilities detailed. Interview surgical staff to determine that the staff is aware of who the designated medical advisor is and the nurse in charge for the surgical department. ST - H SURGICAL DEPT - Nursing Annual Education Title SURGICAL DEPT - Nursing Annual Education Statute or Rule 59A (3)(j), FAC

74 Page 74 of 399 (j) Each hospital shall document that all surgical nursing staff have received at least annual continuing education in safety, infection control and cardiopulmonary resuscitation. Review: Employees record of the surgical nurses and nursing staff to ensure they have been receiving their annual education. Review the facility's Policy and Procedures regarding surgical staff continuation training Interview: Surgical Department nursing staff to see how they keep up with the mandatory trainings. - Verify appropriate continuing education. ST - H SURGICAL DEPT - Surgeons and Privileges Title SURGICAL DEPT - Surgeons and Privileges Statute or Rule 59A (3)(k), FAC (k) Each hospital shall maintain a roster of physicians specifying the surgical privileges of each, shall review the roster annually and revise it as necessary. Interview: The O.R. scheduler how he/she knows what surgical privileges each surgeon has and how they know if those privileges change, especially on week-ends or holidays. What happens if a surgeon wants to perform a surgery the scheduler doesn't know if he has privileges to do? Record Review: Review credentialing file of selected surgeons to ensure the surgeons scheduled for surgery have been granted privileges. Review the facility's policy and procedure to determine the facility's process for granting surgeons privileges. ST - H SURGICAL DEPT - On Call Surgeons Title SURGICAL DEPT - On Call Surgeons Statute or Rule 59A (3)(l), FAC (l) A roster of "on-call" surgeons shall be promptly available at the operating room nursing stations. Review: The on call roster. Review the grievance log to determine if there have been any complaints of physician's failing to come in when they are on call. If there have been any, review the patient's record to determine what occurred and if there were any negative outcomes. If there have been any complaints, determine what the facility has done to address this issue.

75 Page 75 of 399 Interview: Staff to determine how they know who is on call. Do they have an on-call book or list? Where is it kept? How is it accessed? ST - H SURGICAL DEPT - Records Title SURGICAL DEPT - Records Statute or Rule 59A (3)(m) 1-8, FAC (m) Each hospital's surgical department shall maintain a record on a current basis that contains at least the following information: 1. Patient's name; 2. Hospital number; 3. Preoperative diagnosis; 4. Post-operative diagnosis; 5. Procedure; 6. Names of surgeon, first assistant, and anesthetist; 7. Type of anesthetic; and 8. Complications, if any. Review: The record of the observed patient (after the patient has been discharged from the surgical department) and determine if the required information is documented. Review a sample of medical records of patients who had a surgical encounter. Verify that they contain a surgical report that is dated and signed by the responsible surgeon and includes the information specified in the regulation. Determine if complications or incidents meet Code 15 reporting requirements. ST - H SURGICAL DEPT - H&P and Consent Title SURGICAL DEPT - H&P and Consent Statute or Rule 59A (3)(n)1-2, FAC (n) Regardless of whether surgery is classified as major or minor, each hospital shall ensure, prior to any surgery being performed, except in emergency situations: 1. That there is a complete history and physical workup in the REVIEW: Review the record of the patient you will be observing during the surgical procedure. Did the patient have, prior to surgery, a complete history and physical (except in an emergency situation)? Ensure (again except in the case of an emergency) that there is an informed consent for the operation in the chart. Review the facility's policies and procedures regarding pre-surgical assessment. Interview: The patient being observed; did the patient provide an informed consent?

76 Page 76 of 399 chart of every patient or, if such has been transcribed, but not yet recorded in the patient's chart, that there is a statement to that effect and an admission noted by the physician in the chart. 2. That there is evidence of informed consent for the operation in the patient's chart. ST - H SURGICAL DEPT - Operative Report Title SURGICAL DEPT - Operative Report Statute or Rule 59A (3)(o), FAC (o) Each hospital shall ensure that immediately following each surgery, there is an operative report describing techniques and findings that is written or dictated and signed by the surgeon. REVIEW: Post-operative charts to ensure that the report describes techniques and findings and is signed by the surgeon. If the report is not there or not signed by the surgeon, review the policy as to when it must be completed and signed. ST - H SURGICAL DEPT - Equipment Title SURGICAL DEPT - Equipment Statute or Rule 59A (3)(p)1-9, FAC (p) The following minimum equipment shall be in each operating room suite: 1. Call-in system; 2. Oxygen, and means of administration; 3. Mechanical ventilatory assistance equipment, including airways, manual breathing bag, and ventilator and respirator; 4. Cardiac defibrillator with synchronization capability; 5. Respiratory and cardiac monitoring equipment; TOUR: The operating room suites to ensure each room has the required equipment. Ask about/review preventive maintenance on equipment. Check all electrical equipment for current Biomedical inspections OR equipment must be inspected every 6 months.

77 Page 77 of Thoracentesis and closed thoracostomy sets; 7. Tracheostomy set, tourniquets, vascular cutdown sets, infusion pumps, laryngoscopes and endotracheal tubes; 8. Tracheobronchial and gastric suction equipment; and 9. A portable x-ray shall be available, but need not be physically present in the operating suite. ST - H SURGICAL DEPT - Infections Title SURGICAL DEPT - Infections Statute or Rule 59A (3)(q), FAC (q) All infections of clean surgical cases shall be recorded and reported to the appropriate infections control authority, and a procedure shall exist for the investigation of such cases. ASK: What their procedure is for recording, reporting, and investigating infections of clean surgical cases. Who do they report the cases to? Who investigates? Do they have any cases reported and investigated? If concerns, review their policy and a sample of cases investigated. Ask same questions of the Infection Control Nurse. ST - H SURGICAL DEPT - On Call Response Title SURGICAL DEPT - On Call Response Statute or Rule 59A (3)(s), FAC Type Standard (s) An on-call surgeon must be promptly available to the hospital when a call for services has been placed. ASK: Staff what they do when there is an unplanned/emergency case. How do they know who is on call? How do they know the surgeon is qualified to do the procedure? What is a prompt response time? Does anyone track response time? Is someone in house at all times if they have an OB department?

78 Page 78 of 399 ST - H ANESTHESIA DEPT - Physician Director Title ANESTHESIA DEPT - Physician Director Statute or Rule 59A (4), FAC (4) Anesthesia Department. Each Class I and Class II hospital, and each Class III hospital providing surgical or obstetrical services, shall have an anesthesia department, service or similarly titled unit directed by a physician member of the organized professional staff. REVIEW: Medical staff credentialing files for qualifications of physician director. Check Director's file to see if he/she meets the requirements. Check organization chart to ensure anesthesia department staff report to Director. What are his/her responsibilities? Interview: What is Director's role? ST - H ANESTHESIA DEPT - Written Policies & Procedur Title ANESTHESIA DEPT - Written Policies & Procedur Statute or Rule 59A (4)(a)1-5, FAC (a) The anesthesia department of each hospital shall have written policies and procedures that are approved by the organized medical staff, are reviewed annually, dated at time of last review, revised, and enforced as necessary. Such written policies and procedures shall include at least the following requirements: 1. A preanesthesia evaluation of the patient by the physician, or qualified oral surgeon in the case of patients without medical problems admitted for dental procedures, or certified registered nurse anesthetist where authorized by established protocol approved by the medical staff, except in the case of emergencies. 2. A review of the patient's condition immediately prior to REVIEW: Are policies and procedures approved by medical staff and reviewed annually? How are policies enforced? Review surgical charts for compliance with requirements. ASK: What measures do you use with general anesthetic agents in the hospital to ensure safety? Ask for the facility's definition of immediately. Are patients released via protocol or are they seen by anesthesia before discharge or return to room?

79 Page 79 of 399 induction of anesthesia. 3. A mechanism for release of patients from post anesthesia care. 4. A recording of all pertinent events taking place during the induction of, maintenance of, and emergence from anesthesia. 5. Guidelines for the safe use of all general anesthetic agents used in the hospital. ST - H ANESTHESIA DEPT - Staff Respon & Qualif Title ANESTHESIA DEPT - Staff Respon & Qualif Statute or Rule 59A (4)(b), FAC (b) The responsibilities and qualifications of all anesthesia personnel, including physician, nurse and dentist anesthetists and all trainees, must be defined in a policy statement, job description, or other appropriate document. ASK: For a list of all anesthesia staff. Select a small sample to review. Does the hospital have a policy statement, job description, or other documentation listing responsibilities and qualifications of the staff? Interview anesthesia staff regarding their responsibilities and qualifications. If Nurse Anesthetists or trainees are used, who supervises them? How many people are supervised by 1 anesthesiologist? ST - H ANESTHESIA DEPT - Safety Regulations Title ANESTHESIA DEPT - Safety Regulations Statute or Rule 59A (4)(c)1-4, FAC (c) Anesthetic safety regulations shall be developed, posted, and enforced. Such regulations shall include at least the following: 1. A requirement that all operating room electrical and anesthesia equipment be inspected on no less than a TOUR: Look for written semi-annual inspections of all operating room electrical and anesthesia equipment. ASK: What flammable anesthetic agents are used. - How do they ensure these agents are used only in a conductive pathway? - Do all anesthetic gas machines have a pin index or equivalent safety system?

80 Page 80 of 399 semi-annual basis, and that a written record of the results and corrective action be maintained. 2. A requirement that flammable anesthetic agents be employed only in areas in which a conductive pathway can be maintained between the patient and a conductive floor. 3. A requirement that each anesthetic gas machine have a pin-index or equivalent safety system. 4. A requirement that all reusable anesthesia equipment coming in direct contact with the patient be cleaned after each use. - How is all reusable equipment coming in direct contact with the patient cleaned? - Are the safety regs developed? Posted? Enforced? - Inspected semiannually? - Written report of results and corrective action? ST - H NURSING SERVICE - Organized & Staffed Title NURSING SERVICE - Organized & Staffed Statute or Rule 59A (5), FAC 5. Each hospital shall be organized and staffed to provide quality nursing care to each patient. Where a hospital's organizational structure does not have a nursing department or service, it shall document the organizational steps it has taken to assure that oversight of the quality of nursing care provided to each patient is accomplished - Observe the nursing care being provided to assess the delivery of care and determine the adequacy of staffing; Review staffing schedules and tabulate/cross reference with actual assignments. Optional sources to be used in the evaluation of the provision of nursing care: Assessments, Nursing Care Plans, Medical Records Progress Notes, Patient Care Outcomes; Review QAPI Program monitoring, evaluation, and corrective implementations made, and evaluate for results that impacts and improves the provision of the delivery of quality nursing care; Conduct Patient & Family interviews of individuals whose cognitive state allows for keen observations and their records reflect their active involvement in the care they receive. - Ask for an organizational chart for nursing services for all locations where the hospital provides nursing services ; review the org. chart to determine if nursing service is under the direction of "one" RN; determine if this RN is "responsible" for the operation of nursing services, which includes the quality of patient care provided by Nursing Services; Review the RN director's Job Description to ensure types and numbers of nursing care personnel necessary to provide nursing care to all areas of the hospital "must" be determined by the director of nursing. Verify the director of nursing services is involved with and approves the development of nursing service staffing policies and procedures. - How does nursing relate to other departments? - If the hospital does not have a nursing department or service, ask how they assure oversight of the quality of nursing care for each resident.

81 Page 81 of 399 ST - H NURSING SERVICE - Management Title NURSING SERVICE - Management Statute or Rule 59A (5)(a)1-5, FAC (a) Each hospital shall document the relationship of the nursing department to other units of the hospital by an organizational chart, and each nursing department shall have a written organizational plan that delineates lines of authority, accountability and communication. The nursing department shall assure that the following nursing management functions are fulfilled: 1. Review and approval of policies and procedures that relate to qualifications and employment of nurses. 2. Establishment of standards for nursing care and mechanisms for evaluating such care. 3. Implementing approved policies of the nursing department. 4. Assuring that a written evaluation is made of the performance of registered nurses and ancillary nursing personnel at the end of any probationary period and at a defined interval thereafter. 5. Each hospital shall employ a registered nurse on a full time basis who shall have the authority and responsibility for managing nursing services and taking all reasonable steps to assure that a uniformly optimal level of nursing care is provided throughout the hospital. - Ask for an organizational chart. - Are policies and procedures related to qualifications for employment of nurses reviewed and approved? - How are standards of nursing care and mechanisms for evaluating care established? - How are approved nursing policies implemented? - How staff is made aware of new or changed policies? - How often is a written evaluation of the performance of registered nurses and ancillary nursing personnel done? - If the hospital uses agency staffing, traveling nurses, or other temporary services, how are they made aware of policies and evaluated?

82 Page 82 of 399 ST - H NURSING SERVICE - Care Reviews & Evaluation Title NURSING SERVICE - Care Reviews & Evaluation Statute or Rule 59A (5)(b), FAC (b) The registered nurse shall be responsible for assuring that a review and evaluation of the quality and appropriateness of nursing care is accomplished. The review and evaluation shall be based on written criteria, shall be performed at least quarterly, and shall examine the provision of nursing care and its effect on patients. - Review a sample of current medical records for nursing care. If you are doing a complaint investigation and the patient has been discharged, look at current records as well as some closed. - Interview patients and families. Observe care being provided. Ask how the hospital reviews and evaluates nursing care. - How often is this done? What are the criteria? If the effect on patients is not positive, what if any action is taken? ST - H NURSING SERVICE - Education & Training Title NURSING SERVICE - Education & Training Statute or Rule 59A (5)(c), FAC (c) The registered nurse shall ensure that education and training programs for nursing personnel are available and are designed to augment nurses' knowledge of pertinent new developments in patient care and maintain current competence. Cardiopulmonary resuscitation training shall be conducted as often as necessary, but not less than annually, for all nursing staff members who cannot otherwise document their competence. - Ask how the hospital selects education and training programs for nursing personnel? How do they ensure nurses are kept up to date on new developments in patient care and maintain competencies? - Review a sample of personnel files for annual CPR training. The same files can be reviewed for current license and other required training. - Ask staff members about education programs they attended in current year. Do they have input into suggestions for in-services? - How does the hospital ensure that temporary staff is competent?

83 Page 83 of 399 ST - H NURSING SERVICE-Std of Practice & Policy/Proc Title NURSING SERVICE-Std of Practice & Policy/Proc Statute or Rule 59A (5)(d), FAC (d) Each hospital shall develop written standards of nursing practice and related policies and procedures to define and describe the scope and conduct of patient care provided by the nursing staff. These policies and procedures shall be reviewed at least annually, revised as necessary, dated to indicate the time of the last review, signed by the responsible reviewing authority, and enforced. - Observe patient care. - Review a sample of current medical records. Are staff aware and follow hospital policies and procedures? - Interview patients and staff regarding care. If you have questions or discrepancies regarding the care or documentation of care, review the policy. - Is the policy reviewed annually, revised as necessary, dated and signed to indicate the time of last review and enforced? ST - H NURSING SERVICE - Care Process Title NURSING SERVICE - Care Process Statute or Rule 59A (5)(e)1-3, FAC (e) The nursing process of assessment, planning, intervention and evaluation shall be documented for each hospitalized patient from admission through discharge. 1. Each patient's nursing needs shall be assessed by a registered nurse at the time of admission or within the period established by each facility's policy. 2. Nursing goals shall be consistent with the therapy prescribed by the responsible medical practitioner 3. Nursing intervention and patient response, and patient status on discharge from the hospital, must be noted on the medical record. Observe nursing care. Are patients assessed by a Registered Nurse? - Review a sample of medical records. Are patients appropriately assessed? Are nursing goals defined based on the patient's condition? Are care plans current and followed: - Are interventions evaluated and updated as needed? - Do nurses document the patient's condition on discharge? - If there are abnormal labs or vital signs, is the physician made aware prior to discharge?

84 Page 84 of 399 ST - H NURSING SERVICE - Sufficient Staffing Title NURSING SERVICE - Sufficient Staffing Statute or Rule 59A (5)(f), FAC (f) A sufficient number of qualified registered nurses shall be on duty at all times to give patients the nursing care that requires the judgment and specialized skills of a registered nurse, and shall be sufficient to insure immediate availability of a registered nurse for bedside care of any patient when needed, to assure prompt recognition of an untoward change in a patient's condition, and to facilitate appropriate intervention by nursing, medical or other hospital staff members. Observe staff patient ratio. Review assignment sheet for two week period. Interview patients to ensure needs are met and call lights answered. - Review a sample of medical records. - Are patients appropriately assessed? - Observe care and services of sample patients - are Registered Nurses sufficient and qualified to provide care needed by the patient? ST - H NURSING SERVICE - RN On Duty Title NURSING SERVICE - RN On Duty Statute or Rule 59A (5)(g), FAC (g) Each Class I and Class II hospital shall have at least one licensed registered nurse on duty at all times on each floor or similarly titled part of the hospital for rendering patient care services. Ask how the facility ensures sufficient RN staff at all times. Observe RNs present on units.

85 Page 85 of 399 ST - H NURSING SERVICE - List of Licensed Staff Title NURSING SERVICE - List of Licensed Staff Statute or Rule 59A (5)(h), FAC (h) Each hospital shall maintain a list of licensed personnel, including private duty and per diem nurses, with each individual's current license number, and documentation of the nurses' hours of employment, and unit of employment within the hospital. - Ask to see a list of licensed staff. Review a sample (maybe sample used for required in-services) for current licenses. - Ask how the facility ensures all staff for whom licensure is required is current. How do they document hours of employment and unit worked? How do they maintain that information on private duty and per diem nurses? ST - H HOUSEKEEPING SERVICE - Staffing/Contract/Plan Title HOUSEKEEPING SERVICE - Staffing/Contract/Plan Statute or Rule 59A (6)(a)-(c), FAC (6) Each hospital shall have an organized housekeeping department with a qualified person designated as responsible for all housekeeping functions. The designated supervisor of housekeeping shall be responsible for developing written policies and procedures for coordinating housekeeping services with other departments, developing a work plan and assignments for housekeeping staff, and developing a plan for obtaining relief housekeeping personnel. (a) Each hospital shall employ a sufficient number of housekeeping personnel to fulfill the responsibilities of the housekeeping department seven days a week. (b) When housekeeping services are provided by a third party, the hospital shall have a formal written agreement with - Identify and interview the person responsible for the housekeeping department and verify qualifications for the job. - Review the written policies and procedures. Is there a documented work plan and is there always adequate staff to perform this function? Verify by interviewing staff. Is the housekeeping service contracted and, if so, review the contract. - Tour the facility to ensure compliance with the 10 identified housekeeping regulatory requirements. Is the hospital equipment clean? Is the housekeeping department a part of the hospital QI program? What are the QI requirements and is the hospital in compliance? - Consider infection control and the impact of the environment on patient care, safety, or potential for food borne illness. The surveyor is to observe cleaning of rooms, corridors, procedure rooms, food preparation areas; in addition to reviewing the cleaning schedules.

86 Page 86 of 399 the third party provider on file. (c) Each hospital shall develop, implement, and maintain an effective housekeeping plan to ensure that the facility is maintained in compliance with the following: 1. The facility and its contents shall be kept free from dust, dirt, debris, and noxious odors; 2. All rooms and corridors shall be maintained in a clean, safe, and orderly condition, and shall be properly ventilated to prevent condensation, mold growth, and noxious odors; 3. All walls and ceilings, including doors, windows, skylights, screens, and similar closures shall be kept clean; 4. All mattresses, pillows, and other bedding; window coverings, including curtains, blinds, and shades, cubicle curtains and privacy screens; and furniture shall be kept clean 5. Floors shall be kept clean and free from spillage, and non-skid wax shall be used on all waxed floors; 6. Articles in storage shall be elevated from the floor; 7. Aisles in storage areas shall be kept unobstructed; 8. All garbage and refuse from patient areas shall be collected daily and stored in a manner to make it inaccessible to insects and rodents. 9. Garbage or refuse storage rooms, if used, shall be kept clean, shall be vermin-proof, and shall be large enough to store the garbage and refuse containers that accumulate. Outside garbage or refuse storage areas or enclosures shall be large enough to store the garbage and refuse containers that accumulate, and shall be kept clean. Outside storage of unprotected plastic bags, wet strength paper bags, or baled units containing garbage or refuse is prohibited. Garbage and refuse containers, dumpsters, and compactor systems located outside shall be stored on or above a smooth surface of non-absorbent material, such as concrete or machine-laid asphalt, that is kept clean and maintained in good repair; and 10. Garbage and refuse shall be removed from both interior and outside storage areas as often as necessary to prevent

87 Page 87 of 399 sanitary nuisance conditions. If garbage and refuse are disposed of on the facility premises, the method of disposal shall not create a sanitary nuisance and shall comply with the provisions of Chapter 17-7 FAC ST - H HOUSEKEEPING SERVICE - Linen/Laundry Title HOUSEKEEPING SERVICE - Linen/Laundry Statute or Rule 59A (6)(d)1-6, FAC (d) Each hospital shall ensure that: 1. There is a sufficient quantity of linen, including at least sheets, pillow cases, drawsheets or their alternative, blankets, towels and washcloths to provide comfortable, clean and sanitary conditions for each patient at all times; 2. Written policies and procedures for linen and laundry services, including methods of collection, storage, and transportation are developed, implemented, and maintained in conjunction with the policies and procedures developed by the infection control committee; 3. Soiled linen and laundry are collected in a way that minimizes microbial dissemination into the environment 4. Separate containers are used for transporting clean linen and laundry, and soiled linen and laundry; 5. Soiled linen and laundry are stored in a ventilated area separate from any other supplies, and are not stored, sorted, rinsed, or laundered in patient rooms, bathrooms, areas of food preparation or storage, or areas in which clean material and equipment are stored; and 6. When linen and laundry services are provided by a third party, the third party provider shall be required to maintain at least the standards contained herein, and shall ensure that clean linen is packaged and protected from contamination until received by the facility. - Review the written policies and procedures for linen and laundry services. - Tour and observe if there is adequate linen. Observe how soiled linen and clean linen are handled in patient rooms, in clean and soiled utility rooms, during transport and laundry. - Does the hospital have a laundry or is this service contracted? - If contracted, review the contract. Are linen services policies developed by the infection control committee? - Are infection control procedures followed by staff when handling linen? - How is clean linen stored to prevent contamination? - What ongoing monitoring procedures are in place to ensure the proper quantity and handling of linen? - What standards are required for the laundry? - How does the hospital ensure this?

88 Page 88 of 399 ST - H HOUSEKEEPING SERVICE - Pest Control Title HOUSEKEEPING SERVICE - Pest Control Statute or Rule 59A (6)(e), FAC (e) Effective control methods shall be employed to protect against the entrance into the facility and the breeding or presence on the premises of flies, roaches, rodents, and other vermin. Use of pesticides shall be in accordance with Chapter 5E-14, Part No. 1, F.A.C. Does the facility have methods to protect against pest entry? - Does the facility provide its own pest control service or is the service contracted? If contracted, review the service contract. Ask for documentation that pest control is done on a regular basis. Do the reports indicate any problems? Is there followthrough on pest issues? - Tour the facility to observe for any indication of pests. Also, interview patients and staff to ensure this is not a previously or currently identified problem. ST - H HOUSEKEEPING SERVICE - Written Procedures Title HOUSEKEEPING SERVICE - Written Procedures Statute or Rule 59A (6)(f)1-3, FAC (f) Each hospital shall develop and implement, in coordination with the infection control committee, written procedures for the cleaning of the physical plant, equipment, and reusable supplies. Such procedures shall include: 1. Special written procedures for cleaning all infectious disease areas; 2. Special written procedures for cleaning all operating room suites, delivery suites, nurseries, intensive and other critical care units, the emergency suite, and other areas performing similar functions; and 3. Special written procedures for the separate handling and storage of both clean and dirty linen, with special attention - Does the hospital housekeeping department have written policies and procedures developed in conjunction with the hospital infection control committee that specify cleaning requirements for physical plant, equipment and reusable supplies? - Observe how housekeeping is done in infectious disease areas and special patient care areas (i.e., operating room, intensive care, nursery, etc.). - Are there special written policies and procedures for handling of linens from isolation areas? - Interview and observe staff to be sure these special housekeeping procedures are followed. Consider the impact of the cleaning, isolation, and isolation on patient safety and infection control. Observe a terminal cleaning of the operating room suites, if possible.

89 Page 89 of 399 being given to identification, separation and handling of linens from isolation or infectious disease areas. ST - H AMBULATORY CARE SVCS - Policy/Procedures Title AMBULATORY CARE SVCS - Policy/Procedures Statute or Rule 59A (7), FAC (7) Each hospital offering ambulatory care services under its hospital license shall establish policies and procedures to ensure that quality care based on the needs of the patient will be delivered at all times. - Review the written policies regarding ambulatory care services. Look to see if the policies include how the hospital ensures quality care based on the needs of the patient is delivered at all times. Ambulatory care services may include outpatient rehabilitative therapies, diagnostic procedures, outpatient counseling, wound care, outpatient surgery, urgent care, etc. - These policies and procedures must address that these services meet the current standards of practice for the care and treatment being provided. They should also address the provision of supplies and equipment necessary for ensuring quality care. Tour all areas of ambulatory care services offered under the hospital license. Interview staff from the ambulatory care services. Include a sample of staff for licensure, competence, and training for personnel record reviews. Include patients selected from the ambulatory care services for record and observation reviews. ST - H AMBULATORY CARE SVCS -Physician(s) Responsibl Title AMBULATORY CARE SVCS -Physician(s) Responsibl Statute or Rule 59A (7)(a), FAC (a) Ambulatory care services shall be under the direction of a licensed physician(s) responsible for the clinical direction of patient care and treatment services, and whose qualifications, authority, and responsibilities are defined in writing as approved by the governing body. - Interview the licensed physician(s) who provide the clinical direction for patient care and treatment. There may be physician specialists for different specialty ambulatory care services, such as a radiologist for radiological diagnostic services. - Review the licenses of the physician(s). Review the governing body bylaws to determine that the physician's qualifications, authority, and responsibilities are defined in writing and approved by the governing body.

90 Page 90 of 399 ST - H AMBULATORY CARE SVCS - Staffing -Interview the physician if issues are identified during the survey and as needed. Title AMBULATORY CARE SVCS - Staffing Statute or Rule 59A (7)(b), FAC (b) Ambulatory care services shall be staffed with appropriately trained and qualified individuals to provide the scope of services anticipated to meet the needs of the patients. - Observe all of the ambulatory care settings and interview the staff about their credentials and responsibilities. Interview some ambulatory care patients about the quality of their services. - Review the hospital policies and procedures about the qualifications of staff necessary to provide the scope of services anticipated to meet the needs of patients. Review a sample of staff training records. ST - H AMBULATORY CARE SVCS -Physicians & Privileges Title AMBULATORY CARE SVCS -Physicians & Privileges Statute or Rule 59A (7)(c), FAC (c) Each patient's general medical condition shall be managed by a physician with appropriate clinical privileges, as determined by medical staff bylaws. - Review the ambulatory care patient record to determine if the patient's general medical condition is managed by a physician with appropriate clinical privileges. - Review medical staff bylaws to determine which physicians have appropriate clinical privileges - Review a sample of physician credential files from the ambulatory care services. ST - H AMBULATORY CARE SVCS - Safety NonHosp Employe Title AMBULATORY CARE SVCS - Safety NonHosp Employe Statute or Rule 59A (7)(d), FAC

91 Page 91 of 399 (d) When any ambulatory care services are provided by non-hospital employees, the provider shall meet all safety requirements, abide by all pertinent rules and regulations of the hospital and medical staff, and document the quality improvement measures to be implemented. - When visiting the ambulatory care settings, ask which services utilize non-hospital employees. - Interview non-hospital employees regarding their knowledge of safety requirements, pertinent hospital and medical staff rules and regulations. Review the training files of these non-hospital staff to determine if they have received training about safety and pertinent hospital and medical staff rules and regulations. - Review documentation of quality improvement measures implemented. ST - H AMBULATORY CARE SVCS -RN Supervision & Qualif Title AMBULATORY CARE SVCS -RN Supervision & Qualif Statute or Rule 59A (7)(e), FAC (e) The provisions of ambulatory nursing care shall be supervised by a registered nurse who is qualified by relevant training and experience in ambulatory care. - Interview the Registered Nurse (RN) who supervises the provisions of ambulatory nursing care about his/her qualifications and training and experience in ambulatory care. - Review the personnel file of the RN staff to verify credentials and training. ST - H AMBULATORY CARE SVCS - Sufficient Staff Title AMBULATORY CARE SVCS - Sufficient Staff Statute or Rule 59A (7)(f), FAC (f) Sufficient personnel shall be on duty to provide efficient and effective patient care services. - Interview the staff who are responsible for coordinating appointments. Interview patient care services personnel about how they provide coverage. Ask patient care services personnel how they orient new personnel and monitor their performance? - Observe patient care services to determine if patients receive services. Interview ambulatory care patients to determine if they feel if their services are efficient and effective.

92 Page 92 of 399 ST - H AMBULATORY CARE SVCS - Scope/Relationship Title AMBULATORY CARE SVCS - Scope/Relationship Statute or Rule 59A (7)(g), FAC (g) The scope of services offered, and the relationship of the ambulatory services program to other hospital units, as well as all supervisory relationships within the program, shall be defined in writing, and must be provided in accordance with the standards set by the governing body's bylaws and the rules and regulations of the medical staff. - Review the governing body's bylaws and the rules and regulations of the medical staff to determine if the following are defined in writing: The scope of services offered. Relationship of the ambulatory services program to other hospital units, as well as all supervisory relationships within the program. - Look to see that there are established methods of communication, as well as established procedures, to assure integration with inpatient services that provide for continuity of care. - If there are concerns, interview the director of ambulatory care. ST - H AMBULATORY CARE SVCS - Program Operation Title AMBULATORY CARE SVCS - Program Operation Statute or Rule 59A (7)(h), FAC (h) Written policies and procedures to guide the operation of the ambulatory services program shall be developed, reviewed, and revised as necessary, dated to indicate the time of last revision, and enforced. - Review policies and procedures to determine if they are developed, reviewed, and revised as necessary, dated to indicate the time of the last revision, and enforced. - Determine if observations and interviews of the operations during visits to the ambulatory care settings correspond to these policies and procedures.

93 Page 93 of 399 ST - H AMBULATORY CARE SVCS - Medical Records Title AMBULATORY CARE SVCS - Medical Records Statute or Rule 59A (7)(i)1-11, FAC (i) A medical record must be maintained on every patient who receives ambulatory care services. Medical records shall be managed and maintained in accordance with acceptable professional standards and practices. Confidentiality and disclosure of patient information contained in the health record must be maintained in accordance with hospital policy and state and federal law. Each patient's medical record must include at a minimum, the following information, and be updated as necessary: 1. Patient identification; 2. Relevant history of the illness or injury and of physical findings; 3. Diagnostic and therapeutic orders; 4. Clinical observations, including the results of treatment; 5. Reports of procedures and tests, and their results; 6. Diagnosis or impression; 7. Allergies; 8. Referrals to practitioners or providers of services internal or external to the hospital; 9. Communications to and from practitioners or providers of service external to the hospital; 10. Growth charts for children and adolescents as needed when the service is the source of primary care; and 11. Immunization status of children and adolescents and others as determined by law and/or hospital policy. -Interview the personnel charged with the responsibility for the management of the ambulatory care medical records. Request and review their policies and procedures about how these records are managed and maintained. Review their policy regarding confidentially of patient information. -Visit the area were patient medical records are kept. Is the area secured? Ask the personnel who has access to this area. -During the visit to the ambulatory care setting, look for evidence that patient information is kept confidential or not disclosed without patient's knowledge through patient and employee interactions and environment. -Review a sample of ambulatory care patient medical records based on the type and scope of services to determine if they include, as relevant. Patient identification; Relevant history of the illness or injury and of physical findings; Diagnostic and therapeutic orders; Clinical observations, including the results of treatment; Reports of procedures and tests, and their results; Diagnosis or impression; Allergies; Referrals to practitioners or providers of services internal or external to the hospital; Communications to and from practitioners or providers of service external to the hospital; Growth charts for children and adolescents as needed when the service is the source of primary care; and Immunization status of children, adolescents, and others as determined by law and/or hospital policy. -If there is information missing from the ambulatory care medical records, interview personnel responsible for enforcing.

94 Page 94 of 399 ST - H AMBULATORY CARE SVCS - Patient Problem List Title AMBULATORY CARE SVCS - Patient Problem List Statute or Rule 59A (7)(j)1-4, FAC (7) Each hospital offering ambulatory care services under its hospital license shall establish policies and procedures to ensure that quality care based on the needs of the patient will be delivered at all times. (j) To facilitate the ongoing provision of care, a problem list of known significant diagnoses, conditions, procedures, drug allergies and medications shall be maintained for each patient who receives ambulatory services. The problem list shall be initiated no later than the third visit and include items based on any initial medical history and physical examination, and updated on subsequent visits with additional information as necessary. The problem list shall include at least the following items: 1. Known significant medical diagnoses and conditions; 2. Known significant surgical and invasive procedures; 3. Known adverse and allergic reactions to drugs; and 4. Medications known to be prescribed for and/or used by the patient. -Review a sample of ambulatory care patient medical records based on the type and scope of services to determine if they include a problem list with at least the following:. Known significant medical diagnoses and conditions; Known significant surgical and invasive procedures; Known adverse and allergic reactions to drugs; and Medications known to be prescribed for and/or used by the patient. -Look for a medical history and physical exam included in the ambulatory care patient medical record. -Look to see that the problem list is initiated no later than the history and physical exam and updated as necessary. -If the problem list is missing or incomplete, interview personnel responsible for enforcing this. ST - H OBSTETRICAL DEPT - Organization & Operation Title OBSTETRICAL DEPT - Organization & Operation Statute or Rule 59A (8)(a)1-2, FAC

95 Page 95 of 399 (8) Obstetrical Department. If provided, obstetrical services shall include labor, delivery, and nursery facilities, and be formally organized and operated to provide complete and effective care for each patient. (a) Except in hospitals licensed for 75 beds or less, the obstetrical service shall be separated from other patient care rooms and shall have separate nursing staff. When obstetrical services are provided in hospitals of 75 beds or less, there shall be: 1. A written and enforced policy concerning the placement of obstetrical patients in a manner most conducive to meet their special needs, and 2. A demonstration by the hospital that its nursing staff possesses specialized skills in obstetrics and pediatrics, whether by training or by obstetrical experience, and can provide service to obstetrical patients and their infants on a 24 hour basis, whether on duty, on call, or on a consultative basis. - Review Obstetrical services according to size of facility beds. - Select a sample of staff training records to assure specialized skills training or experience. - Are nurses specifically assigned to the OB unit only? - How is Specialized Staffing covered on a 24 hour basis? Are staff utilized from other areas in emergencies and how are they qualified. Review staff competency requirements. ST - H OBSTETRICAL DEPT - Gyn & Surgical Patients Title OBSTETRICAL DEPT - Gyn & Surgical Patients Statute or Rule 59A (8)(b), FAC (b) In those hospitals with a formally organized obstetrical department, clean gynecological and surgical patients may be admitted to the unit under specific written controls approved by the medical staff and governing authority when there is a written demonstrated need in each case. - Review Admission Log and Surgical Schedule for the past three months of specialized approved gynecological or surgical patients. - Review a sample of records of gynecological or surgical cases for compliance with this.

96 Page 96 of 399 ST - H OBSTETRICAL DEPT - Infant Identification Title OBSTETRICAL DEPT - Infant Identification Statute or Rule 59A (8)(c), FAC (c) Every infant born in a hospital shall be properly identified immediately at the time of birth. Identification of the infant shall be done in the delivery room, birthing room, or other place of birth within the hospital, before either the mother or the infant is transferred to another part of the facility. - Interview the head of obstetrics or the Emergency Department. Ask how infants are identified prior to separation from the mother. - Observe that infant identification is consistent throughout the hospital. ST - H LAB & PATH SVCS - Lab Lic/Tests/Avail/Rpts Title LAB & PATH SVCS - Lab Lic/Tests/Avail/Rpts Statute or Rule 59A (9)(a)-(c), FAC (9) Clinical Laboratory-Every hospital must provide on the premises or by contract with a laboratory licensed under Chapter 483, Part I, F.S., a clinical laboratory to provide those services commensurate with the hospital's needs and which conforms to the provisions of Chapter 483, Part I, F.S., and Chapter 59A-7, F.A.C. (a) Provisions shall be made to carry out clinical laboratory examinations, including routine chemistry, microbiology, hematology, general immunology, and urinalysis. (b) Provision shall be made for assuring the availability of emergency laboratory services. Such services shall be available 24 hours a day, seven days a week, including holidays. - Interview administrative and/or laboratory management personnel to determine what level of testing is performed by the hospital, by contracted services, or sent to reference laboratories for testing. If by contract, review contracts. - Request a copy of the Florida Clinical Laboratory license, as provided under Ch. 483, F.S. This license should be current (not beyond the expiration date), and will reflect the specialty(ies) which the facility provides directly. - If the hospital is providing laboratory testing on site and cannot produce a copy of a Florida license, the Laboratory Unit should be contacted for further information regarding potential unlicensed laboratory testing or verification of specialties. Posting of this license is required by clinical laboratory requirements at 59A-7, F.A.C. - The facility may also have a federal CLIA registration, but posting is not required; this is separate from state licensure. - The hospital must provide testing around the clock. Contracts should be reviewed to ensure that all specialties are addressed for emergency care. For example, Blood Bank (Transfusion Services) and Pathology contracts should specify the level of technical services provided, transportation of blood and tissues products and storage, and the method of issuing patient reports. Blood banking services which are provided entirely by contract with an outside

97 Page 97 of 399 (c) Reports of all examinations shall be filed with the patient's record. blood service are not surveyed once the relationship has been verified. - Review of a sample of patient medical records to assure that clinical and pathology reports are included in the record. It is acceptable for these to be either individual reports or in cumulative report formats. ST - H LAB & PATH SVCS - Path Lic/Specimens/Rpts Title LAB & PATH SVCS - Path Lic/Specimens/Rpts Statute or Rule 59A (9)(d)-(f), FAC (d) Pathology Laboratory-Each hospital shall provide on the premises or by contract with a laboratory licensed under Chapter 483, Part I, F.S., pathology laboratory services commensurate with hospital's needs and which conforms with the provisions of Chapter 483, Part I, F.S., and Chapter 59A-7, F.A.C. (e) All specimens removed in operations shall be sent to a pathologist for examination, except when another suitable means of verification of removal is routinely employed, when there is an authenticated report to document the removal, and when quality of care will not be compromised by the exception. Hospitals may establish a policy for excepting certain categories of specimens from examination when it determines quality of care will not be compromised or examination will yield no useful information. Signed reports on all specimens removed in an operation, whether documented by a pathologist or through an alternative means, shall be filed with the patient's record. - Interview administrative, laboratory management and surgical personnel to determine how tissue samples from surgery are handled and tested. The facility should be able to demonstrate that procedures are in place for handling of tissues in surgery, transport to either an in house or contract laboratory for processing and reporting of patient results. (see below) - Observations during tour of the surgery department may reveal the presence of cryostats. If so, determine who is responsible for the maintenance of the equipment and how the pathology specimens are handled and reported. If this is an issue contained in a complaint, observe the tissue transfer process from OR to lab. (f) If the hospital does not maintain a pathology laboratory there shall be policy established and enforced, which meets the provisions of paragraph (a).

98 Page 98 of 399 ST - H LAB & PATH SVCS - Blood Bank Services Title LAB & PATH SVCS - Blood Bank Services Statute or Rule 59A (9)(g), FAC (g) Blood Bank Services-Each hospital shall either maintain on the premises, or by contract have convenient access to, a blood banking service which is under the control and supervision of a pathologist or other authorized physician to perform those services commensurate with the facility's needs, and ensure that the laboratory is licensed under the provisions of Chapter 483, Part I, F.S., and Chapter 59A-7, F.A.C. - Interview administrative or management personnel to determine how blood products and transfusion services are provided to patients in the facility. - For products and technical services provided by an outside blood service organization, there should be a contract agreement. Review the contract. Review with the Lab Manager the turn-around time when blood is acquired from an outside contractor. - For technical services provided by a department of the hospital, policies and procedures should bear the review of the physician director. The pathologist or physician in charge of the service should be appointed. Review his/her curriculum vitae to validate experience in Immunohematology. - Review of the state laboratory license should include the specialty of Immunohematology for the entity providing transfusion services. The Laboratory Unit may be contacted if further clarification is needed. ST - H LAB & PATH SVCS - Blood Bank Records Title LAB & PATH SVCS - Blood Bank Records Statute or Rule 59A (9)(h), FAC (h) Records shall be kept on file indicating the receipt and disposition of all blood provided to patients in the facility. - Records of blood receipt and disposition should be available regardless of who provides services. Review a sample. - These may be reviewed by requesting laboratory personnel to "walk you through" the documentation from order and collection of a cross match specimen from the patient, product ordering and receipt, any additional testing, release to nursing for transfusion, documentation of transfusion, identification of possible reaction, documentation of final disposition of blood product, and record of transfusion(s) in the patient's medical record. - Lack of sufficient records to describe each these steps applicable to the facility may represent deficient record systems.

99 Page 99 of 399 ST - H LAB & PATH SVCS-Blood Procure/Store/Transfuse Title LAB & PATH SVCS-Blood Procure/Store/Transfuse Statute or Rule 59A (9)(i)1-6, FAC (i) All Class I and Class II hospitals, and all Class III hospitals utilizing blood and blood by-products, shall: 1. Maintain facilities for procurement, safekeeping and transfusion of blood and blood products, or have them readily available; 2. Maintain a temperature alarm system for blood storage facilities, where applicable, which is tested and regularly inspected and is otherwise safe. 3. The alarm system must be audible, and must monitor proper blood and blood product storage temperature over a 24 hour period. 4. Tests of the alarm system must be documented. 5. If blood is stored or maintained for transfusion outside of a monitored refrigerator, the laboratory must ensure and document that storage conditions, including temperature, are appropriate to prevent deterioration of the blood or blood product. 6. Promptly dispose of blood which has exceeded its expiration date. - Based on the level of blood and transfusion services determined to be offered at the facility, observation of blood/blood product storage shall be conducted. This may consist of refrigerators (specifically designated for this purpose) and/or temperature monitored ice chests for temporary storage. - Refrigerators may be located in a main laboratory area or in specialty care areas such as surgery, emergency department, or obstetrics. Refrigerators must be monitored by a temperature sensing system connected to an audible alarm. An exception may be made for specialty area refrigerators which are used only for temporary storage during hours when staff is present. - Audible alarms are sometimes located at a switchboard or other centralized location; this is acceptable as long as there is a procedure in place for notification of staff in the area of the refrigerator. For example, when an alarm notifies an operator or security personnel at a location staffed 24 hours a day, there must be a procedure for notifying laboratory staff of the situation so that the inventory can be safeguarded. - Records of alarm system testing should be reviewed, and may consist of log sheet documentation and/or refrigerator graphs. Temperature recording on the graph will usually have a peak in the line indicating an abrupt change of temperature and rapid return to normal range (1-6 degrees C). - You may request a demonstration of the alarm system. Laboratory personnel will assist with chilling/warming the refrigerator temperature probes to activate the alarm. Observation of this process may help resolve questions regarding the system efficacy. - Observation of the blood refrigerator(s) should be made to assure that blood products are not expired, and units which are no longer acceptable for transfusion (expired, contaminated, etc.) are physically separated in the storage compartment and labeled appropriately. ST - H LAB & PATH SVCS -Blood Storage Class III Hosp Title LAB & PATH SVCS -Blood Storage Class III Hosp Statute or Rule 59A (9)(j), FAC

100 Page 100 of 399 (j) Class III hospitals not utilizing blood and blood by-products need not maintain blood storage facilities. No IGs applicable. ST - H RADIOLOGY SVCS - Diagnostic Imaging Provided Title RADIOLOGY SVCS - Diagnostic Imaging Provided Statute or Rule 59A (10), FAC (10) Radiology Services. Each Class I and Class II hospital shall provide on the premises, and each Class III hospital shall provide on the premises or by contract, diagnostic imaging facilities according to the needs of the hospital and conform to Chapter 404, F.S., Chapter 64E-5, F.A.C., Part IV, Chapter 468, F.S., and Chapter 64E-3, F.A.C. Verify with the Director of Radiology Services that the hospital has diagnostic radiologic services that is available at all times to meet the needs of their patients: - Review the facility policy that specifies the scope and complexity of radiologic services as approved by the medical staff and governing body. - Is the department in compliance with Federal and State regulations and acceptable professional standards of practice? - If all or part of the hospital's radiological services are contracted, how is this contracted service integrated into the hospital QAPI program. Chapter 404, F. S. (Fla. Rule for Radiation) Refers to the Department of Health Part IV, Chapter 468, F.S( Radiological Personnel Certification) Chapter 64E-3, F.A.C. (Radiologic technology) ST - H RADIOLOGY SVCS - Hazard Free Title RADIOLOGY SVCS - Hazard Free Statute or Rule 59A (10)(a), FAC (a) The radiology department or other similarly titled part shall be maintained free of hazards for patients and personnel. - Review the radiology department policies and procedures regarding safety for patients and hospital personnel. - Interview staff and observe locations where radiological services are provided to determine if there are any hazards to patients or hospital personnel.

101 Page 101 of Review documentation of annual inspection reports regarding protective shielding and calibration of all equipment. Observe the areas or room containing x-ray equipment for posted signs bearing the radiation symbol and the words "CAUTION -- X-RAY EQUIPMENT", or words having a similar intent. Verify that hazardous materials are stored properly in a safe manner. Observe areas where testing is done for violations in safety precautions for patients and staff. The hospital must implement and ensure compliance with its established safety standards. The hospital policies must contain safety standards for at least: (Refer to the Department of Health (Part III of Chapter 64E-5, F.A.C.) Adequate shielding for patients, personnel and facilities; Observe and Verify that patient shielding (aprons, etc.) are properly maintained and routinely inspected by the hospital. Labeling of radioactive materials, waste, and hazardous areas; Transportation of radioactive materials between locations within the hospital; Security of radioactive materials, including determining who may have access to radioactive materials and controlling access to radioactive materials; Testing of equipment for radiation hazards; Maintenance of personal radiation monitoring devices; Proper storage of radiation monitoring badges when not in use; Storage of radio nuclides and radio pharmaceuticals as well as radioactive waste; and Disposal of radio nuclides, unused radio pharmaceuticals, and radioactive waste. Methods of identifying pregnant patients. Review and verify that the hospital has written safety policy and procedures. Such policy may include standards for radiation machine performance, surveys, calibrations and spot checks; requirements for quality assurance programs and quality control programs; standards for facility electrical systems, safety alarms, radiation-monitoring equipment, and dosimeters systems; requirements for visual and aural communication with patients; procedures for establishing radiation safety committees for a facility; and qualifications of persons who cause a radiation machine to be used, who operate a radiation machine, and who ensure that a radiation machine complies with the requirements of this chapter and with rules of the department of health (404.22, F.S.). (1) Handling and use of sources of radiation to be used so that exposures are maintained as low as reasonably achievable and no individual is likely to be exposed to radiation doses in excess of the limits established in rules contained in Part III of Chapter 64E-5, F.A.C.; (2) Methods and occasions to conduct radiation surveys; (3) Methods to control access to radiographic areas; (4) Methods and occasions to lock and secure sources of radiation; (5) Personnel monitoring and the use of personnel monitoring equipment, including steps to be taken immediately by

102 Page 102 of 399 radiography personnel when a pocket dosimeter is found off-scale, an alarm rate meter alarms unexpectedly, or a personnel monitoring badge is damaged or lost; (6) Transportation of licensed material to field locations and preparation of packages for shipment by common or contract carriers, including packaging, marking, labeling, shipping papers, emergency response information, blocking and bracing, security, surveys, and vehicle placarding in accordance with applicable requirements of the USDOT; 64E-5 Florida Administrative Code 64E (7) Leak testing, quarterly inventories, and equipment inspection, maintenance and operability checks, and disposal of licensed material; (8) Source exchanges for licensees who perform source exchanges; (9) Calibration of survey instruments, dosimeters, and alarm ratemeters for licensees who perform calibrations; (10) Emergency response, including response to loss, damage, or theft of sources of radiation, unauthorized entries into restricted areas, notifications, exposure minimization, and source recovery; (11) Identifying and reporting equipment defects and noncompliance issues; and (12) Maintenance of records. Interview staff and observe locations where radiological services are provided to determine if - does staff wear on the trunk of his or her body at all times during radiographic operations a personal monitoring device. Each personnel monitoring badge shall be assigned to and worn by only one Individual and shall be exchanged monthly. After exchange each badge shall be processed as soon as possible. If a report is received from the badge processor that indicates an individual has received a radiation exposure in excess of 5 rem (0.05 Sv), the licensee or registrant shall notify the department (DOH) within 24 hours as specified in 64E-5.344(2), F.A.C. If a personnel monitoring badge is lost or damaged, the worker shall cease work immediately until a replacement badge is provided and the exposure is calculated by the RSO or the RSO's designee for the time period from issuance to loss or damage of the badge. -The Source Movement Logs, Daily Survey Reports, and Individual Dosimeter Logs: Each time a radiation source is removed from storage, the licensee or registrant shall complete and maintain source movement logs. Review a sample of records of the Quarterly Inventory. Each licensee or registrant shall conduct a quarterly physical inventory to account for all sources of radiation received or possessed during the quarter. -Interview staff to verify that Each licensee or registrant shall perform visual and operability checks on survey instruments, radiation machines, radiographic exposure devices, associated equipment, transport containers, storage containers, and source changers before use on each day the equipment is to be used to ensure the equipment is in good working condition, the sources are shielded adequately, and required labeling is present.

103 Page 103 of 399 ST - H RADIOLOGY SVCS - Radiologist Title RADIOLOGY SVCS - Radiologist Statute or Rule 59A (10)(b), FAC (b) Each hospital shall have a radiologist either full time or part time on a consulting basis to discharge professional radiology services. - Review the personnel file of the radiologist - (full or part time) - Review Radiology Program for adequacy - consider if services are properly discharged to meet patient needs. Interview and Review the personnel file of the Radiation Safety Officer (RSO) to ensure that: (1) The licensee or registrant shall appoint an RSO and delegate the authority needed to fulfill the duties of the position. Except as specified in 64E-5.433(2), F.A.C., below, the minimum qualifications, training, and experience for the RSO, such as: (a) documented industrial radiography experience as a radiographer; and (b) Instruction in the establishment and maintenance of a radiation protection program, including training to perform internal audits and mitigation of radiological incidents. Individuals identified as an RSO on an industrial radiography license or registration before the effective date of this rule are not required to comply with the training requirements of this paragraph. (2) Radiation and safety training and experience in radiographic operations and training in the establishment and maintenance of a radiation protection program can substitute for the requirements specified in 64E-5.433(1)(a) and (b), F.A.C., above. R4 (3) In addition to other duties specified in this part, the RSO shall: (a) Ensure compliance with all components of the licensee's or registrant's radiation protection program as specified in 64E-5.432, F.A.C., the terms and conditions of the license, and this rule; (b) Investigate incidents and direct corrective actions, including halting operations when necessary; (c) Serve as the licensee's or registrant's contact with the department; and (d) Ensure that radiation safety activities are performed using approved in the daily operation of the licensee's program procedures and requirements in Chapter 64E-5, F.A.C., in the daily operation of the licensee's program. ST - H RADIOLOGY SVCS - Techs & Operators Title RADIOLOGY SVCS - Techs & Operators Statute or Rule 59A (10)(c) and (e), FAC

104 Page 104 of 399 (c) Each hospital shall have certified radiologic technologists or basic x-ray machine operator in hospitals of 150 beds or less, and shall be on duty or on call at all times, pursuant to Part IV, Chapter 468, F.S.; and Chapter 64E-3, F.A.C. (e) The credentials of each person providing diagnostic and therapeutic radiation, imaging and nuclear medicine services, including formal training, on-the-job experience, and certification or licensure where applicable, shall be maintained on file at all times. 59A (10)(c), FAC 59A (10)(e), FAC Part IV, Chapter 468, FS; and Chapter 64E-3, FAC - Review a sample personnel file of Certified Radiologic Technologists, samples. - Ask, how credentials, training, and certifications are maintained by the facility - Tour the various units, diagnostic and therapeutic. Verify with staff in hospitals of 150 beds or less, that a certified radiologic technologists or basic x-ray machine operator are on duty or on call at all times Interview staff and review a sample of personnel records to verify that: radiological staff may not use radiation or otherwise practice radiologic technology on a human being unless licensed or certified to do so. -That the licensee or registrant shall not permit any individual to act as a radiographer's assistant until such individual receive the required training Verify that the RSO or the RSO's designee audits the job performance of each radiographer and radiographer's assistant to ensure that the department's regulations, license requirements, and the licensee's or registrant's operating and the licensee's or registrant's operating and emergency procedures are followed. The audits shall include observation of the performance of each radiographer or radiographer's assistant during an actual radiographic operation at intervals not to exceed 6 months ST - H RADIOLOGY SVCS - Apparatus Use Limited Title RADIOLOGY SVCS - Apparatus Use Limited Statute or Rule 59A (10)(d), FAC (d) The use of all diagnostic imaging apparatus shall be limited to personnel designated as specified in Part IV, Chapter 468, F.S., and Chapter 64E-3, F.A.C. Observe and interview staff to ensure that: d) The use of all diagnostic imaging apparatus shall be limited to personnel designated as specified in Part IV, Chapter 468, F.S., and Chapter 64E-3, F.A.C , F.S. The general radiographer identified under this section must successfully complete a training program which include the following areas before assisting with radiation therapy technology duties: 1. Principles of radiation therapy treatment; 2. Biological effects of radiation; 3. Radiation exposure and monitoring;

105 Page 105 of 399 ST - H RADIOLOGY SVCS - Policies & Procedures 4. Radiation safety and protection; 5. Evaluation and handling of radiographic treatment equipment and accessories; and 6. Patient positioning for radiation therapy treatment. (some exclusions apply) Title RADIOLOGY SVCS - Policies & Procedures Statute or Rule 59A (10)(f), FAC (f) Each hospital shall maintain and enforce policies and procedures for the provision of all diagnostic and therapeutic radiation, imaging, and nuclear medicine services, and ensure compliance with the requirements of Chapter 64E-5, F.A.C. Such policies and procedures shall be written, reviewed annually, and revised as necessary in conformance with Chapter 64E-5, F.A.C., and shall be dated as to time of last review. 59A (10)(f), FAC 64E-5, FAC ( refers to Department of Health ) - The scope and complexity of radiology services provided must meet the needs of the hospital patients. - There must be radiology policies and procedures for each type of services provided (all diagnostic and therapeutic radiation, imaging, and nuclear medicine services). Observe the diagnostic and therapeutic radiation, imaging, and nuclear medicine services, to ensure compliance with the requirements Review documentation that the policies are reviewed annually including date of last review and the policies are revised as necessary. Interview the Radiology Director to be sure the policies reflect the current status of patient care provided. Review the requirements in the interpretive guidelines H-149 to H 152 ST - H RADIOLOGY SVCS - Written Orders Title RADIOLOGY SVCS - Written Orders Statute or Rule 59A (10)(g), FAC

106 Page 106 of 399 (g) Each hospital shall require that all diagnostic and therapeutic radiology, imaging or nuclear medicine services be performed only upon written order of a licensed physician. The request and all results must be recorded in the patient's medical record; Review medical records to determine that radiology services are provided only on the order of practitioners with clinical privileges. Any other practitioners that order radiology services must be approved by the governing body, medical staff and conform to applicable State law. - verify that all results are recorded in the patient's medical record; ST - H RADIOLOGY SVCS - Radiation Control Title RADIOLOGY SVCS - Radiation Control Statute or Rule 59A (10)(h), FAC (h) Each hospital shall ensure documentation, and reporting to the Bureau of Radiation Control of the Department of Health of all misadministration of radioactive materials, as those terms are defined by Chapter 64E-5, F.A.C. Chapter 64E-5, F.A.C. ( refers to the Bureau of Radiation Control of the Department of Health) Interview the person over Radiology Services and inquire how they would report any mishandling of radioactive materials. Review and verify that there are Policies for: Reporting of Exposures, Radiation Levels, Concentrations of Radioactive Material Exceeding the Constraints or Limits, Medical Events and Dose to an Embryo/Fetus or a Nursing Child. (1) Reportable Events. In addition to the notification required by Rule 64E-5.344, F.A.C., each licensee or registrant shall submit a written report within 30 days after learning of any these occurrences Review and verify that there are Policies for Operating and Emergency Procedures. The licensee's or registrant's procedures shall include instructions in the following: Verify that the Records of the annual ALARA audits : "ALARA" means as low as reasonably achievable making every reasonable effort to maintain exposures to radiation as far below the dose limits in these rules as practical, consistent with the purpose for which the licensed or registered activity is undertaken, taking into account the state of technology, the economics of improvements in relation to the state of technology, the economics of improvements in relation to benefits to the public health and safety, and other societal and socioeconomic considerations, and in relation to use of nuclear energy and licensed or registered sources of radiation in the public interest

107 Page 107 of 399 ST - H RADIOLOGY SVCS - Quality Control Program Title RADIOLOGY SVCS - Quality Control Program Statute or Rule 59A (10)(i), FAC (i) Each hospital shall maintain and document in writing a quality control program designed to minimize the unnecessary duplication of radiographic studies, to minimize exposure time of patients and personnel, and to maximize the quality of diagnostic information and therapy provided. - The hospital must have a quality assurance program regarding patient radiology records. - Review the Radiology Department Policy and Procedures as they pertain to ensuring authenticity and protecting the privacy of radiology records. Determine the hospital's procedure for maintaining and retrieving radiology records for any care procedure conducted in the past five years. - Review a sample of current and past radiological records to determine that they are signed by the practitioner who read and evaluated the roentgenogram. Determine that radiology records including films, scans, reports, etc., are maintained in compliance with Medical Records and State requirements. ST - H RESPIRATORY THERAPY - Policy/Procedure Review and verify that there are Policies for : Each radiographic exposure device, source changer, storage container, and transport container shall have a durable, legible, clearly visible marking or label attached that includes the standard radiation symbol as specified in 64E-5.322, F.A.C., in conventional colors of magenta, purple, or black on a yellow background has a minimum diameter of 25 millimeters, and has the following wording: CAUTION (or DANGER) RADIOACTIVE MATERIAL - DO NOT HANDLE NOTIFY CIVIL AUTHORITIES (or NAME OF COMPANY. - that Each radiation machine, radiographic exposure device, source changer, and storage container shall be kept locked with the key removed from any keyed lock except when under the direct supervision of radiographic personnel Title RESPIRATORY THERAPY - Policy/Procedure Statute or Rule 59A (11), FAC

108 Page 108 of Each hospital shall have written policies and procedures describing the scope of diagnostic and therapeutic respiratory services provided to patients of the hospital. This document shall contain written guidelines for the transfer or referral of patients requiring respiratory care services not provided at the hospital. - The scope of diagnostic and/or therapeutic respiratory services offered by the hospital should be defined in writing, and approved by the Medical staff. Review Respiratory Therapy policies and procedures. Is there a policy and procedure for each respiratory service provided at the hospital? Do the policies specify how transfer or referral will occur? - Interview the respiratory therapy director and/or respiratory therapists about duties and respiratory services performed. What services are provided in the hospital? What services are contracted out? Is Respiratory Therapy (RT) available 24/7? If not, how are needs met when RT is not available? - Are the hospital's respiratory services integrated into the Quality Improvement program? [There is an expanded policy regulation at 59A (11)(h)(1)-(6), F.A.C. (H0168)] ST - H RESPIRATORY THERAPY - Safety/Quality Title RESPIRATORY THERAPY - Safety/Quality Statute or Rule 59A (11)(a), FAC (a) When respiratory care services are provided outside the hospital, the hospital shall ensure by contract or other enforceable mechanism that such services meet all safety requirements and quality control measures required by the hospital. -Review the contract for respiratory therapy services not provided at the hospital. -Interview the respiratory therapy director regarding how the hospital ensures that contracted services conform to the hospital's safety standards and professional standards of care? What quality control measures does the hospital require of contracted respiratory services? ST - H RESPIRATORY THERAPY - Physician Director Title RESPIRATORY THERAPY - Physician Director Statute or Rule 59A (11)(b), FAC

109 Page 109 of 399 (b) Respiratory care services provided within a hospital shall have medical direction provided by a physician member of the organized medical staff with special interest and knowledge in the management of acute and chronic respiratory problems. The physician director shall be responsible for the overall direction of respiratory services, for conducting a review of the quality, safety and appropriateness of respiratory care services at least quarterly, and shall be available for any required respiratory care consultation. Verify that a director has been appointed and that he/she has fixed lines of authority and delegated responsibility for operation of the service. - Respiratory care services director must be a doctor of medicine or osteopathy with specialized training in pulmonary care. - Review the director's credentialing file for medical staff appointment, educational qualifications and job requirements. The time spent directing the department must be appropriate to the scope and complexity of the services provided. - How is the director available for respiratory care consultation? - Ask for documentation of the director's quarterly review of the services. ST - H RESPIRATORY THERAPY - Supervision Title RESPIRATORY THERAPY - Supervision Statute or Rule 59A (11)(c), FAC (c) Respiratory care services in a hospital may be supervised by a technical director who is registered or certified by the National Board of Respiratory Care Inc., or has the documented equivalent education, training and experience. Other respiratory care personnel shall provide respiratory care commensurate with their documented training, experience, and competence. National Board of Respiratory Care: The National Board for Respiratory Care, Inc. (NBRC) is a voluntary health certifying board created to evaluate the professional competence of respiratory therapists. The NBRC provides credentialing examinations for Registered Respiratory Therapists (RRTs) and Certified Respiratory Therapists (CRTs). The NBRC also offers additional specialization credentialing for respiratory practitioners that hold its certifications, and establishes standards to credential practitioners to work under medical direction. Florida law requires that Respiratory Therapists be licensed through the Florida Department of Health ( Florida Statute 468 defines licensure requirements for different types of respiratory therapists. To be eligible for licensure by the board, an applicant must be an active "certified respiratory therapist" or an active "registered respiratory therapist" as designated by the National Board for Respiratory Care, or its successor. - Certified Respiratory Therapist (CRT): is licensed by DOH and certified by the National Board for Respiratory Care. Under the order of a physician and in accordance with hospital protocols, the CRT can function in situations of unsupervised patient contact requiring individual judgment.

110 Page 110 of Registered respiratory therapist (RRT): is licensed by DOH and registered by the National Board for Respiratory Care. Under the order of a physician and in accordance with hospital protocols, the RRT can function in situations of unsupervised patient contact requiring individual judgment. - Respiratory care practitioner (RCP): Licensed by DOH. Under the order of a physician can deliver respiratory care services under direct supervision. ST - H RESPIRATORY THERAPY - Student Training - Is there a respiratory care services supervisor? - What certification and/or training is required to be the supervisor? - Review a sample of personnel files for respiratory care staff to ensure they meet the requirements specified by the medical staff and State Licensure requirements. Title RESPIRATORY THERAPY - Student Training Statute or Rule 59A (11)(d), FAC (d) The formal training of respiratory therapy students shall be carried out only in programs accredited by appropriate professional educational organizations. Individuals in student status shall be directly supervised when engaged in patient care activities. Does the hospital have an agreement with an accredited organization for training respiratory therapy students? If so, does the agreement require direct supervision when the students are engaged in patient care activities? ST - H RESPIRATORY THERAPY - Education/Training/Exp Title RESPIRATORY THERAPY - Education/Training/Exp Statute or Rule 59A (11)(e), FAC (e) The education, training and experience of personnel who provide respiratory care services shall be documented, and shall be related to each individual's level of participation in the - Does the hospital have written policies to address each type of respiratory care service provided? - Review treatment logs to identify staff providing the service and verify their qualifications. - Review job descriptions, training, and licenses in personnel files. If specialized training or experience is required to

111 Page 111 of 399 provision of respiratory care services. perform specific duties, is this training documented in their personnel file? ST - H RESPIRATORY THERAPY - Hazardous Procedures Title RESPIRATORY THERAPY - Hazardous Procedures Statute or Rule 59A (11)(f), FAC (f) Nonphysician respiratory care personnel shall not perform patient procedures associated with a potential hazard, including arterial puncture for obtaining blood samples, unless authorized in writing by the physician director of the respiratory care service acting in accordance with professional staff policy. - Review respiratory care policies and procedures regarding procedures that non-physician respiratory care personnel may perform. Has the physician director authorized in writing which personnel may perform each procedure? Is this authorization in accordance with policies? - What are the procedures for obtaining arterial blood gases? - Interview the director regarding who is authorized to perform ABGs and other potentially hazardous procedures? How does the hospital ensure staff competency? - Review authorizing documentation from the physician director. - Respiratory therapy is allowed to have their licensed respiratory personnel perform the ABGs and they can be covered under their own CLIA & state license, or they can be under the main lab's CLIA & state license. ST - H RESPIRATORY THERAPY - In-service Education Title RESPIRATORY THERAPY - In-service Education Statute or Rule 59A (11)(g), FAC (g) All personnel providing respiratory care services shall participate in relevant in-service education programs. Such participation occurs at least annually, and includes instruction in safety, infection control, and cardiopulmonary resuscitation, except for individuals who can otherwise demonstrate their competence. - Review the in-service educational programs for respiratory care services personnel. Is there documentation of annual participation by all staff? Are the areas of safety, infection control, and cardiopulmonary resuscitation required? - How is competence otherwise demonstrated?

112 Page 112 of 399 ST - H RESPIRATORY THERAPY - Patient Care Title RESPIRATORY THERAPY - Patient Care Statute or Rule 59A (11)(h)1-6, FAC (h) There shall be written policies and procedures specifying the scope and conduct of patient care rendered in the provision of respiratory care services. All policies and procedures must be approved by the physician director, reviewed at least annually, revised as necessary, dated to indicate the time of last review, and enforced. Respiratory care policies shall include at least the following: 1. Specification as to who may perform specific procedures and provide instruction, under what circumstances, and under what degree of supervision. 2. Assembly and sequential operation of equipment and accessories to implement therapeutic regimes. 3. Steps to be taken in the event of adverse reactions, and other emergencies. 4. Procurement, handling, storage and dispensing of therapeutic gases. 5. Infection control measures, including specifics as to changing and cleansing of equipment. 6. Administration of medications in accordance with the physician's order. - Hospital respiratory care services must be in accordance with medical staff directives. Written policies and procedures appropriate to the scope of services provided must be approved by the physician director. Is there documentation that these policies are reviewed annually, dated as to the last review and revised as necessary? - 1: Review policies on specific procedures. Do the policies specify which types of respiratory therapist (RT) staff can perform which procedures and supervision requirements? (Certified Respiratory Therapists (CRT) and Registered Respiratory Therapists (RRT) are both licensed to function in situations of unsupervised patient contact requiring individual judgment. Respiratory care practitioners (RCP) are licensed, but can only deliver respiratory care services under direct supervision - per Florida Statute 468). - 2: Review the policy on equipment assembly and operation. Interview RT staff regarding their training and understanding. - 3: Review the policy on emergency responses. Interview RT staff regarding responses to adverse drug reactions and other emergencies. - 4: Review the policy on therapeutic gases. From what source are they obtained? Where are gases stored? Observed gas storage areas. Are tanks secure? - 5: Review the policy on infection control. Interview RT staff about the changing and cleansing of equipment. Do interviews agree with the policy and procedures and professional standards? - 6: Review policies on medication administration. Where are the medications stored? If any are stored in the Respiratory Therapy department, observe that they are stored correctly at the right temperature and are in date. Interview RT staff regarding medication storage and the process to ensure expired medications are removed. Professional respiratory therapy organizations: NBRC - National Board of Respiratory Care: AARC - American Association for Respiratory Care: ACCP - American College of Chest Physicians: ATS - American Thoracic Society: [There is another policy regulation at 59A (11), F.A.C.(H0160)]

113 Page 113 of 399 ST - H RESPIRATORY THERAPY - Equipment & Facilities Title RESPIRATORY THERAPY - Equipment & Facilities Statute or Rule 59A (11)(i)1-3, FAC (i) The respiratory care service shall have sufficient equipment and facilities to assure the safe, effective and timely provision of respiratory care service to patients. 1. All equipment is calibrated and operated according to manufacturer's specifications, and is periodically inspected and maintained. 2. Where piped-in gas is used, an evaluation is made prior to use to assure identification of the gas and its delivery within an established safe pressure range. 3. Ventilators used for continuous assistance or controlled breathing has operative alarm systems at all times. Is there available equipment for all respiratory therapy services provided by the hospital? Is the equipment functional? 1. Is there documentation of periodic inspection and maintenance of the equipment to ensure safety and effectiveness? Inspect logs for equipment calibration, pressure range of piped-in gas, and monitoring of alarm systems of ventilators. -2. For piped-in gas: How does the hospital ensure that the gas is properly identified. (the tank labeled oxygen actually contains oxygen)? -3. How often are ventilator alarms tested? ST - H RESPIRATORY THERAPY - Orders Title RESPIRATORY THERAPY - Orders Statute or Rule 59A (11)(j), FAC (j) Prescriptions for respiratory care shall specify the type, frequency and duration of treatment and, as appropriate, the type and dose of medication, the type of diluents, and the oxygen concentration, and shall be incorporated into the patient's medical record. Review medical records of patients receiving respiratory services to verify that the services are provided only on the order of a physician or physician extender in accordance with State Law. Is the order for respiratory care services specific including medications and oxygen concentration? Are the services provided in accordance with these orders?

114 Page 114 of 399 ST - H SPECIAL CARE UNITS -Distinct/Access/Isolation Title SPECIAL CARE UNITS -Distinct/Access/Isolation Statute or Rule 59A (12), FAC (12) Special Care Units. The hospital shall ensure that a special care unit is a physically and functionally distinct entity within the hospital, has controlled access, and has an effective means of isolation for patients suffering from communicable or infectious disease or acute mental disorder. Special care units shall provide: Ask if hospital has any special care units. Observe: On tour, observe the unit to see if access to these units is controlled. Are there isolation rooms/areas if needed? Are units physically and functionally distinct? Interview: Ask the staff on the special unit what would be the reasons to utilize the isolation rooms? Who is authorized access into the special unit? Record Review: Review the facility's Policy and Procedure to ensure that based on your observation and interviews, the facility is following its own policies and procedures. ST - H SPECIAL CARE UNITS - Visual Observation Title SPECIAL CARE UNITS - Visual Observation Statute or Rule 59A (12)(a), FAC (12)...Special care units shall provide: (a) Direct or indirect visual observation by unit staff of all patients from one or more vantage points; Observe: The Special Care Unit to see if staff have direct or indirect visual observation from 1 or more vantage points (camera, window, etc.) Interview: Ask staff how they ensure that they observe all of the patients. Record Review: Review patient's record, does the documentation show the patient is patient being observed. Read the facility's policies and procedures regarding visual observation of all the patients in the secure unit. Based on your observations, interviews and record reviews, is the facility following their own Policy and Procedures?

115 Page 115 of 399 ST - H SPECIAL CARE UNITS - Intercommunication/Alarm Title SPECIAL CARE UNITS - Intercommunication/Alarm Statute or Rule 59A (12)(b), FAC (12)... Special care units shall provide: (b) A direct intercommunication or alarm system between the nurse's station and the bedside. Observation: During the tour of the unit, check intercommunication or alarm system to ensure it works, can be seen/heard from nurses' station. Is staff responding to it in a timely manner? Interview: Speak to patients if possible, does staff respond in a timely manner? Have they ever had to wait an extensive time for assistance? Have they had accidents while waiting for the nurse to respond? Record Review: While reviewing patients' record, is there evidence that the staff is responding to patients? ST - H SPECIAL CARE UNITS - Adjustable Beds Title SPECIAL CARE UNITS - Adjustable Beds Statute or Rule 59A (12)(c), FAC (12)... Special care units shall provide: (c) Beds that are adjustable to positions required by the patient, that are easily movable, and that have a locking or stabilizing mechanism to attain a secure, stationary position. Headboards, when present, shall be removable or adjustable to permit ready access to the patient's head. Observe: Are beds adjustable, easily movable; do they have a locking system and removable and adjustable headboards? If necessary, have staff demonstrate. Do the beds move when the locks are on? Interview staff: Have there been any problems with the beds? Record Review: Review the incident log. Have there been any incidents associated to issues of the patients' beds?

116 Page 116 of 399 ST - H SPECIAL CARE UNITS - Physician Advisor Title SPECIAL CARE UNITS - Physician Advisor Statute or Rule 59A (12)(d), FAC (d) Each special care unit shall be advised by a physician who is a member of the organized medical staff, shall have its relationship to other departments and units of the hospital specified in writing (organizational chart), and shall provide relevant in-service education programs to all staff including, but not limited to, annual education concerning cardiopulmonary resuscitation and safety and infection control requirements. Ask who physician adviser is. Review organization chart for relationship to other departments. Review a few personnel files for in-services on CPR, safety, and infection control. ST - H SPECIAL CARE UNITS - Policies/Procedures Title SPECIAL CARE UNITS - Policies/Procedures Statute or Rule 59A (12)(e)1-6, FAC (e) Written policies and procedures shall be developed concerning the scope and provision of care in each special care unit. Such policies and procedures shall be reviewed at least annually, revised as necessary, dated to indicate the time of last review, enforced, and include at least the following: 1. Specific criteria for the admission and discharge of patients; 2. A system for informing the responsible physician of changes in the patient's condition; 3. Methods for procurement of equipment and drugs at all - Review medical records and interview staff regarding admission and discharge criteria. Review chart to determine if physicians are notified of changes in patient's condition. Ask staff how equipment and drugs are procured during day Monday- Friday. How are supplies obtained on week-ends, nights, and holidays? - Ask: who is allowed access to the unit? Are any special procedures enforced to prevent infections (i.e.: wearing special clothing, shoe coverings lab coats when leaving unit)? - Ask: what special procedures are done in the unit? Who is allowed to do the procedures? Who supervises non-physicians who do the procedures? Are standing orders are used? How often? What protocols do you use for emergency conditions?

117 Page 117 of 399 times; 4. Specific procedures relating to infection and traffic control; 5. Specification as to who may perform special procedures, under what circumstances, and under what degree of supervision; and specific policies as to the use of standing orders; and 6. A protocol for handling emergency conditions related to the breakdown of essential equipment. ST - H SPECIAL CARE UNITS - Trauma Center Title SPECIAL CARE UNITS - Trauma Center Statute or Rule 59A (12)(f), FAC (f) No hospital shall hold itself out as a Trauma Center unless it has been verified by the Department of Health and Rehabilitative Services in accordance with the Trauma Center provisions of Section , F.S., and [Chapter 64J-2, F.A.C.] Any violation of the Trauma Center provisions shall subject any violator to appropriate remedies provided by Section , F.S. Is the hospital designated as a Trauma Center? Check facility files prior to going to the hospital. Are there indications the facility is holding itself out as a Trauma Center when it is not designated as such? ST - H ADULT DIAG CARDIAC CATH PROG - Organized/Staf Title ADULT DIAG CARDIAC CATH PROG - Organized/Staf Statute or Rule 59A (13), FAC (13) Adult Diagnostic Cardiac Catheterization Program. All licensed hospitals that establish adult diagnostic cardiac Each provider of diagnostic cardiac catheterization services shall comply with rules adopted by the agency that establish licensure standards governing the operation of adult inpatient diagnostic cardiac catheterization programs.

118 Page 118 of 399 catheterization laboratory services under Section , F.S., shall operate in compliance with the guidelines of the American College of Cardiology/American Heart Association regarding the operation of diagnostic cardiac catheterization laboratories. Hospitals are considered to be in compliance with American College of Cardiology/American Heart Association guidelines when they adhere to standards regarding staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety. The applicable guideline, herein incorporated by reference, is the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: (American College of Cardiology/American Heart Association guidelines). Aspects of the guideline related to pediatric services or outpatient cardiac catheterization in freestanding non-hospital settings are not applicable to this rule. All such licensed hospitals shall have a department, service or other similarly titled unit which shall be organized, directed and staffed, and integrated with other units and departments of the hospitals in a manner designed to assure the provision of quality patient care. The full text of the "American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards" can be accessed on The Society for Cardiovascular Angiography and Interventions website at - Interview the Cardiac Cath Director for program adherence to standards, training, staffing, operating procedures, equipment, physical plant/equipment, patient selection criteria, and patient quality and safety. Review cardiac cath policy and procedures are based on American College of Cardiology/American Heart Association guidelines. Review cardiac cath personnel records for training and competency. Review physician training files. Review cardiac cath patient safety and integration into hospital quality program. Review patient sample of records and patient interviews for quality of cardiac cath program. Tour cardiac cath unit for patient safety, quality, housekeeping, infection control, and functional safety. ST - H ADULT DIAG CARDIAC CATH PROG - Licensure Title ADULT DIAG CARDIAC CATH PROG - Licensure Statute or Rule 59A (13)(a) 1-2, FAC (a) Licensure. 1. A hospital seeking a license for an adult diagnostic cardiac catheterization laboratory services program shall submit an Check the hospital's license to verify that Adult Cardiac Catheterization is listed on the license as a licensed program.

119 Page 119 of 399 application on a form provided by the Agency, AHCA Form , August 09, License Application Adult Inpatient Diagnostic Cardiac Catheterization, incorporated herein by reference and available at < Regulation/Hospital_Outpatient/hospital.shtml#acs, signed by the chief executive officer of the hospital, confirming the hospital's intent and ability to comply with Section (1), F.S. 2. Hospitals with adult diagnostic cardiac catheterization services programs must renew their licenses at the time of the hospital licensure renewal, providing the information in Section (1), F.S. Failure to renew the hospital's license or failure to update the information in Section (1), F.S., shall cause the license to expire. ST - H ADULT DIAG CARDIAC CATH PROG -Therapeutic Svs Title ADULT DIAG CARDIAC CATH PROG -Therapeutic Svs Statute or Rule 59A (13)3. FAC 3. Therapeutic Procedures. An adult diagnostic cardiac catheterization program established pursuant to an exemption granted under s (3)(n), F.S., shall not provide therapeutic services, such as PERCUTANEOUS CORONARY INTERVENTION, OR STENT INSERTION, intended to treat an identified condition or the administering of intra-coronary drugs, such as thrombolytic agents. Review log of patients who have had cardiac catheterizations. Have any had therapeutic procedures? Review charts of patients to determine therapeutic procedures and circumstances surrounding procedures. Interview staff as to what happens if a patient develops complications or emergency condition during procedures. Review criteria selection for patients to receive diagnostic cardiac caths. Review procedures for emergency interventions or transfer agreements with level II, program.

120 Page 120 of 399 ST - H ADULT DIAG CARDIAC CATH PROG -Diag Procedures Title ADULT DIAG CARDIAC CATH PROG -Diag Procedures Statute or Rule 59A (13)4,a-j, FAC 4. Diagnostic Procedures. Procedures performed in the adult diagnostic cardiac catheterization laboratory shall include, for example, the following: a. Left heart catheterization with coronary angiography and left ventriculography b. Right heart catheterization c. Hemodynamic monitoring line insertion d. Aortogram e. Emergency temporary pacemaker insertion f. Myocardial biopsy g Diagnostic. Trans-septal procedures h. Intra-coronary ultrasound (CVIS) i. Fluoroscopy j. Hemodynamic stress testing Review procedures performed. Interview staff as to what procedures are performed. Review patient selection criteria with the cath lab director. Interview physicians performing cardiac cath procedures for criteria. Conduct cardiac cath patient record reviews. Interview patients and families for selection criteria. Review hospital advertisements, brochures and patient literature for procedures listed. ST - H ADULT DIAG CARDIAC CATH PROG - QI Program Title ADULT DIAG CARDIAC CATH PROG - QI Program Statute or Rule 59A (13)(d) and (g), FAC (d) Radiographic Cardiac Imaging Systems. A quality improvement program for radiographic imaging systems shall include measures of image quality, dynamic range and modulation transfer function. Documentation indicating the 59A (13)(d), FAC 59A (13)(g),FAC Review the cardiac cath quality improvement program for : Radiographic image quality, individual physician procedure volume, major complications, overall complication rates,

121 Page 121 of 399 manner in which this requirement will be met shall be available for the Agency's review. (g) Quality Improvement Program. A quality improvement program for the adult diagnostic cardiac catheterization program laboratory shall include an assessment of proficiency in diagnostic coronary procedures, as described in the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: guidelines. Essential data elements for the quality improvement program include the individual physician procedural volume and major complication rate; the institutional procedural complication rate; relevant clinical and demographic information about patients; verification of data accuracy; and procedures for patient, physician and staff confidentiality. Documentation indicating the manner in which this requirement will be met shall be available for the Agency's review. patient demographic information, verification of data accuracy, and procedures for confidentiality. Ascertain that the hospital cardiac cath quality improvement program is based on the referenced American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards. Review individual physician volume and interview cardiac cath interventionist physicians as needed. ST - H ADULT DIAG CARDIAC CATH PROG - Support Equip Title ADULT DIAG CARDIAC CATH PROG - Support Equip Statute or Rule 59A (13)(c), FAC (c) Support Equipment. A crash cart containing the necessary medication and equipment for ventilatory support shall be located in each procedure room. A listing of all crash cart contents shall be readily available. At the beginning of each shift, the crash cart shall be checked for intact lock; the defibrillator and corresponding equipment shall be checked for function and operational capacity. A log shall be - Tour each procedure room to verify the presence of a locked crash cart. - Review the listing of contents on randomly chosen carts. - Review log and documentation that defibrillator and corresponding equipment are checked for function and operational capacity.

122 Page 122 of 399 maintained indicating review. ST - H ADULT DIAG CARDIAC CATH PROG - Physical Plant Title ADULT DIAG CARDIAC CATH PROG - Physical Plant Statute or Rule 59A (13)(e) FAC (e) Physical Plant Requirements. F.A.C., Section , Florida Building Code, contains the physical plant requirements for the diagnostic adult inpatient cardiac catheterization program. -Health facility surveyor and life safety code surveyor are to tour the cardiac cath lab. ST - H ADULT DIAG CARDIAC CATH PROG - Personnel Title ADULT DIAG CARDIAC CATH PROG - Personnel Statute or Rule 59A (13)(f), FAC (f) Personnel Requirements. There shall be an adequate number of trained personnel available. At a minimum, a team involved in cardiac catheterization shall consist of a physician, one registered nurse, and one technician. - Request Cardiac Catheterization Procedure Schedule for several months. Verify team composition. - Interview members of the Cardiac Catheterization Team to assure usual team member composition. - Sample record reviews from the Adult Impatient Diagnostic Cardiac Catheterization Program during a survey. ST - H ADULT DIAG CARDIAC CATH PROG - Emergency Svcs Title ADULT DIAG CARDIAC CATH PROG - Emergency Svcs Statute or Rule 59A (13)(h)1-2, FAC

123 Page 123 of 399 (h) Emergency Services. Cardiac catheterization programs in a hospital not performing open heart surgery shall have a written protocol for the transfer of emergency patients to a hospital providing open heart surgery, which is within thirty minutes travel time by emergency vehicle under average travel conditions. 1. All providers of adult diagnostic cardiac catheterization program services in a hospital not licensed as a Level II adult cardiovascular services provider shall have written transfer agreements developed specifically for diagnostic cardiac catheterization patients with one or more hospitals that operate a Level II adult cardiovascular services program. Written agreements must be in place to ensure safe and efficient emergency transfer of a patient within 60 minutes. Transfer time is defined as the number of minutes between the recognition of an emergency as noted in the hospital's internal log and the patient's arrival at the receiving hospital. Transfer and transport agreements must be reviewed and tested at least every 3 months, with appropriate documentation maintained, including the hospital's internal log or emergency medical services data. - Review protocol for emergency transporting patients to a hospital providing open heart surgery (Level II adult cardiovascular services). Would travel time be sixty minutes or less by emergency vehicle under average travel conditions? -Review documentation that transfer and transport agreements have been tested and the results indicate a transfer time of no more than 60 minutes from the time the emergency was recognized and the patient arrived at the receiving hospital. Who does the facility consider at high risk for diagnostic catheterization complications? Do they have a policy which they follow for referring high risk patients? Is there evidence the facility has the capability of rapid mobilization of a team 24 hours a day, 7 days a week? 2. Patients at high risk for diagnostic catheterization complications shall be referred for diagnostic catheterization services to hospitals licensed as a Level II adult cardiovascular services provider. Hospitals not licensed as a Level II adult cardiovascular services provider must have documented patient selection and exclusion criteria and provision for identification of emergency situations requiring transfer to a hospital with a Level II adult cardiovascular services program. Documentation indicating the manner in which this requirement will be met shall be available for the Agency's review.

124 Page 124 of 399 ST - H ADULT DIAG CARDIAC CATH PROG - Mdcd/Charity Title ADULT DIAG CARDIAC CATH PROG - Mdcd/Charity Statute or Rule 59A (13)(i)1-2, FAC (i) Policy and Procedure Manual for Medicaid and Charity Care. 1. Each provider of adult diagnostic cardiac catheterization services shall maintain a policy and procedure manual, available for review by the Agency, which documents a plan to provide services to Medicaid and charity care patients. 2. At a minimum, the policy and procedure manual shall document specific outreach programs directed at Medicaid and charity care patients for adult diagnostic cardiac catheterization services. -Review the policy and procedure manual to determine if the hospital has a plan for providing adult diagnostic cardiac catheterization program services to Medicaid and charity care patients. Do the policies and procedures document specific outreach programs directed at Medicaid and charity care patients? How does the hospital implement these outreach programs? -Interview the cardiac cath director. ST - H HEALTH INFORMATION MGMT - Process Title HEALTH INFORMATION MGMT - Process Statute or Rule 59A-3.270(1)(a)-(f), FAC (1) Each hospital shall establish processes to obtain, manage, and utilize information to enhance and improve individual and organizational performance in patient care, governance, management, and support processes. Such processes shall: (a) Be planned and designed to meet the hospital's internal and external information needs; (b) Provide for confidentiality, security and integrity; (c) Provide uniform data definitions and methods for - Health Information Management (HIM) is the body of knowledge and practice that ensures the availability of health information to facilitate real-time healthcare delivery and critical health-related decision making for multiple purposes across diverse organizations, settings, and disciplines. - The hospital HIM is responsible for managing health information and preserving confidentiality of the information. HIM is responsible for ensuring complete and accurate information for patient care and provide coded information to bill for provided services. HIM also makes sure that the health record is maintained securely and in accordance with: state and federal laws, regulatory and accreditation agencies, and community standards for ambulatory records. - Medical records have been a paper-based business, but hospitals are working toward a fully electronic record.

125 Page 125 of 399 capturing and storing data, including electronic mediums and optical imaging; (d) Provide education and training in information management principles to decision-makers and other hospital personnel who generate, collect, and analyze information; (e) Transmit information in a timely and accurate manner; and (f) Provide for the manipulation, communication and linkage of information. Look to see if the HIM department has an established system for ensuring the following: How medical record data is created and managed. How medical records are processed after the patient is discharged How discharged medical record data is stored and indexed for prompt retrieval. How records are coded for billing information How medical records are secured from unauthorized access; how patient health information is protected, and how the integrity of the medical record is maintained. How hospital personnel are trained about generating, collecting and analyzing health information. How patients may access their medical record. - Tour the medical record department to observe how medical records are processed, coded, and stored. Observe the staff involved in the process. - Review the facility policies and procedures regarding the HIM system. Make observations of how staff use the active medical record and conduct interviews of HIM staff to determine that they have an established system. ST - H HEALTH INFORMATION MGMT - Transplant Tracking Title HEALTH INFORMATION MGMT - Transplant Tracking Statute or Rule 59A-3.270(2)(a)1-7 and (2)(b), FAC (2) All hospitals involved in the transplantation of organs or tissues shall maintain a centralized tracking system to record the receipt and disposition of all organs and tissues transplanted within the hospital. (a) The tracking system must be kept separate from patients' medical records, and shall include at a minimum: 1. The organ or tissue type; 2. The donor identification number; 3. The name and license number of the procurement or distribution center supplying the organ or tissue; 4. Recipient information, including, at a minimum the patient's name and identification number; 5. The name of the physician who performed the transplant; 6. The date the organ or tissue was received by the hospital; and 59A-3.270(2)(a)1-7, FAC 59A-3.270(2)(b), FAC - Interview the hospital designated organ and tissue requestor to determine if the hospital has a centralized tracking system. - Is this tracking system separate from the medical record requirements regarding organ and tissue procurement? - Verify that documentation can be retrieved from this tracking system regarding receipt and observation of all organs and tissues transplanted within the hospital. - Review the tracking system print out to ensure that the data includes the information required by regulations, also, request documentation that this information was provided quarterly to the organ procurement organization or tissue bank utilized by the hospital.

126 Page 126 of The date the organ or tissue was transplanted. (b) This information must be provided, on a quarterly basis, to the organ procurement organization or tissue bank that originally provided the organ or tissue. ST - H HEALTH INFORMATION MGMT - Medical Records Title HEALTH INFORMATION MGMT - Medical Records Statute or Rule 59A-3.270(3)(a)-(x), FAC (3) Each hospital shall maintain a current and complete medical record for every patient seeking care or service. The medical record shall contain information required for completion of birth, death and still birth certificates, and shall, at a minimum contain the following information: (a) Identification data; (b) Chief complaint or reason for seeking care; (c) Present illness; (d) Personal medical history; (e) Family medical history; (f) Physical examination report; (g) Provisional and pre-operative diagnosis; (h) Clinical laboratory reports; (i) Radiology, diagnostic imaging, and ancillary testing reports; (j) Consultation reports; (k) Medical and surgical treatment notes and reports; (l) Evidence of appropriate informed consent; (m) Evidence of medication and dosage administered; (n) A copy of Florida EMS Report, HRS Form 1894, given to the hospital as required by Rule 64E-2.013, F.A.C., if the patient was delivered to the hospital by ambulance; (o) Tissue reports; (p) Physician and nurse progress notes; - Review a sample of patient medical records, including active records one from each nursing unit, 5 discharged patient records within the past 3 months, and ambulatory care records representing each different type of ambulatory care services. - Look to see that the medical record contains information required for completion of birth, death and still birth certificates, and, at a minimum contain an original or true copy of the following information, as applicable: Identification data; Chief complaint or reason for seeking care; Present illness; Past medical history; Family medical history; Physical examination report; Provisional and pre-operative diagnosis; Clinical laboratory reports; Radiology, diagnostic imaging, and ancillary testing reports; Consultation reports; Medical and surgical treatment notes and reports; Evidence of appropriate informed consent; Evidence of medication and dosage administered; A copy of Florida EMS Report, HRS Form 1894, given to the hospital as required by Rule 64B , F.A.C., if the patient was delivered to the hospital by ambulance; Tissue reports; Physician and nurse progress notes; Principal diagnosis, secondary diagnoses and procedures when applicable; Discharge

127 Page 127 of 399 (q) Principal diagnosis, secondary diagnoses and procedures when applicable; (r) Discharge summary; (s) Appropriate social work services reports, if provided; (t) Autopsy findings when performed; (u) Individualized treatment plan; (v) Clinical assessment of the patient's needs; (w) Certifications of transfer of the patient between hospitals as specified by Rule 59A-3.255, F.A.C.; and (x) Routine Inquiry Form regarding request for organ donation in the event of the death of the patient. Appropriate social work services reports, if provided; Autopsy findings when performed; Individualized treatment plan; Clinical assessment of the patient's needs; Certifications of transfer of the patient between hospitals as specified by Rule 59A-3.207, F.A.C. Routine Inquiry Form regarding request for organ donation in the event of the death of the patient. - Validate applicable medical record information from patient observations and interviews. - If the medical records are missing applicable information, interview the HIM director and personnel responsible for documenting or obtaining this information this. - Review the HIM policies regarding the required content of the patient medical record. ST - H HEALTH INFORMATION MGMT -Operative Procedures Title HEALTH INFORMATION MGMT -Operative Procedures Statute or Rule 59A-3.270(4)(a)-(c), FAC 4. For patients undergoing operative or other invasive procedures the medical record polices shall also require: (a) The recording of preoperative diagnoses prior to surgery; (b) That operative reports be recorded in the health record immediately following surgery or that an operative progress note is entered in the patient record to provide pertinent information; and (c) Postoperative information shall include vital signs, level of consciousness, medications, blood components, complications and management of those events, identification of direct providers of care, discharge information from the post-anesthesia care area. - Review a sample of inpatient surgical records to ensure that there is a preoperative diagnosis in the record prior to surgery or an invasive procedure. - Are the operative reports or an operative progress note recorded immediately following surgery? - Look to see that the postoperative information includes vital signs, level of consciousness, medications, blood components, complications and management of those events, identification of direct providers of care, and discharge information from the post-anesthesia care area, if applicable?

128 Page 128 of 399 ST - H HEALTH INFORMATION MGMT - Med Records Dept Title HEALTH INFORMATION MGMT - Med Records Dept Statute or Rule 59A-3.270(6)(a)-(c), FAC (6) Each hospital shall have a patient information system, medical records department or similarly titled unit with administrative responsibility for medical records. The medical records department shall: (a) Maintain a system of identification and filing to ensure the prompt location of a patient's medical record. Patient records may be stored on electronic medium such as optical imaging, computer, or microfilm; (b) Centralize all appropriate clinical information relating to a patient's hospital stay in the patient's medical record; (c) Index, and maintain on a current basis, all medical records according to disease, operation and physician. Tour the medical record department to observe how medical records are processed, coded, and stored. Observe the staff involved in the process. Determine the location(s) where medical records are maintained. Verify that a medical record is maintained for each person treated or receiving care. The hospital may have a separate record for both inpatients and outpatients. Verify that there is an established system that addresses at least the following activities of the medical records services: Timely processing of records; Coding/indexing of records according to disease, operation and physician; a Maintenance system of identifying and filing to ensure the prompt location of a patient's medical record and Retrieval of records; The system is Centralized- all appropriate clinical information relating to a patient's hospital stay is located in the patient's medical record; Interview the Director of Health Information Management. Ask him/her to explain the following: How medical record data is created and managed. How medical records are identified and filed. How medical records are processed after the patient is discharged How discharged medical record data is stored and indexed for prompt retrieval. Review a sample of active and closed medical records for completeness and accuracy in accordance with the hospital policy. Include a sample of outpatient records in order to determine compliance in outpatient departments, services, and locations. ST - H HEALTH INFORMATION MGMT - Confidentiality Title HEALTH INFORMATION MGMT - Confidentiality Statute or Rule 59A-3.270(7)(a)-(d) FAC; (4) FS

129 Page 129 of A-3.270(7) Patient records shall have a privileged and confidential status and shall not be disclosed without the consent of the person to whom they pertain pursuant to Section (4), F.S., but appropriate disclosure may be made without such consent to: (a) Hospital personnel for use in connection with the treatment of the patient; (b) Hospital personnel only for internal hospital administrative purposes associated with the treatment, including risk management and quality assurance functions; (c) The Agency for Health Care Administration; or (d) In any civil or criminal action, unless otherwise prohibited by law, upon the issuance of a subpoena from a court of competent jurisdiction and proper notice by the party seeking such records to the patient or his legal representative (4) Patient records are confidential and must not be disclosed without the consent of the patient or his or her legal representative, but appropriate disclosure may be made without such consent to: (a) Licensed facility personnel, attending physicians, or other health care practitioners and providers currently involved in the care or treatment of the patient for use only in connection with the treatment of the patient. (b) Licensed facility personnel only for administrative purposes or risk management and quality assurance functions. (c) The agency, for purposes of health care cost containment. (d) In any civil or criminal action, unless otherwise prohibited by law, upon the issuance of a subpoena from a court of competent jurisdiction and proper notice by the party seeking such records to the patient or his or her legal representative. (e) The agency upon subpoena issued pursuant to s , but the records obtained thereby must be used solely for the purpose of the agency and the appropriate professional board in its investigation, prosecution, and appeal of disciplinary (4) FS 59A-3.270(7)(a)-(d), FAC - Review the facility HIM policy and procedure for confidentiality of patient records. Tour the patient care areas and observe the hospital's security practices for patient records. Verify that only authorized persons are allowed access to patient records. - Interview the HIM director regarding procedures in place to ensure confidentiality of medical records. - Tour the patient care areas and observe the hospital's security practices for patient records. - Interview staff to determine if they are aware of the Privacy and Confidentiality requirements regarding patient information. - Have these policies been implemented and authorized persons allowed access to patient records. - If the hospital utilizes electronic patient records are appropriate security safeguards in place? Are patient records left unsecured or unattended? Are patient records unsecured or unattended in hallways, patient rooms, nurse's stations, or on counters where an unauthorized person could gain access to patient records? - Are there precautions to prevent physical or electronic altering or damaging of patient records? - Review a sample of hospital medical to see if there is evidence of a process for release of information, ex: a form and/or any documentation that this process is in place, to provide confidentiality of patient records. - Investigate into the hospital QI program.

130 Page 130 of 399 proceedings. If the agency requests copies of the records, the facility shall charge no more than its actual copying costs, including reasonable staff time. The records must be sealed and must not be available to the public pursuant to s (1) or any other statute providing access to records, nor may they be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the agency or the appropriate regulatory board. However, the agency must make available, upon written request by a practitioner against whom probable cause has been found, any such records that form the basis of the determination of probable cause. (f) The Department of Health or its agent, for the purpose of establishing and maintaining a trauma registry and for the purpose of ensuring that hospitals and trauma centers are in compliance with the standards and rules established under ss , , , , , and , and for the purpose of monitoring patient outcome at hospitals and trauma centers that provide trauma care services. (g) The Department of Children and Family Services or its agent, for the purpose of investigations of cases of abuse, neglect, or exploitation of children or vulnerable adults. (h) A local trauma agency or a regional trauma agency that performs quality assurance activities, a panel or committee assembled to assist a local trauma agency, or a regional trauma agency performing quality assurance activities. Patient records obtained under this paragraph are confidential and exempt from s (1) and s. 24(a), Art. I of the State Constitution. (i) Organ procurement organizations, tissue banks, and eye banks required to conduct death records reviews pursuant to s (j) The Medicaid Fraud Control Unit in the Department of Legal Affairs pursuant to s (k) The Department of Financial Services, or an agent, employee, or independent contractor of the department who is

131 Page 131 of 399 auditing for unclaimed property pursuant to chapter 717. (l) A regional poison control center for purposes of treating a poison episode under evaluation, case management of poison cases, or compliance with data collection and reporting requirements of s and the professional organization that certifies poison control centers in accordance with federal law. ST - H HEALTH INFORMATION MGMT - Record Copies Title HEALTH INFORMATION MGMT - Record Copies Statute or Rule 59A-3.270(9)(a)-(b), FAC (9) Any licensed facility shall, upon request, and only after discharge of the patient, furnish to any patient admitted or treated in the facility, or to any patient's guardian, curator, or personal representative, or to anyone designated by the patient in writing, a true and correct copy of all of the patient's records, including X-rays, which are in the possession of the licensed facility, provided the person requesting such records agrees to pay a reasonable charge for copying the records, pursuant to Section , F.S. The per page fee is applicable to each page generated during copying of the medical record by the facility or from a copy service providing these services on behalf of the facility. Progress notes and consultation reports of a psychiatric or substance abuse nature concerning the care and treatment performed by the licensed facility are exempted from this requirement. The licensed facility shall further allow any such person to examine the original records in its possession, or microfilms or other suitable reproductions of the records stored on electronic mediums, upon such reasonable terms imposed to assure that the records will not be damaged, destroyed, or altered. (a) The provisions of this section do not apply to any - Interview the HIM director as to how discharged patients, or legal representatives are able to access their medical record. Review the HIM policies about this procedure. - Look to see if these procedures include the exceptions for progress notes and consultation reports of a psychiatric or substance abuse nature concerning the care and treatment performed by the licensed facility. - Ask about their procedure for a person to examine his/her record to assure that the records are not damaged, destroyed or altered. - Select a sample of patients who have been discharged for more than 30 days. Request their medical records. Are those records correct and complete? Chapter , Florida Statute, Department of Corrections, Confidential information.-- (1) Except as otherwise provided by law or in this section, the following records and information held by the Department of Corrections are confidential and exempt from the provisions of s (1) and s. 24(a), Art. I of the State Constitution: (a) Mental health, medical, or substance abuse records of an inmate or an offender. Disclosure of the medical records of inmates of any institution, facility or program of the Department of Corrections shall be made in conformance with Chapter 945, F.S., and applicable rules adopted thereunder.

132 Page 132 of 399 licensed facility whose primary function is to provide psychiatric care or substance abuse treatment to its patients. (b) Disclosure of the medical records of inmates of any institution, facility or program of the Department of Corrections shall be made in conformance with Chapter 945, F.S., and applicable rules adopted thereunder. ST - H HEALTH INFORMATION MGMT - DCF/DC Med Records Title HEALTH INFORMATION MGMT - DCF/DC Med Records Statute or Rule 59A-3.270(10), FAC; FS 59A-3.270(10) Each hospital operated by the Department of Health and Rehabilitative Services and the Department of Corrections shall use a problem oriented medical record for each patient, which shall be initiated at the time of intake or admission and which shall contain all pertinent information required by this section. 59A-3.270(10), FAC , FS Only applies to hospitals operated by the Department of Health and Rehabilitation Services and Department of Corrections Patient records; form and content.-each hospital operated by the agency or by the Department of Corrections shall require the use of a system of problem-oriented medical records for its patients, which system shall include the following elements: basic client data collection; a listing of the patient's problems; the initial plan with diagnostic and therapeutic orders as appropriate for each problem identified; and progress notes, including a discharge summary. The agency shall, by rule, establish criteria for such problem-oriented medical record systems in order to ensure comparability among facilities and to facilitate the compilation of statewide statistics.

133 Page 133 of 399 ST - H HEALTH INFORMATION MGMT-DCF/DC Record Content Title HEALTH INFORMATION MGMT-DCF/DC Record Content Statute or Rule 59A-3.270(11)(a)1-4 and (b)-(d), FAC (11) Each problem oriented medical record maintained by hospitals operated by the Department of Health and Rehabilitative Services and the Department of Corrections shall be standardized within each hospital and shall be capable of providing easy comparison of basic information on medical records at all such hospitals. Each problem oriented medical record maintained by these hospitals shall contain at least the following information: (a) A patient data base which compiles all known facts about the patient which have relevance to his health care, and which in addition to the other requirements of this section contains: 1. Comments and complaints as spoken by the patient or other persons significant in the patient's life, including relatives, friends and caretakers; 2. A patient profile, including health related habits, social, nutritional and educational information, and a review of physical systems; 3. Relevant legal documents, including but not limited to status forms, forensic forms, consent forms, authority permits, and Baker Act forms; and 4. A medical diagnosis listed according to the International Classification of Diseases and a mental illness diagnosis listed according to the Diagnosis and Statistical Manual of Mental Disorders, as relevant to the patient's condition. (b) A problem list, which is a table of contents to the patient's record, which identifies by number, date and description of the patients problems. (c) A plan of care which shall specify the specific course of 59A-3.270(11)(a)1-4, FAC 59A-3.270(11)(b)-(d), FAC Problem oriented medical record is just a different format of how information is in the record. Applies to hospitals operated by the Department of Health and Rehabilitation Services and Department of Corrections

134 Page 134 of 399 action to be taken to address the problem(s) described, including diagnosis, diagnostic and therapeutic orders, treatment, examination, patient education, referral, and other necessary activities. (d) Progress notes which shall document the activity and follow-up undertaken for each problem in a structured format which is dated, titled and numbered according to the problem to which it relates. ST - H HEALTH INFORMATION MGMT - Discharge Summary Title HEALTH INFORMATION MGMT - Discharge Summary Statute or Rule 59A-3.270(12)(a)-(e), FAC 12. The discharge summary of each problem oriented medical record in hospitals operated by the department of Health and Rehabilitative Services and the Department of Corrections are completed, signed and dated within 15 days following the patient's discharge. The summary includes: (a) The reason for admission; (b) A recapitulation of the patient's hospitalization; (c) A statement of the patient's progress and condition upon discharge; (d) The facility or person, including the patient himself when relevant, assuming responsibility for the patient after discharge; and (e) Recommendations, when necessary, for after care, follow-up, referral or other action necessary to help the patient deal with problems. - No Guidance necessary - Only applies to hospitals run by the Department of Health and Rehabilitation Services and Department of Corrections.

135 Page 135 of 399 ST - H SURVEIL/PREVEN/CONTROL OF INFECTION- Program Title SURVEIL/PREVEN/CONTROL OF INFECTION- Program Statute or Rule 59A-3.250(1)(a)-(d), FAC (1) Each hospital shall establish an infection control program involving members of the organized medical staff, the nursing staff, other professional staff as appropriate, and administration. The program shall provide for: (a) The surveillance, prevention, and control of infections among patients and personnel; (b) The establishment of a system for identifying, reporting, evaluating and maintaining records of infections; (c) Ongoing review and evaluation of all septic, isolation and sanitation techniques employed in the hospital; and (d) Development and coordination of training programs in infection control for all hospital personnel. - Tour the facility for implementation of the infection control program. - Interview the Infection Control Officer or person assigned to maintain the program. - Review the Infection Control Program for (a)-(d) components - How does the facility identify infections (is this a house wide responsibility)? - How are infections reported into the Infection Control Program? - How does the evaluation of the reported infections work (consider thoroughness and timelines)? - How does the Infection Control Program provide training programs to all staff? -Observe care and services offered by nurses, medical, or other direct care staff, or involved in sanitization for appropriate utilization of techniques. - Observe for isolation, sanitation and hospital staff understanding of infection control Policies and Procedures. - Select records of active patients with infection when possible as part of a sample. - Does the program involve medical staff, nursing, professional staff and administration as appropriate ST - H SURVEIL/PREVEN/CONTROL OF INFECTION- P&P Title SURVEIL/PREVEN/CONTROL OF INFECTION- P&P Statute or Rule 59A-3.250(2), FAC (2) Each hospital shall have written policies and procedures reflecting the scope of the infection control program outlined in subsection (1). The written policies and procedures shall be reviewed at least every two years by the infection control program members, dated at the time of each review, revised as necessary, and enforced. - Request and review the Infection Control Policies and Procedures. - Do the Policies and Procedures define the scope of the program? - Are the Policies and Procedures reviewed and dated every two years by the Infection Control members? - Review Policies and Procedures for current practice - are there Policies and Procedures which are no longer utilized? - Do your observations on the facility tour show enforcement of the Infection Control Policies and Procedures?

136 Page 136 of 399 ST - H SURVEIL/PREVEN/CONTROL OF INFECTION- Content -Observe care and practice in various units based on the complexity and scope of services provided. Title SURVEIL/PREVEN/CONTROL OF INFECTION- Content Statute or Rule 59A-3.250(3)(a)-(i), FAC (3) The policies and procedures devised by the infection control program shall be approved by the governing body, and shall contain at least the following: (a) Specific policies for the shelf life of all stored sterile items. (b) Specific policies and procedures related to occupational exposure to blood and body fluids. (c) Specific policies and procedures related to admixture and drug reconstitution, and to the manufacture of intravenous and irrigating fluids. (d) Specific policies related to the handling and disposal of biomedical waste in accordance with Chapter 64E-16, FAC, May 1995, OSHA 29 CFR Part Occupational Exposure to Blood Borne Pathogens Final Rule, July 1995, and the Department of Environmental Protection Code Chapter on Biomedical Waste, May (e) Specific policies related to the selection, storage, handling, use and disposition of disposable items. (f) Specific policies related to decontamination and sterilization activities performed in central services and throughout the hospital, including a requirement that steam gas (ETO) and hot air sterilizers be tested with live bacterial spores at least weekly. (g) Specific policies regarding the indications for universal precautions, body substance isolation, CDC isolation guidelines, or equivalent and the types of isolation to be used for the prevention of the transmission of infectious diseases. - Review the Policies and Procedures for the Infection Control Program for the minimum of (a)-(i) the Governing Body approved the program. - Review a sample of personnel records for Infection Control Training. - Tour sterile storage areas and check dates for expiration dates of sterilization. - Tour a sample of Nursing Unit clean storage and check sterile supplies. - Review Infection Control Policies and Procedures specifically for Exposure to Blood & Body Fluids. - Interview Infection Control Officer regarding this program. - Review Policies and Procedures on drug admixtures, reconstituting and additions to IV/Irrigation fluids. Are licensed staff specifically trained to perform this function? Observe staff prepare, and administer injectables, IV's, or aseptic technique. - Do staff adhere to infection control policies and manufacturers recommendations for medication, admixtures, IV's, and injectables? - Review Policies and Procedures for Components of Biomedical Waste Program. - Observe for the specific bagging, collection, storage, and removal (if possible). - Tour and observe for types of isolation precautions. Are facility precautions in accord with CDC or equivalent guidelines? - Are the staff performing within the established precaution instructions? - Observe staff decontaminate and sterilize equipment. - Observe environment and handling of linen. Observe the storage and collection of soiled linen. - Observe sanitation and cleanliness (esp. vent, airflow and humidity). - Interview Infection Control Officer regarding their Reportable Diseases to the Public Health Department. - Review types of Diseases reported.

137 Page 137 of 399 (h) A requirement that soiled linen is collected in such a manner as to minimize microbial dissemination into the environment. (i) A requirement that all cases of communicable diseases as set forth in Chapter 64D-3, FAC, be promptly and properly reported in accordance with the provisions of that rule. ST - H SURVEIL/PREVEN/CONTROL OF INFECTION-Meetings Title SURVEIL/PREVEN/CONTROL OF INFECTION-Meetings Statute or Rule 59A-3.250(4), FAC (4) The individuals involved in the infection control program shall meet at least quarterly, shall maintain written minutes of all meetings, and shall make a report at least annually to the assigned professional staff and the governing body. - Review quarterly Infection Control Program minutes for one year. - Annual report to the Governing Body would be evident in the Governing Body minutes. ST - H SURVEIL/PREVEN/CONTROL OF INFECTION-Empl Hlth Title SURVEIL/PREVEN/CONTROL OF INFECTION-Empl Hlth Statute or Rule 59A-3.250(5), FAC (5) Each hospital shall establish an employee health policy to minimize the likelihood of transmission of communicable disease by both employees and patients. Such policies shall include work restrictions for an employee whenever it is likely that communicable disease may be transmitted until such time as a medical practitioner certifies that the employee may return to work. - Interview Infection Control Officer regarding the specific program which minimizes the likelihood of transmission of communicable disease by employees and patients. - Interview managers in departments for knowledge of employee restrictions for communicable diseases. - Are there work restriction policies for employees? - Does a medical practitioner certify when an employee may return to work?

138 Page 138 of 399 ST - H QUALITY IMPROVEMENT - System Title QUALITY IMPROVEMENT - System Statute or Rule 59A-3.271(1)(a)-(b)8, FAC (1) General Provisions. Each hospital shall have a planned, systematic, hospital wide approach to the assessment, and improvement of its performance to enhance and improve the quality of health care provided to the public. (a) Such a system shall be based on the mission and plans of the organization, the needs and expectations of the patients and staff, up-to-date sources of information, and the performance of the processes and their outcomes. (b) Each system for quality improvement, which shall include utilization review, must be defined in writing, approved by the governing board, and enforced, and shall include: 1. A written delineation of responsibilities for key staff; 2. A policy for all privileged staff, whereby staff members do not initially review their own cases for quality improvement program purposes; 3. A confidentiality policy; 4. Written, measurable criteria and norms; 5. A description of the methods used for identifying problems; 6. A description of the methods used for assessing problems, determining priorities for investigation, and resolving problems; 7. A description of the methods for monitoring activities to assure that desired results are achieved and sustained; and 8. Documentation of the activities and results of the program. 59A-3.271(1)(a), FAC 59A-3.271(b)1-8, FAC - Interview the person(s) assigned to quality improvement and also may interview Department Heads/Managers. - Request the Quality Improvement Plan. - Does the Plan address all departments/housewide and include items 1-8? - Review examples of where the facility has assessed problems, determined priorities for investigations and resolved problems. - How has the QI Program improved processes or outcomes? - Does plan prioritize for investigation and problem resolution plan?

139 Page 139 of 399 ST - H QUALITY IMPROVEMENT - Data Collection System Title QUALITY IMPROVEMENT - Data Collection System Statute or Rule 59A-3.271(2)(a)-(h), FAC (2) Each hospital shall have in place a systematic process to collect data on process outcomes, priority issues chosen for improvement, and the satisfaction of the patients. Processes measured shall include: (a) Appropriate surgical and other invasive procedures; (b) Preparation of the patient for the procedure; (c) Performance of the procedure and monitoring of the patient; (d) Provision of post-procedure care; (e) Use of medications including prescription, preparation and dispensing, administration, and monitoring of effects; (f) Results of autopsies; (g) Risk management activities; (h) Quality improvement activities including at least clinical laboratory services, diagnostic imaging services, dietetic services, nuclear medicine services, and radiation oncology services. - Interview person(s) assigned to Quality Improvement Plan. - Do they have a Data Collection System for items (a)-(h)? - How does the facility evaluate the Patient Satisfaction? - On tour with Manager/Department Heads inquire about their processes which have been selected for improvement. - How is the Risk Management Program incorporated into the overall QI Program? - The preparation, surgical procedure, post procedural care and use of medications must be monitored for outcomes and opportunities to improve the processes. Review data and outcomes. - The QI Program must be specific to the types of patients and population served (i.e. psych/behavior consider safety/observations, general acute facility consider surgical services care). - Interview the person responsible for the QI Program - inquire about current programs on processes under QI review. ST - H QUALITY IMPROVEMENT - Data Assessment Process Title QUALITY IMPROVEMENT - Data Assessment Process Statute or Rule 59A-3.271(3)(a)-(c), FAC Type Standard (3) Each hospital shall have a process to assess data collected - Review Quality Improvement Plan for data for existing activities (house wide).

140 Page 140 of 399 to determine: (a) The level and performance of existing activities and procedures, (b) Priorities for improvement, and (c) Actions to improve performance. - Which processes are selected currently for Quality Improvement? - What actions have been implemented to improve process/outcomes? ST - H QUALITY IMPROVEMENT -Incorporated Into Proced Title QUALITY IMPROVEMENT -Incorporated Into Proced Statute or Rule 59A-3.271(4), FAC (4) Each hospital shall have a process to incorporate quality improvement activities in existing hospital processes and procedures. -Interview managers and staff on units for quality improvement measures. - Interview person assigned to Quality Improvement. - Ask for examples where quality improvement has been incorporated into procedures. ST - H GOVERNING BODY Title GOVERNING BODY Statute or Rule 59A-3.272(1), FAC (1) The licensee shall have a governing body responsible for the conduct of the hospital as a functioning institution - Review the facility's governing body minutes to ensure issues discussed have to do with the hospital's function. - Review the governing body written bylaws, rules and regulations to see how the governing body is organized. ST - H GOVERNING BODY - Organization Title GOVERNING BODY - Organization Statute or Rule 59A-3.272(2)(a)-(e), FAC

141 Page 141 of 399 (2) The governing body shall be organized under written bylaws, rules and regulations which it reviews at least every two years, dates to indicate time of last review, revises as necessary, and enforces. Governing body by-laws shall: (a) State the role and purpose of the hospital, including an organizational chart defining the lines of authority. The description of the structure of the hospital shall include full disclosure in writing of the names and addresses of all owners and persons controlling 5 percent or more interest in the hospital. In the case of corporations, holding companies, partnerships, and similar organizations, the names and addresses of officers, directors, and stockholders, both beneficial and of record, when holding 5 percent or more interest, shall be disclosed. (b) State the qualifications for governing body membership, and the method of selecting members as well as the terms of appointment or election of members, officers and chairmen of committees. (c) Provide for the designation of officers, their duties, and for the organization of the governing body into essential committees with the number and type consistent with the size and scope of the hospital's activities. (d) Coordinate through an executive committee or the governing body as a whole, the policies and activities of the facility and special committees established by the governing body. (e) Specify the frequency of meetings, at regularly stated intervals, the number or percentage of members constituting a quorum, and require that minutes be recorded and made available to all members of the governing body. - Request documentation showing that the governing body written bylaws, rules and regulations are reviewed at least every two years. - Review the governing body's minutes for one year. Does the governing body meet as often as required by their bylaws, rules and regulations? - Review the hospital organizational chart. - Ask to see disclosure documentation of any person, organization, partnership, etc., that has five percent or more interest in the hospital. - Review the governing body's by laws. What are the required qualifications for governing body memberships? - What are the duties, terms of appointment, etc. specified in the bylaws for its officers? - Determine if the organization of the governing body is consistent with the size and scope of the hospital?

142 Page 142 of 399 ST - H GOVERNING BODY - CEO Title GOVERNING BODY - CEO Statute or Rule 59A-3.272(3), FAC (3) The governing body shall establish the position of chief executive officer or other similarly titled position, and define in writing the responsibility, authority and accountability of the chief executive officer for operation and maintenance of the hospital. - Review the hospital's organization chart. Does the facility have a Chief Executive Officer? If the position is not titled Chief Executive Officer: Interview the Administrator and ask the title of the position that acts as the CEO? - Review the CEO's record. - Was this position established by the governing body? - Are the responsibilities and authority of the CEO clearly established in writing? - How is the CEO held accountable for the daily operation and maintenance of the hospital? ST - H GOVERNING BODY - Membership/Privileges Title GOVERNING BODY - Membership/Privileges Statute or Rule 59A-3.272(4)(a)-(b) FAC, (1) FS 59A-3.272(4)(a)-(b), FAC (4) The governing body shall approve the by-laws, rules and regulations of the organized medical staff, provide for the appointment, reappointment, or dismissal of members of the organized medical staff, and provide a procedure for hearings and appeals on all actions concerning appointment, reappointment or dismissal. No action on appointment, reappointment, or dismissal of a member of the organized medical staff shall be taken without prior referral to the organized medical staff for their recommendation, except in emergency cases. (a) The governing body shall provide that no qualified 59A-3.272(4)(a)-(b), FAC (1), FS - Determine how the governing body determines who is eligible for appointment, what criteria is used. - Interview the HR Director/CEO and ask what procedure is used to appoint the medical staff privileges? What criteria has the governing body given the HR Director for hiring medical staff? Ensure the requirements do not discriminate based on race, sex, age, or ethnicity. - Select a sample of medical staff to verify that the governing body has been the one to appoint the medical staff. Has the HR Director followed the governing body's requirements?

143 Page 143 of 399 applicant is denied organized medical staff privileges or clinical privileges solely because the applicant is licensed as a physician, dentist or podiatrist. (b) The governing body shall set standards and procedures to be applied by the hospital and the organized medical staff in considering and acting upon applications for staff membership or professional privileges, including delineation of privileges. Such standards or procedures shall be available for public inspection, and shall not operate to deny staff privileges or clinical privileges in an arbitrary, unreasonable or capricious manner, or on the basis of sex, race, creed, or national origin F.S. Staff membership and clinical privileges. (1) No licensed facility, in considering and acting upon an application for staff membership or clinical privileges, shall deny the application of a qualified doctor of medicine licensed under chapter 458, a doctor of osteopathic medicine licensed under chapter 459, a doctor of dentistry licensed under chapter 466, a doctor of podiatric medicine licensed under chapter 461, or a psychologist licensed under chapter 490 for such staff membership or clinical privileges within the scope of his or her respective licensure solely because the applicant is licensed under any of such chapters. ST - H GOVERNING BODY - Membership/Privilege AMA/AOA Title GOVERNING BODY - Membership/Privilege AMA/AOA Statute or Rule 59A-3.272(4)(c), FAC; (3), FS 59A-3.272(4)(c), FAC (c) When the standards and procedures established by the governing body require, as a precondition to obtaining staff membership or professional clinical privileges, the completion of or eligibility in, a program established by the American 59A-3.272(4)(c), FAC (3), FS - Interview the HR Director/CEO and ask if the governing body's requirements for providing privileges are based on the American Medical Association requirements. Completion of comparable programs established by the American Osteopathic Association is acceptable.

144 Page 144 of 399 Medical Association or the Liaison Committee on Graduate Medical Education, the governing body shall also make available staff membership or privileges to physicians who have obtained the completion of or eligibility in, any program which is in the same area of medical specialization established by the American Osteopathic Association. - Review the medical staff's records to ensure that when the American Medical Association requirements are utilized, then the criterion is met. American Medical Association: American Osteopathic Association: (3), FS (3) When a licensed facility requires, as a precondition to obtaining staff membership or clinical privileges, the completion of, eligibility in, or graduation from any program or society established by or relating to the American Medical Association or the Liaison Committee on Graduate Medical Education, the licensed facility shall also make available such membership or privileges to physicians who have attained completion of, eligibility in, or graduation from any equivalent program established by or relating to the American Osteopathic Association. ST - H GOVERNING BODY - Specialty Designation Title GOVERNING BODY - Specialty Designation Statute or Rule 59A-3.272(4)(d), FAC (d) The governing body shall require a delineation of privileges for each member of the organized medical staff. The delineation of privileges shall not be stated simply as a specialty designation, such as "general surgery" or "general medicine" unless such terms are specifically defined elsewhere. - Review a sample of medical staff records to ensure their specialty designation is defined.

145 Page 145 of 399 ST - H GOVERNING BODY - Applicant Eligibility Title GOVERNING BODY - Applicant Eligibility Statute or Rule 59A-3.272(4)(e)-(h), (4), A-3.272(4)(e)-(h) FAC (e) The governing body shall require that eligibility for privileges, delineation of privileges, and reappointments, be based on the applicant's background, experience, health, training, demonstrated current competence, adherence to applicable professional ethics, reputation, ability to work with others, ability of the hospital to provide adequate facilities and supportive services for the applicant and his patients, and such other elements as the governing body determines that are not inconsistent with this part. (f) The governing body shall establish a procedure, within a time-limited period, for approving, approving in part, or denying an applicant's request for privileges. (g) The governing body shall establish a procedure for an applicant for privileges to appeal an adverse decision, and shall establish a time-limited period for rendering a final decision after the appeal. (h) The governing body shall set standards and procedures which provide for reasonable access by licensed chiropractors to the reports of diagnostic x-rays and laboratory tests of the institutions licensed facilities, subject to the same standards and procedures as other licensed physicians. However, nothing contained in the provisions of this section shall require a licensed facility to grant staff privileges to a chiropractor. 59A-3.272(4)(e)-(h), FAC (4), FS , FS - Do these criteria include evaluation of individual character, competence, training and judgment? - Are there written criteria for staff appointments to the medical staff? - The governing body must ensure that the hospital's rules and criteria for medical staff memberships and granting of clinical privileges are applied equally to all practitioners. - Review the governing body criteria for appointment and documentation of their application. - What is the time frame for this application process? - Is there a written process for approval if there is an adverse decision? - Are there written governing body policies and procedures regarding providing diagnostic laboratory tests and X-rays to licensed chiropractors? - Review sample of credentialing files for privileges, delineation of privileges and reappointments. Review background checks, health status, training, specialized credentials and disciplinary action. - Review policy and procedure for approving, partial approval or denying and applicant's request for privileges. - Review procedure for appealing an adverse decision (4) FS (4) Nothing herein shall restrict in any way the authority of the medical staff of a licensed facility to review for approval or

146 Page 146 of 399 disapproval all applications for appointment and reappointment to all categories of staff and to make recommendations on each applicant to the governing board, including the delineation of privileges to be granted in each case. In making such recommendations and in the delineation of privileges, each applicant shall be considered individually pursuant to criteria for a doctor licensed under chapter 458, chapter 459, chapter 461, or chapter 466, or for an advanced registered nurse practitioner licensed and certified under part I of chapter 464, or for a psychologist licensed under chapter 490, as applicable. The applicant's eligibility for staff membership or clinical privileges shall be determined by the applicant's background, experience, health, training, and demonstrated competency; the applicant's adherence to applicable professional ethics; the applicant's reputation; and the applicant's ability to work with others and by such other elements as determined by the governing board, consistent with this part FS Access of chiropractic physicians to diagnostic reports. Each hospital shall set standards and procedures which provide for reasonable access by licensed chiropractic physicians to the reports of diagnostic X rays and laboratory tests of licensed facilities, subject to the same standards and procedures as other licensed physicians. However, this section does not require a licensed facility to grant staff privileges to a chiropractic physician. ST - H GOVERNING BODY - Suspend/Deny/Revoke/Curtail Title GOVERNING BODY - Suspend/Deny/Revoke/Curtail Statute or Rule 59A-3.272(5)(a)-(c)1-5 FAC

147 Page 147 of 399 (5) The governing body of any licensed facility, is authorized to suspend, deny, revoke, or curtail the staff privileges of any staff member for good cause. (a) The procedures for such actions shall comply with the facility's established bylaws, standards, and procedures. (b) The proceedings and records of committees and governing bodies which relate solely to actions taken in carrying out the provisions of this section shall not under any circumstances be subject to inspection under the provisions of Chapter 119, F.S.; nor shall meetings held pursuant to achieving the objectives of such committees and governing bodies be open to the public under the provisions of Chapter 286, F.S. (c) Good cause shall include, but not be limited to: 1. Incompetence. 2. Negligence. 3. Being found to be a habitual user of intoxicants or drugs to the extent that he is deemed dangerous to himself or others. 4. Mental or physical impairment which may adversely affect patient care. 5. Behavior disruptive to the hospital environment. 59A-3.272(5)(a)-(b), FAC 59A-3.272(5)(c)1-5, FAC - Review the governing body written procedure for suspending, denying, revoking, or curtailing staff privileges of any staff member for good cause. Good causes shall include, but not be limited to paragraphs (c) 1-5 of the regulation. ST - H GOVERNING BODY - Written Notification Title GOVERNING BODY - Written Notification Statute or Rule 59A-3.272(6),FAC; (6)FS 59A-3.272(6) FAC (6) Within 30 days of receipt of a written request, either by an applicant for staff privileges, or by a member of the organized medical staff whose privileges have been suspended, denied, 59A-3.272(6), FAC (6), FS - Review the governing body policy for notifying an applicant for staff privileges or member of the medical staff, who provides a written request of this action, is provided a written response.

148 Page 148 of 399 revoked or curtailed, whether in whole or in part, the licensed facility shall supply the reasons for such action in writing to the requesting applicant or staff member. A denial of staff membership or professional clinical privileges to any applicant shall be submitted, in writing, to the applicant's respective licensing board. - Is this response provided within 30 days? - If there was a denial of staff memberships or clinical privileges, was the applicant's licensing board notified in writing of this action? (6) FS (6) Upon the written request of the applicant, any licensed facility that has denied staff membership or clinical privileges to any applicant specified in subsection (1) or subsection (2) shall, within 30 days of such request, provide the applicant with the reasons for such denial in writing. A denial of staff membership or clinical privileges to any applicant shall be submitted, in writing, to the applicant's respective licensing board. ST - H GOVERNING BODY - Licensee Acting as Gov Body Title GOVERNING BODY - Licensee Acting as Gov Body Statute or Rule 59A-3.272(7), FAC (7) Nothing herein shall prohibit the licensee of the facility from acting as the governing body, provided that the articles of incorporation or other written organizational plan describe the manner in which the licensee executes the governing body's responsibility. - Does this hospital licensee act as this hospital's governing body? - If so, review the hospital's Articles of Incorporation or other written organizational plan to determine how the licensee executes this responsibility.

149 Page 149 of 399 ST - H MGMT & ADMIN - CEO Appoint By Gov Body Title MGMT & ADMIN - CEO Appoint By Gov Body Statute or Rule 59A-3.273(1), FAC 1. Each hospital is under the direction of a chief executive officer appointed by the governing body, who is responsible for the operation of the hospital in a manner commensurate with the authority conferred by the governing body. - Verify that the hospital has a Chief Executive Officer appointed by the governing body for the entire hospital. - Review the governing body requirements for this position. - Interview the Chief Executive Officer regarding operation of the hospital. Verify management of the entire hospital. - Is the hospital operated as required by State law and in compliance with the governing body guidelines? ST - H MGMT & ADMIN - CEO Regulatory Responsibility Title MGMT & ADMIN - CEO Regulatory Responsibility Statute or Rule 59A-3.273(2)(a)-(b), FAC (2) The chief executive officer shall take all reasonable steps to provide for: (a) Compliance with applicable laws and regulations; and (b) The review of and prompt action on reports and recommendations of authorized planning, regulatory, and inspecting agencies. - Does the Chief Executive Officer insure compliance with all regulations and laws? - Does the hospital respond promptly to regulatory requirements found out of compliance? - Review State inspection reports and hospital survey findings for identified problems. - Tour and interview staff to determine if these identified problems has been corrected. - Review documentation that reports were sent promptly to Federal, State and Local agencies as required. ST - H MGMT & ADMIN -CEO Organization Responsibility Title MGMT & ADMIN -CEO Organization Responsibility Statute or Rule 59A-3.273(3) FAC

150 Page 150 of 399 (3) The chief executive officer shall provide for the following: (a) Establishment and implementation of organized management and administrative functions, including: 1. Clear lines of responsibility and accountability within and between department heads and administrative staff; 2. Effective communication mechanisms among departments, medical staff, the administration and the governing body; 3. Internal controls; 4. Coordination of services with the identified needs of the patient population; 5. A policy on patient rights and responsibilities; 6. A mechanism for receiving and responding to complaints concerning patient care; 7. A policy on withholding resuscitative services; 8. Policies and procedures on identification and referral of organ and tissue donors including notification of organ and tissue procurement agencies when organs and tissues become available as specified under Rule 59A-3.219, F.A.C.; 9. Policies and procedures for meeting the communication needs of multicultural populations and persons with impaired hearing or speaking skills; 10. Policies and procedures on discharge planning; 11. A policy to assist in accessing educational services for children or adolescents when treatment requires a significant absence from school; 12. Policies and procedures to assure that the treatment, education and developmental needs of neonates, children and adolescents transferred from one setting to another are assessed; 13. Dissemination and enforcement of a policy prohibiting the use of smoking materials in hospital buildings and procedures for exceptions authorized for patients by a physician's written authorization; 14. A policy regarding the use of restraints and seclusion; 59A-3.273(3)(a)1-15, FAC 59A-3.273(3)(b)1-4, FAC 59A-3.273(c)-(e), FAC - The hospital Chief Executive Officer is responsible for implementing organized management with administrative functions. Based on the hospital's organizational chart are the department heads identified and responsible for developing and implementing appropriate hospital policies and procedures for their department? - Do these policies cover the areas identified in paragraph (a) 1-15 of this regulation? - Review personnel policies and procedures to ensure they meet the requirements under paragraph (b) of this regulation. - Review a sample of personnel records to ensure compliance with State regulations. - Interview the hospital risk management department to ensure compliance with State regulations. - Review a sample of personnel records to ensure State educational licensee requirements are met regarding human immune deficiency virus education as identified in paragraph (e) of this regulation.

151 Page 151 of 399 and 15. A comprehensive emergency management plan which meets the requirements of paragraph (1)(c), F.S., and Rule 59A-3.078, F.A.C. (b) Personnel policies and practices which address: 1. Non-discriminatory employment practices; 2. Verification of credentials including current licensure and certification; 3. Periodic performance evaluations; and 4. Provision of employee health services. (c) Financial policies and procedures; (d) An internal risk management program which meets the requirements of Section , F.S., and Chapter 59A-10, F.A.C., and (e) Assurance of compliance with educational requirements on human immunodeficiency virus and acquired immune deficiency syndrome pursuant to Sections and , F.S., and Chapter 64D-2, F.A.C., September ST - H ANATOMICAL GIFTS, ROUTINE INQ - Donation Title ANATOMICAL GIFTS, ROUTINE INQ - Donation Statute or Rule 59A-3.274(1), FAC (1) Each Class I and Class II hospital shall establish a mechanism whereby the next of kin of all patients who are deemed medically acceptable and who die in Florida hospitals are given the opportunity to consider the donation of organs, tissues and eyes for transplantation and research. - Does the hospital have policies and procedures for requesting organ, tissue and eyes of medically suitable donors? - Are there written protocols to ensure that once the Organ Procurement Organization (OPO) determines medical suitability, the person's family is informed of donation options? - Is the family informed of the right to decline to donate?

152 Page 152 of 399 ST - H ANATOMICAL GIFTS, ROUTINE INQ - Educ/Training Title ANATOMICAL GIFTS, ROUTINE INQ - Educ/Training Statute or Rule 59A-3.274(2)(a)-(f), FAC (2) Education and Training of Designee. The hospital administrator or designee making the request of the next of kin for organ, tissue and eye donations shall be trained in the request procedures used in organ and tissue donation. The Organ Procurement Organization (OPO), tissue bank and eye bank shall, in conjunction with their affiliated hospitals, develop a requester training curriculum that will meet the individual needs of each affiliated hospital. The AHCA shall assist, if requested, in the implementation of the requester training curriculum in conjunction with an OPO, tissue bank and eye bank where the OPO, tissue bank and eye bank do not have adequate resources for the implementation of the requester training curriculum within their affiliated hospitals. This training shall include the following minimum basic curriculum: (a) The criteria used by the affiliated OPO, tissue bank, and eye bank for determining the acceptability of patients as organ, tissue, or eye donors; (b) The requirements of Florida law to be met in order for a donation to be allowed to proceed including: 1. Explanatory information regarding the family's rights to allow or refuse a donation, to donate specific organs, tissues or eyes and to designate the organs, tissues or eyes for the purpose of transplantation, medical research or instruction, and 2. The criteria for determining whether a particular death falls within the scope of Section , F.S., necessitating close communication with the Medical Examiner's office, and 59A-3.274(2), FAC 59A-3.274(2)(a), FAC 59A-3.274(2)(b)(1)-(2), FAC 59A-3.274(2)(c)(1)-(4), FAC 59A-3.274(2)(d)-(f), FAC - Verify that the hospital's governing body has approved the hospital's organ procurement policy. - Review the hospital's written agreement with the OPO to ensure it is consistent with facility policies and procedures. - Is the name, address, and phone number of the OPO on file? - Does the hospital have personnel with sensitivity training for discussing organ and/or tissue donation with the family? - Review a sample of death records to verify the hospital has implemented organ and/or tissue procurement policies. - Interview staff to verify they are aware of the hospital's organ procurement policies and procedures. - Review the hospital's Routine Inquiry Report.

153 Page 153 of 399 permission from the Medical Examiner when required; (c) Necessary basic information regarding the process and procedures related to organ, tissue, and eye donation and transplantation including the following: 1. The procedures and techniques used in the recovery and preservation of organs, tissues and eyes; 2. The success rates of currently accepted transplant procedures; 3. The numbers of patients presently awaiting these procedures; and 4. The financial procedures and arrangements applicable to the donation of organs, tissues and eyes. (d) The various approaches which can be used in dealing with a family in a grief situation and offering them the opportunity of organ, tissue, or eye donation. These approaches shall be based on the criteria of the affiliated OPO, tissue bank, and eye bank, which shall not be inconsistent with these guidelines; (e) Notification of the affiliated OPO, tissue bank and eye bank; and (f) Training regarding the administrative rules and guidelines promulgated by the agency for the purpose of implementing the Routine Inquiry provisions of the Anatomical Gift Act. ST - H ANATOMICAL GIFTS, ROUTINE INQ - Procedures Title ANATOMICAL GIFTS, ROUTINE INQ - Procedures Statute or Rule 59A-3.274(3)(a)-(c), FAC (3) Each Class I and Class II hospital or its designee shall, using the criteria of the affiliated OPO, tissue bank, and eye bank, implement the following procedures: (a) Establish and publish a formal written policy and procedure for the identification and referral of organ, tissue, - Does the hospital have written criteria to identify potential organ and tissue donors? - Is there a written protocol specifying the designated requestor or OPO representative responsible for approaching potential donor families? - Review training schedules and personnel files to ensure all designated requestors have completed the required training.

154 Page 154 of 399 and eye donors. This policy shall include the procedure to be followed for the determination of brain death. (b) Identify and designate the personnel or organization which will make the request for organ, tissue, or eye donation. These personnel shall be trained as required in paragraph (2) above and shall be available on a 24-hour "on call" basis to make the initial evaluations of donor suitability, request, and referrals. (c) The Hospital Administrator or designee shall ensure that the District Medical Examiner is contacted in all medical examiners' cases regarding the wishes of the family as to organ, tissue, and eye donation and to determine whether or not the medical examiner has released such organs, tissues or eyes for transplantation, medical research or instruction. This contact shall be recorded on the Routine Inquiry Form and placed in the patient's medical record. When completion of the Routine Inquiry Form is designated by the hospital administrator and accepted by the affiliated procurement agency, the contact shall be noted in the records of the affiliated procurement agency. This notation shall indicate that request for donation of organs, tissue or eyes was made. - Is there a hospital policy that includes determination of brain death? - Are Routine Inquiry Forms completed when referral is made to an OPO? - Is a Routine Inquiry Form completed for medical examiner cases? - Are the completed forms filed in the patient's medical record? ST - H ANATOMICAL GIFTS, ROUTINE INQ - Referral Title ANATOMICAL GIFTS, ROUTINE INQ - Referral Statute or Rule 59A-3.274(3)(d), FAC (d) The hospital administrator or designee shall ensure that all identified potential organ, tissue, or eye donors meeting the criteria of brain death as defined in Section , F.S., or cardiorespiratory death as defined in subsection 59A-3.201(9), F.A.C., shall be referred to the affiliated OPO, tissue bank, or eye bank for evaluation and recovery of the organs, tissues, or eyes to be donated according to the medical standards of the - Review the hospital's policy and procedures that ensure coordination between facility staff and OPO staff regarding identification of potential donors. - Does the policy specify that a referral be documented on the Routine Inquiry Form and placed in the patient's medical record?

155 Page 155 of 399 affiliated OPO, tissue bank and eye bank. This referral shall be recorded on the Routine Inquiry Form and placed in the patient's medical record. When completion of the Routine Inquiry Form is designated by the hospital administrator and accepted by the affiliated procurement agency, the referral shall be noted in the records of the affiliated procurement agency. ST - H ANATOMICAL GIFTS, ROUTINE INQ - Affiliations Title ANATOMICAL GIFTS, ROUTINE INQ - Affiliations Statute or Rule 59A-3.274(3)(e)1-3, FAC (e) The hospital shall work with the affiliated OPO, tissue bank, and eye bank to evaluate the patient as a potential organ, tissue, or eye donor. The medical acceptability of such organs, tissues, and eyes shall be determined according to the medical standards of the affiliated procurement agency. The hospital administrator may designate personnel of the affiliated OPO, tissue bank, or eye bank who shall make the request for donation. Where non-hospital personnel are designated to make the request for organ, tissue or eye donation, the affiliated OPO, tissue bank, or eye bank shall be given the opportunity to approach the next of kin about donation and shall utilize the following procedure when approaching the next of kin: 1. The affiliated OPO shall be given the opportunity to approach the next of kin about donation of organs in all suitable vascular organ donor cases when the potential donor meets the medical standards of the affiliated OPO. Where the suitable vascular organ donor also meets the medical standards of the affiliated tissue bank or eye bank, and in the absence of a contrary agreement between the affiliated OPO, tissue bank, and eye bank, the affiliated OPO may represent the affiliated Verify that the hospital has an agreement with at least one tissue bank and eye bank. If not, the hospital has an agreement with an OPO that also has the responsibility for tissue and eye donations. The hospital administrator may designate OPO to make the request for organ, tissue and eye donations if hospital staff is not utilized.

156 Page 156 of 399 tissue bank and eye bank and approach the next of kin about donation in all suitable tissue and eye donor cases. 2. The affiliated tissue bank shall be given the opportunity to approach the next of kin about donation in all suitable tissue donor cases where the potential donor meets the medical standards of the affiliated tissue bank and where the affiliated OPO has not already approached the next of kin for donation of tissues and eyes in all non-suitable vascular organ donor cases. Where the suitable tissue donor also meets the medical standards of the affiliated eye bank, and in the absence of a contrary agreement between the affiliated tissue bank and eye bank, the affiliated tissue bank may represent the affiliated eye bank and approach the next of kin about donation in all suitable eye donor cases. 3. The affiliated eye bank shall be given the opportunity to approach the next of kin about donation in all suitable eye donor cases where the potential donor meets the medical standards of the affiliated eye bank, and where the affiliated OPO or tissue bank has not already approached the next of kin for donation of eyes. Where the suitable eye donor also meets the medical standards of the affiliated tissue bank, and in the absence of a contrary agreement between the affiliated eye bank and tissue bank, the affiliated eye bank may represent the affiliated tissue bank and approach the next of kin about donation in all suitable tissue donor cases. ST - H ANATOMICAL GIFTS, ROUTINE INQ - Timing/Form Title ANATOMICAL GIFTS, ROUTINE INQ - Timing/Form Statute or Rule 59A-3.274(3)(f) and (g)1-3, FAC (f) The request for organ, tissue, or eye donation shall be made at or near the time of death, and in a manner which is conducive to the discussion of organ, tissue, and eye donation 59A-3.274(3)(f), FAC 59A-3.274(3)(g)1-3, FAC - Procurement agency protocol for medically suitable donors is written in the affiliated OPO's, tissue banks and eye

157 Page 157 of 399 with the grieving next of kin according to the priority specified in Section , F.S. (g) A Routine Inquiry Form shall be completed upon every patient death occurring within the hospital and shall become a part of each patient's medical record. 1. The form shall document whether the patient was deemed medically suitable for donation of organs, tissues and eyes, and if the patient is not medically suitable for donation, the form shall document the specific reason according to the criteria of the affiliated procurement agency. 2. If the patient is deemed medically acceptable for donation, the form shall document that the patient's appropriate next of kin was approached, as well as the outcome of the patient's expressed wishes, if known, regarding the donation of organs, tissues, and eyes. If the family allows donation, a specific consent form shall be signed or completed by means of telegraphic, recorded telephonic, or other recorded message by the appropriate next of kin as specified in Section , F.S. 3. If a request for donation is deemed to be exempted according to paragraph (4) of this section, or the medical standards of the affiliated OPO, tissue bank, and eye bank, the form shall document the specific reason for the lack of a request. banks agreements with the hospital. - Verify that the Routine Inquiry Form indicates why patients were not medically suitable as organ and tissue donors. - The hospital or affiliated OPO, tissue bank or eye bank contacts the donor registry to determine whether a medically suitable donor has consented to organ and tissue donation. - Verify if the Routine Inquiry Form indicates that the next of kin was approached regarding organ and tissue donation. ST - H ANATOMICAL GIFTS, ROUTINE INQ - Med Rec/Stats Title ANATOMICAL GIFTS, ROUTINE INQ - Med Rec/Stats Statute or Rule 59A-3.274(3)(h)-(i), FAC (h) The lack of request and a complete written explanation shall be noted on the Routine Inquiry Form and made a part of the patient's medical record or if designated by the hospital administrator, and accepted by the affiliated procurement - Review a sample of death records to determine if the Routine Inquiry Form was completed and made a part of the patient's medical record. - Is statistical data regarding this form forwarded to AHCA on a quarterly basis? - Summary Data Form to AHCA quarterly as required?

158 Page 158 of 399 agency, in the affiliated procurement agency's records. If the affiliated procurement agency has been designated, the patient's medical record shall document the referral of the potential donor to the affiliated procurement agency. All Routine Inquiry Forms maintained by the affiliated procurement agency shall be complete and include the patient's name and medical record number. These records shall be made available to the hospital during normal working hours. A copy of the form shall be sent to the AHCA for data analysis. The referral of the affiliated procurement agency shall be documented in the patient's medical record. This documentation shall include the name of the procurement agency and time and date of the referral. This referral shall be documented in the patient's death record. - Verify whether the Routine Inquiry Forms are completed and made part of donor records. If a request is not made of the next of kin of a medically suitable donor, verify the Routine Inquiry Form is completed and forwarded to AHCA for data analysis. - Verify that the statistical data is forwarded to AHCA on a quarterly basis. (i) Each Class I and Class II hospital or designee shall, on a quarterly basis, aggregate the statistical data relating to organ, tissue, and eye donation requests as required by the agency and forward them to the agency on the Donation Request Summary Data Form, AHCA Form February 94, which is incorporated by reference. The affiliated OPO, tissue bank and eye bank may agree to be designated by the hospital administrator to aggregate and forward the required AHCA forms to the agency. This form shall be submitted on a quarterly basis, due on April 15, July 15, October 15 and January 15, for the respective previous quarters. This information shall be made available by the agency upon written request from an OPO, tissue bank or eye bank. ST - H ANATOMICAL GIFTS, ROUTINE INQ - Exemptions Title ANATOMICAL GIFTS, ROUTINE INQ - Exemptions Statute or Rule 59A-3.274(4)(a)1-5, FAC

159 Page 159 of 399 (4) Request Exemptions. (a) The appropriate next of kin as defined by Section , F.S., of patients deemed medically acceptable by the medical standards of the affiliated OPO, tissue bank and eye bank, and dying in the hospital shall be asked about organ, tissue, and eye donation except as follows: 1. There is on record notification of prior objection by the individual, or the appropriate next of kin as defined by Section , F.S., or 2. The appropriate next of kin is in a violent state, or cannot be found after a reasonable search; or 3. No positive identification of the potential donor has been found; or 4. The medical examiner has denied permission; or 5. The hospital or designee, in accordance with a request for the affiliated procurement agency, has agreed to delay the request until the family has left the hospital. - Does the hospital have an exception policy that excludes asking a patient about organ, tissue or eye donation in certain cases even though the patient was deemed medically acceptable? - Interview the hospital designated requestors to ensure that this policy has been implemented. ST - H ORGANIZED MEDICAL STAFF Title ORGANIZED MEDICAL STAFF Statute or Rule 59A-3.275(1), FAC (1) Each hospital shall have an organized medical staff organized under written by-laws approved by the governing body and responsible to the governing body of the hospital for the quality of all health care provided to patients in the facility and for the ethical and professional practices of its members. - Request a list of medical staff hired within the past year. - Select a sample of medical staff for record review to determine how they were selected and accepted to work in the facility. - Review the facility's written by-laws regarding medical staff organization. - Determine if the by-laws were approved by the facility's governing body meeting minutes. - Interview the facility's Risk Manager and Administrator to determine how the facility evaluates the facility quality of healthcare provided to the facility's patients? - How is that information reported to the governing body?

160 Page 160 of 399 ST - H ORGANIZED MEDICAL STAFF - Committees - While reviewing the facility's governing body minutes, is there written evidence that the facility is reporting quality of healthcare issues to the governing body? Is there evidence of the medical staff being held accountable for ensuring quality of healthcare to the facility's patients? Title ORGANIZED MEDICAL STAFF - Committees Statute or Rule 59A-3.275(2)(a)-(j), FAC (2) Each hospital's organized medical staff shall determine its appropriate committee structure and shall provide that the following required committee functions are carried out with sufficient periodicity to assure their objectives being achieved by separate committee, combined committees, or committee of the whole: (a) Coordination of the activities and general policies of the various departments. (b) Interim decision making for the organized medical staff between staff meetings, under such limitations as shall be set by the organized medical staff. (c) Follow-up and appropriate disposition of all reports dealing with the various staff functions. (d) Review of all applications for appointment and reappointment to all categories of staff, and recommendations on each to the governing body, including delineation of privileges to be granted in each case, and right of hearing and appearance. Except in emergency cases, recommendations to the governing body for withdrawal of any privileges of a member of the organized medical staff or dismissal from the organized medical staff will be made only after a thorough investigation by the organized medical staff or a committee thereof, with the subject member being given the right of hearing before the organized medical staff or a committee thereof, if requested within a reasonable time as specified in - Review the medical staff bylaws to determine the facility's committee's structure. How are the committees connected/coordinated with the organized medical staff? How often do the committees meet? How and how often do the committees report to the organized medical staff? - How are decisions from the medical staff filtered to the various committees and departments of the hospital? - Review the facility's governing body minutes and determine if the governing body to determine how they appoint, privilege and revoke privilege of the medical staff. Has the governing body allowed a hearing and appearance before revoking a medical staff's privilege? - When conducting medical record review, are the patient's records complete? Can you determine the patient's condition, what the medical staff did to treat the condition, was the patient discharged in better condition or was a successful transfer completed? Who ordered the patient's test, consultations and discharge? Was a final assessment completed prior to discharge or transfer? - How does the facility track and trend hospital acquired infections? What is the facility's infection control/prevention program? - Does the facility follow their own policies and procedure regarding pharmacy practices? How often is the efficiency of the pharmacy department evaluated as it applies to patient care and safety? - How does the medical staff ensure the patient care is complete?

161 Page 161 of 399 the hospital's by-laws. (e) Medical records currently maintained describing the condition, treatment, and progress of patient in sufficient completeness to assure transferable comprehension of the case at any time. (f) Clinical evaluation of the quality of medical care provided to all categories of patients on the basis of documented evidence. (g) Review of hospital admissions with respect to need for admission, length of stay, discharge practices and evaluation of the services ordered and provided. (h) Surveillance of hospital infection potentials and cases and the promotion of a preventive and corrective program designed to minimize these hazards. (i) Surveillance of pharmacy and therapeutic policies and practices within the institution. (j) Hospital tests may be ordered only by the attending physician, or by another licensed health professional if that licensed health professional is acting within his scope of practice as defined by applicable laws and rules of the agency. Nothing herein shall be construed to expand or restrict such laws and rules pertaining to the practice of the various health professions. ST - H MAINTENANCE - Preventive Plan Title MAINTENANCE - Preventive Plan Statute or Rule 59A-3.276(1)(a)-(g), FAC (1) Each hospital shall develop, implement, and maintain a written preventive maintenance plan, in conjunction with the policies and procedures developed by the infection control committee, to ensure that the facility is maintained in accordance with the following: - Review the facility written preventative maintenance plan. There should be an established preventative maintenance schedule and ongoing maintenance inspections to identify areas or equipment in need of repair. All medical devices and equipment should be routinely checked by a clinical or biomedical engineer. The routine and preventive maintenance and testing activities should be incorporated into the hospital's quality improvement and/or safety committees.

162 Page 162 of 399 (a) The interior and exterior of buildings shall be in good repair, free of hazards, and painted as needed. (b) All patient care equipment shall be maintained in a clean, properly calibrated, and safe operating condition; (c) All plumbing fixtures shall be maintained in good repair to assure proper functioning, and provided with back flow prevention devices, when required, to prevent contamination from entering the water supply; (d) All mechanical and electrical equipment shall be maintained in working order, and shall be accessible for cleaning and inspection; (e) Loose, cracked, or peeling wallpaper or paint shall be promptly replaced or repaired to provide a satisfactory finish; (f) All furniture and furnishings, including mattresses, pillows, and other bedding; window coverings; including curtains, blinds, shades, and screens; and cubicle curtains or privacy screens, shall be maintained in good repair; and (g) The grounds and buildings shall be maintained in a safe and sanitary condition and kept free from refuse, litter, and vermin breeding or harborage areas. - Were the policies and procedures developed in conjunction with the hospital infection control program? - Is the physical plant and environment maintained in a manner to ensure the safety and well-being of patients? - Observe the building exterior. Is it maintained in good repair and free of hazards? The grounds and buildings should be maintained in a safe and sanitary condition free from refuse/litter and vermin breeding or harborage areas. - Observe the building interior. Is there peeling paint and wallpaper? Is mechanical, electrical and patient care equipment throughout the hospital clean and functional? - Observe a sample of patient rooms. Observe the beds, mattresses, pillows and bedding, privacy curtains, window curtains, blinds and/or screens, bedside tables, window air-conditioner units and any other furnishings in the patient rooms. Are the furnishings clean and in good repair? How are the rooms cleaned between different patients? - Observe plumbing fixtures. Are they maintained in good repair? Interview maintenance staff regarding the monitoring and maintenance of plumbing including backflow devices. - Review the equipment maintenance log. Equipment includes both facility equipment (e.g., elevators, generators, air handlers, medical gas systems, air compressors and vacuum systems, etc.) and medical equipment (e.g., biomedical equipment, radiological equipment, patient beds, stretchers, IV infusion equipment, ventilators, laboratory equipment, etc.). Is there a regular, periodic maintenance program for medical devices and equipment? - Interview maintenance regarding their process for inspecting medical equipment and review logs. Does the facility have a qualified maintenance person (i.e., clinical or biomedical engineer) to test, calibrate and maintain equipment in accordance with manufacturers' regulations? Verify that all medical devices and equipment are routinely checked by a clinical or biomedical engineer. (e.g., cardiac monitors, IV infusion pumps, ventilators, defibrillators, etc.). Are these inspections in accordance with manufacturer's instructions? ST - H MAINTENANCE - Sufficient Personnel Title MAINTENANCE - Sufficient Personnel Statute or Rule 59A-3.276(2), FAC (2) Each hospital shall employ or otherwise arrange for sufficient personnel to implement and maintain its preventive maintenance program. - Review staffing documentation to confirm that there is adequate staff to implement and maintain the preventative maintenance program. - Interview staff regarding the maintenance program.

163 Page 163 of 399 ST - H FUNCTIONAL SAFETY - Hospital Safety Committee Title FUNCTIONAL SAFETY - Hospital Safety Committee Statute or Rule 59A-3.277(1)(a)-(d), FAC (1) Each hospital shall have a hospital safety committee to adopt, implement and monitor a comprehensive, hospital wide safety program. The committee's functions and responsibilities may be assumed by another hospital committee. The committee shall adopt written policies and procedures to enhance the safety of the hospital, its personnel and patients. Such policies shall include but not be limited to the following: (a) A method of coordination of the safety policies of the various hospital units, departments and committees; (b) An incident reporting system; (c) A method of conveying safety-related information to all hospital employees; and (d) Conduct of a hazardous surveillance program at specifically defined intervals. - Has a hospital wide safety program been adopted and implemented? The concept of safety is incorporated throughout the hospital regulations to include: pharmacy, surgery, anesthesia, ambulatory care, radiology, respiratory therapy, special care units, dietary, rehab, psych and substance abuse, etc. - Interview staff to verify their awareness of the safety program and that it has been implemented. - Interview patients regarding safety and security issues (e.g. proper identification before medication or procedure). - Review the hospital safety policies and procedures. Do they include incident reporting, safety training, hazardous surveillance drills, and the coordination of safety policies throughout the hospital? See also the risk management section on incident reports. Risk Management and safety should be intertwined. - Request documentation that there is an ongoing safety monitoring program. - Does the hospital follow current standards of practice to ensure patient safety regarding environment, infection control, and security? - For the hazardous surveillance program (drills), see also the regulation on comprehensive emergency management plan at 59A (H0007). The hospital must test the implementation of the emergency management plan semiannually or at a frequency specified by the Joint Commission if accredited. The hospital's performance must be evaluated and reported to the safety committee. - Is there documentation of periodic staff training regarding emergency situations and handling of hazardous materials? ST - H FUNCTIONAL SAFETY-Patient Identification Syst Title FUNCTIONAL SAFETY-Patient Identification Syst Statute or Rule 59A-3.277(2), FAC (2) In addition to other requirements, each hospital shall - Review the hospital safety policy regarding patient identification for all patient care areas. Is this policy periodically

164 Page 164 of 399 provide a complete system for patient identification within the hospital, including a system for all emergency room cases, including DOA, and disasters. re-evaluated? - Tour and observe if the patient identification policy is consistently implemented. - Interview staff in the surgical departments, Obstetrics, anesthesia etc regarding patient identification procedures. - Interview floor staff on patient identification procedures. (Upon admission, medication pass, prior to a procedure). - Interview patients regarding proper identification especially before medications or procedures. - In the emergency room review who, how and at what point the patient is identified/id bands are placed. - See also 'Patient Safety Plan' requirements at (1) F.S. (H0425) and Patient Safety Officer and Committee at (2), F.S. (H0426 ). ST - H REHAB, PSYCH & SUBST ABUSE -Pt Eval/Assess/Tx Title REHAB, PSYCH & SUBST ABUSE -Pt Eval/Assess/Tx Statute or Rule 59A-3.278(1)(a)-(f), FAC (1) All rehabilitation, psychiatric, and substance abuse programs provided by hospitals shall provide to the patient: (a) An evaluation upon referral; (b) Establishment of goals; (c) Development of a plan of treatment, including discharge planning, in coordination with the referring individual and rehabilitation staff, and after discussion with the patient and family; (d) Regular and frequent assessment, performed on an interdisciplinary basis, of the patient's condition and progress, and of the results of treatment; (e) Maintenance of treatment and progress records; and (f) At least a quarterly assessment of the quality and appropriateness of the care provided. - Review the hospital's Policies and Procedures for Rehab Psych and Substance Abuse to determine the scope of services. - Review a sample of patient records for documentation of patient referral and admission treatment goals. - Was a plan of treatment developed on admission including discharge planning as required? - Is there documentation in the clinical record of ongoing interdisciplinary review and assessment of the patients' correction and treatment?

165 Page 165 of 399 ST - H REHAB, PSYCH & SUBST ABUSE - Contracted Title REHAB, PSYCH & SUBST ABUSE - Contracted Statute or Rule 59A-3.278(2), FAC (2) When any rehabilitation activity, psychiatric or substance abuse treatment is provided from outside the hospital, the source shall be available whenever needed for patient care, meet all safety requirements, abide by all pertinent rules and regulations of the hospital and medical staff, and document the quality assurance measures to be implemented. - Determine if any of the psychiatric rehabilitation or substance abuse treatment is provided from services outside the hospital. If this service is by contract review the contract or agreement to ensure that all hospital regulations and medical staff requirements are met. - Does the hospital have a quality assurance program for this service? ST - H REHAB, PSYCH & SUBST ABUSE - Scope of Svcs Title REHAB, PSYCH & SUBST ABUSE - Scope of Svcs Statute or Rule 59A-3.278(3), FAC (3) The scope of services offered, and the relationship of the rehabilitation, psychiatric or substance abuse program to other hospital units, as well as all supervisory relationships within the program, shall be defined in writing. Responsibility for the performance of clinical services also shall be clearly defined. Delegation of authority within the program shall be specified in job descriptions and in organizational plans. Written policies and procedures to guide the operation of the rehabilitation program shall be developed and reviewed at least annually, revised as necessary, dated to indicate the time of last revision, and enforced. - Request documentation in writing of the job description for the supervisor of Rehab Psych and Substance Abuse clinical services provided. - Review the department's written policies and procedures and are they reviewed annually as required? - Interview the staff to verify that the current policies and procedures have been implemented.

166 Page 166 of 399 ST - H REHAB, PSYCH & SUBST ABUSE - Plan of Care Title REHAB, PSYCH & SUBST ABUSE - Plan of Care Statute or Rule 59A-3.278(4), FAC (4) There shall be a current written plan of care for each patient receiving rehabilitative, psychiatric or substance abuse services. The plan shall state the diagnosis, and problem list when appropriate, pertinent to the rehabilitation or treatment process; precautions necessitated by the patient's general medical condition or other factors; the short-term and long-term goals of the treatment program; and require monthly or more frequent review of the patient's progress. The medical record and the written plan shall evidence a team approach, with participation of the professional and administrative staffs, the patient, and, as appropriate, the patient's family. The medical record shall document the written instructions given to the patient and the family concerning appropriate care after discharge from the hospital. - Each patient must have an individualized plan of treatment. - Review a sample of patient records to verify interdisciplinary participation of the hospital professional staff including patient and family in developing the treatment plan. - Are there measurable long and short term goals? - Does this plan include ongoing frequent review and reports of the patient's progress? - Does the plan include discharge planning? - Is there documentation in the clinical record that written instructions concerning appropriate care after discharge were given to the patient and or family? ST - H REHAB, PSYCH & SUBST ABUSE - Sep Notes/Logs Title REHAB, PSYCH & SUBST ABUSE - Sep Notes/Logs Statute or Rule 59A-3.278(5), FAC (5) The rehabilitation, psychiatric or substance abuse program must have notes and log records that are separately identified from the other admission and discharge records in the hospital in which it is located, and are separately retrievable. - Are the Rehab Psych and Substance Abuse logs and clinical records separately identified from the hospital admission and discharge records? - Document that these records can be retrieved separately from other hospital records. - Tour and interview staff to ensure that HIPPA and confidentiality requirements are met.

167 Page 167 of 399 ST - H REHAB, PSYCH & SUBST ABUSE - Distinct Beds Title REHAB, PSYCH & SUBST ABUSE - Distinct Beds Statute or Rule 59A-3.278(6), FAC (6) The beds assigned to the program must be physically separate from and not commingled with beds not included in the unit. Rehabilitation, psychiatric or substance abuse programs and beds may be located on the same floor as other programs or beds. Observe: During tour of the units, observe if any rooms do not have patients' beds in them. Interview: Ask unit staff where the patients' beds come from if any were to break? Ask staff if any unit beds commingled with any of the other hospital units? Record Review: If concerns arise, review the facility's policies and procedures regarding ensuring rehabilitation, psychiatric and substance abuse units have beds. ST - H REHAB, PSYCH & SUBST ABUSE-Physician In Charg Title REHAB, PSYCH & SUBST ABUSE-Physician In Charg Statute or Rule 59A-3.278(7), FAC (7) In addition to meeting the requirements of (1) through (6) of this section, rehabilitation programs provided by hospitals must place responsibility for the medical direction of the rehabilitation program on a physician member of the organized medical staff who, on the basis of training, experience and interest, is knowledgeable in the rehabilitation services offered. Unless otherwise permitted by law, rehabilitation services shall be initiated by a physician. The written request for services shall include reference to the diagnosis or problems for which treatment is planned. -Interview: Unit staff and ask who they relate patient medical issues to? Who refers patients to rehabilitation services? - Record Review: The hospital's medical staff requirements for a qualified professional to be in charge of this program. - Review the credential file for the physician in charge of the Rehab Psych and Substance Abuse program to ensure this person is licensed in accordance with State law and credentialed according to hospital's medical staff criteria. - Review sample patients' records. Are services provided in accordance with orders of practitioners who are authorized by the medical staff? Does the patient's record have the diagnosis/problem that leads to the treatment plan? - Review samples of clinical records to verify documentation of physician's orders.

168 Page 168 of 399 ST - H REHAB, PSYCH & SUBST ABUSE - Stds of Practice Title REHAB, PSYCH & SUBST ABUSE - Stds of Practice Statute or Rule 59A-3.278(8)(a)-(d), FAC (8) In addition to meeting the requirements of (1)-(6) of this section, psychiatric, or substance abuse rehabilitation programs provided by hospitals shall meet at least the following additional standards: (a) The program, unit, service or similarly titled part shall treat only those patients whose primary reason for admission was a diagnosis contained in the third edition of the American Psychiatric Association Diagnostic and Statistical Manual. (b) The program, unit, service or similarly titled part shall have medical direction by an appropriately qualified practitioner, including a physician who is certified by the American Board of Psychiatry and Neurology or is eligible for examination by the Board or similar specialty board recognized by the American Osteopathic Association, a clinical psychologist, or a licensed physician with postgraduate training and experience in the diagnosis and treatment of nervous and mental disorders. (c) The program, unit, service or similarly titled part shall furnish, through qualified personnel, psychological services, social work services, psychiatric nursing, occupational therapy, and recreational therapy, as appropriate to the needs of the patient. (d) The program, unit, service or similarly titled part shall have a charge nurse who is a registered professional nurse qualified in psychiatric or mental health nursing. - The Rehab Psych and Substance Abuse program as provided by the hospital must meet Accepted Standards of Practice. If an issue/concern is identified: - Interview the Medical Director and Psychiatric Nurse to determine the Acceptable Standard of Practice the unit is utilizing. Review the practice being utilized and determine if your concerns comply with those standards. - Review sampled patients' records to confirm that only patients with an appropriate psychiatric diagnosis (according to the American Psychiatric and Diagnostic manual) are treated in this program. - Review the program staffing list to confirm that the program is directed by a MD, DO, Clinical Psychologist, or licensed physician certified in mental health. - Review the MD, DO, Clinical Psychologist or licensed physician's record to verify that the individual directing the program is certified in mental health. - Review personnel files to verify that other professional services such as Social Worker, Occupational therapy, etc., are provided by personnel trained in mental health. Is there a continuing education program required for staff? - Review the record for the charge nurse to ensure he/she is certified in psychiatric or mental health nursing.

169 Page 169 of 399 ST - H REHAB, PSYCH & SUBST ABUSE - Pt Rights Title REHAB, PSYCH & SUBST ABUSE - Pt Rights Statute or Rule (5)(a)-(b), FS (a) Adherence to patient rights, standards of care, and examination and placement procedures provided under part I of chapter 394 shall be a condition of licensure for hospitals providing voluntary or involuntary medical or psychiatric observation, evaluation, diagnosis, or treatment. (b) Any hospital that provides psychiatric treatment to persons under 18 years of age who have emotional disturbances shall comply with the procedures pertaining to the rights or patients prescribed in part I of chapter (5)(a)-(b), FS - Observe the patients on the unit; does it appear that the facility is honoring the patients' rights? - Interview patients' on this unit, are there any concerns regarding patients' rights voiced by the patients? Do voluntary admitted patients have the right to leave if they no longer wish to remain in the hospital? - Review patients' records to see if any voluntary admitted patients have asked to be discharged and the facility has taken proper steps? If the patient poses a danger to self or others, has the facility taken the proper steps to request the court to do an involuntary admission? - Review the patients' records to ensure that their rights have been discussed with them upon admission to the program. - Interview staff regarding any concerns voiced or observed regarding patients' rights. - Review the facilities grievance log; has anyone filed a grievance regarding the facility's failure to honor patients' rights? - Review the facility's P&P regarding patient's rights. Is there provision for any person under the age of 18 being admitted to the facility? Is what you observed, were informed through interview and reviewed in records in compliance with the facility's P&P? Rights of patients. (1) RIGHT TO INDIVIDUAL DIGNITY. It is the policy of this state that the individual dignity of the patient shall be respected at all times and upon all occasions, including any occasion when the patient is taken into custody, held, or transported. Procedures, facilities, vehicles, and restraining devices utilized for criminals or those accused of crime shall not be used in connection with persons who have a mental illness, except for the protection of the patient or others. Persons who have a mental illness but who are not charged with a criminal offense shall not be detained or incarcerated in the jails of this state. A person who is receiving treatment for mental illness shall not be deprived of any constitutional rights. However, if such a person is adjudicated incapacitated, his or her rights may be limited to the same extent the rights of any incapacitated person are limited by law. (2) RIGHT TO TREATMENT. (a) A person shall not be denied treatment for mental illness and services shall not be delayed at a receiving or treatment facility because of inability to pay. However, every reasonable effort to collect appropriate reimbursement

170 Page 170 of 399 for the cost of providing mental health services to persons able to pay for services, including insurance or third-party payments, shall be made by facilities providing services pursuant to this part. (b) It is further the policy of the state that the least restrictive appropriate available treatment be utilized based on the individual needs and best interests of the patient and consistent with optimum improvement of the patient's condition. (c) Each person who remains at a receiving or treatment facility for more than 12 hours shall be given a physical examination by a health practitioner authorized by law to give such examinations, within 24 hours after arrival at such facility. (d) Every patient in a facility shall be afforded the opportunity to participate in activities designed to enhance self-image and the beneficial effects of other treatments, as determined by the facility. (e) Not more than 5 days after admission to a facility, each patient shall have and receive an individualized treatment plan in writing which the patient has had an opportunity to assist in preparing and to review prior to its implementation. The plan shall include a space for the patient's comments. (3) RIGHT TO EXPRESS AND INFORMED PATIENT CONSENT. (a)1. Each patient entering treatment shall be asked to give express and informed consent for admission or treatment. If the patient has been adjudicated incapacitated or found to be incompetent to consent to treatment, express and informed consent to treatment shall be sought instead from the patient's guardian or guardian advocate. If the patient is a minor, express and informed consent for admission or treatment shall also be requested from the patient's guardian. Express and informed consent for admission or treatment of a patient under 18 years of age shall be required from the patient's guardian, unless the minor is seeking outpatient crisis intervention services under s Express and informed consent for admission or treatment given by a patient who is under 18 years of age shall not be a condition of admission when the patient's guardian gives express and informed consent for the patient's admission pursuant to s or s Before giving express and informed consent, the following information shall be provided and explained in plain language to the patient, or to the patient's guardian if the patient is 18 years of age or older and has been adjudicated incapacitated, or to the patient's guardian advocate if the patient has been found to be incompetent to consent to treatment, or to both the patient and the guardian if the patient is a minor: the reason for admission or treatment; the proposed treatment; the purpose of the treatment to be provided; the common risks, benefits, and side effects thereof; the specific dosage range for the medication, when applicable; alternative treatment modalities; the approximate length of care; the potential effects of stopping treatment; how treatment will be monitored; and that any consent given for treatment may be revoked orally or in writing before or during the treatment period by the patient or by a person who is legally authorized to make health care decisions on behalf of the patient. (b) In the case of medical procedures requiring the use of a general anesthetic or electroconvulsive treatment, and prior to performing the procedure, express and informed consent shall be obtained from the patient if the patient is legally competent, from the guardian of a minor patient, from the guardian of a patient who has been adjudicated incapacitated, or from the guardian advocate of the patient if the guardian advocate has been given express court

171 Page 171 of 399 authority to consent to medical procedures or electroconvulsive treatment as provided under s (c) When the department is the legal guardian of a patient, or is the custodian of a patient whose physician is unwilling to perform a medical procedure, including an electroconvulsive treatment, based solely on the patient's consent and whose guardian or guardian advocate is unknown or unlocatable, the court shall hold a hearing to determine the medical necessity of the medical procedure. The patient shall be physically present, unless the patient's medical condition precludes such presence, represented by counsel, and provided the right and opportunity to be confronted with, and to cross-examine, all witnesses alleging the medical necessity of such procedure. In such proceedings, the burden of proof by clear and convincing evidence shall be on the party alleging the medical necessity of the procedure. (d) The administrator of a receiving or treatment facility may, upon the recommendation of the patient's attending physician, authorize emergency medical treatment, including a surgical procedure, if such treatment is deemed lifesaving, or if the situation threatens serious bodily harm to the patient, and permission of the patient or the patient's guardian or guardian advocate cannot be obtained. (4) QUALITY OF TREATMENT. (a) Each patient shall receive services, including, for a patient placed under s , those services included in the court order which are suited to his or her needs, and which shall be administered skillfully, safely, and humanely with full respect for the patient's dignity and personal integrity. Each patient shall receive such medical, vocational, social, educational, and rehabilitative services as his or her condition requires in order to live successfully in the community. In order to achieve this goal, the department is directed to coordinate its mental health programs with all other programs of the department and other state agencies. (b) Facilities shall develop and maintain, in a form accessible to and readily understandable by patients and consistent with rules adopted by the department, the following: 1. Criteria, procedures, and required staff training for any use of close or elevated levels of supervision, of restraint, seclusion, or isolation, or of emergency treatment orders, and for the use of bodily control and physical management techniques. 2. Procedures for documenting, monitoring, and requiring clinical review of all uses of the procedures described in subparagraph 1. and for documenting and requiring review of any incidents resulting in injury to patients. 3. A system for investigating, tracking, managing, and responding to complaints by persons receiving services or individuals acting on their behalf. (c) A facility may not use seclusion or restraint for punishment, to compensate for inadequate staffing, or for the convenience of staff. Facilities shall ensure that all staff are made aware of these restrictions on the use of seclusion and restraint and shall make and maintain records which demonstrate that this information has been conveyed to individual staff members. (5) COMMUNICATION, ABUSE REPORTING, AND VISITS. (a) Each person receiving services in a facility providing mental health services under this part has the right to

172 Page 172 of 399 communicate freely and privately with persons outside the facility unless it is determined that such communication is likely to be harmful to the person or others. Each facility shall make available as soon as reasonably possible to persons receiving services a telephone that allows for free local calls and access to a long-distance service. A facility is not required to pay the costs of a patient's long-distance calls. The telephone shall be readily accessible to the patient and shall be placed so that the patient may use it to communicate privately and confidentially. The facility may establish reasonable rules for the use of this telephone, provided that the rules do not interfere with a patient's access to a telephone to report abuse pursuant to paragraph (e). (b) Each patient admitted to a facility under the provisions of this part shall be allowed to receive, send, and mail sealed, unopened correspondence; and no patient's incoming or outgoing correspondence shall be opened, delayed, held, or censored by the facility unless there is reason to believe that it contains items or substances which may be harmful to the patient or others, in which case the administrator may direct reasonable examination of such mail and may regulate the disposition of such items or substances. (c) Each facility must permit immediate access to any patient, subject to the patient's right to deny or withdraw consent at any time, by the patient's family members, guardian, guardian advocate, representative, Florida statewide or local advocacy council, or attorney, unless such access would be detrimental to the patient. If a patient's right to communicate or to receive visitors is restricted by the facility, written notice of such restriction and the reasons for the restriction shall be served on the patient, the patient's attorney, and the patient's guardian, guardian advocate, or representative; and such restriction shall be recorded on the patient's clinical record with the reasons therefor. The restriction of a patient's right to communicate or to receive visitors shall be reviewed at least every 7 days. The right to communicate or receive visitors shall not be restricted as a means of punishment. Nothing in this paragraph shall be construed to limit the provisions of paragraph (d). (d) Each facility shall establish reasonable rules governing visitors, visiting hours, and the use of telephones by patients in the least restrictive possible manner. Patients shall have the right to contact and to receive communication from their attorneys at any reasonable time. (e) Each patient receiving mental health treatment in any facility shall have ready access to a telephone in order to report an alleged abuse. The facility staff shall orally and in writing inform each patient of the procedure for reporting abuse and shall make every reasonable effort to present the information in a language the patient understands. A written copy of that procedure, including the telephone number of the central abuse hotline and reporting forms, shall be posted in plain view. (f) The department shall adopt rules providing a procedure for reporting abuse. Facility staff shall be required, as a condition of employment, to become familiar with the requirements and procedures for the reporting of abuse. (6) CARE AND CUSTODY OF PERSONAL EFFECTS OF PATIENTS. A patient's right to the possession of his or her clothing and personal effects shall be respected. The facility may take temporary custody of such effects when required for medical and safety reasons. A patient's clothing and personal effects shall be inventoried upon their removal into temporary custody. Copies of this inventory shall be given to the patient and to the patient's guardian,

173 Page 173 of 399 guardian advocate, or representative and shall be recorded in the patient's clinical record. This inventory may be amended upon the request of the patient or the patient's guardian, guardian advocate, or representative. The inventory and any amendments to it must be witnessed by two members of the facility staff and by the patient, if able. All of a patient's clothing and personal effects held by the facility shall be returned to the patient immediately upon the discharge or transfer of the patient from the facility, unless such return would be detrimental to the patient. If personal effects are not returned to the patient, the reason must be documented in the clinical record along with the disposition of the clothing and personal effects, which may be given instead to the patient's guardian, guardian advocate, or representative. As soon as practicable after an emergency transfer of a patient, the patient's clothing and personal effects shall be transferred to the patient's new location, together with a copy of the inventory and any amendments, unless an alternate plan is approved by the patient, if able, and by the patient's guardian, guardian advocate, or representative. (7) VOTING IN PUBLIC ELECTIONS. A patient who is eligible to vote according to the laws of the state has the right to vote in the primary and general elections. The department shall establish rules to enable patients to obtain voter registration forms, applications for absentee ballots, and absentee ballots. (8) HABEAS CORPUS. (a) At any time, and without notice, a person held in a receiving or treatment facility, or a relative, friend, guardian, guardian advocate, representative, or attorney, or the department, on behalf of such person, may petition for a writ of habeas corpus to question the cause and legality of such detention and request that the court order a return to the writ in accordance with chapter 79. Each patient held in a facility shall receive a written notice of the right to petition for a writ of habeas corpus. (b) At any time, and without notice, a person who is a patient in a receiving or treatment facility, or a relative, friend, guardian, guardian advocate, representative, or attorney, or the department, on behalf of such person, may file a petition in the circuit court in the county where the patient is being held alleging that the patient is being unjustly denied a right or privilege granted herein or that a procedure authorized herein is being abused. Upon the filing of such a petition, the court shall have the authority to conduct a judicial inquiry and to issue any order needed to correct an abuse of the provisions of this part. (c) The administrator of any receiving or treatment facility receiving a petition under this subsection shall file the petition with the clerk of the court on the next court working day. (d) No fee shall be charged for the filing of a petition under this subsection. (9) VIOLATIONS. The department shall report to the Agency for Health Care Administration any violation of the rights or privileges of patients, or of any procedures provided under this part, by any facility or professional licensed or regulated by the agency. The agency is authorized to impose any sanction authorized for violation of this part, based solely on the investigation and findings of the department. (10) LIABILITY FOR VIOLATIONS. Any person who violates or abuses any rights or privileges of patients provided by this part is liable for damages as determined by law. Any person who acts in good faith in compliance

174 Page 174 of 399 ST - H REHAB, PSYCH & SUBST ABUSE-Specialty Supv/Adm with the provisions of this part is immune from civil or criminal liability for his or her actions in connection with the admission, diagnosis, treatment, or discharge of a patient to or from a facility. However, this section does not relieve any person from liability if such person commits negligence. (11) RIGHT TO PARTICIPATE IN TREATMENT AND DISCHARGE PLANNING. The patient shall have the opportunity to participate in treatment and discharge planning and shall be notified in writing of his or her right, upon discharge from the facility, to seek treatment from the professional or agency of the patient's choice. (12) POSTING OF NOTICE OF RIGHTS OF PATIENTS. Each facility shall post a notice listing and describing, in the language and terminology that the persons to whom the notice is addressed can understand, the rights provided in this section. This notice shall include a statement that provisions of the federal Americans with Disabilities Act apply and the name and telephone number of a person to contact for further information. This notice shall be posted in a place readily accessible to patients and in a format easily seen by patients. This notice shall include the telephone numbers of the Florida local advocacy council and Advocacy Center for Persons with Disabilities, Inc. Title REHAB, PSYCH & SUBST ABUSE-Specialty Supv/Adm Statute or Rule 59A-3.278(9)(a)-(f), FAC (9) In addition to the medical direction required in subsection (7), overall supervision and administration of the following specialty rehabilitation programs may be provided by staff with the following credentials: (a) Physical Therapy - A qualified physical therapist who shall be a graduate of a physical therapy program approved by a nationally recognized accrediting body or have documented equivalent training or experience, shall meet any current requirements for licensure or registration, and shall be currently competent in the field. (b) Occupational Therapy - A qualified occupational therapist who shall be a graduate of an occupational therapy program approved by a nationally recognized accrediting body; or shall currently hold certification by the American Occupational Therapy Association as an Occupational Therapist, Registered; or shall have documented equivalent - Observe the unit, what specialty services are being utilized by the program? - Interview the patients receiving the services; are they satisfied with the services they are receiving? Do they have any concerns regarding the services they are receiving? - Interview individuals providing these services to see how the facility ensures their competencies and how often is competency determined? - Review the facility's P&P regarding the hiring practices for these individuals. Do they need to be credentialed? How does the facility ensure competency? How often are competencies determined? - Review the facility's staffing and on call schedules, are any of the individuals being utilized for this program? Review the records of the individuals providing services to the patients to ensure they are qualified. How is the facility ensuring competency for these individuals? How often have these individuals had their continued competency determined? - Does the information you have obtained from interviews and reviewed in the personnel records comply with the facility's P&P regarding qualification and continuing competency?

175 Page 175 of 399 training or experience; and shall meet all current requirements for licensure under Chapter 468, Part IV, F.S. (c) Speech Pathology and Audiology - A qualified speech-language pathologist or audiologist who shall hold the Certificate of Clinical Competence or a Statement of Equivalence in either speech pathology or audiology issued by the American Speech-Language-Hearing Association, or have documented equivalent training or experience; and shall meet all current requirements for licensure under Chapter 468, Part II, F.S. (d) Rehabilitation Nursing - A professionally qualified licensed registered nurse who shall have documented training in rehabilitation nursing and at least one year of rehabilitation nursing experience. (e) Vocational or Educational Rehabilitation - A qualified individual who shall be a graduate of vocational rehabilitation program at the graduate level, or have documented equivalent training or experience. (f) Comprehensive Medical Rehabilitation - A qualified physician who shall be a member of the organized professional staff and who is certified, or eligible for examination, either by the American Board of Physical Medicine and Rehabilitation or by a specialty related to rehabilitation. ST - H REHAB, PSYCH & SUBST ABUSE - CON Title REHAB, PSYCH & SUBST ABUSE - CON Statute or Rule 59A-3.278(10), FAC (10) Nothing in this section shall be construed to prevent a hospital from providing rehabilitation, psychiatric or substance abuse programs to its patients. However, no hospital shall have rehabilitation, psychiatric, intensive residential - Interview the hospital's Administrator. Request written documentation that shows that the hospital has a certificate of need (CON) as required by State law for Rehab Psych and Substance Abuse programs. Does the program meet the regulatory requirements under State law for licensure? - Request a copy of the hospital license to validate this requirement.

176 Page 176 of 399 treatment program, or substance abuse beds unless it has obtained a valid certificate of need as required by Section through , F.S., and meets the requirements of this section. Section through , FS Index.html&StatuteYear=2011&Title=%2D%3E2011%2D%3EChapter%20408%2D%3EPart%20I ST - H ITEMIZED PATIENT BILL -Initial Form & Content Title ITEMIZED PATIENT BILL -Initial Form & Content Statute or Rule 59A-3.279(1) FAC, (1) FS 59A-3.279(1) FAC (1) Within seven days following discharge or release from a licensed hospital not operated by the state, or within seven days after the earliest date at which the loss or expense from the service may be determined, the licensed hospital providing the service shall, upon request, submit to the patient, or to his survivor or legal guardian as may be appropriate, an itemized statement detailing in language comprehensible to an ordinary layman the specific nature of charges or expenses incurred by the patient, which in the initial billing shall contain a statement of specific services received and expenses incurred for such items of service, enumerating in detail the constituent components of the services received within each department of the licensed facility and including unit-price data on rates charged by the licensed facility. 59A-3.279(1), FAC (1), FS Review the Policy and Procedure for facility submitting an Itemized Patient Bill, based upon request FS Itemized patient bill; form and content prescribed by the agency. (1) A licensed facility not operated by the state shall notify each patient during admission and at discharge of his or her right to receive an itemized bill upon request. Within 7 days following the patient's discharge or release from a licensed facility not operated by the state, the licensed facility

177 Page 177 of 399 providing the service shall, upon request, submit to the patient, or to the patient's survivor or legal guardian as may be appropriate, an itemized statement detailing in language comprehensible to an ordinary layperson the specific nature of charges or expenses incurred by the patient, which in the initial billing shall contain a statement of specific services received and expenses incurred for such items of service, enumerating in detail the constituent components of the services received within each department of the licensed facility and including unit price data on rates charged by the licensed facility, as prescribed by the agency. ST - H ITEMIZED PATIENT BILL - Exclusions Title ITEMIZED PATIENT BILL - Exclusions Statute or Rule 59A-3.279(2)(a)-(d) FAC, (2) FS 59A-3.279(2)(a)-(d) FAC (2) Each such statement shall: (a) Not include charges of hospital-based physicians if billed separately. (b) Not include any generalized category of expenses such as "other" or "miscellaneous" or similar categories. (c) List drugs by brand or generic name and not refer to drug code numbers when referring to drugs of any sort. (d) Specifically identify therapy treatment as to the date, type, and length of treatment when therapy treatment is a part of the statement. Any person receiving a statement pursuant to this section shall be fully and accurately informed as to each charge and service provided by the institution preparing the statement. 59A-3.279(2)(a)-(d), FAC (2), FS - Review Policy and Procedure for all items (a)-(d). - Interview Billing Office/Financial Personnel if questions/concerns (usually as a complaint only). - Inquire how the facility determines and assures exclusion of physician services FS (2)(a) Each such statement submitted pursuant to this section:

178 Page 178 of May not include charges of hospital-based physicians if billed separately. 2. May not include any generalized category of expenses such as "other" or "miscellaneous" or similar categories. 3. Shall list drugs by brand or generic name and not refer to drug code numbers when referring to drugs of any sort. 4. Shall specifically identify therapy treatment as to the date, type, and length of treatment when therapy treatment is a part of the statement. (b) Any person receiving a statement pursuant to this section shall be fully and accurately informed as to each charge and service provided by the institution preparing the statement. ST - H ITEMIZED PATIENT BILL - Ownership Status Title ITEMIZED PATIENT BILL - Ownership Status Statute or Rule 59A-3.279(3),FAC; (3), FS 59A-3.279(3) FAC On each such itemized statement there shall appear the words "FOR-PROFIT (or NOT-FOR-PROFIT or PUBLIC) HOSPITAL LICENSED BY THE STATE OF FLORIDA" or substantially similar words sufficient to identify clearly and plainly the ownership status of the licensed facility. 59A-3.279(3), FAC (3), FS Review Policy and Procedure for assurance of this statement (3) FS (3) On each itemized statement submitted pursuant to subsection (1) there shall appear the words "A FOR-PROFIT (or NOT-FOR-PROFIT or PUBLIC) HOSPITAL (or AMBULATORY SURGICAL CENTER) LICENSED BY THE STATE OF FLORIDA" or substantially similar words sufficient to identify clearly and plainly the ownership status of the licensed facility. Each itemized statement must prominently display the phone number of the medical facility's

179 Page 179 of 399 patient liaison who is responsible for expediting the resolution of any billing dispute between the patient, or his or her representative, and the billing department. ST - H ITEMIZED PATIENT BILL - Subsequent Bill Title ITEMIZED PATIENT BILL - Subsequent Bill Statute or Rule 59A-3 FAC, 395 FS 59A-3.279(5) FAC (5) In any billing for services subsequent to the initial billing for such services, the patient, or his survivor or legal guardian, may elect, at his option, to receive a copy of the detailed statement of specific services received and expenses incurred for each such item of service as provided in subsection (1). 59A-3.279(5), FAC (5), FS - Review the Itemized Patient Bill Policy and Procedure for subsequent bill of receipt based upon the request of the patient, survivor, or legal guardian. - Interview Financial Personnel based on concerns (5) FS (5) In any billing for services subsequent to the initial billing for such services, the patient, or the patient's survivor or legal guardian, may elect, at his or her option, to receive a copy of the detailed statement of specific services received and expenses incurred for each such item of service as provided in subsection (1). ST - H INTENSIVE RES TX PROG - Purpose/Obj/Plan Title INTENSIVE RES TX PROG - Purpose/Obj/Plan Statute or Rule 59A-3.301, FAC Each program shall have a written statement of its purpose and - Record Review - Review the facility's Policy and Procedures to insure they include the purposes and objectives for

180 Page 180 of 399 objectives, which will include but not be limited to a formal, long range plan adopted to guide and schedule steps leading to attainment of its projected objectives. This plan shall include an officially promulgated description of the services the program offers so that there is a frame of reference for judging the various aspects of the program. Proposed changes in treatment programs must be reported to and approved by the appropriate licensing agency. The plan shall also include but not be limited to the following: (1) A description of the target population including but not limited to age, types of disorders, sex, and financial requirements; (2) The initial screening process; (3) The intake/admission process; (4) Methods for involving family members or significant others (i.e., guardians, counselors, friends) in assessment, treatment, discharge, and follow-up care plans; (5) An organizational chart with a description of each unit or department and its services, goals, policies and procedures, staffing patterns and its relationship to other services and departments and how these are to contribute to the priorities and goals of the program; (6) Ways in which the program carries out any community education consultation programs; and (7) Ways in which the program provides or makes referrals or arrangements for other medical, health care, dental, special assessment and therapeutic services. This shall be in the plan for: (a) Clinical services; (b) Emergency services and crisis intervention; (c) Educational services for all residents; and (d) Discharge and follow-up care and evaluation. all of their programs as well as a description of the services each program offers. Ensure that the policy includes a component for family member and significant other to be involved in the assessment, treatment, discharge and follow-up plans. Insure that the listed required information is also included in the policy and procedures. - Interview the intake person to ensure they are following the facility's policy. -Interview the nursing department to ensure the initial screening and how medical issues may be address while the patient is in this program. Determine how they ensure referrals for medical, healthcare, dental, special assessment and therapeutic services. - Interview the discharge planner to see how the outcome of this program is carried out once the patient enter the community. How they ensure each patient received follow-up care and evaluations?

181 Page 181 of 399 ST - H INTENSIVE RES TX PROG - Composition of Staff Title INTENSIVE RES TX PROG - Composition of Staff Statute or Rule 59A-3.302(1), FAC (1) Composition. The composition of the staff shall be determined by the needs of the patients being served and the goals of the facility, and shall have available a sufficient number of mental health professionals, health care workers, program staff and administrative personnel to meet these goals. -Record Review: Review the facility's Staffing Policy and Procedures. Does the facility staff the unit based on the number of patients or by the acuity of the patients on the unit. - Review the facility's staffing pattern for the day and compare it to the facility current census and the needs of those patients. Are the patients' needs being met by the number of staff on the unit? - Interview the Department Head of the Intensive Residential Treatment Program to determine how the staffing patters are developed. -Interview the staff on the unit to see how if the staff feels there is there enough staff to meet the patients' needs. If not, If not, what is the problem with meeting the patients' needs? - Interview the patients; are their needs being met? - Observe the unit to determine if the staff is answering the call lights in a timely manner. Are the patients' needs being met? ST - H INTENSIVE RES TX PROG - Staff Qualifications Title INTENSIVE RES TX PROG - Staff Qualifications Statute or Rule 59A-3.302(1)(a)-(f), FAC 59A-3.302(1) (a) The administrator of the facility shall have a master's degree in administration or be of a professional discipline related to child and adolescent mental health and have at least three (3) years administrative experience. A person with a baccalaureate degree may also qualify for administrator with seven (7) years experience of child and adolescent mental - During the entrance conference, ask the Administrator who the Clinical Director is and is he/she a full-time employee? - If the Clinical Director is not full time, then ask who is the person responsible for the coordination of the treatment aspect of the program? - Interview the Administrator/ Clinical Director to see if the mental health professionals (include, but not limited to: psychiatrist, psychologist and social worker) are employed on a full-time basis or on a consulting basis? - Observe the unit; is the psychiatrist, psychologist, and social worker on the floor?

182 Page 182 of 399 health care with no less than three (3) years administrative experience. Persons occupying this position on or before the effective date of these rules may be allowed to continue in this position. (b) The clinical director shall be at least board eligible in psychiatry with the American Board of Psychiatry with experience in child and adolescent mental health. (c) If the clinical director is not full-time, then there shall be a full-time service coordinator who is a mental health professional with at least a master's degree who is experienced in child and adolescent mental health and is responsible for the coordination of treatment aspects of the program. (d) Mental health professionals shall include, but are not limited to, psychiatrists, psychologists, and social workers. These persons, if not on a full-time basis, must be on a continuing consulting basis. The authority and participation of such mental health professionals shall be such that they are able to assume responsibility for supervising and reviewing the needs of the patients and the services being provided. Such individuals shall participate in specific functions, e.g., assessment, treatment planning, treatment plan and individual case reviews, and program planning and policy and procedure development and review. (e) Other professional and paraprofessional staff shall include, but not be limited to, physicians, registered nurses, educators and 24-hour a day mental assistants. Also included on a regular staff basis, or as consultants on a continuing basis, shall be activity staff and vocational counselors. (f) Consultation shall be available as needed from dieticians, speech, hearing and language specialists, or other specialists. - Interview staff on the floor to see if the facility employs a psychiatrist, psychologists and social worker? How often are they in the facility or on the unit? - While on the unit, identify who the physician, Registered Nurse, educators, and metal health assistants are. - Review the staffing schedule. Does the unit have physician, a registered nurse, and an educator scheduled? Does the schedule reflect that a mental assistant is scheduled 24 hours a day? - Interview Administrator/Clinical Director and other staff to see what role the mental health professional plays in provision of services to the patients? - How are they involved in the overall development of the facility's policy and procedures? - Select the Administrator's and the Clinical Director's file for record review. Does the Administrator's record reflect that he/she has a master's degree in administration or has a professional degree related to child and adolescent mental health and has been an administrator for at least three years or baccalaureate degree with seven years of experience? - Interview the Administrator/Clinical Director in order to determine the process for obtaining services.- - Review the Clinical Director's record to insure that he/she is at least board eligible. - If the Clinical Director is not a full time employee, select the record of the person who coordinated the treatment aspect of the program's file. - Review this individual's file to insure that he/she is has a master's degree and is experienced in child and adolescent mental health. - Review the policy and procedures regarding the functions and involvement of professionals and paraprofessionals, including doctors, registered nurses, educators, 24-hour a day mental health assistant, activity staff and vocational counselors. - Interview the Human Resource Director as to who is responsible for insuring that all of the staff's certifications are up to date? - Interview the responsible person regarding how he/she ensures that everyone's certifications are up-to-date? - Review policy and procedure on obtaining necessary consultations in dietary, speech, hearing and language or other specialties. - Review patients' charts to verify that all necessary services/consultations are being provided.

183 Page 183 of 399 ST - H INTENSIVE RES TX PROG -Organization/Personnel Title INTENSIVE RES TX PROG -Organization/Personnel Statute or Rule 59A-3.302(2) through (4)(b), FAC (2) Organization. The program shall have an organizational plan which clearly explains the responsibilities of the staff. This plan shall also include: (a) lines of authority, accountability and communication; (b) committee structure and reporting or dissemination of material; and (c) established requirements regarding the frequency of attendance at general and departmental/service or team/unit meetings. (3) Policies and Records. Personnel policies and practices shall be designed, established and maintained to promote the objectives of the program and to insure that there are personnel to support a high quality of patient care. (a) Each program shall have a written personnel practice plan covering the following areas: job classification; pay plan; personnel selection; probation or work-test period; tenure of office; dismissal; salary increases; procedure for health evaluations; holidays; leave policies; training programs; work evaluation procedures; additional employment benefits; and personnel records. Each new employee shall be given a copy of personnel practices when hired and documentation of receipt shall be maintained in the employee's personnel file. A procedure shall be established for notifying employees of changes in established policies. (b) There shall be clear job descriptions for all personnel. Each description shall contain the position title, immediate supervisor, responsibilities and authority. These shall also be used as a basis for periodic evaluations by the supervisor. 59A-3.302(2)(a)-(c), FAC 59A-3.302(3)(a)-(c), FAC 59A-3.302(3)(c)(1)-(5), FAC 59A-3.302(4)(a)-(b), FAC - Review the files of employees hired within the past six months, to insure the receipt of the facility's personnel policies. Also confirm that these newly hired employees' files contain information regarding their background screening, application, references, any documentation that justify the employment, verification of employee's license, and verification of accreditation. Confirm that these records also contain documentation regarding pre-employment health examination to ensure that all employees are physically and emotionally able to perform their duties. Do these employees have a job description? Review the facilities orientation and training program for all new employees. - Review the records of employees who have been employed for several years. Have the employees been notified of changes in the facility's established policies? If so, what procedure was utilized to inform the employees? Do these employees have a job description? Verify the renewal of their license is in the file. Review the facilities orientation and training program for all new employees. Is there justification for continued employment? Has the employee's job performance been evaluated? Is continued education evident I the employee's record? - Interview a few employees and see how they are notified of changes in the facility's policies. - Interview the person responsible for education and see how often the training programs are reviewed and approved. - Interview staff developer to determine how they assure that the programs provides opportunities and motivation for continuous staff training to enable each member to add to his/her knowledge and skills. - Where do they document the information? - Ask who is the designated person or committee who is responsible for planning and insuring that education plans are implemented. - Review the facility's organization plan. Does it include the required information? - Review the personnel policies and practices. Do they promote the objectives of the programs? - Review the personnel practice plan for each program. Does it include the required information (includes but not limited to job classification, pay plan, personnel selection, probation, etc.)?

184 Page 184 of 399 (c) Accurate and complete personnel records shall be maintained on each employee. Content shall be established to include but not be limited to the following: 1. current background information, including the application, references and any accompanying documentation sufficient to justify the initial and continued employment of the individual and the position for which he was employed. Applicants for the positions requiring a licensed person shall be employed only after the facility has obtained verification of their licenses. Where accreditation is a requirement, this shall also be verified. Evidence of renewal of license as required by the licensing agent shall be maintained in the employee's personnel record; 2. current information relative to work performance evaluation; 3. records of pre-employment health examinations and subsequent health services rendered to employees, as are necessary to ensure that all facility employees are physically and emotionally able to perform their duties; 4. medical reports that verify the absence of active communicable disease in facility employees; and 5. record of any continuing education or staff development programs completed. (4) Staff Development. The program must provide opportunities and motivation for continuous staff training to enable each member to add to his knowledge and skills and thus improve the quality of services offered. This must be documented. (a) Programs shall be facility-based with a designated person or committee who is responsible, on a continuing basis, for planning and insuring that Plans are implemented. The facility shall also make use of educational programs outside the facility such as workshops, and seminars; and (b) There shall be appropriate orientation and training programs available for all new employees.

185 Page 185 of 399 ST - H INTENSIVE RES TX PROG-Therapeutic Environment Title INTENSIVE RES TX PROG-Therapeutic Environment Statute or Rule 59A-3.303(1), FAC Facilities (1) General Requirements. The facility shall plan and provide an environment that is therapeutic to, and supportive of, all the patients in regard to their disturbances, their healthy development and their changing needs. The therapeutic environment shall take into consideration the architecture of the facility, indoor and outdoor activity areas, furnishings, equipment, decorations and all other factors that involve the interpersonal and physical environment. - Tour the unit to ensure that there is a therapeutic environment. The facility is in compliance with the therapeutic environment if the needs of the patients are being met. (For example: Are there wheelchair ramps for residents with wheelchairs? If there are to be any outdoor therapies, does the facility provide the patients with an outdoor area in which the therapy can be provided?) Is the unit furnished in a manner to promote a therapeutic environment? (Is the unit in good repair? Is there enough furniture and beds for the number of patients in the unit?) ST - H INTENSIVE RES TX PROG - Physical Plant Safety Title INTENSIVE RES TX PROG - Physical Plant Safety Statute or Rule 59A-3.303(2), FAC Physical Plant Safety. (2) Facilities shall: (a) Be designed to meet the needs of the age group of the patients and the objectives of the program; (b) Provide adequate and appropriate space and equipment for all of the programs of the facility and the various functions within the facility; (c) Provide sufficient space and equipment to ensure housekeeping and maintenance programs capable of keeping - Tour the unit/hospital to ensure it is structurally sound. (Are there any holes in the walls, floors cracked or missing tiles, are there any broken toilets or bathroom fixtures, and are the patients' beds and furnishings in good repair? Are there any signs that may indicate water damage on the ceiling? Are ceiling tiles damaged, broken, missing or discolored?) Are there any concerns regarding possible hazards which may result in a potential for harm to the patients? Where are needles & sharps stored after use? Are medications kept secure and out of reach of patients? Is there enough light throughout the hospital or unit? Do the patients' rooms have enough light? - While towing the unit/hospital, are there any offensive odors noted? Are the vents clean and in gone repair? Are the vents covered with gray, fuzzy matter? Is the temperature in the unit/hospital kept comfortable? - While touring the facility ensure that there is sufficient outdoor space to carry out any outdoor therapies and

186 Page 186 of 399 the building and equipment clean and in good repair; and (d) Provide buildings and grounds of the special hospital that shall be maintained, repaired and cleaned so that they are not hazardous to the health and safety of the patients and staff. 1. Floors, walls, ceilings, windows, doors and all appurtenances of the structures shall be of sound construction, properly maintained, easily cleanable and shall be kept clean. 2. All areas of the facility other than closets or cabinets shall be well lighted. Dormitories, toilets and dayrooms shall have light sources capable of providing adequate illumination to permit observation, cleaning, maintenance and reading. Light fixtures shall be kept clean and maintained. 3. All housing facilities shall be kept free of offensive odors with adequate ventilation. a. If natural ventilation is utilized, the opened window area for ventilation purposes shall be equal to one- tenth of the floor space in the residential area. b. When mechanical ventilation or cooling systems are employed, the system shall be kept clean and properly maintained. Intake air ducts shall be designed and installed so that dust or filters can be readily removed. In residence areas and isolation rooms without natural ventilation, mechanical ventilation systems shall provide a minimum of 10 cubic feet of fresh or filtered recirculated air per minute for each patient occupying the area. c. All toilet rooms shall be provided with direct openings to the outside or provided with mechanical ventilation to the outside. d. Facilities which utilize permanent heating units shall maintain a minimum temperature of 65 degrees F at a point 20 inches above the floor in sleeping areas. Facilities, such as outdoor programs, which cannot provide permanent heating units, shall ensure that patients are provided with items which will provide adequate warmth during sleep. These shall include items such as portable catalytic heaters and sleeping activities; observe the sleeping area to ensure the area promotes comfort and dignity and there is enough space for all of the occupants; each bed has appropriate bedding that is kept clean and in good repair; mattresses are clean and in good condition with fire retardant mattress covers or protector; each individual has his/her own personal storage area; each individual has his/her own clean towels and wash cloth. - Observe the bathrooms; do they promote privacy? Are there enough bathrooms for the amount of patients in the unit/hospital? Is there enough space for the amount of patients in the unit/hospital? Is there enough equipment for the amount of patients? Is the unit/hospital, kept clean? - Interview the housekeeping staff to ensure they have adequate supplies to keep the facility clean and odor free. Is there a cleaning schedule for the unit? How often is the unit cleaned? - Interview the maintenance director to determine how the facility ensures the facility is kept in good repair? (Is there a maintenance schedule? Is there a clearing schedule?) Are the mirrors in the unit made of shatterproof glass? - Interview sample patients/residents; do they have enough space on the units/hospital? Do they have privacy in the bathrooms? Do they have enough storage space for their belongings? Do they get the opportunity to use the outside space? When conducting outdoor activities, is there enough space for the amount of patients participating in the activities? Is there enough light throughout the facility? When was the last time their sheets were laundered? Do they provide toothbrushes, toothpaste, soap, and other items for personal hygiene, if the individual does not bring in his/her own? - Review the facility's maintenance policies and procedures. Did the information obtained through observation and interviews meet the requirements in the facility's policy and procedures? - Review the facility's latest Health Inspection to confirm that it was satisfactory. - Review the facility's policy and procedures regarding privacy and personal hygiene.

187 Page 187 of 399 bags, extra blankets and clothing designed to ensure comfortable sleep in cold weather. (e) Provide both indoor and outdoor areas where patients can gather for appropriate activities. The grounds on which the facility is located shall provide adequate space to carry out the stated goals of the program; for outdoor activity areas that are appropriate for the ages and clinical needs of children; and provide an appropriate transitional area between the facility and the surrounding neighborhood which is consistent with the goals of the facility, and compatible with existing zoning ordinances. (f) Provide sleeping areas that shall promote comfort and dignity and provide space and privacy for residents. 1. There shall be no more than eight patients in a sleeping room unless written justification on the basis of the program requirements has been submitted to and approved by the licensing agency. 2. Beddings, Clothing and Personal Items. Beds and beddings shall be kept in good repair and cleaned regularly. Used mattress and pillow covers shall be laundered before being issued. Sheets and personal clothing shall be washed at least weekly and blankets washed or dry cleaned at least quarterly. Sheets and blankets shall be stored in a clean, dry place between laundering and issue. 3. Each patient shall have his own bed consisting of a level bedstead and a clean mattress in good condition. 4. All mattresses shall have fire retardant mattress covers or protectors. Water repellent mattress covers shall be available if needed. (g) Provide individual and separate accessible storage areas for each resident's clothing and personal possessions. (h) Provide laundry and/or dry cleaning facilities. Where laundry facilities are provided, they shall be adequate to ensure an ample quantity of clean clothing, bed linens and towels. Laundry facilities shall be of sound construction and

188 Page 188 of 399 shall be kept clean and in good repair. Laundry rooms shall be well lighted and properly ventilated. Clothes dryers and dry cleaning machines shall be vented to the exterior. Exposure to dry cleaning solvents shall not exceed threshold limit values set by the American Conference of Governmental Hygienists. If laundry facilities are not available, sheets and blankets shall be sent to commercial laundries. (i) Provide privacy for personal hygiene. 1. All toilets shall have secured seats and be kept clean and in good working order, and all toilets shall be partitioned for privacy. 2. Bathrooms shall be cleaned thoroughly each day. 3. Bathrooms shall be conveniently located to the sleeping areas. (j) Provide for the personal hygiene for all patients. 1. A written policy shall be maintained on file at the facility. 2. Toothbrushes, toothpaste, soap, and other items of personal hygiene shall be provided by the facility if not provided by the patients. 3. Shatterproof mirrors shall be furnished in each bathroom. (k) Maintain food service facilities in accordance with the regulations described in Chapter 64E-11, F.A.C. ST - H INTENSIVE RES TX PROG - Construction/Maintena Title INTENSIVE RES TX PROG - Construction/Maintena Statute or Rule 59A-3.303(3), FAC (3) The facility shall be constructed and maintained in a manner that protects the lives and insures the physical safety of patients, staff and visitors. The center will comply with all relevant federal, state and local building codes, fire, health, - While touring the unit/facility, are there any potential hazards observed? Are there overflowing garbage cans on the unit or in the resident/patient rooms? - Is there enough water on the unit/facility? Are water bottles, fountains (with cups) or pitchers observed on the unit/facility?

189 Page 189 of 399 safety laws and ordinances and regulations as specified below. Current inspection reports shall be retained in the facility's files for AHCA review. (a) It is the responsibility of the program to arrange for the necessary inspections and to comply within the time frame with any resulting recommendations noted in the inspection reports. (b) The grounds and all buildings on the grounds shall be maintained in a safe and sanitary condition, as required in Chapter 386, F.S. (Nuisances Injurious to Health). (c) Water Supply. Water supplies shall be adequate to serve the demands of the facility and shall be constructed, operated and maintained in accordance with requirements of Chapter 64E-8, F.A.C. 1. Drinking water shall be accessible to all clients. When drinking fountains are available, the jet of the fountain shall issue from a nozzle of non-oxidizing impervious material set at an angle from the vertical. The nozzle and every other opening in the water pipe or conductor leading to the nozzle shall be above the edge of the bowl so that such nozzle or opening will not be flooded in case a drain from the bowl of the fountain becomes clogged. The end of the nozzle shall be protected by non-oxidizing guards to prevent persons using the fountain from coming into contact with the nozzle. Vertical or bubbler drinking fountains shall be replaced with approved type water fountains or be disconnected. When no approved drinking fountains are available, clients shall be provided with single service cups which shall be stored and dispensed in a manner to prevent contamination. Common drinking cups are prohibited. 2. Hot and cold running water under pressure and at safe temperatures (not to exceed 120 degrees F for washing and bathing to prevent scalding) shall be provided at regular washing and bathing areas. (d) Sanitary System, Facilities and Fixtures. - Test the water to ensure the water temperature does not exceed 120 degrees. - Are the showers, sinks, toilets and fountains in good working order? - If the facility/unit has more than 9 patients/residents, do the floors have drains to help maintain the facilities' cleanliness? - Observe the garbage storage area. Are the garbage cans properly closed? Are there any hazards in the recreation area? Are there any observable signs that there might be a rodent infestation problem inside or outside of the facility? - Tour the outside of the facility to ensure there are no sewage problems. - Interview staff on the unit. Have they had any concerns with overflowing garbage, physical plant hazards, water being too hot or cold, or not enough drinking water for the amount of residents/patients on the unit? - Interview the patients/residents. Do they have enough water to drink in the facility? Does their room get cleaned often or does the garbage overflow? Have they had any problems with the water temperature? - Interview the Administrator/Clinical Director and find out how they make sure the facility is structurally safe for all patients, employees, and visitors. Ask if the facility has had any incidents regarding scalding water; if they do please review. - Interview the maintenance people regarding how they ensure there is appropriate water pressure throughout the facility. What is the facility waste management program? How often does the pest control company come out to exterminate? - Review the facility's latest fire inspection. - Review the facility's program for ensuring an adequate supply of water. - Review the facility's waste management program. How often is the waste picked up? Where is it stored? - Review the facility's pest control program and contract to determine how often they are scheduled to exterminate the facility.

190 Page 190 of All sewage and liquid waste shall be disposed of in accordance with Chapter 64E-6, F.A.C. 2. All plumbing shall comply with the requirements of Chapter 9B-51, F.A.C., or the plumbing code legally applicable to the area where the facility is located. 3. For facilities with nine or more patients, curbed areas with floor drains shall be available in convenient locations throughout the facility for the proper disposal of cleaning water and to facilitate cleaning. (e) Garbage and Rubbish. All garbage, trash and rubbish from residential areas shall be collected daily and taken to storage facilities. Garbage shall be removed from storage facilities at least twice per week. Wet garbage shall be collected and stored in impervious, leak proof, fly tight containers pending disposal. All containers, storage areas and surrounding premises shall be kept clean and free of vermin. If public or contract garbage collection service is available, the facility shall subscribe to these services unless the volume makes on-site disposal feasible. If garbage and trash are disposed on premises, the method of disposal shall not create sanitary nuisance conditions and shall comply with provisions of Chapter 64E , F.A.C. (f) Outdoor Areas. Outdoor areas shall be kept free of litter and trash and be well drained. If swimming pools are available in facilities with nine or more clients, such pools shall comply with requirements of Chapter 64E-9, F.A.C., and shall be supervised at all times when they are in use. Indoor and outdoor recreational areas shall be provided with safeguards designed for the needs of the residents. (g) Insect and Rodent Control. Facilities shall be kept free of all insects and rodents. All outside openings shall be effectively sealed or screened to prevent entry of insects or rodents. All pesticides used to control insects or rodents shall be applied in accordance with instructions on the registered product label. Persons applying restricted use pesticides shall

191 Page 191 of 399 be certified by the Department. Facilities not having certified pest control operators shall utilize commercial licensed pest control companies. ST - H INTENSIVE RES TX PROG - Fire Safety Title INTENSIVE RES TX PROG - Fire Safety Statute or Rule 59A-3.303(4)-(5)(a)-(c), FAC (4) All facilities shall be required to meet the uniform fire safety standards for special hospitals as established by the State Fire Marshal pursuant to Section (8), F.S. (a) All staff shall be instructed in the use of fire extinguishers. (b) All fire extinguishers shall be inspected as regulated by local requirements and shall be serviced as required. (c) All fire safety systems shall be kept in good operating condition. (d) Fire safety systems shall be inspected regularly as regulated by local requirements, and records of such inspections shall be kept on file. (5) The special hospital shall provide for safety inspections by a facility personnel committee. (a) Personnel responsible for safety evaluation shall receive appropriate training. (b) Safety inspections shall be done on a monthly basis, shall be made into a written report, and shall be maintained on file at the facility. (c) Special safety measures shall be provided for areas of the facility that may present an unusual hazard to patients, staff or visitors. Poisonous or toxic compounds are to be stored apart from food and other areas that would constitute a hazard to the residents. 59A-3.303(4), FAC 59A-3.303(5)(a)-(c), FAC - While on tour of the facility check that fire extinguishers have been inspected. - Interview staff on the unit and see if they know how to operate the facility's fire extinguishers. Ask employees how they are trained in the use of fire extinguishers. If you have concerns, review the employees' records to ensure training. - Interview the maintenance director and see how they ensure that the facility's fire safety system is maintained. See if the patient safety committee inspects the facility's safety system. - Interview the hospital's Administrator to determine who is responsible for conducting the safety evaluations. - Interview the head of the safety committee to determine how often fire safety inspections are done. - Review the employee record of the person responsible for conducting the safety evaluations; what training has been provided to the individual. - Review the safety inspection reports for the past 6 months. Has the inspection been completed on a monthly basis? - Review the facility's last fire inspection, are there any deficiencies? Has the facility corrected the deficiencies or are there plans for the corrections? - Review the facility's policies and procedure regarding fire safety, training and inspections. Does everything you have been informed and read comply with the facility's policies and procedures?

192 Page 192 of 399 ST - H INTENSIVE RES TX PROG - Disaster Planning Title INTENSIVE RES TX PROG - Disaster Planning Statute or Rule 59A-3.303(6), FAC (6) Disaster Planning, All licensed programs shall comply with Rule 59A-3.078, F.A.C., in regard to a Comprehensive Emergency Management Plan. - Interview the county maintenance director regarding the facility's Emergency Management Plan. Has it been submitted to the emergency management department for approval? Have any changes been made in the last year to the Emergency Management Plan? - Interview facilities staff members regarding their responsibilities in implementing the plan. - Do they know where the emergency plan is located? - Review the approval letter for the facility's Emergency Management Plan. - Review the evaluation of the facility's performance in its latest drill of the plan. ST - H INTENSIVE RES TX PROG - Intake & Admission Title INTENSIVE RES TX PROG - Intake & Admission Statute or Rule 59A-3.110(1)(a)-(g), FAC Services shall be designed to meet the needs of the emotionally disturbed patient and must conform to stated purposes and objectives of the program. (1) Intake and Admission. (a) Acceptance of a child or adolescent for inpatient treatment shall be based on the assessment, arrived at by the multidisciplinary clinical staff involved and clearly explained to the patient and the family. Whether the family voluntarily requests services or the patient is referred by the court, the special hospital shall involve the family's participation to the fullest extent possible. Discharge planning shall begin at the - Tour the facility through the admission process. Is the staff observed communicating with the child's parents? Are discharge plans discussed with the children and their parents/guardians? - Interview the admissions staff to see what criteria they utilize during admission of children? Ask the admission staff how much are parents/guardians involved in the admissions process? When does discharge planning begin? - Interview staff on the unit who did not participate in the patient's admission process. How are they informed about the child's admission? Were they oriented on the child prior to meeting the child? How are other children on the unit informed of a new child participating in group activities? Are new children admitted to the unit assigned to a specific employee? How is that decision made? - Review a sample of patients' records. Was the decision to admit the child based on assessments conducted by multidisciplinary clinical staff? - Review policies and procedures for admission. Did the patients' admission records review meet the facility's criteria

193 Page 193 of 399 time of intake and admission. (b) Acceptance of the child or adolescent for treatment shall be based on the determination that the child or adolescent requires treatment of a comprehensive and intensive nature and is likely to benefit by the programs that the facility has to offer. (c) Admission shall be in keeping with stated policies of the special hospital and shall be limited to those patients for whom the special hospital is qualified by staff, program and equipment to give adequate care. (d) Staff members who will be working with the patient, but who did not participate in the initial assessment shall be oriented regarding the patient and the patient's anticipated admission prior to meeting the patient. When the patient is to be assigned to a group, the other patients in the group shall be prepared for the arrival of the new member. There shall be a specific staff member assigned to the new patient to observe him and help with the unit orientation period. (e) The admission procedure shall include documentation concerning: 1. Responsibility for and amount of financial support; 2. Responsibility for medical and dental care, including consent for medical and surgical care and treatment; 3. Arrangements for appropriate family participation in the program, phone calls and visits when indicated; 4. Arrangements for clothing, allowances and gifts; and 5. Arrangements regarding the patient's leaving the facility with or without medical consent. (f) Decisions for admission shall be based on the initial assessment of the patient made by the appropriate multidisciplinary clinical staff. This assessment must be documented on the record of treatment on admission. (g) The admission order must be written by a staff or consultant physician. for admissions? - Review current and discharged patients' records to ensure that they meet the criteria for admission, assessments were completed as required, discharge planning was conducted from admission and that all charts contain documentation indicated in section (e) 1-5. Do the patients' records document assessments and a written order by a staff or physician?

194 Page 194 of 399 ST - H INTENSIVE RES TX PROG - Patient Assessment Title INTENSIVE RES TX PROG - Patient Assessment Statute or Rule 59A-3.254(1), FAC (1) Patient Assessment. Each hospital shall develop and adopt policies and procedures to ensure an initial assessment of the patient's physical, psychological and social status, appropriate to the patient's developmental age, is completed to determine the need and type of care or treatment required, and the need for further assessment. The scope and intensity of the initial assessment shall be determined by the patient's diagnosis, the treatment setting, the patient's desire for treatment, and response to previous treatment. - Interview clinical director/administrator regarding how the facility determines the patients' needs, type of care and treatment which will be provided and ensure further assessment. - Review patient's initial assessments for compliance. - Review the facility's policies and procedures. Does the information obtained from interviews and record reviews match the facility's policies and procedures? ST - H INTENSIVE RES TX PROG - Treatment Planning Title INTENSIVE RES TX PROG - Treatment Planning Statute or Rule 59A-3.254(a)1 and 2(b)-(e), FAC Treatment Planning: (a) Such policies shall: 1. Specify the time period preceding or following admission within which the initial assessment shall be conducted; 2. Require that the initial assessment be documented in writing in the patient's medical record; (b) The initial assessment shall determine the need for an assessment of the patient's nutritional and functional status, as well as discharge planning needs, when appropriate; - Observe sampled patients during treatment. Document detailed information on your observation. - Review sampled patients' records to see documented nutritional assessment and discharge planning. Did any patient have a change in condition? If so, was a reassessment of the patient completed and was a new treatment plan developed? Did your observation of the patients' treatment meet the patients' documented care plan? - Review facility's policies and procedures on treatment planning, including conducting the initial assessment, periodic reassessments based on changes, ensuring treatment and decisions are based on patients' needs and treatment priorities.

195 Page 195 of 399 (c) The hospital shall have policies and procedures to ensure that periodic reassessments of the patient are conducted based on changes in either the patient's condition, diagnosis, or response to treatment; (d) The hospital shall ensure that care and treatment decisions are based on the patient's identified needs and treatment priorities; (e) An individualized treatment plan shall be developed for each patient based upon the initial assessment and other diagnostic information as appropriate. ST - H INTENSIVE RES TX PROG - Coordination of Care Title INTENSIVE RES TX PROG - Coordination of Care Statute or Rule 59A-3.254(2)(a)-(d), FAC (2) Coordination of Care: Each hospital shall develop and implement policies and procedures on discharge planning which address: (a) Identification of patients requiring discharge planning; (b) Initiation of discharge planning on a timely basis; (c) The role of the physician, other health care givers, the patient, and the patient's family in the discharge planning process; and (d) Documentation of the discharge plan in the patient's medical record including an assessment of the availability of appropriate services to meet identified needs following hospitalization. - Interview staff on discharge planning process. When is the discharge planning commenced? How are patients identified as required discharge planning? - Review current and discharged patients for documentation of discharge planning and that the discharge planning meets the needs of the patients. Who played a role in the patients' discharge planning? - Review the facility's policies and procedures for discharge planning. Does the information obtained from interviews and record reviews meet the requirements as dictated in the facility's policies and procedures?

196 Page 196 of 399 ST - H INTENSIVE RES TX PROG - Pt & Family Education Title INTENSIVE RES TX PROG - Pt & Family Education Statute or Rule 59A-3.254(3), FAC (3) Patient and Family Education. (a) General Provisions. Each hospital shall develop a systematic approach to educating the patient and family to improve patient outcomes by promoting recovery, speedy return to function, promoting healthy behaviors, and involving patients in their care and care decisions. (b) Each hospital shall provide the patient and family with education specific to the patient's assessed needs, capabilities, and readiness. Such education shall include when indicated: 1. An assessment when indicated, of the educational needs, capabilities, and readiness to learn based on cultural and religious practices, emotional barriers, desire and motivation to learn, physical and cognitive limitations, and language barriers; 2. Instruction in the specific knowledge or skills needed by the patient or family to meet the patient's ongoing health care needs including: a. The use of medications. b. The use of medical equipment. c. Potential drug or food interactions, and nutritional intervention or modified diets. d. Rehabilitation techniques. e. Available community resources. f. When and how to obtain further treatment; and g. The patient's and family's responsibilities in the treatment process. 3. Information about any discharge instructions given to the patient or family shall be provided to the organization or - Interview patients and families identified as requiring education to ensure the provision of these services. Has the facility discussed the patient's needs once the patient has been discharged? Has the facility discussed issues (a-g)? Has the facility provided the family with any training, education, and resources to ensure continuation of care once the patient has been discharged? - Interview administrative staff on the policy and procedure of education, including how they identify patients and/or families that require education. Ask how the facility educates the patient and family. - Review patient records for assessment of educational needs and provision of the required education. Are identified resources provided to the patient's family? - Review policies and procedures for patient and family education.

197 Page 197 of 399 individual responsible for providing continuing care. 4. Each hospital shall plan and support the provision and coordination of patient and family education activities by ensuring that: a. Educational resources required are identified and made available; and b. The educational process is interdisciplinary, as appropriate to the plan of care. ST - H INTENSIVE RES TX PROG - Patient Rights P&P Title INTENSIVE RES TX PROG - Patient Rights P&P Statute or Rule 59A-254(4) FAC (4) Patient Rights. Each hospital shall develop and adopt policies and procedures to ensure the following rights of the patient: (a) The right to refuse treatment and life-prolonging procedures as specified under Section , F.S.; (b) The right to formulate advance directives and designate a surrogate to make health care decisions on behalf of the patient as specified under Chapter 765, F.S. The policies shall not condition treatment or admission upon whether or not the individual has executed or waived an advance directive. In the event of conflict between the facility's policies and procedures and the individual's advance directive, provision should be made in accordance with Section , F.S. Policies shall include: 1. Provide each adult individual, at the time of the admission as an inpatient, with a copy of "Health Care Advance Directives - The Patient's Right to Decide," effective , which is hereby incorporated by reference, or with a copy of some other substantially similar document which is a written description of Chapter 765, F.S., regarding advance During tour of the unit, are the patient's rights being adhered to? Are any patients currently in restraints? Observe patients to ensure rights are not violated. Interview patients have they filed any grievances to the facility? How has the facility addressed the grievance? Are the facility staff members respecting their rights? Interview the facility's staff, how are patient's informed of the facility's rights? Has the facility staff been trained on patients' rights? Review patients' records, are there documented evidence that the facility provided the patients with a copy of the "Health Care Advance Directives- The Patient's Right to Decide", patient's rights as set forth in (c-h). Review the facility's grievance log, how does the facility response to the patients' grievances? Review policies and procedures to ensure patients' rights. Review the facility's grievance policies and procedures. SUMMARY OF THE FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows: A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy. A patient has the right to a prompt and reasonable response to questions and requests.

198 Page 198 of 399 directives; 2. Providing each adult individual, at the time of admission as an inpatient, with written information concerning the health care facility's policies respecting advance directives; and 3. The requirement that documentation of the existence of an advance directive be contained in the medical record. A health care facility which is provided with the individual's advance directive shall make the advance directive or a copy thereof a part of the individual's medical record. (c) The right to information about patient rights as set forth in Section , F.S., and procedures for initiating, reviewing and resolving patient complaints; (d) The right to participate in the consideration of ethical issues that arise in the care of the patient; (e) The right to personal privacy and confidentiality of information including access to information contained in the patient's medical records as specified under Section , F.S.; (f) The right of the patient's next of kin or designated representative to exercise rights on behalf of the patient; (g) The right to an itemized patient bill upon request as specified under Section , F.S.; (h) The right to be free of restraints consistent with the rights of mentally ill persons or patients as provided in Section , F.S. A patient has the right to know who is providing medical services and who is responsible for his or her care. A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English. A patient has the right to know what rules and regulations apply to his or her conduct. A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis. A patient has the right to refuse any treatment, except as otherwise provided by law. A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care. A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate. A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care. A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment. A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research. A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency. A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health. A patient is responsible for reporting unexpected changes in his or her condition to the health care provider. A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her. A patient is responsible for following the treatment plan recommended by the health care provider. A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility. A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions. A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as

199 Page 199 of 399 ST - H INTENSIVE RES TX PROG - Pt Bill of Rights possible. A patient is responsible for following health care facility rules and regulations affecting patient care and conduct Patient and personnel records; copies; examination.- (1) Any licensed facility shall, upon written request, and only after discharge of the patient, furnish, in a timely manner, without delays for legal review, to any person admitted therein for care and treatment or treated thereat, or to any such person's guardian, curator, or personal representative, or in the absence of one of those persons, to the next of kin of a decedent or the parent of a minor, or to anyone designated by such person in writing, a true and correct copy of all patient records, including X rays, and insurance information concerning such person, which records are in the possession of the licensed facility, provided the person requesting such records agrees to pay a charge. The exclusive charge for copies of patient records may include sales tax and actual postage, and, except for nonpaper records that are subject to a charge not to exceed $2, may not exceed $1 per page. A fee of up to $1 may be charged for each year of records requested. These charges shall apply to all records furnished, whether directly from the facility or from a copy service providing these services on behalf of the facility. However, a patient whose records are copied or searched for the purpose of continuing to receive medical care is not required to pay a charge for copying or for the search. The licensed facility shall further allow any such person to examine the original records in its possession, or microforms or other suitable reproductions of the records, upon such reasonable terms as shall be imposed to assure that the records will not be damaged, destroyed, or altered Itemized patient bill; form and content prescribed by the agency.- (1) A licensed facility not operated by the state shall notify each patient during admission and at discharge of his or her right to receive an itemized bill upon request. Within 7 days following the patient's discharge or release from a licensed facility not operated by the state, the licensed facility providing the service shall, upon request, submit to the patient, or to the patient's survivor or legal guardian as may be appropriate, an itemized statement detailing in language comprehensible to an ordinary layperson the specific nature of charges or expenses incurred by the patient, which in the initial billing shall contain a statement of specific services received and expenses incurred for such items of service, enumerating in detail the constituent components of the services received within each department of the licensed facility and including unit price data on rates charged by the licensed facility, as prescribed by the agency , F.S. A facility may not use seclusion or restraint for punishment, to compensate for inadequate staffing, or for the convenience of staff. Facilities shall ensure that all staff are made aware of these restrictions on the use of seclusion and restraint and shall make and maintain records which demonstrate that this information has been conveyed to individual staff members. Title INTENSIVE RES TX PROG - Pt Bill of Rights Statute or Rule 59A-254(5) FAC

200 Page 200 of 399 Patient Rights (5) In addition to the provisions of this section, hospitals must comply with Section , F.S., which remains in effect. Refer to Florida Patient's Bill of Rights and Responsibilities. SUMMARY OF THE FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows: A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy. A patient has the right to a prompt and reasonable response to questions and requests. A patient has the right to know who is providing medical services and who is responsible for his or her care. A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English. A patient has the right to know what rules and regulations apply to his or her conduct. A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis. A patient has the right to refuse any treatment, except as otherwise provided by law. A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care. A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate. A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care. A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment. A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research. A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency. A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters

201 Page 201 of 399 ST - H INTENSIVE RES TX PROG - Emergency Mgmt Plan relating to his or her health. A patient is responsible for reporting unexpected changes in his or her condition to the health care provider. A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her. A patient is responsible for following the treatment plan recommended by the health care provider. A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility. A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions. A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible. A patient is responsible for following health care facility rules and regulations affecting patient care and conduct. Title INTENSIVE RES TX PROG - Emergency Mgmt Plan Statute or Rule 59A FAC (1) Each hospital shall develop and adopt a written comprehensive emergency management plan for emergency care during an internal or external disaster or an emergency, which is reviewed and updated annually. (2) The emergency management plan shall be developed in conjunction with other agencies and providers of health care services within the local community pursuant to Section (2), F.S., and in accordance with the "Emergency Management Planning Criteria for Hospitals," AHCA Form September 94, which is incorporated by reference. At a minimum, the plan shall include: (a) Provisions for internal and external disasters and emergencies, pursuant to Section , F.S.; (b) A description of the hospital's role in community wide emergency management plans; (c) Information about how the hospital plans to implement 59A-3.078, FAC Refer to H Record Review: Request the letter indicating the facility has an approved emergency management plan, annually. Review facility's performance in the latest drill. Review employees' records to verify the staff has been trained in the facility's emergency management plan. - Interview staff on the emergency management plan and what their responsibilities are for implementing the plan. Ask staff where the emergency management plan is Kept. Is the plan easily accessible? (2): It is further declared to be the purpose of ss and the policy of the state that all emergency management functions of the state be coordinated to the maximum extent with comparable functions of the Federal Government, including its various departments, agencies of other states and localities, and private agencies of every type, to the end that the most effective preparation and use may be made of the workforce, resources, and facilities of the nation for dealing with any emergency that may occur Definitions.-As used in this part, the term: (1) "Disaster" means any natural, technological, or civil emergency that causes damage of sufficient severity and magnitude to result in a declaration of a state of emergency by a county, the Governor, or the President of the United States. Disasters shall be identified by the severity of resulting damage, as follows:

202 Page 202 of 399 specific procedures outlined in the hospital's emergency management plan; (d) Precautionary measures, including voluntary cessation of hospital admissions, to be taken by the hospital in preparation and response to warnings of inclement weather, or other potential emergency conditions; (e) Provisions for the management of patients, including the discharge of all patients that meet discharge requirements, in the event of an evacuation order, at the direction of the hospital administrator, or when a determination is made by the agency that the condition of the facility or its support services is sufficient to render it a hazard to the health and safety of patients and staff, pursuant to Chapter 59A-3, F.A.C. Such provisions shall address moving patients within the hospital and relocating patients outside the hospital, including the roles and responsibilities of the physician and the hospital in the decision to move or relocate patients whose life or health is threatened; (f) Education and training of personnel in carrying out their responsibilities in accordance with the adopted plan; (g) A provision for coordinating with other hospitals that would receive relocated patients; (h) Provisions for the management of staff, including the distribution and assignment of responsibilities and functions, and the assignment of staff to accompany those patients located at off-site locations; (i) Provisions for the individual identification of patients, including the transfer of patient records; (j) Provisions to ensure that a verification check will be made to ensure relocated patients arrive at designated hospitals; (k) Provisions to ensure that medication needs will be reviewed and advance medication for relocated patients will be forwarded to respective hospitals, when permitted by existing supplies, and state and federal law; (l) Provisions for essential care and services for patients who (a) " Catastrophic disaster" means a disaster that will require massive state and federal assistance, including immediate military involvement. (b) " Major disaster" means a disaster that will likely exceed local capabilities and require a broad range of state and federal assistance. (c) " Minor disaster" means a disaster that is likely to be within the response capabilities of local government and to result in only a minimal need for state or federal assistance Emergency management powers; Division of Emergency Management (2) The division is responsible for carrying out the provisions of ss In performing its duties, the division shall: 1. Include an evacuation component that includes specific regional and interregional planning provisions and promotes intergovernmental coordination of evacuation activities. This component must, at a minimum: contain guidelines for lifting tolls on state highways; ensure coordination pertaining to evacuees crossing county lines; set forth procedures for directing people caught on evacuation routes to safe shelter; establish strategies for ensuring sufficient, reasonably priced fueling locations along evacuation routes; and establish policies and strategies for emergency medical evacuations Emergency management powers of political subdivisions. (1) COUNTIES (e) County emergency management agencies may charge and collect fees for the review of emergency management plans on behalf of external agencies and institutions. Fees must be reasonable and may not exceed the cost of providing a review of emergency management plans in accordance with fee schedules established by the division.

203 Page 203 of 399 may be relocated to the facility during a disaster or an emergency, including staffing, supplies and identification of patients; (m) Provisions for contacting relatives and necessary persons advising them of patient location changes. A procedure must also be established for responding to inquiries from patient families and the press; (n) Provisions for the management of supplies, communications, power, emergency equipment, security, and the transfer of records; (o) Provisions for coordination with designated agencies including the Red Cross and the county emergency management office; and (p) Plans for the recovery phase of the operation, to be carried out as soon as possible. (3) The plan, including the "Emergency Management Planning Criteria for Hospitals," shall be submitted annually to the county emergency management agency for review and approval. A fee may be charged for the review of the plan as authorized by Section (2)(l) and (1)(e), F.S. (a) The county office of emergency management has 60 days in which to review and approve the plan, or advise the facility of necessary revisions. If the county emergency management agency advises the facility of necessary revisions to the plan, those revisions shall be made and the plan resubmitted to the county office of emergency management within 30 days of notification by the county emergency management agency. (b) The county office of emergency management shall be the final administrative authority for emergency plans developed by hospitals. (4) The hospital shall test the implementation of the emergency management plan semiannually, either in response to a disaster or an emergency or in a planned drill, and shall evaluate and document the hospital's performance to the hospital's safety committee. As an alternative, the hospital may

204 Page 204 of 399 test its plan with the frequency specified by the Joint Commission on Accreditation of Healthcare Organizations. (5) The emergency management plan shall be located for immediate access by hospital staff. (6) In the event a disaster or emergency conditions have been declared by the local emergency management authority, and the hospital does not evacuate the premises, a facility may provide emergency accommodations above the licensed capacity for patients. However, the following conditions must be met: (a) The facility must report being over capacity and the conditions causing it to the agency area office within 48 hours or as soon as practical. As an alternative, the facility may report to the agency central office, Hospital and Outpatient Services Section, at (850) ; (b) Life safety cannot be jeopardized for any individual; (c) The essential needs of patients must be met; and (d) The facility must be staffed to meet the essential needs of patients. (7) If the hospital will be over capacity after the declared disaster or emergency situation ends, the agency shall approve the over capacity situation on a case-by-case basis using the following criteria: (a) Life safety cannot be jeopardized for any individual; (b) The essential needs of patients must be met; and (c) The facility must be staffed to meet the essential needs of patients. (8) If a facility evacuates during or after a disaster or an emergency situation, the facility shall not be reoccupied until a determination is made by the hospital administrator that the facility can meet the needs of the patients. (9) A facility with significant structural damage shall relocate patients until approval is received from the agency's Office of Plans and Construction that the facility can be safely reoccupied, pursuant to Rules 59A through 59A-3.093,

205 Page 205 of 399 F.A.C. (10) A facility that must evacuate the premises due to a disaster or emergency conditions shall report the evacuation to the agency area office within 48 hours or as soon as practical. The administrator or designee is responsible for knowing the location of all patients until the patient has been discharged from the facility. The names and location of patients relocated shall be provided to the local emergency management authority or it's designee having responsibility for tracking the population at large. The licensee shall inform the agency area office of a contact person who will be available 24 hours a day, seven days a week, until the facility is reoccupied. ST - H INTENSIVE RES TX PROG - Pharmaceutical Svcs Title INTENSIVE RES TX PROG - Pharmaceutical Svcs Statute or Rule 59A-3.110(7) FAC (7) Pharmaceutical Services. Pharmaceutical services, if provided, shall be maintained and delivered as described in the applicable sections of Chapter 465, F.S., Chapter 893, F.S., Chapter 500, F.S., and Board of Pharmacy Chapter 21S, F.S. During facility tour, observe for the proper storage of medication on the unit. Are all medications kept secure? Observe medication pass to ensure proper delivery of medication. - Interview clinical director/administrator on how pharmaceutical services are monitored for compliance with requirements. ST - H INTENSIVE RES TX PROG - Lab & Path Svcs Title INTENSIVE RES TX PROG - Lab & Path Svcs Statute or Rule 59A-3.110(8)(a) and (b), FAC (8) Laboratory and Pathology Services. 59A-3.110(a)(1)(4), FAC

206 Page 206 of 399 (a) The facility shall provide clinical and pathology services within the institution, or by contractual arrangement with a laboratory commensurate with the facility's needs and which is registered under the provisions of Chapter 483, F.S. 1. Provision shall be made for the availability of emergency laboratory services 24 hours a day, 7 days a week, including holidays. 2. All laboratory tests shall be ordered by a physician. 3. All laboratory reports shall be filed in the patient's medical record. 4. The facility shall have written policies and procedures governing the collection, preservation and transportation of specimens to assure adequate stability of specimens. (b) Where the facility depends on an outside laboratory for services, there shall be a written contract detailing the conditions, procedures and availability of work performed. The contract shall be reviewed and approved by the medical staff, administrator and the governing body. 59A-3.110(8)(b), FAC - Interview Administrator/ Clinical Director to determine if the facility provides laboratory and pathology services in the facility or do they have a contractual arrangement with a laboratory. Are the services provided 24 hours a day, 7 days a week, including holidays? If contracted laboratory services are used, how often is the contract reviewed? Who is approving this contract? Interview the nurses on the floor. How are laboratory test completed on the unit? Are the laboratory services provided 24/7, including on holidays? Interview the Clinical Director regarding how they ensure all laboratory results are properly filed in the patient's records. - If the facility contracts these services with a laboratory outside of the facility, request to review the contract. Does the contract address conditions, procedures and availability of work performed? Review the governing body minutes. Was the contract approved by the medical staff, administrator, and the governing body? - Review the facility's policy and procedures for ordering, collecting, preserving, and transporting specimens. ST - H INTENSIVE RES TX PROG - Patient Rights Title INTENSIVE RES TX PROG - Patient Rights Statute or Rule 59A-3.110(9)(a) and (b)(1-5) FAC (9) Patients' Rights. Every effort shall be made to safeguard the legal and civil rights of patients and to make certain that they are kept informed of their rights, including the right to legal counsel and all other requirements of due process. (a) Individual dignity and human rights are guaranteed to all clients of mental health facilities in Florida by the Florida Mental Health Act, known as the "Baker Act," Chapter 394, F.S. (b) Each facility shall be administered in a manner that protects the client's rights, his life, and his physical safety 59A-3.110(9)(a), FAC 59A-3.110(9)(b)(1)-(5), FAC - During tour of the facility, do the staff members respect the patients' rights? Are the patients' rights posted in the facility, in areas where is easily seen by the patients? Are any of the patients being visited by family? Do patients and visitors have privacy? Are care and services provided in private? While on tour request a list of patients who have had their rights to visitors and mail revoked? - Interview the Clinical Director to determine how residents' patients are informed of their rights. How are residents' patients' records safe-guarded? What are the facility's regular visiting hours? Can a residents visitation rights ever be revoked? If so, under what condition? How do they control patient's behaviors? Interview patients on the unit and determine if their rights to privacy have been explained to them. Has the facility

207 Page 207 of 399 while under treatment. 1. The special hospital's space and furnishings should be designed and planned to enable the staff to respect the patient's right to privacy and, at the same time, provide adequate supervision according to the development and clinical needs of the patients. Provisions for an individual patient's rights regarding privacy shall be made explicit to the patient and family. A written policy concerning patient's rights shall be provided to the patient of authentic research or studies, or innovations of client's record. 2. The special hospital center's policies shall allow patient visitation and communication with all members of the family and other visitors as clinically indicated and when such visits are consistent with the facility's program. When therapeutic considerations recommended by the responsible licensed psychologist or physician necessitate restriction of communication or visits, as set forth in the programs policies and procedures, these restrictions shall be evaluated at least weekly by the clinical staff for their continuing effectiveness. These restrictions shall be documented and signed by the responsible psychologist or physician and be placed in the patient's record. The special hospital shall make known to the patient, the family and referring agency its policies regarding visiting privileges on and off the premises, correspondence and telephone calls. These policies shall be stated in writing and shall be provided to the patient and family and updated when change in policy occurs. When limitations on such visits, calls or other communications are indicated by practical reason, e.g., the expense of travel or telephone calls, such limitations shall be determined with participation of the patient's family or guardian. 3. Patients shall be allowed to request an attorney through their parents or guardians. This shall be established as written policy, and the policy shall be provided to families and patients. allowed them to have privacy during visits? Have they had their mailed open prior to them getting it? Does the facility treat them with respect? How are their concerns regarding their programs handled? Have any of them requested a lawyer and if they have, what has the facility done for them? What do they do if they have a grievance? - Observe the facility to ensure residents' rights are posted throughout the facility. s (12) F.S. - Interview the parents of a patient who has had their rights to visitors and /or mail (If applicable). Has the facility explained the rational to revoking these rights? Upon admission into the facility, did the facility explain the patient's rights to request an attorney? - Review the facility's policy and procedure regarding residents' rights. - Review the facility's Admission packet. Are the facility's visiting hours, residents' rights, any restrictions, correspondence, and telephone use addressed in the admissions packet? - Review facility's policy and procedure for residents requesting an attorney. - Review the facility's policy for responding to patient communications concerning their total program. - Interview patients to determine if they are aware of what their rights are. Does the facility treat them with respect? How are their concerns regarding their programs handled? Have any of them requested a lawyer and if they have, what has the facility done for them? What do they do if they have a grievance?

208 Page 208 of Patient's opinions and recommendations shall be considered in the development and continued evaluation of the therapeutic program. The special hospital shall have written policies to carry out appropriate procedures for receiving and responding to patient communications concerning the total program. 5. The special hospital shall have written policies regarding methods used for control of patients' behavior. Such written policies shall be provided to the appropriate staff and to the patient and his family. Only staff members responsible for the care and treatment of patients shall be allowed to handle discipline. Patients shall not be subject to cruel, severe, unusual or unnecessary punishment. Patients shall not be subjected to remarks which ridicule them or their families, or others. ST - H INTENSIVE RES TX PROG-Restraint/Seclusion/Oth Title INTENSIVE RES TX PROG-Restraint/Seclusion/Oth Statute or Rule 59A-3.110(9)(b)(6)-(10), F.A.C. 6. Protective restraint consists of any apparatus or condition which interferes with the free movement of the patient. Only in an emergency shall physical holding be employed unless there are physician's orders for a mechanical restraint. Physical holding or mechanical restraints, such as canvas jackets or cuffs, shall be used only when necessary to protect the patient from injury to himself or others. Use of mechanical restraints reflect a psychiatric emergency and must be ordered by the responsible staff/consultant physician, be administered by trained staff and be documented in the patient's clinical records. The need for the type of restraint used and the length of time it was employed and condition of the patient shall be recorded in the patient's record. An order for a mechanical During the tour of the facility, does the facility have a seclusion room? Does the facility have canvas jackets or cuffs? Interview Clinical Director and have him/her explain the seclusion procedures. Which staff can implement restraint/seclusion? - Interview staff, why would a patient be restrained? What is the facility's policy for physically restraining a patient? How often are patients placed on restraints? - Select patients' records of patients who have been restrained in order to ensure the initiation process was done correctly, the patient was checked upon, all bathroom releases have been documented; verify that the patient was not left in restraints for more than 24 hours. If the patient had to be in restraints for more than 24 hours, were new orders obtained and why was the patient required to be restrained longer than 24 hours? - Select some of these employees' files to determine if they have been trained in the proper use of the procedures. - Review the facility restraint/seclusion policy and procedure. Review the facility's restraint log to ensure they follow their own policy. Does everything you have learned through observations, interviews and record reviews concur with the information in the facility's policies and procedures?

209 Page 209 of 399 restraint shall designate the type of restraint to be used, the circumstance under which it is to be used and the duration of its use. A patient in a mechanical restraint shall have access to a staff member at all times during the period of restraint. 7. The facility shall have written policies and procedures which govern the use of seclusion. The use of seclusion shall require clinical justification and shall be employed only to prevent a patient from injuring himself or others, or to prevent serious disruption of the therapeutic environment. Seclusion shall not be employed as punishment or for the convenience of staff. A written order from a physician shall be required for the use of seclusion for longer than one hour. Written orders for seclusion shall be limited to twenty-four (24) hours. The written approval of the medical director or the director of psychiatrist services shall be required when seclusion is utilized for more than twenty-four (24) hours. Staff who implement written orders for seclusion shall have documented training in the proper use of the procedures. Appropriate staff shall observe and visually monitor the patient in seclusion every fifteen (15) minutes, documenting the patient's condition and identifying the time of observation. A log shall be maintained which will record on a quarter- hour basis the observation of the patient in seclusion, and will also indicate when the patient was taken to the bathroom, when and where meals were served, when other professional staff visited, etc., and shall be signed by the observer. The need or reason for seclusion shall be made clear to the patient and shall be recorded in the patient's clinical record. The length of time in seclusion shall also be recorded in the clinical record, as well as the condition of the patient. A continuing log shall be maintained by the facility that will indicate by name the patients placed in seclusion, date, time, specified reason for seclusion and length of time in seclusion. In an emergency, orders may be given by a physician over the telephone to a registered professional nurse. Telephone orders must be

210 Page 210 of 399 reviewed within twenty-four (24) hours by the director of psychiatric services. 8. The special hospital shall not exploit a patient or require a patient to make public statements to acknowledge his gratitude to the treatment center. 9. Patients shall not be required to perform at public gatherings. 10. The special hospital shall not use identifiable patients' pictures without written consent. The signed consent form shall be on file at the facility before any such pictures are used. A signed consent form must indicate how pictures shall be used and a copy shall be placed in the patient's clinical record. ST - H INTENSIVE RES TX PROG - Clinical Record Std Title INTENSIVE RES TX PROG - Clinical Record Std Statute or Rule 59A-3.110(10)(a)(1-14) and (10)(b), FAC (10) Records. The form and detail of the clinical records may vary but shall minimally conform to the following standards: (a) Content. All clinical records shall contain all pertinent clinical information and each record shall include but not be limited to: 1. Identification data and consent forms; when these are not obtainable, reason shall be noted; 2. Source of referral; 3. Reason for referral, example, chief complaint, presenting problem; 4. Record of the complete assessment; 5. Initial formulation and diagnosis based upon the assessment; 6. Written treatment plan; 7. Medication history and record of all medications 59A-3.110(10)(a)(1-14), FAC 59A-3.110(10)(b), FAC Select a few records of patients in order to ensure the proper paper work is in the file. For example: physician's orders, complete assessment, diagnosis, treatment plan, medication history, treatment summaries, consultation reports, discharge and termination summary report, etc. Are consent forms in the files?

211 Page 211 of 399 prescribed; 8. Record of all medication administered by facility staff, including type of medication, dosages, frequency of administration, persons who administered each dose, and route of administration; 9. Documentation of course of treatment and all evaluations and examinations, including those from other facilities, for example, emergency rooms or general hospitals; 10. Periodic treatment summaries; updated at least every 90 days; 11. All consultation reports; 12. All other appropriate information obtained from outside sources pertaining to the patient; 13. Discharge or termination summary report; and 14. Plans for follow-up and documentation of its implementation. (b) Identification data and consent form shall include the patient's name, address, home telephone number, date of birth, sex, next of kin, school and what grade, date of initial contact or admission to the program, legal status and legal document, and other identifying data as indicated. ST - H INTENSIVE RES TX PROG - Progress Notes Title INTENSIVE RES TX PROG - Progress Notes Statute or Rule 59A (10)(c)(1)-(6) FAC (10) Records: (c) Progress Notes. Progress notes shall include regular notations at least weekly by staff members, consultation reports and signed entries by authorized identified staff. Progress notes by the clinical staff shall: 1. Document a chronological picture of the patient's clinical course; When reviewing patients' records ensure Progress Notes have regular notations. Which reflect the chronological picture of patient's clinical course, treatment the patient has received while in the facility, treatment plan, and description of any changes in the patient's condition? Have any of the patients had a change in condition (medically/behaviorally)? Has the change in condition clearly been documented in the patients' records?

212 Page 212 of Document all treatment rendered to the patient; 3. Document the implementation of the treatment plan; 4. Describe each change in each of the patient's conditions; 5. Describe responses to and outcome of treatment; and 6. Describe the responses of the patient and the family or significant others to significant inter-current events ST - H INTENSIVE RES TX PROG - Discharge Summary Title INTENSIVE RES TX PROG - Discharge Summary Statute or Rule 59A-3.110(10)(d) FAC (10) Records: (d) Discharge Summary. The discharge summary shall include the initial formulation and diagnosis, clinical resume, final formulation and final primary and secondary diagnoses, the psychiatric and physical categories. The final formulation shall reflect the general observations and understanding of the patient's condition during appraisal of the fundamental needs of the patients. The relevant discharge diagnoses shall be recorded and coded in the standard nomenclature of the current "Diagnostic and Statistical Manual of Mental Disorders," published by the American Psychiatric Association, and the latest edition of the "International Classification of Diseases," regardless of the use of other additional classification systems. Records of discharged patients shall be completed following discharge within a reasonable length of time, and not to exceed 15 days. In the event of death, a summation statement shall be added to the record either as a final progress note or as a separate resume. This final note shall take the form of a discharge summary and shall include circumstances leading to death. All discharge summaries must be signed by a staff or consultant physician. Select some closed records for review. Ensure there is a discharge summary diagnosis; The discharge has occurred within 15 days and the discharge summary has been signed by a staff or consultant physician.

213 Page 213 of 399 ST - H INTENSIVE RES TX PROG-Recording/Documentation Title INTENSIVE RES TX PROG-Recording/Documentation Statute or Rule 59A-3.110(10)(e) FAC (10) Records: (e) Recording. Entries in the clinical records shall be made by staff having pertinent information regarding the patient, consistent with the facility policies, and authors shall fully sign and date each entry. When mental health trainees are involved in patient care, documented evidence shall be in the clinical records to substantiate the active participation of supervisory clinical staff. Symbols and abbreviations shall be used only when they have been approved by the clinical staff and when there is an explanatory notation. Final diagnosis, both psychiatric and physical, shall be recorded in full, and without the use of either symbols or abbreviations. - When reviewing patients' records ensure all symbols/abbreviations have been approved by the clinical staff. Review closed records ensure that there is a final psychiatric and physical diagnosis recorded. In reviewing open and close records, are all orders and entries dated and timed? Review the facility's policies and procedures. Do the records' entries abide by the facility's own policies and procedures. ST - H INTENSIVE RES TX PROG - Records P&P Title INTENSIVE RES TX PROG - Records P&P Statute or Rule 59A-3.110(10)(f)(1)-(7) FAC (10) Records: (f) Policies and Procedures. The facility shall have written policies and procedures regarding clinical records which shall provide that: 1. Clinical records shall be confidential, current and accurate; - During the facility's tour, observe where the patients' records are being stored. Are the records safeguarded to ensure they are protecting the patients' identities? Did you see any records left open or easily accessible to other patients or visitors? Are there boards in the unit that may have identifying or patient specific information posted where other patients or visitors can observe? - Interview the Clinical Director and ask how they protect the patients' private information. Identify who is allowed access to patients' information.

214 Page 214 of The clinical record is the property of the facility and is maintained for the benefit of the patient, the staff and the facility; 3. The facility is responsible for safeguarding the information in the record against loss, defacement, tampering or use by unauthorized persons; 4. The facility shall protect the confidentiality of clinical information and communication between staff members and patients; 5. Except as required by law, the written consent of the patient, family, or other legally responsible parties, is required for the release of clinical record information; 6. Records may be removed from the facility's jurisdiction and safekeeping only according to the policies of the facility or as required by law; and 7. That all staff shall receive training, as part of new staff orientation and with periodic update, regarding the effective maintenance of confidentiality of the clinical record. It shall be emphasized that confidentiality refers as well to discussions regarding patients inside and outside the facility. Verbal confidentiality shall be discussed as part of all employee training. Interview facility staff, how do they protect the patients' records? How do they protect the patients' personal information? - Interview the person responsible for training. When are new employees trained in patient confidentiality? How often does training occur for current staff? Review employees' records. Is there evidence of new employee and continued training in patient confidentiality? Review the facility's confidentiality policy and procedure. ST - H INTENSIVE RES TX PROG - Records Maintenance Title INTENSIVE RES TX PROG - Records Maintenance Statute or Rule 59A-3.110(10)(g)(1)-(5) FAC (10) Records: (g) Maintenance of Records. Each facility shall provide for a master filing system which shall include a comprehensive record on each patient's involvement in every program aspect. 1. Appropriate records shall be kept on the unit where the patient is being treated or be directly and readily accessible to 59A-3.110(10)(g)(1)-(5), FAC See H0276 Tag - While on the unit, observe the area where clinical records are stored to ensure they are kept in an area where they are readily available to the staff. - Interview the Clinical Director and the employees to determine what the coding system is utilized in the facility. Ask the Clinical Director where are closed patients' records stored?

215 Page 215 of 399 the clinical staff caring for the patient; 2. The facility shall maintain a system of identification and coding to facilitate the prompt location of the patient's clinical records; 3. There shall be policies regarding the permanent storage disposal or destruction of the clinical records of disclosure of confidential information later in life; 4. The clinical record services required by the facilities shall be directed, staffed and equipped to facilitate the accurate processing, checking, indexing, filing, retrieval and review of all clinical records. The clinical records\service shall be the responsibility of an individual who has demonstrated competence and training or experience in clinical record administrative work. Other personnel shall be employed as needed, in order to effect the functions assigned to the clinical record services; 5. There shall be adequate space, equipment and supplies, compatible with the needs of the clinical record service, to enable the personnel to function effectively and to maintain clinical records so that they are readily accessible. Interview the person in charge of medical records. How long are patients' records stored? How are the patients' medical records destroyed? Are the records stored in the hospital or are they sent to a storage facility? Is the storage facility secured? - Review the facility's policy and procedure regarding the permanent storage, disposal or destruction of the clinical records. Does the information obtained through observation and interview comply with the facility's policies and procedures? ST - H INTENSIVE RES TX PROG -Eval/Indiv Case Review Title INTENSIVE RES TX PROG -Eval/Indiv Case Review Statute or Rule 59A-3.110(11)(a)(1)-(2), FAC (11) Program and Patient Evaluation. The staff shall work towards enhancing the quality of patient care through specified, documented, implemented and ongoing the designing professions having as their purpose processes of clinical care evaluation studies and utilization review mechanisms. (a) Individual Case Review. 1. There shall be regular staff meetings or unit meetings to - Interview clinical Director about staff meetings to review and monitor patient progress, how follow-up is conducted on discharged patients, and how this information is used. - Interview staff members about their participation in the meeting and the use of the meeting for revisions of treatment plans. How often are the meeting held? Have they seen changes discussed in the meetings implemented? - Review documentation of meetings for the sampled patients. Has the patients' treatment plans been changed as per the meeting minutes? - Review documentation of follow-ups with discharged patients. Review Facility policies and procedures on these meetings and following up on discharged patients.

216 Page 216 of 399 review and monitor the progress of the individual child or adolescent patient. Each patient's case shall be reviewed within a month after admission and as least monthly during residential treatment. This shall be documented. This meeting may also be used for review and revision of treatment plans. 2. The facility shall provide for a follow-up review on each discharged patient to determine effectiveness of treatment and disposition. ST - H INTENSIVE RES TX PROG -Eval/Clinical Care Title INTENSIVE RES TX PROG -Eval/Clinical Care Statute or Rule 59A-3.110(11)(b)(1)(a)-(f) FAC (11) Program and Patient Evaluation: (b) Program Evaluation. 1. Clinical Care Evaluation Studies. There shall be evidence of ongoing studies to define standards of care consistent with the goals of the program effectiveness of the program, and to identify gaps and inefficiencies in service. Evaluation shall include, but is not limited to, follow-up studies. Studies shall consist of the following elements: a. Selection of an appropriate design; b. Specification of information to be included; c. Collection of data; d. An analysis of data with conclusions and recommendations; e. Transmissions of findings; and f. Follow-up on recommendations. - Interview the clinical director about clinical care evaluation studies and how information obtained is used to develop standards of care, and improve services. - Interview employees to determine how they determine the effectiveness of the programs? Are there any studies being conducted to evaluate the facility's programs? - Review policies and procedures for clinical care evaluation studies. - Review completed studies.

217 Page 217 of 399 ST - H INTENSIVE RES TX PROG - Eval/Utiliz Review Title INTENSIVE RES TX PROG - Eval/Utiliz Review Statute or Rule 59A-3.110(11)(b)(2) FAC (11) Program and Patient Evaluation: 2. Utilization Review. Each facility shall have a plan for and carry out utilization review. The review shall cover the appropriateness of admission to services, the provision of certain patterns of services, and duration of services. There shall be documentation of utilization review meetings either in minutes or in individual clinical records. The improvement of patient care, shall receive special consideration following a request and documentation of the proposed project by the individual sponsor. - Interview Clinical Director about Utilization reviews, and how that information is used to improve patient care. Who sits in the committee that is responsible for Utilization reviews? - Interview the person responsible for conducting the Utilization review. What programs are currently under review? How often is do the committee meets? Review the meeting minutes. Who are the results of the review reported to? - Review policies and procedures about utilization reviews. - Review documentation of utilization reviews for compliance with their policy. ST - H INTENSIVE RES TX PROG - Assessment Title INTENSIVE RES TX PROG - Assessment Statute or Rule 59A-3.110(2)(a) FAC (a) Assessment. The facility is responsible for a complete assessment of the patient, some of which may be required just prior to admission, by professionals acceptable to the facility's staff... Interview the Admissions Department, when are patients assessed prior to admissions? How are these assessments utilized to determine admissions? Interview employees on the unit. For patients newly admitted, when are assessments completed? Under what conditions will patients be reassessed? Review patients' records. Are assessments in the file? Have any assessments been completed prior to admissions? How are the assessments used to determine admissions? Review the facility's policies and procedures. Is the information obtained to this point comply with the facility's

218 Page 218 of 399 ST - H INTENSIVE RES TX PROG - Physical Assess policies and procedures? Title INTENSIVE RES TX PROG - Physical Assess Statute or Rule 59A-3.110(2)(a)-(m) FAC Services shall be designed to meet the needs of the emotionally disturbed patient and must conform to stated purposes and objectives of the program. (2) Assessment and Treatment Planning Including Discharge (a) Assessment. The facility is responsible for a complete assessment of the patient...the complete assessment shall include: 1. Physical. Subparagraphs a., b. and c. must be completed by a physician on the staff of the facility prior to admission or within 24 hours after admission. a. Complete medical history, including history of medications; b. General physical examinations; c. Neurological assessment; d. Motor development and functioning; e. Dental assessment; f. Speech, hearing and language assessment; g. Vision assessment; h. Review of immunization status and completion according to the U.S. Public Health Service Advisory Committee on Immunization Practices and the Committee on Control of Infectious diseases of the American Academy of Pediatrics; i. Laboratory workup including routine blood work and analysis; j. Chest x-ray and/or tuberculin test; k. Serology; and - Review sample patients' records for timelines of physical and completeness of record. - If further testing or treatment is indicted, has it been ordered? - Are the evaluations or treatment being done by appropriately trained staff? - Are plans for these treatments included in the patient's overall treatment plan? Review the facility's policies and procedures, are the assessments completed as per the facility's own policies and procedures?

219 Page 219 of 399 l. Urinalysis. m. If any of the physical health assessments indicate the need for further testing or definitive treatment, arrangements shall be made to carry out or obtain the necessary evaluations or treatment by clinicians or physicians trained as applicable, and plans for these treatments shall be coordinated with the patient's overall treatment plan. ST - H INTENSIVE RES TX PROG - Psych Assess Title INTENSIVE RES TX PROG - Psych Assess Statute or Rule 59A-3.110(2)(a)(2)(a)-(b) FAC 2. Psychiatric/Psychological. a. The assessment includes direct psychiatric evaluation and behavioral appraisal, evaluation of sensory, motor functioning, a mental status examination appropriate to the age of the patient and a psychodynamic appraisal. A psychiatric history, including history of any previous treatment for mental, emotional or behavioral disturbances shall be obtained, including the nature, duration and results of the treatment, and the reason for termination. b. The psychological assessment includes appropriate testing. - Interview the staff on the unit. Has the psychiatric/psychological evaluation been done or scheduled? Has the psychiatrist/psychologist completed a direct evaluation and behavioral appraisal? - Review the patient's record. Is there a history of previous treatment? - Review the facility's policies and procedures; has testing been done as indicated? ST - H INTENSIVE RES TX PROG -Develop/Social Assess Title INTENSIVE RES TX PROG -Develop/Social Assess Statute or Rule 59A-3.110(2)(a)(3)(a)-(b) FAC 3. Developmental/Social. - Review sampled patients' records. Is the developmental history complete?

220 Page 220 of 399 a. The developmental history of the patient includes the prenatal period and from birth until present, the rate of progress, developmental milestones, developmental problems, and past experiences that may have affected the development. The assessment shall include an evaluation of the patient's strengths as well as problems. Consideration shall be given to the healthy developmental aspects of the patient, as well as to the pathological aspects, and the effects that each has on the other shall be assessed. There shall be an assessment of the patient's current age, appropriate developmental needs, which shall include a detailed appraisal of his peer and group relationships and activities. b. The social assessment includes evaluation of the patient's relationships within the structure of the family and with the community at large, and evaluation of the characteristics of the social, peer group, and institutional settings from which the patient comes. Consideration shall be given to the patient's family circumstances, including the constellation of the family group, their current living situation, and all social, religious, ethnic, cultural, financial, emotional and health factors. Other factors that shall be considered are past events and current problems that have affected the patient and family; potential of the family's members meeting the patient's needs; and their accessibility to help in the treatment and rehabilitation of the patient. The expectations of the family regarding the patient's treatment, the degree to which they expect to be involved, and their expectations as to the length of time and type of treatment required shall be assessed. - Is the social history complete? Interview facility staff. Who completes the developmental and social histories? Review the facility's policies and procedures. Does the facility follow their own policies and procedures? ST - H INTENSIVE RES TX PROG - Nursing Assess Title INTENSIVE RES TX PROG - Nursing Assess Statute or Rule 59A-3.110(2)(a)(4)(a)-(f) FAC

221 Page 221 of Nursing. The nursing assessment shall be performed by a person, who at a minimum, is duly licensed in the State of Florida to practice as a registered nurse and shall include the evaluation of: a. Self-care capabilities including bathing, sleeping, eating; b. Hygienic practices such as routine dental and physical care and establishment of healthy toilet habits; c. Dietary habits including a balanced diet and appropriate fluid and calorie intake; d. Response to physical diseases (e.g., acceptance by the patient of a chronic illness as manifested by his compliance with prescribed treatment); e. Responses to physical handicaps (e.g., the use of prostheses for coping patterns used by the visually handicapped); and f. Responses to medications (e.g., allergies or dependence). - Observe the facility staff. Is the nursing staff conducting assessments? Interview the nursing staff. Determine what assessments are completed by the nursing staff and how often? Review sample patients' records. Are nursing assessments completed? ST - H INTENSIVE RES TX PROG -Educ/Vocational Assess Title INTENSIVE RES TX PROG -Educ/Vocational Assess Statute or Rule 59A-3.110(2)(a)(5) FAC 5. Educational/Vocational. The patient's current educational/vocational needs in functioning, including deficits and strengths, shall be assessed. Potential educational impairment and current and future educational vocational potential shall be evaluated using, as indicated, specific educational testing and special educators or others. - Review sampled patients' records. Have the patients' current educational/vocational needs been assessed? What resource will be utilized to ensure meeting future needs are met?

222 Page 222 of 399 ST - H INTENSIVE RES TX PROG - Recreational Assess Title INTENSIVE RES TX PROG - Recreational Assess Statute or Rule 59A-3.110(2)(a)(6) FAC 6. Recreational. The patient's work and play experiences, activities, interests and skills shall be evaluated in relation to planning appropriate recreational activities. - Observe the sampled patients on the unit. What activities have the patients participated in? - Review the sampled patients' records. Were past work and play experiences, activities, interests, and skills used to plan appropriate recreational activities? What activities have the facility planned for the patients? Were the activities observed the same as the activities planned? ST - H INTENSIVE RES TX PROG - Treatment Planning Title INTENSIVE RES TX PROG - Treatment Planning Statute or Rule 59A-3.110(2)(b)(1-4) and(b)(4) (a-d) FAC (b) Treatment Planning. An initial treatment plan shall be formulated, written and interpreted to the staff and patient within 72 hours of admission. The comprehensive treatment plan shall be developed for each child by a multidisciplinary staff, within 14 days of admission. This plan must be reviewed at least monthly, or more frequently if the objectives of the program indicate. Review shall be noted in the record. A psychiatrist as well as multidisciplinary professional staff must participate in the preparation of the plan and any major revisions. 1. The treatment plan shall be based on the assessment and shall include clinical consideration of the physical, developmental, psychological, chronological age, family, education, social and recreational needs. The reason for 59A-3.110(2)(b)(1)-(4), FAC 59A-3.110(2)(b)(4) (a)-(d), FAC - Observe the patient on the unit. Observe treatment, programs and activities as applicable. - Review the sampled patients' records. Was an initial treatment plan written within 72 hours of admission? - Is a comprehensive treatment plan developed by multidisciplinary staff within 14 days? - Is the plan reviewed at least monthly? - Did a psychiatrist and multidisciplinary staff participate in the plan and any major revisions? - Is it based on the assessment of the patient? - Are procedures that place the patient at physical risk for pain justified? - Review policies and procedures for electro convulsive therapy and other forms of convulsive therapy. - Review policies and procedures as to who can perform these procedures. - Tour for availability of emergency equipment. - Review personal files for training. How often are training conducted? Are the staffs' abilities evaluated?

223 Page 223 of 399 admission shall be specified as shall specific treatment goals, stated in measurable terms, including a projected time frame, treatment modalities to be used, staff who are responsible for coordinating and carrying out the treatment, and expected length of stay and designation of the person or agency to whom the child will be discharged. 2. The degree of the family's involvement (parent or parent surrogates) shall be defined in the treatment planning program. 3. Collaboration with resources and significant others shall be included in treatment planning, when the treatment team determines it will not interfere with the child's treatment. 4. Procedures that place the patient at physical risk or pain shall require special justification. The rationale for their use shall be clearly set forth in the treatment plan and shall reflect the prior involvement and specific review of the treatment plan by a child psychiatrist. When potentially hazardous procedures or modalities are contemplated for treatment, there shall be additional program specific policies governing their use to protect the rights and safety of the patient. The facility shall have specific written policies and procedures governing the use of electroconvulsive therapy or other forms of convulsive therapy. If such procedures are to be used they shall be carried out in a setting with emergency equipment available and shall be administered only by medical personnel who have been trained in the use of such equipment. Policies and procedures shall insure that: a. Electroconvulsive therapy or other forms of convulsive therapy shall not be administered to any patient unless, prior to the initiation of treatment, two child psychiatrists with training or experience in the treatment of adolescents, who are not affiliated with the treating facility, have examined the patient, consulted with the responsible child psychiatrist and have written and signed reports which show concurrence with the administration of such treatment. Such reviews shall be carried out only by American Board of Psychiatry certified or

224 Page 224 of 399 American Board of Psychiatry eligible child psychiatrists; b. All signed consultation reports, either recommending or opposing the administration of such treatment, shall be made a part of the patient's clinical record; c. Written informed consent of members of the family authorized to give consent, and where appropriate the patient's consent shall be obtained and made a part of the patient's clinical records. The person who is giving such consent may withdraw consent at any time; d. Lobotomies or other surgical procedures for intervention or alterations of a mental, emotional or behavioral disorder shall not be performed on patients. ST - H INTENSIVE RES TX PROG - Discharge Planning Title INTENSIVE RES TX PROG - Discharge Planning Statute or Rule 59A-3.110(2)(c)(1) FAC (c) Discharge. Discharge planning begins at the time of admission. A discharge date shall be projected in the treatment plan. Discharges shall be signed by a staff physician of the facility. A discharge summary shall be included in the records. Discharge planning shall include input from the multidisciplinary staff and will include family participation. 1. Discharge planning shall include a period of time for transition into the community (e.g., home visits gradually lengthened) for those patients who have been in the program for six months or longer. There must be a written plan for follow-up services, either by the facility or by another agency. - Interview families and staff regarding the discharge program. - When is discharge planning initiated? - Review sampled patients' records. Is a discharge summary included in the record? - Is it signed by a staff physician? - Do you see evidence of discharge planning in the open record?

225 Page 225 of 399 ST - H INTENSIVE RES TX PROG - Staff Coverage Title INTENSIVE RES TX PROG - Staff Coverage Statute or Rule 59A-3.110(3)(a)-(d) FAC (3) Staff Coverage. There shall be a master clinical staffing pattern which provides for adequate clinical staff coverage at all times. (a) There shall be at least one registered nurse on duty at all times. Services of a registered nurse shall be available for all patients at all times. (b) A physician shall be on call twenty-four (24) hours a day and accessible to the facility within forty-five (45) minutes. (c) Special attention shall be given to times which probably indicate the need for increased direct care (e.g., weekends, evenings, during meals, transition contained herein, and substantiated by the results between activities, and waking hours). (d) Staff interaction shall insure that there is adequate communication of information regarding patients (e.g., between working shifts or change of personnel) with consulting professional staff for routine planning and patient review meetings. These interactions shall be documented in writing. - Review the facility's staffing patterns. - Is there at least one registered nurse on duty at all times? Is there a physician on call 24 hours a day? - Observe care. - Interview staff regarding staffing patterns. Interview the registered nurse and see how long it takes the physician to be accessible to the facility? Does it take longer than 45 minutes? How is staffing determined? - Are patient needs met based on the treatment plan? Are there enough staff to meet the patients' needs? ST - H INTENSIVE RES TX PROG - Program Activities Title INTENSIVE RES TX PROG - Program Activities Statute or Rule 59A-3.110(4)(a)-(d) FAC

226 Page 226 of 399 (4) Program Activities. Program goals of the facility shall include those activities designed to promote the physical and emotional growth and development of the patients, regardless of pathology or age level. There should be positive relationships with general community resources, and the facility staff shall enlist the support of these resources to provide opportunities for patients to participate in normal community activities as they are able. All labeling of vehicles used for transportation of patients shall be such that it does not call unnecessary attention to the patients. (a) Group Size. The size and composition of each living group shall be therapeutically planned and depend on the age, developmental level, sex and clinical conditions. It shall allow for staff-patient interaction, security, close observation and support. (b) Routine Activities. Basic routine shall be delineated in a written plan which shall be available to all personnel. The daily program shall be planned to provide a consistent well structured yet flexible framework for daily living and shall be periodically reviewed and revised as the needs of the individual patient or the living group change. Basic daily routine shall be coordinated with special requirements of the patient's treatment plan. (c) Social and Recreation Activities. Program of recreational and social activities shall be provided for all patients for daytime, evenings and weekends, to meet the needs of the patients and goals of the program. There shall be documentation of these activities as well as schedules maintained of any planned activities. (d) Religious Activities. Opportunity shall be provided for all patients to participate in religious services and other religious activities within the framework of their individual and family interests and clinical status. The option to celebrate holidays in the patient's traditional manner shall be provided and encouraged. - Observe group activities. How are group size and composition determined? Observe the vehicle used to transport patients, does it call unnecessary attention? - Do basic activities follow a written plan? - Is the plan available to all staff? - Is the plan reviewed and revised as needed? - How are the patient's religious needs met?

227 Page 227 of 399 ST - H INTENSIVE RES TX PROG - Education Title INTENSIVE RES TX PROG - Education Statute or Rule 59A-3.110(4)(e)(1-2) and (f)(1-2) FAC (e) Education. The facility shall arrange for or provide an educational program for all patients receiving services in that facility. 1. The particular educational needs of each patient shall be considered in both placement and programming. 2. Children or adolescents placed in the special hospital by a public agency or at the expense of a public agency shall receive education consistent with the requirements of Chapter 6A-15 or Chapter 6A-6, F.A.C., as applicable. (f) Vocational Programs. The facility shall arrange for, or provide, vocational or prevocational training for patients in the facility for whom it is indicated. 1. If there are plans for work experience developed as part of the patient's overall treatment plan, the work shall be in the patient's interest with payment where appropriate, as determined by the treatment facility and the vocational program, and never solely in the interest of the facility's goals or needs. 2. Patients shall not be solely responsible for any major phase or institutional operation or maintenance, such as cooking, laundering, housekeeping, farming or repairing. Patients shall not be considered as substitutes for employed staff. 59A-3.110(4)(e)(1)-(2), FAC 59A-3.110(4)(f)(1)-(2), FAC - Interview facility staff. What arrangements has the facility made for an educational or vocational program based on the assessed needs of each child or adolescent? How is each individual patient's treatment plan incorporated in the day to day activities of the unit? - Interview patients. Are they ever utilized to body up with a new patient? Are they ever placed in the position of a staff member? - Observe operational and maintenance staffing. - Are patients used in place of employees? - Are patients solely responsible for any major institutional operation?

228 Page 228 of 399 ST - H INTENSIVE RES TX PROG - Nutrition & Standards Title INTENSIVE RES TX PROG - Nutrition & Standards Statute or Rule 59A-3.110(4)(g) FAC (g) Nutrition and Standards. There shall be a provision of planning and preparation of special diets as needed (e.g., diabetic, bland, high calorie). Menus shall be evaluated by a consultant dietitian relative to nutritional adequacy at least monthly, with observation of food intake and changes seen in the patient - Interview the unit staff are there any patients that require a special diet? Are any patients diagnosed as diabetic, hypertensive, or have swallowing difficulties? Does the facility have a dietitian on staff or consulting? Does a dietitian evaluate the nutritional adequacy at least monthly? - Review the facility's record. Does the facility have written menus to meet the ordered needs of the patients? - Review the patients' records. Is there evidence the dietitian observes food intake and changes in the patient related to nutrition? ST - H INTENSIVE RES TX PROG - Physical Care Title INTENSIVE RES TX PROG - Physical Care Statute or Rule 59A-3.110(5) FAC (5) Physical Care. The facility shall have available, either within its own organizational structure or by written agreements or contracts with outside health care clinicians or facilities, a full range of services for the treatment of illnesses and the maintenance of general physical health. - Interview the Administrator. How does the facility provide a full range of services? - Interview the nurses on the unit, what do they do if the patients' general health declines? How do the patients obtain services for their health care concerns? - Review written contracts for outside clinicians or facilities. Does the contract specify the services that will be provided? - Review patients' records, have any patient suffered a health issue which required medical attention? How did the patient obtain the services required?

229 Page 229 of 399 ST - H INTENSIVE RES TX PROG - Plan for Medical Svcs Title INTENSIVE RES TX PROG - Plan for Medical Svcs Statute or Rule 59A-3.110(5)(a)(1)-(2) FAC (a) The facility shall develop a written plan for medical services which delineates the ways the facility obtains or provides all general and specialized medical, surgical, nursing, pharmaceutical and dental services. 1. Insofar as Rules 59A through 59A-3.111, F.A.C., are intended to establish minimum requirements for intensive residential treatment programs for children and adolescents that have a primary purpose of treating emotional and mental disorders, such facilities are not required to establish and maintain medical buildings and equipment required of general or specialty hospitals as specified in Rules 59A through 59A-3.232, F.A.C. Services which require such specialized buildings and equipment may be obtained from outside health care providers by written agreement or contract. This shall not preclude the facility from maintaining a medical services area or building which does not meet the requirements of Rules 59A through 59A-3.232, F.A.C., for the purpose of isolating patients with contagious diseases, conducting physical examinations, providing preventive medical care services, or providing first aid services. 2. If the facility chooses to establish and operate a specialty or general hospital for the purposes of offering medical care more intensive than those specified in subsection 59A-3.201(32), F.A.C., the plans for construction shall be submitted for review in accordance with Rule 59A-3.080, F.A.C., and such facilities shall be required to be licensed, built and operated in accordance with Rules 59A through 59A-3.232, F.A.C. - Interview the Administrator. How does the facility provide a full range of services? - Review written contracts for outside clinicians or facilities. Does the contract specify the services that will be provided? - Review patients' records, have any patient suffered a health issue which required medical attention? How did the patient obtain the services required? - Review the facility's policies and procedures. Does the information obtained through interviews and record review comply with the facility's policies and procedures? - Verify with Plans and Construction that the plans were submitted for review and approved.

230 Page 230 of 399 ST - H INTENSIVE RES TX PROG - Illness Tx/Hlth Maint Title INTENSIVE RES TX PROG - Illness Tx/Hlth Maint Statute or Rule 59A-3.110(5)(b)-(g) FAC (b) Patients who are physically ill may be cared for on the grounds of the facility if medically feasible as determined by a physician. If medical isolation is necessary, there shall be sufficient and qualified staff available to provide care and attention. (c) Provisions shall be made in writing for patients from the facility to receive care from outside health care providers and hospital facilities, in the event of serious illness which the facility cannot properly handle. Such determinations shall be made by a licensed physician. (d) Every patient shall have a complete physical examination annually and more frequently if indicated. This examination shall be as inclusive as the initial examination. Efforts shall be made by the institution to have physical defects of the patients corrected through proper medical care. Immunization shall be kept current (DT, polio, measles, mumps, M-M-R). (e) Each member of the program staff shall be trained to recognize common symptoms of the illnesses of patients, and to note any marked dysfunctions of patients. (f) Staff shall have knowledge of basic health needs and health problems of patients, such as mental health, physical health and nutritional health. Staff shall teach attitudes and habits conducive to good health through daily routines, examples and discussion, and shall help the patients to understand the principles of health. (g) Each program shall have a planned program of dental care and dental health which shall be consistently followed. Each patient shall receive a dental examination by a qualified - Interview facility's staff regarding how they care for ill patients? What happens when they believe a patient is ill? What is the procedure for obtaining healthcare services for patients who may be ill? If it is determined that the patient may have an infectious disease, what is the facility's policy for isolation? Who determines this? Can the facility provide for medical isolation? Are staff trained to provide the care? - Observe the facility where are physically ill patients cared for?. - Review the patients' record. Is there documentation of a complete annual physical exam? - Has medical care been provided to correct physical defects? If not, is there documentation as to why? - Are the patients' immunizations current? Is there documented evidence of dental care for each patient? - Review employee records. Is there evidence that staff are trained and are knowledgeable of basic health needs and common symptoms of the illnesses of patients? - Review the facility's policy and procedure regarding obtaining medical services. What is the facility's policy and procedure regarding isolation and infectious disease? - Is the facility following their own policy and procedures?

231 Page 231 of 399 dentist and prophylaxis at least once a year. Reports of all examinations and treatment shall be included in the patient's clinical record. ST - H INTENSIVE RES TX PROG - Emergency Svcs Title INTENSIVE RES TX PROG - Emergency Svcs Statute or Rule 59A-3.110(6)(a-h)and (h)(1-2) FAC (6) Emergency Services. All clinical staff shall have training in matters related to handling emergency situations. (a) Policies and procedures shall be written regarding handling and reporting of emergencies and these shall be reviewed at least yearly thereafter by all staff. (b) There shall be a physician on call twenty-four (24) hours a day; his name and where he can be reached shall be clearly posted in accessible places for program staff. (c) All direct service program staff must maintain current first aid certificate. (d) An emergency medication kit shall be made available and shall be constituted to meet the needs of the facility. The emergency medication kit shall contain items selected by the staff or consultant medical doctor and staff or consultant pharmacist which shall be maintained and safeguarded in accordance with federal and state laws and regulations pertaining to the specific drug items included. (e) There shall be an adequate number of first aid kits available to program staff at all times. Contents of the first aid kits shall be selected by the staff or consultant medical personnel and shall include items designed to meet the needs of the facility. (f) The program shall have written policies and procedures of obtaining emergency diagnosis and treatment of dental problems. The program shall have written agreement with a 59A-3.110(6)(a)-(h), FAC 59A-3.110(6)(h)(1)-(2), FAC - While touring the facility, where does the facility keep the emergency medication kit? Observe to ensure the plan regarding who is authorized to provide emergency medical & psychiatric care. - Interview staff, does the facility have a physician covering 24 hours a day? Where is the on call schedule kept? How does the facility ensure the emergency medication kit is complete and current? Where are all of the emergency plans maintained? - Observe the emergency medication kit. Is it complete? - Review training for all clinical staff related to handling emergency situations. Are the trainings up to date. - How do they ensure kits are kept current and complete? - Review patients' records. Is there evidence that the patient's/legal guardian are notified of emergencies? - Review the emergency plans. Are they current? Does the facility have written agreements?

232 Page 232 of 399 licensed dentist(s) who is a consultant or a member of the staff for emergency dental care. (g) The facility shall have a written plan to facilitate emergency hospitalization in a licensed medical facility. The facility shall make available a written agreement from a licensed hospital verifying that routine and emergency hospitalization will be provided. (h) The special hospital shall have a written plan for providing emergency medical and psychiatric care. 1. There shall be a written posted plan which shall clearly specify who is available and authorized to provide necessary emergency psychiatric or medical care, or to arrange for referral or transfer to another facility to include ambulance arrangements, when necessary. 2. There shall be a written plan regarding emergency notification to the parents or legal guardian. This plan and arrangements shall be discussed with all families or guardians of patients upon admission. ST - H INSPECTION REPORTS Title INSPECTION REPORTS Statute or Rule F.S. 1) Each licensed facility shall maintain as public information, available upon request, records of all inspection reports pertaining to that facility. Copies of such reports shall be retained in its records for not less than 5 years from the date the reports are filed and issued. (2) Any records, reports, or documents which are confidential and exempt from s (1) shall not be distributed or made available for purposes of compliance with this section unless or until such confidential status expires. (3) A licensed facility shall, upon the request of any person - Ask the facility staff to see a specific inspection report(s) no later than 5 years old. Are there policies in place to ensure that inspection reports are maintain as public information, and available upon request. - All records of all inspection reports pertaining to that facility must be retained for 5 years from the date the reports are filed and issued. - Review and verify that there are policies in place to ensure that a copy of the last inspection report filed with or issued by the agency pertaining to the licensed facility, as provided in subsection (1), be provided to the person (who has completed a written application with intent to be admitted to such facility, any person who is a patient of such facility, or any relative, spouse, guardian, or surrogate of any such person,) requesting such report as long as he/she agrees to pay a reasonable charge to cover copying costs, not to exceed $1 per page. - The records, reports, or documents which are confidential and exempt from s (1) shall not be distributed or

233 Page 233 of 399 who has completed a written application with intent to be admitted to such facility, any person who is a patient of such facility, or any relative, spouse, guardian, or surrogate of any such person, furnish to the requester a copy of the last inspection report filed with or issued by the agency pertaining to the licensed facility, as provided in subsection (1), provided the person requesting such report agrees to pay a reasonable charge to cover copying costs, not to exceed $1 per page. made available for purposes of compliance with this section unless or until such confidential status expires. ST - H DISCIPLINE ACTION REPORT TO AGENCY Title DISCIPLINE ACTION REPORT TO AGENCY Statute or Rule (4) F.S. (4) Pursuant to ss and , any disciplinary actions taken under subsection (3) shall be reported in writing to the Division of Health Quality Assurance of the agency within 30 working days after its initial occurrence, regardless of the pendency of appeals to the governing board of the hospital. The notification shall identify the disciplined practitioner, the action taken, and the reason for such action. All final disciplinary actions taken under subsection (3), if different from those which were reported to the agency within 30 days after the initial occurrence, shall be reported within 10 working days to the Division of Health Quality Assurance of the agency in writing and shall specify the disciplinary action taken and the specific grounds therefore. The division shall review each report and determine whether it potentially involved conduct by the licensee that is subject to disciplinary action, in which case s shall apply. The reports are not subject to inspection under s (1) even if the division's investigation results in a finding of probable cause. Interview the staff responsible to ensure that there are policies and procedures in place for reporting in writing to the Division of Health Quality Assurance of the agency within 30 working days after its initial occurrence, regardless of the pendency of appeals to the governing board of the hospital. The notification shall identify the disciplined practitioner, the action taken, and the reason for such action. All final disciplinary actions taken under subsection (3), if different from those which were reported to the agency within 30 days after the initial occurrence, shall be reported within 10 working days to the Division of Health Quality Assurance of the agency in writing and shall specify the disciplinary action taken and the specific grounds therefore Reports of disciplinary actions by medical organizations and hospitals. 1)(a) The department shall be notified when any physician Reports of disciplinary actions by medical organizations.- (1) The department shall be notified when any osteopathic physician Note: The reports are not subject to inspection under s (1) even if the division's investigation results in a finding of probable cause.

234 Page 234 of 399 ST - H PATIENT RECORDS, PENALTIES FOR ALTERATION Title PATIENT RECORDS, PENALTIES FOR ALTERATION Statute or Rule F.S. Statutory Only Citation , F.S. (1) Any person who fraudulently alters, defaces, or falsifies any medical record, or causes or procures any of these offenses to be committed, commits a misdemeanor of the second degree, punishable as provided in s or s (2) A conviction under subsection (1) is also grounds for restriction, suspension, or termination of license privileges. - Falsification of medical record is incorporated into most health practitioner licensure statutes. - Confirmation of fraudulent alterations, defacement or falsifications should be cited and referred to the Department of Health. - Review a sample of patient medical records - Is there any evidence of the records being altered? ST - H PEER REVIEW Title PEER REVIEW Statute or Rule (2) F.S. Statutory Only Citation (2), FS Each licensed facility, as a condition of licensure, shall provide for peer review of physicians who deliver heath care services at the facility. Each licensed facility shall develop written, binding procedures by which such peer review shall be conducted. Such procedures shall include: (a) Mechanism for choosing the membership of the body or bodies that conduct peer review. (b) Adoption of rules of order for the peer review process. (c) Fair review of the case with the physician involved. - Review Peer Review when you are reviewing Governing Body and or medical staff. - Interview and verify: - Does the facility have a Peer Review Program? - Is the Peer Review Program Focus on the process rather than individual physicians reviewed? - How has the Peer Review Process reduced mortality and morbidity and improved patient care? - Is the peer review procedures reviewed, at least annually by the governing board of the licensed Facility? - Is there mechanism to identify and avoid conflict of interest on the part of the peer review panel members?

235 Page 235 of 399 (d) Mechanism to identify and avoid conflict of interest on the part of the peer review panel members. (e) Recording of agendas and minutes which do not contain confidential material, for review by the Division of Health Quality Assurance of the agency. (f) Review, at least annually, of the peer review procedures by the governing board of the licensed facility. (g) Focus of the peer review process on review of professional practices at the facility to reduce morbidity and mortality and to improve patient care. ST - H TREATMENT, SEXUAL ASSAULT VICTIMS Title TREATMENT, SEXUAL ASSAULT VICTIMS Statute or Rule F.S. Statutory Only Citation s , F.S. Any licensed facility which provides emergency room services shall arrange for the rendering of appropriate medical attention and treatment of victims of sexual assault through: (1) Such gynecological, psychological, and medical services as are needed by the victim. (2) The administration of medical examinations, tests, and analyses required by law enforcement personnel in the gathering of evidence required for investigation and prosecution. (3) The training of medical support personnel competent to provide the medical services and treatment as described in subsections (1) and (2). Such licensed facility shall also arrange for the protection of the victim's anonymity while complying with the laws of this state and may encourage the victim to notify law enforcement personnel and to cooperate with them in apprehending. - Review Program for the Treatment of Sexual Assault Victims. Interview staff assigned to the program for their knowledge of the treatment, support and protection of Sexually Assaulted Victims. - Review personnel records of staff assigned to this program for the specialized training in the Treatment of Sexually Assaulted Victims. - Review policies and interview emergency room and nursing staff: - How does the staff work closely with law enforcement in the gathering of evidence required for investigation, for reporting and apprehending? - How is the victims' anonymity maintained?

236 Page 236 of 399 ST - H INFECTIOUS DISEASES, NOTIFICATION Title INFECTIOUS DISEASES, NOTIFICATION Statute or Rule FS Statutory Only Citation s , FS Notwithstanding the provisions in s , if, while treating or transporting an ill or injured patient to a licensed facility, an emergency medical technician, paramedic, or other person comes into direct contact with the patient who is subsequently diagnosed as having an infectious disease, it shall be the duty of the licensed facility receiving the patient to notify the emergency medical technician, paramedic, or his emergency medical transportation service employer, or other person of the individual's exposure to the patient within 48 hours, or sooner, of confirmation of the patient's diagnosis and to advise him of the appropriate treatment, if any. Notification made pursuant to this section shall be done in a manner which will protect the confidentiality of such patient information and shall not include any patient's name. - Request Program for Notification of Infections Disease Exposure to Emergency Medical Transport Personnel. - Interview Emergency Department Director or Designee to ascertain a working knowledge of this process. 1) How do they notify the emergency medical technician, paramedic, or his emergency medical transportation service employer, or other person of the individual's exposure to the patient within 48 hours, or sooner, of confirmation of the patient's diagnosis and to advise him of the appropriate treatment, if any? 2) How do they ensure that the Notification is made pursuant to this section, and is being done in a manner which will protect the confidentiality of the patient's information and shall not include any patient's name? ST - H PHYSICAL PLANT REQUIREMENTS FEN, REHAB, PSYCH Title PHYSICAL PLANT REQUIREMENTS FEN, REHAB, PSYCH Statute or Rule 59A FAC (1) The following minimum standards of construction and specified minimum essential facilities to be included in - The surveyor should be familiar with all components of 59A-3.081, FAC - Request a floor plan or facility layout in entrance conference

237 Page 237 of 399 hospitals shall apply to all new hospital construction, and all additions, alterations or renovations to an existing hospital on the effective date of these rules. Construction work in process on the effective date of these rules shall conform to the requirements in effect on the date the Stage II preliminary plans were approved. Minimum Standard Requirements 1-55, 59A Ask facility if any waivers or if there has been any recent physical plant modifications. - Physical plant should be observed in any assigned area of tour. One surveyor should coordinate findings of physical plant. - Tour patient care areas including patient rooms, nursing care units, specialty care units, surgical operating rooms, recovery, outpatient surgery, obstetrical units, emergency departments, pharmacy, dining and food service areas, clean and soiled utility rooms, medication/treatment rooms, linen distribution areas, and other areas specific to services offered by the facility. ST - H Urgent Care Ctrs- Publishing, Posting Charges Title Urgent Care Ctrs- Publishing, Posting Charges Statute or Rule Urgent care centers; publishing and posting schedule of charges.-an urgent care center must publish a schedule of charges for the medical services offered to patients. The schedule must include the prices charged to an uninsured person paying for such services by cash, check, credit card, or debit card. The schedule must be posted in a conspicuous place in the reception area of the urgent care center and must include, but is not limited to, the 50 services most frequently provided by the urgent care center. The schedule may group services by three price levels, listing services in each price level. The posting must be at least 15 square feet in size. The failure of an urgent care center to publish and post a schedule of charges as required by this section shall result in a fine of not more than $1,000, per day, until the schedule is published and posted. Tour urgent care centers under the hospital license for schedule of charges. Add definition of urgent care center FS

238 Page 238 of 399 ST - H PRIMARY STROKE CENTERS Title PRIMARY STROKE CENTERS Statute or Rule 59A (15)(a) 59A (15) (a) Primary Stroke Centers. A hospital program will be designated as a primary stroke center on the basis of that hospital providing to the Agency for Health Care Administration an affidavit on AHCA Form , December 2005, which is incorporated by reference, signed by the Chief Executive Officer of the hospital, attesting that the program has been certified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (The Joint Commission) as a primary stroke center, or that the program meets the criteria applicable to primary stroke centers as outlined in the Joint Commission on Accreditation of Healthcare Organizations: Disease-Specific Care Certification Manual, 2nd Edition, Oakbrook Terrace, IL; Joint Commission Resources, Reprinted with permission. Attestation must also indicate that the program meets requirements outlined in the "Updated Primary Stroke Center Certification Appendix for the Disease-Specific Care Manual," which are incorporated by reference. Copies of these standards are available from the Agency for Health Care Administration Hospital and Outpatient Services Unit, or from the Joint Commission on the Accreditation of Healthcare Organizations at One Renaissance Boulevard, Oak Terrace, IL Hospitals shall ensure that stroke centers establish specific procedures for screening patients that recognize that numerous conditions, including cardiac disorders, often mimic stroke in children. Stroke centers should ensure that transfer to an appropriate facility for specialized care is provided to children Primary Stroke Centers: -Review attestation and current designation. -Observe all areas of the hospital which comprise the primary stroke center. -Interview the Professional responsible for the Primary stroke center program. -Review the Standards, Clinical Practice Guidelines, and Performance Measures; as required by The Joint Commission. Required Measures are: 1. DVT Prophylaxis 2. Discharged on Antithrombotics 3. Patients with Atrial Fibrillation Receive Anticoagulation Therapy 4. Tissue Plasminogen Activator (t-pa) Considered Review all Elements for Primary Stroke Center Certification: 1. Hospital and Administrative Support 2. Acute Stroke Team 3. Written care Protocols 4. Emergency Medical Systems 5. Emergency Department 6. Stroke Units 7. Neurosurgical Services 8. Neuroimaging 9. Laboratory Services 10. Outcomes/Quality Improvement 11. Educational Programs -Interview physicians and clinical professionals providing stroke center care and services for standard knowledge, stroke team response times/measures, and quality improvement measures. -Review stroke center staff personnel and training records for education and competency. -Observe care and services to patients who are in the Primary Stroke Center areas, and sample review patient medical

239 Page 239 of 399 and young adults with known childhood diagnoses. records. -Interview patients and families for care and services. ST - H COMPREHENSIVE STROKE CENTERS Title COMPREHENSIVE STROKE CENTERS Statute or Rule 59A (15)(b)1-5 59A (15)(b) Comprehensive Stroke Center (CSC). Hospitals shall ensure that stroke centers establish specific procedures for screening patients that recognize that numerous conditions, including cardiac disorders, often mimic stroke in children. Stroke centers should ensure that transfer to an appropriate facility for specialized care is provided to children and young adults with known childhood diagnoses. A hospital's program may be designated as a Comprehensive Stroke Center on the basis of that hospital providing to the Agency for Health Care Administration an affidavit signed by the Chief Executive Officer of the hospital that the program has received initial Primary Stroke Center designation as provided in paragraph 59A (15)(a), F.A.C., and that the program meets the following criteria: 1. Health care personnel with clinical expertise in a number of disciplines available 2. Advanced Diagnostic Capabilities 3. Neurological Surgery and Endovascular Interventions 4. Specialized Infrastructure 5. Quality Improvement and Clinical Outcomes Measurement Comprehensive Stroke Center - Observe all areas of the hospital which are designated a part of the Comprehensive Stroke Center. - Interview the professional responsible for the stroke center. - Interview the stroke center medical director. - Interview Neurosurgeons, Interventionists, and physicians in the ED. - Interview nursing staff in the ED, ICU and Neuro units who provide care and services for patients with stroke. - Review quality improvement program for standards and measure performance. Review personnel and training records of stroke center personnel for education, training, and competence. - Interview patients and families for care and services. - Review a sample of patient medical records for stroke care and services.

240 Page 240 of 399 ST - H INTERNAL RISK MANAGEMENT PROGRAM Title INTERNAL RISK MANAGEMENT PROGRAM Statute or Rule (1), F.S. Every licensed facility shall, as a part of its administrative functions, establish an internal risk management program. Such program shall include: S (1), F.S. R.59A (15), F.A.C. R.59A (2), F.A.C. R.59A (3), F.A.C. R.59A (14), F.A.C. Licensed Hospital and Ambulatory Surgical Centers are required to have an Internal Risk Management Program. PROBE The surveyor should review: - The Risk Management Program/Plan - Interview the Licensed Health Care Risk Manager responsible for the program. - Review personnel file of the Risk Manager for appropriate licensure - Review a minimum sample of Incident Reports (review period since the last risk manager survey) o Hospitals - 30 ST - H RM Prog - Investigation & Analysis Title RM Prog - Investigation & Analysis Statute or Rule (1)(a), F.S. The internal risk management program shall include: (a) The investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents to patients. S (1)(a), F.S. S (5), F.S. The Risk Management Program must establish the general categories and specific types of incidents. Further, the program must contain the investigative process and analysis of the incidents. PROBES - Does the plan establish the incident categories? - Are the incidents specific to this facility? - Review 5 Monthly Logs and 4 Quarterly Summary Reports.

241 Page 241 of 399 ST - H RM Prog -Develop of Measures to Minimize Risk Title RM Prog -Develop of Measures to Minimize Risk Statute or Rule (1)(b), F.S. The internal risk management program shall include: (b) The development of appropriate measures to minimize the risk of adverse incidents to patients. S (1)(b), F.S. S (5), F.S. GUIDANCE TO SURVEYORS 1. Review the Risk Manager's role in the development and implementation of risk reduction and risk prevention strategies. 2. Consider evidence that patient and non-patient department staff have involvement in the process. 3. Review previous incidents identified as risk/process improvement opportunities including the analysis of the incident and trends. PROBES - Review identified incident trends. - Review measures put in place to correct. - Verify correction measures are systematic and facility-wide. - Has the facility minimized the risk to other patients? - Validate implementation of measures in departments or units of facility. ST - H Approp Measure - Education & Training Title Approp Measure - Education & Training Statute or Rule (1)(b)1, F.S. The development of appropriate measures shall include: 1. Risk management and risk prevention education and training of all non-physician personnel as follows: a. Such education and training of all non-physician personnel as part of their initial orientation; and GUIDANCE TO SURVEYORS: Review orientation program(s) for documentation that the incident reporting system and adverse incident reporting (Code 15 and Annual Incident Reporting) is included. Select a sample of new employees, 5 new and 5 existing employees, and agency (contract) personnel for evidence of training at orientation and annual review. Interview 5 employees in regard to their education and training. (Example: RN's, CAN's, PT's, RT's, etc.)

242 Page 242 of 399 b. At least 1 hour of such education and training annually for all personnel of the licensed facility working in clinical areas and providing patient care, except those persons licensed as health care practitioners who are required to complete continuing education coursework pursuant to chapter 456 or the respective practice act. PROBES - Review 5 new and 5 existing clinical staff for education and training as required. - Interview 5 clinical staff to ascertain the knowledge of how to report an incident. How do you report an incident? Are all incidents reported the same way (fall, elopement, allegation of abuse, rape)? ST - H Approp Measure - Recovery Room Prohibition Title Approp Measure - Recovery Room Prohibition Statute or Rule (1)(b)2, F.S. The development of appropriate measures shall include: 2. A prohibition, except when emergency circumstances require otherwise, against a staff member of the licensed facility attending a patient in the recovery room, unless the staff member is authorized to attend the patient in the recovery room and is in the company of at least one other person. However, a licensed facility is exempt from the two-person requirement if it has: a. Live visual observation; b. Electronic observation; or c. Any other reasonable measure taken to ensure patient protection and privacy. GUIDANCE TO SURVEYORS: Review facility Policy and Procedures for prohibitions against staff members attending patients in the recovery room alone. Review the facility policy, i.e. either each authorized staff person in the recovery room is accompanied by at least one other person or the recovery room has live visual observation; or electronic observation; or any other reasonable measure taken to ensure patient protection and privacy. PROBES 1. Request the schedule of recovery room personnel for all shifts. 2. Review the Policy and Procedures regarding the two-person requirement. 3. Tour the recovery room, preferably in the afternoon. 4. Interview staff regarding recovery room procedures and staffing patterns. 5. How does the facility handle live visual observation, electronic observation, or any other reasonable measure to ensure patient protection and privacy? 6. What type of electronic observation is used? 7. Who monitors the camera when patients are present in the recovery room? 8. What type of documentation is maintained by the facility?

243 Page 243 of 399 ST - H Approp Measure - Surgical Proc Prohibition Title Approp Measure - Surgical Proc Prohibition Statute or Rule (1)(b)3, F.S. The development of appropriate measures shall include: 3. A prohibition against an unlicensed person from assisting or participating in any surgical procedure unless the facility has authorized the person to do so following a competency assessment, and such assistance or participation is done under the direct and immediate supervision of a licensed physician and is not otherwise an activity that may only be performed by a licensed health care practitioner. PROBES Does the facility prohibit unlicensed person from assisting or participating in a surgical procedure, unless complete and direct physician supervision. Interview surgical staff to ascertain if unlicensed staff participate/assisting in surgical procedures - provisions. Review surgical schedule or records utilized to record other unlicensed staff surgical participation. Review competencies for Private or Contractual Scrub individuals. ST - H Approp Measure - Ongoing Eval of Proc/Systems Title Approp Measure - Ongoing Eval of Proc/Systems Statute or Rule (1)(b)4, F.S. The development of appropriate measures shall include: 4. Development, implementation, and ongoing evaluation of procedures, protocols, and systems to accurately identify patients, planned procedures, and the correct site of the planned procedure so as to minimize the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patient's diagnosis or medical condition. GUIDANCE TO SURVEYORS: Review adverse incidents for a defined period of time 6 months to 1 year. Does the facility have an established procedure/protocol to prevent wrong site, wrong procedure, and wrong patient surgery? How does the facility identify the correct patient and the correct site for procedures? How is the surgical site identified? How does the facility identify and confirm the correct procedure(s)? Does the facility involve the patient and his/her family members in identifying the patient, correct site, and correct procedure? If so, what systems does the facility have in place for appropriate communication techniques for any identified language or communication barriers?

244 Page 244 of 399 Does facility staff have a method to verify that the identification process contains correct information? Are protocols and procedures to prevent wrong site, wrong procedure, wrong patient incidents used facility-wide? How is education and training of staff (including physicians) regarding the facility's procedures and protocols accomplished? Review documentation. How does the facility monitor compliance with the protocols for quality control purposes? PROBES - Review systems which prevent or minimize wrong patient, wrong surgical procedure, wrong site, or a surgical procedure unrelated. - If an incident, breaches protocols - how is it reviewed to minimize risk to other patients. ST - H RM Prog - Pt Grievance Analysis Title RM Prog - Pt Grievance Analysis Statute or Rule (1)(c), F.S. The internal risk management program shall include: (c) The analysis of patient grievances that relate to patient care and the quality of medical services. S (1)(c), F.S. R. 59A (10), F.A.C. GUIDANCE TO SURVEYORS: Review all grievances relating to patient care and medical services. Review grievance analysis report relating to patient care and medical services. Look at grievances analysis to determine plan to prevent re-occurrences. Interview Risk Manager on analysis methodology. Determine how follow up on grievances are conducted. How does the Risk Manager formulate recommendations for improvement in process? 1. Determine if the facility has a patient satisfaction patient grievance and a system to analyze the quality of medical services. Review form(s): 2. Select a sample of patient grievances/patient satisfaction responses related to patient care and the quality of medical services. Trace the process. 3. Review Policy and Procedures establishing the process that refers issues related to quality of care to the Risk Manager, Quality Assurance/Performance Improvement and the facility representative. 4. Review evidence that issues related to quality of care/medical care are analyzed including outcomes. PROBES - Is the Risk Manager involved in the analysis of grievances and quality of medical services improvement? - Is there evidence of grievance analysis in the samples grievances? - Were corrective measures placed into facility-wide systems?

245 Page 245 of 399 ST - H RM Prog - Pt Notification of Adv Incidents Title RM Prog - Pt Notification of Adv Incidents Statute or Rule (1)(d), F.S. The internal risk management program shall include: (d) A system for informing a patient or an individual identified pursuant to Section (1), F.S., that the patient was the subject of an adverse incident. Such notice shall be given by an appropriately trained person designated by the licensed facility as soon as practicable to allow the patient an opportunity to minimize damage or injury. S (1)(d), F.S. S (1), F.S. S (5), F.S. GUIDANCE TO SURVEYORS Review sample of adverse incidents to determine how patients were notified of the adverse incident. Review policy and procedures to ensure that they were followed. Interview Risk Manager as needed to determine compliance if policies and procedures not followed. Who is responsible for notifying patients of adverse incidents? How are patients told of the adverse incident? What training does staff receive? Review the Policy and Procedures developed to enable patient notification (or the patient's healthcare surrogate) of all adverse incidents. Refer to definition of adverse incident, s (5), F.S. Review all Code 15's and Annual Report incidents to determine whether the patient and/or healthcare surrogate was informed of the incident. Verify documentation that the patient was notified following the adverse incident. Interview patient(s) involved in adverse incident if the patient is accessible. PROBES Did facility develop and implement a system for patient notification? Does facility staff evaluate the system for informing patients that they have been the subject of an adverse incident? ST - H RM Prog - Incident Reporting System Title RM Prog - Incident Reporting System Statute or Rule (1)(e), F.S. The internal risk management program shall include: (e) The development and implementation of an incident GUIDANCE TO SURVEYORS Review the Policy and Procedures for incident reporting to determine if it is in accordance with F.S ;

246 Page 246 of 399 reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. S (1)(e), F.S. R. 59A (8), F.A.C. R. 59A (9), F.A.C. S (5), F.S. R. 59A (21), F.A.C. determine the facility's method used to ensure and verify the risk manager/designee acknowledges each incident report. Interview a sample of staff to determine their awareness of the responsibilities, requirements, and method for incident reporting. Review a sample of personnel files for education and training on incident reporting. Review a sample of Incident/Occurrence Reports for determining that incidents are reported within three (3) business days to the Risk Manager or to the Risk Manager Designee. Interview a sample of staff to determine the facility's method for reporting within 3 business days. If there is a Risk Manager Designee, verify evidence of appointment. PROBES What are the guidelines for reporting incidents? Does staff understand who reports, what is reported, when and where to report, how to report, and why to report? Can facility staff provide and account for dissemination of information on the incident reporting system to all health care providers, agents and employees? Did all new non-physician personnel receive, within 30 days of employment, instruction about the operation of and the responsibilities of the incident reporting system? ST - H INCIDENT REPORTING SYSTEM-Procedures/Training Title INCIDENT REPORTING SYSTEM-Procedures/Training Statute or Rule 59A (1) FAC (1) INCIDENT REPORTING....Procedures shall be detailed in writing and disseminated to all employees of the facility. All new employees, within 30 days of employment, shall be instructed about the operation of the incident reporting system and responsibilities of it. At least annually, all non-physician personnel of the facility working in clinical areas and providing patient care shall receive 1 hour risk management and risk prevention education and training, including the importance of accurate and timely incident reporting. R. 59A (2), F.A.C. R. 59A (8), F.A.C. GUIDANCE TO SURVEYORS: Interview the Risk Manager and determine what the facility considers annual? Is it calendar year or date of hire year? Request a list of non-physician personnel with their hire dates. Include private/contract surgical scrub personnel. Interview a sample of newly hires and experienced staff to determine their awareness of the responsibilities, requirements, and method for incident reporting. Review a sample of personnel, both newly hired and personnel who have been employed over 2 years, files for education and training on incident reporting. PROBES: What are the guidelines for reporting incidents? Ask staff which incidents are reportable, who is supposed to report the incidents, how is it done, when does it need to be done by, and where does the report go once they have completed it? Did all non-physician personnel receive, within 30 days of employment, instruction about the operation of and the

247 Page 247 of 399 ST - H INCIDENT REPORTING SYSTEM - Reports responsibilities of the incident reporting system? When was the last annual, 1 hour Risk Management and Risk Prevention training conducted? Title INCIDENT REPORTING SYSTEM - Reports Statute or Rule 59A (2)(c)-(e), FAC (c) Whether or not a physician was called: and if so, a brief statement of said physician's recommendations as to medical treatment, if any; (d) A listing of all persons then known to be involved directly in the incident, including witnesses, along with locating information for each; (e) The name, signature and position of the person completing the reports, along with date and time that the report was completed. R. 59A (2), F.A.C. R. 59A (18), F.A.C. R. 59A (19), F.A.C. R. 59A (20), F.A.C. GUIDANCE TO SURVEYORS Review a sample of not less than 3 months incident/occurrence reports filed since the date of the previous survey to verify if the physician is notified, also review the patient(s) involved medical records to verify if the physician is notified of incident occurrences and the physician's response. Witnesses locating information should document how to contact witnesses. Select a sample of incident/occurrence reports to determine compliance with the incident form requirements. The sample size is based on the issues identified. PROBES What are the types of incident reports used in the facility? Does the incident/occurrence report form contain the required information? ST - H RESP OF GOVERNING BOARD AND RISK MANAGER Title RESP OF GOVERNING BOARD AND RISK MANAGER Statute or Rule (2), F.S. (2) The internal risk management program is the responsibility of the governing board of the health care facility. Each licensed facility shall hire a risk manager, licensed under GUIDANCE TO SURVEYORS: Review the facility's organization chart to see who the Risk Manger reports to. When was the Risk Manager appointed? When was the Risk Manager approved by the Board/Governing Body?

248 Page 248 of 399 Section , F.S., who is responsible for implementation and oversight of such facility's internal risk management program as required by this section. A risk manager must not be made responsible for more than four internal risk management programs in separate licensed facilities, unless the facilities are under one corporate ownership or the risk management programs are in rural hospitals. S (2), F.S. S , F.S. R. 59A (12) R. 59A (15), F.A.C. R. 59A (2), F.A.C. R. 59A (3), F.A.C. Review reporting lines of authority Verify that the Risk Manager is currently licensed. Interview the licensed Risk Manager and verify the number of current facilities for which the Risk Manager currently has responsibility. Determine, based on sample, incident reporting issues, timely recommendations and effective corrective actions, whether the risk manager spends sufficient time at the facility that is adequate to meet the risk management needs of the facility. See probes below. Review the Risk Manger's job description for his/her responsibilities. PROBES: Inquire with the Risk Manager and the Hospital Administrator about the amount of time that the Risk Manager spends on-site at each facility for which the Risk Manager is responsible. What is considered enough time in the facility? Does the Risk Manager only come to the facility for administrative and clinical meetings? Verify the participation in administrative and clinical meetings, by reviewing meeting minutes. ST - H RISK MANAGER ACCESS TO RECORDS Title RISK MANAGER ACCESS TO RECORDS Statute or Rule (4), F.S. (4)...The individual responsible for the risk management program shall have free access to all medical records of the licensed facility.... GUIDANCE TO SURVEYORS: Verify that the Risk Manager has access to all medical records of the facility by asking the Risk Manager and the Administrator. Review the Risk Manager's job description to ensure the Risk Manager has access to all of the medical records. Review the Governing Body Minutes and the facility's Policy and Procedures. ST - H DEVELOPMENT OF CORRECTIVE PROCEDURES Title DEVELOPMENT OF CORRECTIVE PROCEDURES Statute or Rule (4), F.S.

249 Page 249 of 399 (4)...As a part of each internal risk management program, the incident reports shall be used to develop categories of incidents which identify problem areas. Once identified, procedures shall be adjusted to correct the problem areas. S (4), F.S. R. 59A (7), F.A.C. GUIDANCE TO SURVEYORS: Ask the Risk Manager how they have determined what incidents to track and trend? Are the issues being tracked and trended, facility identified concerns? Review all tracking and trending reports for the period since the previous survey. How was the root cause of the concern identified? What investigation was done? Did the root cause analysis target actual variables that contributed to the occurrence (Refer to H0402)? Did the root cause analysis result in the identification of issues that are addressed in the developed and implemented corrective actions? Review all pertinent documentation for the verification that the Risk Manager's recommendations were developed and the corrective actions(s) were implemented. How was the corrective action(s) implemented? Staff educated on corrective action? How was the corrective action measured to determine its effectiveness? If it did not reduce the number of occurrences, what new corrective action(s) was implemented? Training? PROBES: How is information shared with other departments? How does the Risk Manager know if problems exist in other areas? Ask floor staff if they have ever submitted an incident report? If yes, did they receive any feedback after the incident report was reviewed? What was the outcome of that incident report? Question floor staff regarding how they were informed of the corrective actions implemented after an incident. ST - H DAY REPORTS Title 15 DAY REPORTS Statute or Rule (7), F.S. (7) Any of the following adverse incidents, whether occurring in the licensed facility or arising from health care prior to admission in the licensed facility, shall be reported by the facility to the Agency for Health Care Administration within 15 calendar days after its occurrence: (a) The death of a patient; (b) Brain or spinal damage to a patient; GUIDANCE TO SURVEYORS: Review the facility's Policy and Procedures regarding reporting death, brain or spinal damage, wrong patient/wrong cite/wrong surgical procedure, unnecessary surgical procedure, surgical repair of damage resulting from surgical procedure, and removal of unplanned foreign body left after a surgical procedure. Request a list of any discharged patient that was re-admitted into the facility within days of being discharge. Review a few re-admitted patients' records to determine if any were admitted for the previous treatment or surgical procedure.

250 Page 250 of 399 (c) The performance of a surgical procedure on the wrong patient; (d) The performance of a wrong-site surgical procedure; (e) The performance of a wrong surgical procedure; (f) The performance of a surgical procedure that is medically unnecessary or otherwise unrelated to the patient's diagnosis or medical condition; (g) The surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage is not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process; or (h) The performance of procedures to remove unplanned foreign objects remaining from a surgical procedure. The 15-day report shall be made on AHCA Form August 1993, Code 15 Report, which is incorporated by reference and may be obtained from the Agency for Health Care Administration. The Agency may require an additional final report. Any reportable incidents pursuant to this section that are submitted more than 15 calendar days from occurrence by the facility must be justified in writing by the facility administrator. S (7), F.S. R. 59A , F.A.C. S (5), F.S. Request a list of patients who have expired in the facility in the past year. Review those deaths which resulted in an autopsy being conducted. What was the outcome? Did the Risk Manager file the Code 15 within 15 calendar days? Review the consent form, signed by the patient prior to surgery, was the incident outcome listed as one of the specific risk of the surgical procedure. PROBES: Interview the Risk Manager regarding the facility's process for reporting Code 15 events. Is the Risk Manager following the facility's Policy and Procedures when a Code 15 reportable incident occurs? If it is determined, through interview that the Risk Manager was unable to submit an adverse incident within 15 calendar days, did the Risk Manager request an extension from AHCA? Review the extension request. ST - H SEXUAL MISCONDUCT Title SEXUAL MISCONDUCT Statute or Rule (9), F.S. (9) The internal risk manager of each licensed facility shall: (a) Investigate every allegation of sexual misconduct which is made against a member of the facility's personnel who has direct patient contact, when the allegation is that the sexual GUIDANCE TO SURVEYORS: Review a list of incidents and chose those relating to allegations of sexual misconduct. Was the victim safe from further sexual misconduct during the investigation? How? What is the facility's Policy and Procedures regarding the investigation of an allegation of sexual misconduct? Was

251 Page 251 of 399 misconduct occurred at the facility or on the grounds of the facility. (b) Report every allegation of sexual misconduct to the administrator of the licensed facility. (c) Notify the family or guardian of the victim, if a minor, that an allegation of sexual misconduct has been made and that an investigation is being conducted. (d) Report to the Department of Health every allegation of sexual misconduct, as defined in Chapter 456, F.S., and the respective practice act, by a licensed health care practitioner that involves a patient. S (9), F.S. R. 59A (19), F.A.C. the Policy and Procedures followed? If the allegation was confirmed, what corrective action was implemented? Were the police, DCF/APS, and the Department of Health notified? Interview floor staff to see if they are aware of the facility's Policy and Procedures for an allegation of sexual misconduct? Review the accused and other employees' personnel file to determine if the facility conducted a background screening, prior to the employees working in the facility? If the background screening results for the employee allegedly accused of sexual misconduct is greater than 5 years, does or when does the facility's policy require an updated background screening to be done. What education/training regarding sexual misconduct and reporting an allegation of sexual misconduct have the employees received? PROBES: Interview the facility's staff, can they tell you what they would do if someone accused an employee of sexual misconduct? Does it meet the facility's Policy and Procedures? Review the facility's Policy and Procedures regarding background screening. ST - H SEXUAL ABUSE REPORTS Title SEXUAL ABUSE REPORTS Statute or Rule (10), F.S. (10) Any witness who witnessed or who possesses actual knowledge of the act that is the basis of an allegation of sexual abuse shall: (a) Notify the local police; and (b) Notify the hospital risk manager and the administrator. For purposes of this subsection, "sexual abuse" means acts of a sexual nature committed for the sexual gratification of anyone upon, or in the presence of, a vulnerable adult, without the vulnerable adult's informed consent, or a minor. "Sexual abuse" includes, but is not limited to, the acts defined in Section (1)(h), F.S., fondling, exposure of a vulnerable adult's or minor's sexual organs, or the use of the vulnerable adult or minor to solicit for or engage in prostitution or sexual performance. "Sexual abuse" does not GUIDANCE TO SURVEYORS: Review a list of incidents and chose some incidents regarding allegations of sexual abuse. Review the facility's Policy and Procedures regarding the prevention and investigation of sexual abuse. Was the alleged victim protected from any further abuse during the facility's investigation? How? If the allegation was confirmed, what did the facility do to rectify the situation which resulted in the abuse? What preventive measures have been taken to ensure this situation does not recur? What in service/training was conducted in order to educate all of the facility's staff on the new prevention method? Were the police, DCF/APS, Administrator, and/or the Health Department notified? Access DCF FSFN Abuse Reports to determine if DCF/APS was notified. Review the accused and other facility employee's file to determine if background checks were conducted prior to the employee working in the facility? What training have the facility's employees received regarding preventing and reporting abuse or neglect? PROBES: Interview facility staff (LPN, RN, CNA, Maintenance, Housekeeping) to determine if they know what to do if

252 Page 252 of 399 include any act intended for a valid medical purpose or any act which may reasonably be construed to be a normal care giving action. S (10), F.S. S (1)(h), F.S. someone reports sexual abuse to them. Is the information provided by staff incompliance with the facility's abuse Policy and Procedures? Did the investigation into allegation of sexual abuse comply with the facility's Policy and Procedures? What was the outcome of the investigation? ST - H RISK MANAGER REVIEW OF INCIDENT REPORTS Title RISK MANAGER REVIEW OF INCIDENT REPORTS Statute or Rule 59A (3), FAC The risk manager shall be responsible for the regular and systematic reviewing of all incident reports, including 15-day incident reports, for the purpose of identifying trends or patterns as to time, place or persons. Upon emergence of any trend or pattern in incident occurrence, the risk manager shall develop recommendations for corrective actions and risk management prevention education and training. Summary data thus accumulated shall be systematically maintained for 3 years. R. 59A (3), F.A.C. R. 59A (7), F.A.C. GUIDANCE TO SURVEYORS: Review all tracking and trending reports for the year. Review results to ascertain that the Risk Manager has trended the information to identify patterns and any problem areas. Determine if the Risk Manager/Designee review incident reports including 15 day incident reports. Review policy & procedure to determine if it establishes a timeframe within which the Risk Manager shall review an incident report relative to the date of occurrence; identify whether there is a pattern of delay in reviewing these reports. Interview the risk manager regarding the method utilized to identify trends, patterns, analysis, and corrective action. Review all pertinent documents for verification that the Risk Manager's recommendations were developed and the corrective action(s) implemented. Discuss and review documentation as to whether the corrective action(s) was effective and if not was the plan revised. Verify that action has been taken to reduce and prevent risks to patients. Review in-service education documents for programs pertinent to risk management education and training relating to the corrective action(s).verify that the past 3 years of accumulated summary data has been maintained and reviewed. PROBES Describe the manner by which the Risk Manager ensures that staff from individual departments/units identify safety hazards and risk exposures in clinical and facility-wide systems. Does staff receive feedback regarding incident reports that they completed? Has an incident report that you filed resulted in a change? What type of system does the Risk Manager utilize to track and trend incidents?

253 Page 253 of 399 ST - H SUMMARY REPORT TO GOVERNING BODY Title SUMMARY REPORT TO GOVERNING BODY Statute or Rule 59A (3)(a), FAC (a) At least quarterly, or more often as may be required by the governing body, the risk manager shall provide a summary report to the governing body, which includes information about activities of risk management as defined herein. R. 59A (3)(a), F.A.C. R. 59A (12), F.A.C R. 59A (14), F.A.C. GUIDANCE TO SURVEYORS Review the Governing Body minutes for risk management documentation. Interview the Licensed Risk Manager and staff regarding the current risk management program and current activities. Who presents the risk management summary report? ST - H ANNUAL REPORT OF JUDGMENTS Title ANNUAL REPORT OF JUDGMENTS Statute or Rule (3), F.S. (3) Each licensed facility shall annually report to the Agency for Health Care Administration and the Department of Health the name and judgments entered against each health care practitioner for which it assumes liability. S (3), F.S. S (4), F.S. GUIDANCE TO SURVEYORS: Review documentation of reporting. PROBES Does the facility have a report that identifies and summarizes judgments, not actions against practitioners? Have these identified practitioners been reported to the Department of Health and Agency for Healthcare Administration?

254 Page 254 of 399 ST - H ANNUAL REPORT SUMMARIZING INCIDENT REPORTS Title ANNUAL REPORT SUMMARIZING INCIDENT REPORTS Statute or Rule (6)(a), (c), F.S. (6)(a) Each licensed facility subject to this section shall submit an annual report to the Agency for Health Care Administration summarizing the incident reports that have been filed in the facility for that year. The report shall include: 1. The total number of adverse incidents. 2. A listing, by category, of the types of operations, diagnostic or treatment procedures, or other actions causing the injuries, and the number of incidents occurring within each category. 3. A listing, by category, of the types of injuries caused and the number of incidents occurring within each category. 4. A code number using the health care professional's licensure number and a separate code number identifying all other individuals directly involved in adverse incidents to patients, the relationship of the individual to the licensed facility, and the number of incidents in which each individual has been directly involved. Each licensed facility shall maintain names of the health care professionals and individuals identified by code numbers for purposes of this section. 5. A description of all malpractice claims filed against the licensed facility, including the total number of pending and closed claims and the nature of the incident which led to, the persons involved in, and the status and disposition of each claim. Each report shall update status and disposition for all prior reports. (c) The annual report submitted to the Agency shall also contain the name and license number of the risk manager of (6)(a), (c), F.S. GUIDANCE TO SURVEYORS Review the Annual Report(s) submitted to AHCA for: --Timeliness. --Verification the AHCA form is being used. --Number of incidents reported. --Types of incidents. --Number and types of claims. The Annual Report includes: --Death; --Brain or spinal damage; --Permanent disfigurement; --Fracture or dislocation of bones or joints; --A limitation of neurological, physical, or sensory function which continues after discharge from the facility; --Any condition that required specialized medical attention or surgical intervention resulting from non-emergency medical intervention other than an emergency medical condition, to which the patient has not given his or her informed consent; --Any condition that requires the transfer of the patient within or outside the facility to a unit providing a more acute care level of care due to the adverse incident, rather than the patient's condition prior to the adverse incident; --Was the performance of a surgical procedure on the wrong patient; --A wrong surgical procedure; --A wrong-site surgical procedure; --A surgical procedure otherwise unrelated to the patient's diagnosis or medical condition; --Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process; or --Was a procedure to remove unplanned foreign objects remaining from a surgical procedure? Review a sample of disciplinary actions and outcomes against practitioners and the reporting of all actions to

255 Page 255 of 399 the licensed facility, a copy of its policy and procedures which govern the measures taken by the facility and its risk manager to reduce the risk of injuries and adverse incidents, and the results of such measures. S (6)(a), (c), F.S. R. 59A (7), F.A.C. S (5), F.S. S (1)(a), F.S. Department of Health/Medical Quality Assurance. Review the facility's results of outcome measures, QA/PI initiatives; risk prevention and risk reduction strategies for the year. (Reference s (6)(c), F.S.) Is there a process in place for determining reportable incidents? How does it function? Is there a system developed to report the required adverse events to the Agency? Determine who has the final authority for determination that an incident meets the definition of an "adverse incident" to be reported to the Agency. Have any discharged patients required readmission for previous treatment or surgical episodes? Have any current patients required additional surgery, and/or treatment interventions as a result of an adverse incident? Any transfers to a higher level of care? Review the facility's annual reports for compliance of reporting the following: Total number of pending and closed claims; Claim number for each claim; Nature of incident; License numbers of persons involved in the claim and Status or disposition of the claim. ST - H AGENCY ACCESS TO RECORD Title AGENCY ACCESS TO RECORD Statute or Rule (13), F.S. (13) The Agency for Health Care Administration shall have access to all licensed facility records necessary to carry out the provisions of this section. Evidence of the incidents reporting and analysis system and copies of summary reports, incident reports filed within the facility, and evidence of recommended and accomplished corrective actions shall be made available for review to any authorized representative of the Agency upon request during normal working hours. S (13), F.S. R. 59A (3)(b), F.A.C (13), F.S. GUIDANCE TO SURVEYORS All facility records are to be made available to surveyors upon request. Surveyors are to notify their field office managers if a facility refuses access to records.

256 Page 256 of 399 ST - H UNLAWFUL COERCION OF REPORTING OBLIGATION Title UNLAWFUL COERCION OF REPORTING OBLIGATION Statute or Rule (19), F.S. (19) It shall be unlawful for any person over whom the facility exercises control to coerce, intimidate, or preclude a Risk Manager from lawfully executing his or her reporting obligations pursuant to this chapter. Such unlawful action shall be subject to civil monetary penalties not to exceed $10,000 per violation (19), F.S. Interview the risk manager regarding their ability to report. ST - H PATIENT SAFETY PLAN Title PATIENT SAFETY PLAN Statute or Rule (1), F.S. 1) Each licensed facility must adopt a patient safety plan. A plan adopted to implement the requirements of 42 C.F.R. Part shall be deemed to comply with this requirement. GUIDANCE TO SURVEYORS Review the facility's patient safety plan. If applicable, review QA/PI (HOSPITALS ONLY) plan to assure patient safety issues are addressed within the QA/PI plan. PROBES Does the facility have a patient safety plan? How often is the patient safety plan updated/reviewed? As relevant, consider information the facility representatives utilized to demonstrate compliance with 42 CFR (Quality Assurance and Performance Improvement Plan) (FOR HOSPITALS ONLY).

257 Page 257 of 399 ST - H PATIENT SAFETY OFFICER AND COMMITTEE Title PATIENT SAFETY OFFICER AND COMMITTEE Statute or Rule (2), F.S. (2) Each licensed facility shall appoint a patient safety officer and a patient safety committee, which shall include at least one person who is neither employed by nor practicing in the facility, for the purpose of promoting the health and safety of patients, reviewing and evaluating the quality of patient safety measures used by the facility, and assisting in the implementation of the facility patient safety plan. S (2), F.S. R. 59A (15), F.A.C. R. 59A (2), F.A.C. R. 59A (3), F.A.C. GUIDANCE TO SURVEYORS Determine if facility management has appointed a Patient Safety Officer. Review position description. Interview the Patient Safety Officer regarding roles and responsibilities. Review the composition of the Patient Safety Committee. Determine the eligibility of the committee member not employed by the facility, not a contracted employee of the facility, nor in practice at the facility. A review facility documentation of the Patient Safety Committee activities such as minutes, reports, QA/PI projects and outcomes, Patient Safety Initiatives, etc. Review the process by which the committee reviews and evaluates the quality of patient safety measures implemented by the facility. Review the process by which the committee assists in the implementation of the facility's Patient Safety Plan. ST - HB001 - Designated Receiving Facility - Noncompliance PROBES Do the committee members maintain records (surveys, evaluations, monitoring and corrective actions)? Does the Patient Safety Committee document the proceedings? Title Designated Receiving Facility - Noncompliance Statute or Rule 65E-5.351(1), FAC (1) Any facility designated as a receiving facility failing to comply with this chapter may have such designation In addition to possible loss of designation, chapter 395 requires compliance with the provisions of the Baker Act law and rule as a condition of licensure.

258 Page 258 of 399 suspended or withdrawn. Utilize this reg set when conducting a licensure survey, or complaint investigation of a hospital which is a designated receiving facility. ST - HB002 - Designated Recvg Fac - Policies/ Procedures Title Designated Recvg Fac - Policies/ Procedures Statute or Rule 65E-5.351(2), FAC (2) Each receiving facility shall have policies and procedures that prescribe, monitor and enforce all requirements specified in Chapter 65E-5, F.A.C. Review the facility's policies and procedures manual(s) to determine if major issues are incorporated and that information correctly reflects statutory and regulatory requirements. See Policy and Procedure Worksheet. -Interview the person responsible for the Baker Act program. ST - HB003 - Designated Recvg Fac - Operating Hours Title Designated Recvg Fac - Operating Hours Statute or Rule 65E-5.351(3), FAC (3) Each receiving facility shall assure that its reception, screening, and inpatient services are fully operational 24-hours-per-day, 7-days-per-week. Satellite sites belonging to a more comprehensive designated receiving facility, which are not fully operational at all times, are ineligible for inclusion in the designation. -Observe all portions of the hospital which provide care and services to persons under the Baker Act. -Review for 24/7 operation of the baker act program as a receiving facility. ST - HB004 - Designated Recvg Fac - Monitoring Compliance Title Designated Recvg Fac - Monitoring Compliance Statute or Rule 65E-5.351(4), FAC

259 Page 259 of 399 (4) Each receiving facility shall have a compliance program that monitors facility and professional compliance with Chapter 394, Part I, F.S., and this chapter [Chapter 65E-5, F.A.C]. Every such program shall specifically monitor the adequacy of and the timeframes involved in the facility procedures utilized to expedite obtaining informed consent for treatment. This program may be integrated with other activities. Review the facility's policy and procedure manual(s) to ensure that facility and professional compliance is monitored through its internal compliance program. -Review compliance monitoring program for informed consent compliance. -Interview person responsible for monitoring. -Review a sample of patient medical records for compliance. -Interview patients and families for informed consent provision. ST - HB005 - Delegation of Authority - Prior - In Writing Title Delegation of Authority - Prior - In Writing Statute or Rule 65E-5.110, FAC In order to protect the health and safety of persons treated in or served by any receiving or treatment facility or any service provider, any delegation of an administrator's authority pursuant to Chapter 394, F.S., or these rules shall be documented in writing prior to exercising the delegated authority. Routine delegations of authority shall be incorporated in the facility's written policies. Review facility policies and procedures to confirm if delegations of authority have been formalized and approved by the governing board. ST - HB006 - Min Stds -Training - Abuse Reporting Title Min Stds -Training - Abuse Reporting Statute or Rule (5)(f), FS

260 Page 260 of 399 (5)(f) Facility staff shall be required, as a condition of employment, to become familiar with the requirements and procedures for the reporting of abuse. Sample personnel files to ensure training in abuse reporting is documented. See also Rights (5)(f), F.S. ST - HB007 - Background Screening Title Background Screening Statute or Rule (1)(a)-(d), FS (1)(a) The department and the Agency for Health Care Administration shall require level 2 background screening pursuant to chapter 435 for mental health personnel. "Mental health personnel" includes all program directors, professional clinicians, staff members, and volunteers working in public or private mental health programs and facilities who have direct contact with individuals held for examination or admitted for mental health treatment. For purposes of this chapter, employment screening of mental health personnel also includes, but is not limited to, employment screening as provided under chapter 435 and s (b) Students in the health care professions who are interning in a mental health facility licensed under chapter 395, where the primary purpose of the facility is not the treatment of minors, are exempt from the fingerprinting and screening requirements if they are under direct supervision in the actual physical presence of a licensed health care professional. (c) A volunteer who assists on an intermittent basis for less than 10 hours per month is exempt from the fingerprinting and screening requirements if a person who meets the screening requirement of paragraph (a) is always present and has the volunteer within his or her line of sight. Sample personnel files to ensure that fingerprinting requirements are met for those individuals who have direct patient contact.

261 Page 261 of 399 (d) Mental health personnel working in a facility licensed under chapter 395 who work on an intermittent basis for less than 15 hours per week of direct, face-to-face contact with patients, and who are not listed on the Department of Law Enforcement Career Offender Search or the Dru Sjodin National Sex Offender Public Website, are exempt from the fingerprinting and screening requirements, except that persons working in a mental health facility where the primary purpose of the facility is the mental health treatment of minors must be fingerprinted and meet screening requirements. ST - HB008 - Removal of Certain Articles - Contraband Title Removal of Certain Articles - Contraband Statute or Rule (1)(a), FS (1)(a)Except as authorized by law or as specifically authorized by the person in charge of each hospital providing mental health services under this part, it is unlawful to introduce into or upon the grounds of such hospital, or to take or attempt to take or send therefrom, any of the following articles, which are hereby declared to be contraband for the purposes of this section: 1. Any intoxicating beverage or beverage which causes or may cause an intoxicating effect; 2. Any controlled substance as defined in chapter 893; or 3. Any firearms or deadly weapon. Review facility policies and procedures that address contraband, weapons, intoxicating beverages or controlled substances and methods to deal with those situations when they may arise. Interview staff at admissions to determine if patients are searched for contraband prior to admission to a unit. -Interview staff for knowledge of contraband items.

262 Page 262 of 399 ST - HB010 - Continuity of Care Management Title Continuity of Care Management Statute or Rule 65E-5.130, FAC Persons receiving case management services. (1) At the time of admission receiving facilities shall inquire of the person or significant others as to the existence of any advance directives and as to the identity of the person's case manager. If a case manager for the person is identified, the administrator or designee shall request the person's authorization to notify the person's case manager or the case management agency of the person's admission to the facility. If authorized, such notification shall be made within 12 hours to the published 24-hour telephone listing for the case manager or case management agency. This inquiry, notification, and the identity of the case manager or case management agency, if any, shall be documented on the face sheet or other prominent location in the person's clinical record. (2) A department funded mental health case manager, when notified by a receiving facility that a client has been admitted, shall visit that person as soon as possible but no later than two working days after notification to assist with discharge and aftercare planning to the least restrictive, appropriate and available placement. If the person is located in a receiving facility outside of the case manager's district or region of residence, the department funded mental health case manager may substitute a telephone contact for a face-to-face visit which shall be documented in the case management record and in the person's clinical record at the receiving facility. If the clinical record reflects that the patient has a case manager, determine if the case manager's agency was notified of the patient's presence in the receiving facility within 12 hours. -Review a sample of patient medical records for compliance. -Interview patients, families, and case managers.

263 Page 263 of 399 ST - HB011 - Admission to State Treatment Fac - Documents Title Admission to State Treatment Fac - Documents Statute or Rule 65E (1)-(2), FAC (1) Before discharging a person who has been admitted to a facility, the person shall be encouraged to actively participate in treatment and discharge planning activities and shall be notified in writing of his or her right to seek treatment from the professional or agency of the person's choice and the person shall be assisted in making appropriate discharge plans. The person shall be advised that, pursuant to Section , F.S., no professional is required to accept persons for psychiatric treatment. (2) Discharge planning shall include and document consideration of the following: (a) The person's transportation resources; (b) The person's access to stable living arrangements; (c) How assistance in securing needed living arrangements or shelter will be provided to individuals who are at risk of re-admission within the next 3 weeks due to homelessness or transient status and prior to discharge shall request a commitment from a shelter provider that assistance will be rendered; (d) Assistance in obtaining a timely aftercare appointment for needed services, including continuation of prescribed psychotropic medications. Aftercare appointments for psychotropic medication and case management shall be requested to occur not later than 7 days after the expected date of discharge; if the discharge is delayed, the facility will notify the aftercare provider. The facility shall coordinate with the aftercare service provider and shall document the aftercare planning; For patients who have been transferred from the receiving facility to a state mental hospital, review the closed record to ensure that the three required forms were provided in advance of the pre-admission staffing conducted by state hospital staff and that the recommended Physician-to-Physician Transfer form was prepared and delivered to the state hospital on the day of the patient's admission prior to or at the time of the patient's arrival. -Interview staff who are involved with the transfer process.

264 Page 264 of 399 (e) To ensure a person's safety and provide continuity of essential psychotropic medications, such prescribed psychotropic medications, prescriptions, or multiple partial prescriptions for psychotropic medications, or a combination thereof, shall be provided to a person when discharged to cover the intervening days until the first scheduled psychotropic medication aftercare appointment, or for a period of up to 21 calendar days, whichever occurs first. Discharge planning shall address the availability of and access to prescribed psychotropic medications in the community; (f) The person shall be provided education and written information about his or her illness and psychotropic medications including other prescribed and over-the-counter medications, the common side-effects of any medications prescribed and any adverse clinically significant drug-to-drug interactions common between that medication and other commonly available prescribed and over-the-counter medications; (g) The person shall be provided contact and program information about and referral to any community-based peer support services in the community; (h) The person shall be provided contact and program information about and referral to any needed community resources; (i) Referral to substance abuse treatment programs, trauma or abuse recovery focused programs, or other self-help groups, if indicated by assessments; and (j) The person shall be provided information about advance directives, including how to prepare and use the advance directives. ST - HB012 - Discharge from Treatment Facility Title Discharge from Treatment Facility Statute or Rule 65E (1)-(2), FAC

265 Page 265 of 399 (1) Before discharging a person who has been admitted to a facility, the person shall be encouraged to actively participate in treatment and discharge planning activities and shall be notified in writing of his or her right to seek treatment from the professional or agency of the person's choice and the person shall be assisted in making appropriate discharge plans. The person shall be advised that, pursuant to Section , F.S., no professional is required to accept persons for psychiatric treatment. (2) Discharge planning shall include and document consideration of the following: (a) The person's transportation resources; (b) The person's access to stable living arrangements; (c) How assistance in securing needed living arrangements or shelter will be provided to individuals who are at risk of re-admission within the next 3 weeks due to homelessness or transient status and prior to discharge shall request a commitment from a shelter provider that assistance will be rendered; (d) Assistance in obtaining a timely aftercare appointment for needed services, including continuation of prescribed psychotropic medications. Aftercare appointments for psychotropic medication and case management shall be requested to occur not later than 7 days after the expected date of discharge; if the discharge is delayed, the facility will notify the aftercare provider. The facility shall coordinate with the aftercare service provider and shall document the aftercare planning; (e) To ensure a person's safety and provide continuity of essential psychotropic medications, such prescribed psychotropic medications, prescriptions, or multiple partial prescriptions for psychotropic medications, or a combination thereof, shall be provided to a person when discharged to cover the intervening days until the first scheduled psychotropic medication aftercare appointment, or for a period Review open records of patients nearing discharge and closed records to ensure that all required elements were addressed in the patient's discharge planning. Interview patient as to level of participation in discharge planning. -Discharges are to an appropriately licensed facility to meet the needs of the patient. -If possible, observe a discharge which is in process -Interview patients and families/representatives. See BA 088

266 Page 266 of 399 of up to 21 calendar days, whichever occurs first. Discharge planning shall address the availability of and access to prescribed psychotropic medications in the community; (f) The person shall be provided education and written information about his or her illness and psychotropic medications including other prescribed and over-the-counter medications, the common side-effects of any medications prescribed and any adverse clinically significant drug-to-drug interactions common between that medication and other commonly available prescribed and over-the-counter medications; (g) The person shall be provided contact and program information about and referral to any community-based peer support services in the community; (h) The person shall be provided contact and program information about and referral to any needed community resources; (i) Referral to substance abuse treatment programs, trauma or abuse recovery focused programs, or other self-help groups, if indicated by assessments; and (j) The person shall be provided information about advance directives, including how to prepare and use the advance directives. ST - HB013 - Discharge Policies - Written Title Discharge Policies - Written Statute or Rule 65E , FAC Receiving and treatment facilities shall have written discharge policies and procedures which shall contain: (1) Agreements or protocols for transfer and transportation arrangements between facilities; (2) Protocols for assuring that current medical and legal Review the receiving facility's policy and procedure manuals to ensure that each of the required elements are included. Are the protocols implemented?

267 Page 267 of 399 information, including day of discharge medication administered, is transferred before or with the person to another facility; and (3) Policy and procedures which address continuity of services and access to necessary psychotropic medications. ST - HB016 - Pt Rights - Written Copy Title Pt Rights - Written Copy Statute or Rule 65E-5.140(1), FAC (1) Every person admitted to a designated receiving or treatment facility or ordered to treatment at a service provider shall be provided with a written description of his or her rights at the time of admission. Recommended form CF-MH 3103, Feb. 05, "Rights of Persons in Mental Health Facilities and Programs," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. A copy of the rights statement, signed by the person evidencing receipt of the copy, shall be placed in the person's clinical record and shall also be provided to the person's guardian, guardian advocate, representative, and health care surrogate or proxy. Form entitled "Rights of Patients" (CF-MH 3103) is considered by the department to be sufficient. Interview staff and patients to verify that rights have been explained and a copy provided. ST - HB017 - Pt Rights - Available on Request Title Pt Rights - Available on Request Statute or Rule 65E-5.140(2), FAC (2) To assure that persons have current information as to their Observe unit and ask to see a copy of the Baker Act law (394, F.S.) and rules (65E-5, F.A.C.)

268 Page 268 of 399 rights, a copy of the Florida Mental Health Act (Chapter 394, Part I, F.S.) and Mental Health Act Regulations (Chapter 65E-5, F.A.C.) shall be available, and provided upon request, in every psychiatric unit of each receiving and treatment facility and by each service provider and, upon request shall be made available for review by any person, guardian, guardian advocate, representative, or health care surrogate or proxy. The administrator or designee of the facility or service provider shall make physicians, nurses, and all other direct service staff aware of the location of these documents so they are able to promptly access them upon request. ST - HB018 - Pt Rights Posters Title Pt Rights Posters Statute or Rule 65E-5.140(3), FAC (3) Posters delineating rights of persons served in mental health facilities and by service providers, including those with telephone numbers for the Florida Abuse Hotline, Florida Local Advocacy Council, and the Advocacy Center for Persons with Disabilities, shall be legible, a minimum of 14 point font size, and shall be posted immediately next to telephones which are available for persons served by the facility or provider. Observe the unit to verify that phone numbers for the abuse Hotline, HORACE, and the Advocacy Center are posted near the telephones. While the font size may not be verified, it is necessary that the information be legible. ST - HB019 - Pt Rights - Exercise of Rights Title Pt Rights - Exercise of Rights Statute or Rule 65E-5.140(4), FAC

269 Page 269 of 399 (4) Each person shall be afforded the opportunity to exercise his or her rights in a manner consistent with Section (1), F.S. The imposition of individual or unit restrictions and the development of unit policies and procedures shall address observance of protecting rights of persons served in developing criteria or processes to provide for care and safety. Interview patients to determine if any restrictions of rights or privileges, other than those provided for in the law and rule, have been placed on individuals or the entire unit. -Review a sample of patient medical records for the imposition of individual or unit restrictions. ST - HB020 - Pt Rights - Access to Outdoor Title Pt Rights - Access to Outdoor Statute or Rule 65E-5.150(1), FAC (1) Freedom of movement is a right of persons in mental health receiving and treatment facilities. Any restriction of this right requires a physician's order based upon risk factors. Each receiving and treatment facility shall have policies that describe freedom of movement and access to grounds. When a suitable area is immediately adjacent to the unit, the staff shall afford each person an opportunity to spend at least one half hour per day in an open, out of doors, fresh air activity area, unless there is a physician's order prohibiting this, with documentation in the person's clinical record of the clinical reasons that access to fresh air will not be accommodated. Interview patients to ensure that they have the opportunity to spend at least 30 minutes a day out-of-doors if desired, unless there is a physician's order prohibiting such activity or unless no secured area is available at the facility. -Observe patients in outdoor activity as part of the survey process. ST - HB021 - Pt Rights - Special Clothing Prohibitd Title Pt Rights - Special Clothing Prohibitd Statute or Rule 65E-5.150(2), FAC

270 Page 270 of 399 (2) Use of special clothing for identification purposes such as surgical scrubs or hospital gowns to identify patients who are in need of special precautions or behavior modification restrictions is prohibited as a violation of individual dignity. Prison or jail attire shall not be permitted for persons admitted or retained in a receiving facility except while accompanied by a uniformed law enforcement officer, for purposes of security. Under non-psychiatric medical circumstances, use of special clothing may be ordered by the person's physician on an individual basis. Documentation of the circumstances shall be included in the person's clinical record. Observe the patients on each unit to ensure they are wearing street clothing. If any patients are not wearing street clothing, interview the patients to determine the reason and review the clinical record to determine if orders for special clothing had been issued. ST - HB022 - Pt Rights - Treatment Denied/Delayed Title Pt Rights - Treatment Denied/Delayed Statute or Rule (2)(a), FS (2)(a) A person shall not be denied treatment for mental illness and services shall not be delayed at a receiving or treatment facility because of inability to pay. However, every reasonable effort to collect appropriate reimbursement for the cost of providing mental health services to persons able to pay for services, including insurance or third-party payments, shall be made by facilities providing services pursuant to this part. Ensure compliance with federal and State health care emergency access provisions. Interview local law enforcement agency personnel to determine if persons are denied admission or if admission is delayed while insurance is verified. -Observe care and services in the ED for the emergency provision of care. -Interview patients, families/representatives, and case managers regarding how costs are collected, as appropriate. ST - HB023 - Pt Rights - Treatment - Least Restrictive Title Pt Rights - Treatment - Least Restrictive Statute or Rule (2)(b), FS

271 Page 271 of 399 (2)(b) It is further the policy of the state that the least restrictive appropriate available treatment be utilized based on the individual needs and best interests of the patient and consistent with optimum improvement of the patient's condition. -Observe care and treatments for least restrictive and in the best interest of the patient needs. -Interview staff how least restrictive is assessed and reassessed for the best interest of the patient. ST - HB024 - Pt Rights-Participate in Activities Title Pt Rights-Participate in Activities Statute or Rule (2)(d), FS (2)(d) Every patient in a facility shall be afforded the opportunity to participate in activities designed to enhance self-image and the beneficial effects of other treatments, as determined by the facility. -Observe care on the unit and activity participation. -Review a sample of patient medical records. ST - HB025 - Pt Rights - Physical Exam Title Pt Rights - Physical Exam Statute or Rule (2)(c), FS (2)(c) Each person who remains at a receiving or treatment facility for more than 12 hours shall be given a physical examination by a health practitioner authorized by law to give such examinations, within 24 hours after arrival at such facility. Review clinical records to find a physical examination performed within 24 hours of patient arrival. This may be documented on a form or dictated in narrative form. -Interview staff, patients, and families how this is conducted.

272 Page 272 of 399 ST - HB026 - Pt Rights -Treatment Plan Title Pt Rights -Treatment Plan Statute or Rule (2)(e), FS (2)(e) Not more than 5 days after admission to a facility, each patient shall have and receive an individualized treatment plan in writing which the patient has had an opportunity to assist in preparing and to review prior to its implementation. The plan shall include a space for the patient's comments. Interview patients to determine that they have participated in the development of an individualized treatment plan within five days of admission. Review patient medical records to ensure the presence of the plan and that it is signed by the patient or guardian and that the form has space for the patient's comments. Interview staff to determine how the facility affords the patient or patient's guardian the opportunity to participate in treatment planning. ST - HB027 - Pt Rights-Treatmt-Assessmt/Planning Title Pt Rights-Treatmt-Assessmt/Planning Statute or Rule 65E-5.160(2), FAC (2) Comprehensive service assessment and treatment planning, including discharge planning, shall begin the day of admission and shall also include the person's case manager if any, the person's friends, family, significant others, or guardian, as desired by the person. If the person has a court appointed guardian, the guardian shall be included in the service assessment and treatment planning. Obtaining legal consent for treatment, assessment and planning protocols shall also include the following: (a) How any advance directives will be obtained and their provisions addressed and how consent for treatment will be expeditiously obtained for any person unable to provide consent; a) Review policies and procedures to ensure staff are directed to obtain advance directives, if any, from patients upon admission. b) Review patient medical records to ensure that significant results of diagnostic testing have been included in treatment planning, when appropriate. c) Review patient medical records to ensure the presence of treatment goals in the patient's treatment plan, individualized to address the problems causing the admission. d) Review patient medical records to ensure that each of the four required elements is incorporated into the individualized treatment plan and that the plan addresses the patient's preferences and support system. e) Review patient medical records to ensure each goal details actions needed to reach specified outcomes. f) Review patient medical records to ensure legibility so that staff and the patient can read the progress notes. Ensure the notes respond to the goals and objectives established in the individualized treatment plan. g) If the patient is to be retained beyond brief stabilization, periodic reviews of the patient's condition should be conducted and documented in order to modify the treatment plan, as needed.

273 Page 273 of 399 (b) Completion of necessary diagnostic testing and the integration of the results and interpretations from those tests. The results and interpretation of the results shall be reviewed with the person; (c) The development of treatment goals specifying the factors and symptomology precipitating admission and addressing their resolution or mitigation; (d) The development of a goal within an individualized treatment plan, including the individual's strengths and weaknesses, that addresses each of the following: living arrangements, social supports, financial supports, and health, including mental health. Goals shall be inclusive of the person's choices and preferences and utilize available natural social supports such as family, friends, and peer support group meetings and social activities; (e) Objectives for implementing each goal shall list the actions needed to obtain the goal, and shall be stated in terms of outcomes that are observable, measurable, and time-limited; (f) Progress notes shall be dated and shall address each objective in relation to the goal, describing the corresponding progress, or lack of progress being made. Progress note entries and the name and title of writer must be clearly legible; g) Periodic reviews shall be comprehensive and shall be the basis for major adjustments to goals and objectives. Frequency of periodic reviews shall be determined considering the degree to which the care provided is acute care and the projected length of stay of the person; (h) Progress note observations, participation by the person, rehabilitative and social services, and medication changes shall reflect an integrated approach to treatment; (i) Facilities shall update the treatment plan, including the physician summary, at least every 30 days during the time a person is in a receiving or treatment facility except that persons retained for longer than 24 months shall have updates at least every 60 days; h) Review the clinical record to ensure that all parts of the patient's treatment are integrated toward a common outcome. i) Review the clinical record to ensure the physician summarizes the patient's plan at least monthly, except in long-term care (over 2 years) in which the update can occur every other month. j) Review the seclusion/restraint logbook and ensure that entries are also incorporated in each patient's clinical record. The clinical records should also detail any injuries mentioned by patients during interviews. k) Continued involuntary placement hearings generally take place after the original six-month order has expired.

274 Page 274 of 399 (j) The clinical record shall comprehensively document the person's care and treatment, including injuries sustained and all uses of emergency treatment orders; and (k) Persons who will have a continued involuntary outpatient placement hearing pursuant to Section (7), F.S., shall be provided with comprehensive re-assessments, the results of which shall be available at the hearing. ST - HB029 - Schedule of Daily Activities Title Schedule of Daily Activities Statute or Rule 65E (2), FAC (2) Each designated receiving and treatment facility shall develop a schedule of daily activities listing the times for specific events, which shall be posted in a common area and provided to all persons. Observe each patient unit of a receiving or treatment facility to observe the posted schedule of daily activities. Determine if the activity scheduled at the time of the tour is actually occurring. Interview patients to determine if the posted activities generally occur as scheduled. ST - HB030 - Quality of Treatment-Interventions Title Quality of Treatment-Interventions Statute or Rule 65E , FAC (1) Management and personnel of the facility's treatment environment shall use positive incentives in assisting persons to acquire and maintain socially positive behaviors as determined by the person's age and developmental level. (3) Interventions such as the loss of personal freedoms, loss of earned privileges or denial of activities otherwise available to other persons shall be minimized and utilized only after the Observe for any evidence of a punitive approach to patient care. Review patient medical records for documentation of removal of a patient's privileges. Interview patients to determine if privileges have been removed, with or without documentation in the clinical record.

275 Page 275 of 399 documented failure of the unit's positive incentives for the individuals involved. (4) Facilities shall ensure that any verbal or written information provided to persons must be accessible in the language and terminology the person understands. ST - HB031 - Behavioral Management Programs Title Behavioral Management Programs Statute or Rule 65E , FAC When an individualized treatment plan requires interventions beyond the existing unit rules of conduct, the person shall be included, and the person's treatment plan shall reflect: (1) Documentation, signed by the physician that the person's medical condition does not exclude the proposed interventions; (2) Consent for the treatment to be provided; (3) A general description of the behaviors requiring the intervention, which may include previous emergency interventions; (4) Antecedents of that behavior; (5) The events immediately following the behavior; (6) Objective definition of the target behaviors, such as specific acts, level of aggression, encroachment on others' space, self-injurious behavior or excessive withdrawal; (7) Arrangements for the consistent collection and recording of data; (8) Analysis of data; (9) Based on data analysis, development of intervention strategies, if necessary; (10) Development of a written intervention strategy that includes criteria for starting and stopping specific staff interventions and the process by which they are to occur; Review patient medical record for any patient for whom privileges have been removed or specific behavioral interventions are implemented beyond those applied to all patients, to ensure the 12 essential elements are incorporated in the individual patient's behavior management plan.

276 Page 276 of 399 (11) Continued data collection, if interventions are implemented; and (12) Periodic review and revision of the plan based upon data collected and analyzed. ST - HB032 - Pt Rights to Consent Title Pt Rights to Consent Statute or Rule (3)(a), FS (a)1. Each patient entering treatment shall be asked to give express and informed consent for admission and treatment. If the patient has been adjudicated incapacitated or found to be incompetent to consent to treatment, express and informed consent to treatment shall be sought instead from the patient's guardian or guardian advocate. Express and Informed consent means consent voluntarily given in writing, by a competent person, after sufficient explanation and disclosure of the subject matter involved to enable the person to make a knowing and willful decision without any element of force, fraud, deceit, duress, or other form of constraint or coercion. [ (9),F.S.] Incompetent to Consent to Treatment means that a person's judgment is so affected by his or her mental illness that the person lacks the capacity to make a well-reasoned, willful, and knowing decision concerning his or her medical or mental health treatment. [ (15), F.S.] Review clinical records to ensure that a signed consent for treatment has been signed by an individual authorized to provide consent before any treatment has been administered. Ensure from the progress notes and other documentation that the patient is not too confused or disoriented to provide informed consent. Use of recommended form "Certification of Patient's Competence to Provide Express and Informed Consent" (CF-MH 3104) is considered by the department to be sufficient to document the competence of a person to give express and informed consent. Interview several patients authorizing their own treatment to determine their ability to provide informed consent. For patients who are incompetent to consent to treatment and have a guardian or guardian advocate, has that surrogate been asked to provide consent? If possible, telephone the guardian or guardian advocate to ensure that they were provided full disclosure of the proposed treatment prior to being asked to sign the authorization for treatment. ST - HB033 - Pt Rights to Consent - Competence Title Pt Rights to Consent - Competence Statute or Rule 65E-5.170(1)(a), FAC

277 Page 277 of 399 (1)(a) The facility shall determine whether a patient has been adjudicated as incapacitated and whether a guardian has been appointed by the court. If a guardian has been appointed by the court, the limits of the authority of the guardian shall be determined prior to allowing the guardian to authorize treatment. A copy of any court order delineating a guardian's authority to consent to mental health or medical treatment shall be obtained by the facility and included in the person's clinical record prior to allowing the guardian to give express and informed consent to treatment for the person. Review the patient medical record of any patients in the facility that have a court-appointed guardian. Ensure that the court order and/or letters of guardianship are in the record. Review the order/letters to determine what rights have been removed from the patient and delegated by the court to the guardian to ensure that the guardian has been given the authority to consent to mental health and/or medical treatment of the patient. ST - HB034 - Pt Rights To Consent-Minors Title Pt Rights To Consent-Minors Statute or Rule (3)(a), FS (3)(a)1. Express and informed consent must be provided by the patient's guardian....if the patient is a minor, express and informed consent for admission or treatment shall also be requested from the patient's guardian. Express and informed consent for admission or treatment of a patient under 18 years of age shall be required from the patient's guardian, unless the minor is seeking outpatient crisis intervention services under s Express and informed consent for admission or treatment given by a patient who is under 18 years of age shall not be a condition of admission when the patient's guardian gives express and informed consent for the patient's admission pursuant to s or s

278 Page 278 of 399 ST - HB035 - Determine Ability To Consent Title Determine Ability To Consent Statute or Rule 65E-5.170(1)(a), FAC (1)(a) As soon as possible, but in no event longer than 24 hours from entering a designated receiving facility on a voluntary or involuntary basis, each person shall be examined by the admitting physician to assess the person's ability to provide express and informed consent to admission and treatment. The examination of a minor for this purpose may be limited to the documentation of the minor's age. The examination of a person alleged to be incapacitated for this purpose may be limited to the documentation of letters of guardianship. Documentation of the assessment results shall be placed in the person's clinical record. Ensure that the physician for a voluntary patient has documented the patient's competence to provide express and informed consent to the admission and to treatment within 24 hours of admission. Where the patient is a minor or and adult who is adjudicated as incapacitated by a court order, such documentation is sufficient to preclude the patient's ability to consent to his or her own treatment. In such situations, a guardian must decide whether or not to provide express and informed consent to recommended treatment. ST - HB036 - Pt Rights To Disclosure Title Pt Rights To Disclosure Statute or Rule (3)(a)2., FS (3)(a)2. Before giving express and informed consent, the following information shall be provided and explained in plain language to the patient, or to the patient's guardian if the patient is 18 years of age or older and has been adjudicated incapacitated, or to the guardian advocate if the patient has been found to be incompetent to consent to treatment, or to both the patient and guardian if the patient is a minor: the Examine the explanation in the patient medical record of the treatment to be given to determine if the information does in fact explain the risk/benefit of the treatment and alternatives. Review documentation of disclosure in patient medical record and interview selected patients to determine if full disclosure had been provided prior to being asked to sign consent to treatment form. Confirm that guardians or guardian advocates had been provided full disclosure prior to being asked to sign consent for treatment for persons adjudicated by a court to be incapacitated or incompetent to consent to treatment.

279 Page 279 of 399 reason for admission or treatment; the proposed treatment; the purpose of the treatment to be provided; the common risks, benefits, and side effects thereof; the specific dosage range for the medication, when applicable; alternative treatment modalities; the approximate length of care; the potential effects of stopping treatment; how treatment will be monitored; and that any consent given for treatment may be revoked orally or in writing before or during the treatment period by the patient or by a person who is legally authorized to make health care decisions on behalf of the patient. ST - HB037 - Pt Rights To Consent - Consent Obtained Title Pt Rights To Consent - Consent Obtained Statute or Rule (3)(b), FS (3)(b) In the case of medical procedures requiring the use of a general anesthetic or electroconvulsive treatment, and prior to performing the procedure, express and informed consent shall be obtained from the patient, if the patient is legally competent, from the guardian of a minor patient, from the guardian of a patient who has been adjudicated incapacitated, or from the guardian advocate of the patient if the guardian advocate has been given express court authority to consent to medical procedures or electroconvulsive treatment as provided under s Review policies and procedures of the facility to ensure that informed consent of the patient, guardian or guardian advocate is obtained only after full disclosure of all aspects of risk/benefit is given. ST - HB038 - Pt Rights to Receive Services Title Pt Rights to Receive Services Statute or Rule (4)(a), FS

280 Page 280 of 399 (4)(a) Each patient shall receive services, including for a patient placed under s , those services included in the court order which are suited to his or her needs, and which shall be administered skillfully, safely, and humanely with full respect for the patient's dignity and personal integrity. Each patient shall receive such medical, vocational, social, educational, and rehabilitative services as his or her condition requires in order to live successfully in the community. In order to achieve this goal, the department is directed to coordinate its mental health programs with all other programs of the department and other state agencies. Interview staff/patients and observe the environment and staff-patient interaction to confirm that patients receive treatment where they are safe, treated appropriately, and protected from harm. ST - HB039 - Quality Mental Health Treatment Title Quality Mental Health Treatment Statute or Rule 65E-5.180, FAC The following standards shall be required in the provision of quality mental health treatment: (1) Each receiving and treatment facility and service provider shall, using nationally accepted accrediting standards for guidance, develop written policies and procedures for planned program activities designed to enhance the person's self-image, as required by Section (2)(d), F.S. These policies and procedures shall include curriculum, specific content, and performance objectives and shall be delivered by staff with content expertise. Medical, rehabilitative, and social services shall be integrated and provided in the least restrictive manner consistent with the safety of the persons served. (2) Each facility and service provider, using nationally accepted accrediting standards for guidance, shall adopt 1) Program policies and procedures should be based on nationally accepted standards. Staff training shall be performed by persons who are competent by reason of training and/or experience in the subject matter. 2) Review patient medical records to determine that reports are legible, understandable, signed and dated. Issues raised by these reports should be addressed in the individualized treatment and discharge plans for each patient.

281 Page 281 of 399 written professional standards of quality, accuracy, completeness, and timeliness for all diagnostic reports, evaluations, assessments, examinations, and other procedures provided to persons under the authority of Chapter 394, Part I, F.S. Facilities shall monitor the implementation of those standards to assure the quality of all diagnostic products. Standards shall include and specify provisions addressing: (a) The minimum qualifications to assure competence and performance of staff who administer and interpret diagnostic procedures and tests; (b) The inclusion and updating of pertinent information from previous reports, including admission history and key demographic, social, economic, and medical factors; (c) The dating, accuracy and the completeness of reports; (d) The timely availability of all reports to users; (e) Reports shall be legible and understandable; (f) The documentation of facts supporting each conclusion or finding in a report; (g) Requirements for the direct correlation of identified problems with problem resolutions that consider the immediacy of the problem or time frames for resolution and which include recommendations for further diagnostic work-ups; (h) Requirement that the completed report be signed and dated by the administering staff; and (i) Consistency of information across various reports and integration of information and approaches across reports. ST - HB040 - Pt Rights-Psychiatric Exams Include Title Pt Rights-Psychiatric Exams Include Statute or Rule 65E-5.180(3), FAC

282 Page 282 of 399 (3) Psychiatric Examination. Psychiatric examinations shall include: (a) Medical history, including psychiatric history, developmental abnormalities, physical or sexual abuse or trauma, and substance abuse; (b) Examination, evaluative or laboratory results, including mental status examination; (c) Working diagnosis, ruling out non-psychiatric causes of presenting symptoms of abnormal thought, mood or behaviors; (d) Course of psychiatric interventions including: 1. Medication history, trials and results; 2. Current medications and dosages; 3. Other psychiatric interventions in response to identified problems; (e) Course of other non-psychiatric medical problems and interventions; (f) Identification of prominent risk factors including physical health, psychiatric and co-occurring substance abuse; and (g) Discharge or transfer diagnoses. Review clinical records for the presence of a psychiatric examination for all patients within 72 hours of admission on a voluntary or involuntary basis. The examination must include essential elements (a-g) required in the rule; issues of discharge or transfer diagnosis should be incorporated in the discharge or transfer summary completed upon the patient's departure from the facility. ST - HB041 - Pt Rights - Physical Transfer Title Pt Rights - Physical Transfer Statute or Rule 65E-5.180(4), FAC (4) So that care will not be delayed upon arrival, procedures for the transfer of the physical custody of persons shall specify and require that documentation necessary for legal custody and medical status, including the person's medication administration record for that day, shall either precede or accompany the person to his or her destination. Review facility policies and procedures to ensure the specified documents are required to be transferred prior to or with the patient. Review closed clinical records to ensure that the facility is following the rule and its own policy in the transfer of records with a patient.

283 Page 283 of 399 ST - HB042 - Mental Health Services Title Mental Health Services Statute or Rule 65E-5.180(5), FAC (5) Mental health services provided shall comply with the following standards: (a) In designated receiving facilities, the on-site provision of emergency psychiatric reception and treatment services shall be available 24-hours-a-day, seven-days a week, without regard to the person's financial situation. (b) Assessment standards shall include provision for determining the presence of a co-occurring mental illness and substance abuse, and clinically significant physical and sexual abuse or trauma. (c) A clinical safety assessment shall be accomplished at admission to determine the person's need for, and the facility's capability to provide, an environment and treatment setting that meets the person's need for a secure facility or close levels of staff observation. (d) The development and implementation of protocols or procedures for conducting and documenting the following shall be accomplished by each facility: 1. Determination of a person's competency to consent to treatment within 24 hours after admission; 2. Identification of a duly authorized decision-maker for the person upon any person being determined not to be competent to consent to treatment; 3. Obtaining express and informed consent for treatment and medications before administration, except in an emergency; and 4. Required involvement of the person and guardian, guardian advocate, or health care surrogate or proxy, in treatment and a. Ensure that the facility is open and fully staffed to provide all essential functions 24-hours per day, 7-days per week. Each facility shall accept all persons brought to the facility by law enforcement officers for involuntary examination. b. Psychosocial evaluations shall address the patient's history of physical or sexual abuse or trauma, as well as substance abuse. Treatment and discharge planning should address these issues. c. The patient medical record should include documentation of the patient's need for a staff or facility-secure setting for the protection of the patient or others. d. Review the policies and procedures to ensure the inclusion of the four required elements related to express and informed consent and involvement of the patient and substitute decision-makers in the treatment planning process. a) Review policies and procedures to ensure special recognition is given in the application of seclusion or restraints to minors, elders, or persons with special medical problems. b) Review patient medical records to ensure that the reasons for any use of emergency interventions is specified in such a way that the patient or other authorized person may understand its necessity. c) Review patient medical records to ensure that any emergency use of psychotropic mediations is based on an individual order by a physician and not standing orders. d) Review patient medical records of patients who have had a guardian advocate proposed/appointed by the court to ensure the required training has been provided to assist in treatment and discharge planning.

284 Page 284 of 399 discharge planning. (e) Use of age sensitive interventions in the implementation of seclusion or in the use of physical force as well as the authorization and training of staff to implement restraints, including the safe positioning of persons in restraints. Policies, procedures and services shall incorporate specific provisions regarding the restraining of minors, elders, and persons who are frail or with medical problems such as potential problems with respiration. (f) Plain language documentation in the person's clinical record of all uses of "as needed" or emergency applications of psychotropic medications, and all uses of physical force, restraints, seclusion, or "time-out" procedures upon persons, and the explicit reasons for their use. (g) The prohibition of standing orders or similar protocols for the emergency use of psychotropic medication, restraint, or seclusion. (h) Provision of required training for guardian advocates including activities and available resources designed to assist family members and guardian advocates in understanding applicable treatment issues and in identifying and contacting local self-help organizations. ST - HB050 - Abuse Reporting, Training, etc. Title Abuse Reporting, Training, etc. Statute or Rule 65E-5.330, FAC (1) In order to ensure the protection of the health, safety, and welfare of persons treated in receiving and treatment facilities, required by Section (5)(b), F.S., the following is required: (a) Each designated receiving and treatment facility shall develop policies and procedures for abuse reporting and shall a) Review facility policies and procedures to ensure staff are correctly instructed to immediately report suspected abuse, neglect, or exploitation of any child, elder, or disabled person, without internal review. Review personnel records (see Personnel Worksheet) to ensure documentation is present of staff training in these policies and procedures. b) Review personnel records to ensure each employee with patient contact has received training in a team approach to physical management techniques.

285 Page 285 of 399 conduct training which shall be documented in each employee's personnel record or in a training log. (b) All staff who have contact with persons served shall receive training in verbal de-escalation techniques and the use of bodily control and physical management techniques based on a team approach. Less restrictive verbal de-escalation interventions shall be employed before physical interventions, whenever safety conditions permit. (c) All staff who have contact with persons served shall receive training in cardiopulmonary resuscitation within the first six months of employment if not already certified when employed and shall maintain current certification as long as duties require direct contact with persons served by the facility. (d) A personnel training plan that prescribes and assures that direct care staff, consistent with their assigned duties, shall receive and complete before providing direct care or assessment services, 14 hours of basic orientation training, documented in the employee's personnel record, in the following: 1. Rights of persons served by the facility and facility procedures required under Chapter 394, Part I, F.S., and Chapter 65E-5, F.A.C.; 2. Confidentiality laws including psychiatric, substance abuse, HIV and AIDS; 3. Facility incident reporting; 4. Restrictions on the use of seclusion and restraints, consistent with unit policies and procedures, and this chapter; 5. Abuse reporting required by Chapter 415, F.S.; 6. Assessment for past or current sexual, psychological, or physical abuse or trauma; 7. Cross-training for identification of, and working with, individuals recently engaging in substance abuse; 8. Clinical risk and competency assessment; 9. Universal or standard practices for infection control; c) Review personnel records to ensure each employee with patient contact has received training in CPR within the timeframes permitted. d) Review the facility's personnel training plan to ensure it contains the type and length of training events required in rule. Also review the personnel record of a sample of these staff to ensure the training events detailed in the plan were actually provided. In staff interviews, ask staff if they remember receiving the specified training events.

286 Page 286 of Crisis prevention, crisis intervention and crisis duration services; 11. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Test Revision, as referenced in subparagraph 65E-5.285(1)(a)2., F.A.C., and 12. Honoring preferences contained in advance directives prepared by persons served by the facility. ST - HB051 - Orientation, Cont. Training, Inservice Title Orientation, Cont. Training, Inservice Statute or Rule 65E-5.330(2), FAC (2) In addition to the training required in this rule, procedures must assure that mental health services staff shall annually receive 12 hours continuing training in the skills and knowledge employed in performing their respective responsibilities. Employees during their first year of employment shall undergo no less than the 14 hours of orientation, as described in paragraph (1)(c) above, and 12 hours of in-service training. Review the training plan to ensure the continuing education is included and review personnel records to ensure the planned training was actually provided. ST - HB052 - Training by Qualified Professionals Title Training by Qualified Professionals Statute or Rule 65E-5.330(3). FAC (3) Procedures shall require that individuals who deliver the staff training curriculum for mental health services shall be qualified by their experience and training in the content Review the facility's training plan to determine if the proposed trainer, if designated, is qualified to provide the training. If none is designated, review past training events to determine if the trainer for those events was qualified.

287 Page 287 of 399 presented. ST - HB053 - Training Plan - Mandatory Baker Act Title Training Plan - Mandatory Baker Act Statute or Rule 65E-5.330(4), FAC (4) A plan shall be developed and implemented providing for the mandatory training for employees, emergency room personnel and physicians in the Baker Act, relative to their positions and responsibilities, and any implementing local coordination agreements or protocols. Review the facility's training plan to determine if a comprehensive training schedule has been prepared to address the needs of the specified personnel. ST - HB061 - Pt Rights - Complaints Title Pt Rights - Complaints Statute or Rule 65E-5.180(6), FAC (6) Each facility shall develop a written policy and procedure for receiving, investigating, tracking, managing and responding to formal and informal complaints by a person receiving services or by an individual acting on his or her behalf. (a) The complaint process shall be verbally explained during the orientation process and provided in writing in language and terminology that the person receiving services can understand. It will explain how individuals may address complaints informally through the facility staff and treatment team, and formally through the staff person assigned to handle formal complaints, as well as the administrator or designee of Review the policy and procedure manual to ensure the presence of an approved procedure for handling patient complaints. Interview staff to determine if they understand their facility's procedure. Interview patients to determine how any complaints they made were addressed. Review clinical records to ensure the presence of any patient complaint, if any.

288 Page 288 of 399 the facility. The person receiving services shall also be advised that he or she may contact the Local Advocacy Council, the Florida Abuse Registry, the Advocacy Center for Persons with Disabilities, or any other individual or agency at anytime during the complaint process to request assistance. The complaint process, including telephone numbers for the above named entities, shall be posted in plain view in common areas and next to telephones used by individuals receiving services. Any complaint may be verbal or written. Any staff person receiving an informal or formal complaint dealing with life-safety issues will take immediate action to resolve the matter. (b) Informal complaints are initial complaints that are usually made verbally by a person receiving services or by an individual acting on his or her behalf. If resolution cannot be mutually agreed upon, a formal written complaint may be initiated. (c) When the person receiving services, or a person acting upon that person's behalf, makes a formal complaint a staff person not named in the complaint shall assist the person in initiating the complaint. The complaint shall include the date and time of the complaint and detail the issue and the remedy sought. All formal complaints shall be forwarded to the staff person, or designee, who is assigned to track and monitor formal complaints. All formal complaints shall be tracked and monitored for compliance and shall contain the following information: 1. The date and time the formal complaint was originally received by staff; 2. The date and time the formal complaint was received by the staff assigned to track formal complaints; 3. The nature of the complaint; 4. The name of the person receiving services; 5. The name of the person making the complaint; 6. The name of the individual assigned to investigate the

289 Page 289 of 399 complaint; 7. The date the individual making the complaint was notified of the individual assigned to investigate the complaint; 8. The due date for the written response; and 9. At closure, the written disposition of the formal complaint. (d) The investigation shall be completed within 7 days from the date of entry into the system for tracking complaints. (e) A written response must be given or mailed to the person receiving services within 24 hours of disposition. The individual acting on behalf of the person receiving services shall be notified of the completion of the investigation but will not be given specific details of the disposition unless they have a legal right to the information or a signed release of information is in place. (f) The disposition of a complaint may be appealed to the administrator of the facility. If appealed, the facility administrator or designee shall review the written complaint and the initial disposition. Within five working days, the facility administrator or designee will make a final decision concerning the outcome of the complaint and will provide a written response within 24 hours to the person receiving services. A copy of the written response shall also be given to the staff member assigned to track complaints. ST - HB062 - Pt Rights-Behavior Mgt - De-Escalation Title Pt Rights-Behavior Mgt - De-Escalation Statute or Rule 65E-5.180(7), FAC (7) Seclusion and Restraint for Behavior Management Purposes. All facilities, as defined in Section (10), F.S., are required to adhere to the standards and requirements of subsection (7). (a) General Standards. a) Review personnel records to ensure each staff member with direct patient care responsibilities has received training in verbal de-escalation and team oriented physical management techniques. b) Review personnel records to ensure that staff members who have patient contact receive training in alternatives to seclusion and restraint. c) Review patient medical records of persons for whom the unit logbook indicates restraints have been applied. The

290 Page 290 of Each facility will provide a therapeutic milieu that supports a culture of recovery and individual empowerment and responsibility. Each person will have a voice in determining his or her treatment options. Treatment will foster trusting relationships and partnerships for safety between staff and individuals. Facility practices will be particularly sensitive to persons with a history of trauma. 2. The health and safety of the person shall be the primary concern at all times. 3. Seclusion or restraint shall be employed only in emergency situations when necessary to prevent a person from seriously injuring self or others, and less restrictive techniques have been tried and failed, or if it has been clinically determined that the danger is of such immediacy that less restrictive techniques cannot be safely applied. 4. There is a high prevalence of past traumatic experience among persons who receive mental health services. The response to trauma can include intense fear and helplessness, a reduced ability to cope, and an increased risk to exacerbate or develop a range of mental health and other medical conditions. The experience of being placed in seclusion or being restrained is potentially traumatizing. Seclusion and restraint practices shall be guided by the following principles of trauma-informed care: assessment of traumatic histories and symptoms; recognition of culture and practices that are re-traumatizing; processing the impact of a seclusion or restraint with the person; and addressing staff training needs to improve knowledge and sensitivity. 5. When a person demonstrates a need for immediate medical attention in the course of an episode of seclusion or restraint, the seclusion or restraint shall be discontinued, and immediate medical attention shall be obtained. 6. Persons will not be restrained in a prone position. Prone containment will be used only when required by the immediate situation to prevent imminent serious harm to the person or clinical record should document less restrictive interventions were attempted and failed before the use of restraints, unless physical injury was imminent.

291 Page 291 of 399 others. To reduce the risk of positional asphyxiation, the person will be repositioned as quickly as possible. 7. Responders will pay close attention to respiratory function of the person during containment and restraint. All staff involved will observe the person's respiration, coloring, and other possible signs of distress and immediately respond if the person appears to be in distress. Responding to the person's distress may include repositioning the person, discontinuing the seclusion or restraint, or summoning medical attention, as necessary. 8. Objects that impair respiration shall not be placed over a person's face. In situations where precautions need to be taken to protect staff, staff may wear protective gear. 9. Unless necessary to prevent serious injury, a person's hands shall not be secured behind the back during containment or restraint. 10. The use of walking restraints is prohibited except for purposes of off-unit transportation and may only be used under direct observation of trained staff. In this instance, direct observation means that staff maintains continual visual contact of the person and is within close physical proximity to the person at all times. 11. The person shall be released from seclusion or restraint as soon as he or she is no longer an imminent danger to self or others. 12. Seclusion or restraint use shall not be based on the person's seclusion or restraint use history or solely on a history of dangerous behavior. Dangerous behaviors include those behaviors that jeopardize the physical safety of oneself or others. 13. Seclusion and restraint may not be used simultaneously for children less than 18 years of age. 14. A person who is restrained must not be located in areas, whenever possible, subject to view by persons other than involved staff or where exposed to potential injury by other

292 Page 292 of 399 persons. This does not apply to the use of walking restraints. 15. Each facility utilizing seclusion or restraint procedures shall establish and utilize a Seclusion and Restraint Oversight Committee. ST - HB063 - Pt Rights - Isolation Title Pt Rights - Isolation Statute or Rule 65E-5.180(7)(b)- (c), FAC (b) Staff training. Staff must be trained as part of orientation and subsequently on at least an annual basis. Staff responsible for the following actions will demonstrate relevant competency in the following areas before participating in a seclusion or restraint event or related assessment, or before monitoring or providing care during an event: 1. Strategies designed to reduce confrontation and to calm and comfort people, including the development and use of a personal safety plan, 2. Use of nonphysical intervention skills as well as bodily control and physical management techniques, based on a team approach, to ensure safety, 3. Observing for and responding to signs of physical and psychological distress during the seclusion or restraint event, 4. Safe application of restraint devices, 5. Monitoring the physical and psychological well-being of the person who is restrained or secluded, including but not limited to: respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by facility policy associated with the one hour face-to-face evaluation, 6. Clinical identification of specific behavioral changes that indicate restraint or seclusion is no longer necessary, 7. The use of first aid techniques, and a) Review personnel records to ensure each staff member with direct patient care responsibilities has received training in verbal de-escalation and team oriented physical management techniques. b) Review personnel records to ensure that staff members who have patient contact receive training in alternatives to seclusion and restraint. c) Review patient medical records of persons for whom the unit logbook indicates restraints have been applied. The clinical record should document less restrictive interventions were attempted and failed before the use of restraints, unless physical injury was imminent.

293 Page 293 of Certification in the use of cardiopulmonary resuscitation, including required periodic recertification. The frequency of training for cardiopulmonary resuscitation will be in accordance with certification requirements, notwithstanding provision subparagraph (7)(b). (c) Prior to the Implementation of Seclusion or Restraint. 1. Prior intervention shall include individualized therapeutic actions such as those identified in a personal safety plan that address individual triggers leading to psychiatric crisis. Recommended form CF-MH 3124, Feb. 05, "Personal Safety Plan," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for the purpose of guiding individualized techniques. Prior interventions may also include verbal de-escalation and calming strategies. Non physical interventions shall be the first choice unless safety issues require the use of physical intervention. 2. A personal safety plan shall be completed or updated as soon as possible after admission and filed in the person's medical record. a. This form shall be reviewed by the recovery team, and updated if necessary, after each incident of seclusion or restraint. b. Specific intervention techniques from the personal safety plan that are offered or used prior to a seclusion or restraint event shall be documented in the person's medical record after each use of seclusion or restraint. c. All staff shall be aware of and have ready access to each person's personal safety plan. ST - HB064 - Pt Rights - Isolation - Implementation Title Pt Rights - Isolation - Implementation Statute or Rule 65E-5.180(8), FAC

294 Page 294 of 399 (d) Implementation of Seclusion or Restraint. 1. A registered nurse or highest level staff member, as specified by written facility policy, who is immediately available and who is trained in seclusion and restraint procedures may initiate seclusion or restraint in an emergency when danger to oneself or others is imminent. An order for seclusion or restraint must be obtained from the physician, Advanced Registered Nurse Practitioner (ARNP), or Physician's Assistant (PA), if permitted by the facility to order seclusion and restraint and stated within their professional protocol. The treating physician must be consulted as soon as possible if the seclusion or restraint was not ordered by the person's treating physician. 2. An examination of the person will be conducted within one hour by the physician or may be delegated to an Advanced Registered Nurse Practitioner, Physician's Assistant, or Registered Nurse (RN), if authorized by the facility and trained in seclusion and restraint procedures as described in paragraph (7)(b). This examination shall include a face-to face assessment of the person's medical and behavioral condition, a review of the clinical record for any pre-existing medical diagnosis or physical condition which may contraindicate the use of seclusion or restraint, a review of the person's medication orders including an assessment of the need to modify such orders during the period of seclusion or restraint, and an assessment of the need or lack of need to elevate the person's head and torso during restraint. The comprehensive examination must determine that the risks associated with the use of seclusion or restraint are significantly less than not using seclusion or restraint and whether to continue or terminate the intervention. A licensed psychologist may conduct only the behavioral assessment portion of the comprehensive assessment if authorized by the facility and trained in seclusion and restraint procedures as described in paragraph (7)(b). Documentation of the comprehensive

295 Page 295 of 399 examination, including the time and date completed, shall be included in the person's medical record. If the face-to-face evaluation is conducted by a trained Registered Nurse, the attending physician who is responsible for the care of the person must be consulted as soon as possible after the evaluation is completed. 3. Each written order for seclusion or restraint is limited to four hours for adults, age 18 and over; two hours for children and adolescents age nine through 17; or one hour for children under age nine. A seclusion or restraint order may be renewed in accordance with these limits for up to a total of 24 hours, after consultation and review by a physician, ARNP, or PA in person, or by telephone with a Registered Nurse who has physically observed and evaluated the person. When the order has expired after 24 hours, a physician, ARNP, or PA must see and assess the person before seclusion or restraint can be re-ordered. The results of this assessment must be documented. Seclusion or restraint use exceeding 24 hours requires the notification of the Facility Administrator or designee. 4. All orders must be signed within 24 hours of the initiation of seclusion or restraint. 5. The order shall include the specific behavior prompting the use of seclusion or restraint, the time limit for seclusion or restraint, and the behavior necessary for the person's release. Additionally, for restraint, the order shall contain the type of restraint ordered and the positioning of the person, including possibly elevating the person's head for respiratory and other medical safety considerations. Consideration shall be given to age, physical fragility, and physical disability when ordering restraint type. 6. An order for seclusion or restraint shall not be issued as a standing order or on an as-needed basis. 7. In order to protect the safety of each person served by a facility, each person shall be searched for contraband before

296 Page 296 of 399 or immediately after being placed into seclusion or restraints. 8. The person shall be clothed appropriately for temperature and at no time shall a person be placed in seclusion or restraint in a nude or semi-nude state. 9. Every secluded or restrained person shall be immediately informed of the behavior that resulted in the seclusion or restraint and the behavior and the criteria reflecting absence of imminent danger that are necessary for release. 10. For persons under the age of 18, the facility must notify the parent(s) or legal guardian(s) of the person who has been restrained or placed in seclusion as soon as possible, but no later than 24 hours, after the initiation of each seclusion or restraint event. This notification must be documented in the person's medical record, including the date and time of notification and the name of the staff person providing the notification. 11. For each use of seclusion or restraint, the following information shall be documented in the person's medical record: the emergency situation resulting in the seclusion or restraint event; alternatives or other less restrictive interventions attempted, as applicable, or the clinical determination that less restrictive techniques could not be safely applied; the name and title of the staff member initiating the seclusion or restraint; the date/time of initiation and release; the person's response to seclusion or restraint, including the rationale for continued use of the intervention; and that the person was informed of the behavior that resulted in the seclusion or restraint and the criteria necessary for release. ST - HB065 - Restraints, Seclusion - Facility Guide Title Restraints, Seclusion - Facility Guide Statute or Rule (4)(b), FS

297 Page 297 of 399 (b) Facilities shall develop and maintain, in a form accessible to and readily understandable by patients and consistent with rules adopted by the department, the following: 1. Criteria, procedures, and required staff training for any use of close or elevated levels of supervision, of restraint, seclusion, or isolation, or of emergency treatment orders, and for the use of bodily control and physical management techniques. 2. Procedures for documenting, monitoring and requiring clinical review of all uses of the procedures described in subparagraph 1. and for documenting and requiring review of any incidents resulting in injury to patients. 3. A system for investigating, tracking, managing, and responding to complaints by persons receiving services or individuals acting on their behalf. Review policies and procedures to ensure criteria for use of these interventions is in place as well as staff training, incident review, and complaint review. Such information must be made available to staff, guardian advocates and patients. Interview selected staff and patients to see if they are aware of such policies and procedures. Review restraint and seclusion log to determine frequency of use. Review patient medical records to determine what prompted use of the intervention, what alternatives were attempted, and whether adequate justification existed for their use. Were restraints and seclusion terminated as soon as the behavior which prompted their use is no longer a factor? ST - HB066 - Pt Rights-Restraint, Seclusion Limits Title Pt Rights-Restraint, Seclusion Limits Statute or Rule (4)(c), FS (c) A facility may not use seclusion or restraint for punishment, to compensate for inadequate staffing, or for the convenience of staff. Facilities shall ensure that all staff is made aware of these restrictions on the use of seclusion and restraint and shall make and maintain records which demonstrate that this information has been conveyed to individual staff members. Review policies and procedures to ensure use of restraint and seclusion is prohibited for reasons of punishment, inadequate staffing or staff convenience. Review personnel files to ensure each staff member has received training in these policies.

298 Page 298 of 399 ST - HB067 - Restraints, Seclusion - Review Committee Title Restraints, Seclusion - Review Committee Statute or Rule 65E-5.180(13), FAC (e) During Seclusion or Restraint Use. 1. When restraint is initiated, nursing staff shall see and assess the person as soon as possible but no later than 15 minutes after initiation and at least every hour thereafter. The assessment shall include checking the person's circulation and respiration, including necessary vital signs (pulse and respiratory rate at a minimum). 2. The person over age 12 who is secluded shall be observed by trained staff every 15 minutes. At least one observation an hour will be conducted by a nurse. Restrained persons must have continuous observation by trained staff. Secluded children age 12 and under must be monitored continuously by face-to-face observation or by direct observation through the seclusion window for the first hour and then at least every 15 minutes thereafter. 3. Monitoring the physical and psychological well-being of the person who is secluded or restrained shall include but is not limited to: respiratory and circulatory status; signs of injury; vital signs; skin integrity; and any special requirements specified by facility policies. This monitoring shall be conducted by trained staff as required in paragraph (7)(b). 4. During each period of seclusion or restraint, the person must be offered reasonable opportunities to drink and toilet as requested. In addition, the person who is restrained must be offered opportunities to have range of motion at least every two hours to promote comfort. Each facility shall have written policies and procedures specifying the frequency of providing drink, toileting, and check of bodily positioning to avoid

299 Page 299 of 399 traumatizing a person and retaining the person's maximum degree of dignity and comfort during the use of bodily control and physical management techniques. 5. Documentation of the observations and the staff person's name shall be recorded at the time the observation takes place. ST - HB068 - Pt Rights - Seclusion/Restraint-Release, Post Title Pt Rights - Seclusion/Restraint-Release, Post Statute or Rule 65E-5.180(7)(f), FAC (f) Release from Seclusion or Restraint and Post-Release Activities. 1. Release from seclusion or restraint shall occur as soon as the person no longer appears to present an imminent danger to themselves or others. Upon release from seclusion or restraint, the person's physical condition shall be observed, evaluated, and documented by trained staff. Documentation shall also include: the name and title of the staff releasing the person; and the date and time of release. 2. After a seclusion or restraint event, a debriefing process shall take place to decrease the likelihood of a future seclusion or restraint event for the person and to provide support. a. Each facility shall develop policies to address: (I) A review of the incident with the person who was secluded or restrained. The person shall be given the opportunity to process the seclusion or restraint event as soon as possible but no longer than within 24 hours of release. This debriefing discussion shall take place between the person and either the recovery team or another preferred staff member. This review shall seek to understand the incident within the framework of the person's life history and mental health issues. It should assess the impact of the event on the person and help the person identify and expand coping mechanisms to avoid the

300 Page 300 of 399 use of seclusion or restraint in the future. The discussion will include constructive coping techniques for the future. A summary of this review should be documented in the person's medical record. (II) A review of the incident with all staff involved in the event and supervisors or administrators. This review shall be conducted as soon as possible after the event and shall address: the circumstances leading to the event, the nature of de-escalation efforts and alternatives to seclusion and restraint attempted, staff response to the incident, and ways to effectively support the person's constructive coping in the future and avoid the need for future seclusion or restraint. The outcomes of this review should be documented by the facility for purposes of continuous performance improvement and monitoring. The review findings will be forwarded to the Seclusion and Restraint Oversight Committee, and (III) Support for other persons served and staff, as needed, to return the unit to a therapeutic milieu. b. Within 2 working days after any use of seclusion or restraint, the recovery team shall meet and review the circumstances preceding its initiation and review the person's recovery plan and personal safety plan to determine whether any changes are needed in order to prevent the further use of seclusion or restraint. The recovery team shall also assess the impact the event had on the person and provide any counseling, services, or treatment that may be necessary as a result. The recovery team shall analyze the person's clinical record for trends or patterns relating to conditions, events, or the presence of other persons immediately before or upon the onset of the behavior warranting the seclusion or restraint, and upon the person's release from seclusion. The recovery team shall review the effectiveness of the emergency intervention and develop more appropriate therapeutic interventions. Documentation of this review shall be placed in the person's clinical record.

301 Page 301 of 399 c. The Seclusion and Restraint Oversight Committee shall conduct timely reviews of each use of seclusion and restraints and monitor patterns of use, for the purpose of assuring least restrictive approaches are utilized to prevent or reduce the frequency and duration of use. ST - HB069 - Pt Rights - Seclusion - Reporting Title Pt Rights - Seclusion - Reporting Statute or Rule 65E-5.180(9), FAC (g) Reporting 1. All facilities, as defined in Section (10), Florida Statutes, are required to report each seclusion and restraint event to the Department of Children and Families. This reporting shall be done electronically using the Department's web-based application either directly via the data input screens or indirectly via the File Transfer Protocol batch process. The required reporting elements are: Provider tax identification number; Person's social security number and identification number; date and time the seclusion or restraint event was initiated; discipline of the person ordering the seclusion or restraint; discipline of the person implementing the seclusion or restraint; reason seclusion or restraint was initiated; type of restraint used; whether significant injuries were sustained by the person; and date and time seclusion or restraint was terminated. Facilities shall report seclusion and restraint events on a monthly basis. Events that result in death or significant injury either to a staff member or person shall be reported to the department's web based system in accordance with department operating procedures. 2. All facilities that are subject to the Conditions of Participation for Hospitals, 42 Code of Federal Regulations, part 482, under the Centers for Medicare and Medicaid Seclusion means an emergency response in which, as a means of controlling a patient's immediate symptoms or behavior, the patient's ability to move about freely has been limited by staff or in which a patient has been physically segregated in any fashion from other patients. Seclusion is an involuntarily imposed closed door or locked door isolation of the patient from others and requires a written order by a physician except as described and authorized in section 65E , F.A.C. Interview patients to determine if they have been involuntarily secluded in a locked or closed door setting. Ensure that such events are documented in the clinical record and that alternatives to seclusion were attempted by staff before seclusion was implemented. The seclusion process shall evidence consideration that alternatives have been considered by implementing staff. In order to enhance patient safety, each patient shall be searched for contraband before placing the patient into seclusion. c) Review clinical records to ensure the presence of a physician order for any seclusion. d) Review facility policies and procedures to ensure that policies permit staff other than physicians to initiate seclusion in an emergency situation. If such emergency initiation of seclusion is permitted, review unit logbook to determine if seclusion has been implemented on any current patients. Review those patient's clinical records to ensure that a verbal physician order was received within one hour and that a written order was signed within 24 hours. Also ensure that a RN or ARNP assessed the patient within 15 minutes if emergency seclusion was initiated by other than a RN or ARNP. e) Review by-laws, policies, and minutes of the facility's medical oversight committee to ensure it had authorized each physician who had ordered seclusion. f) Review clinical records to ensure no physician order for seclusion exceeds the period of time permit by rule. g) Review clinical records to ensure that any extension of seclusion orders was reviewed by a physician or ARNP. h) See Tag BA 031 i) Ensure each unit that uses restraint or seclusion maintains a logbook or similar registry. Examine the logbook to

302 Page 302 of 399 Services (CMS), must report to CMS any death that occurs in the following circumstances: a. While a person is restrained or secluded; b. Within 24 hours after release from seclusion or restraint; or c. Within one week after seclusion or restraint, where it is reasonable to assume that use of the seclusion or restraint contributed directly or indirectly to the person's death. Each death described in this section shall be reported to CMS by telephone no later than the close of business the next business day following knowledge of the persons' death. A report shall simultaneously be submitted to the Director of Mental Health/Designee in the Mental Health Program Office headquarters in Tallahassee, FL. The address is: 1317 Winewood Blvd., Tallahassee, Fl, The Department shall collect and review the data on a monthly basis. The Director of Mental Health shall be informed of any deaths or significant injuries related to seclusion or restraint and significant trends regarding seclusion and restraint use. determine that it sequentially records all uses of seclusion and other data required by rule. Examine clinical records to ensure the seclusion events were documented. j) Review policies and procedures to ensure that the facility has informed its staff of seclusion requirements. Review clinical records of persons placed in seclusion to ensure each observation of patients is recorded, that the frequency of observation is no more than 15 minutes apart, and that one observation per hour is conducted by a nurse. Conduct interviews of patients who were secluded to ensure that they were offered the opportunity to drink, toilet, and have range of motion while in seclusion. k) Interview patients who had been secluded to ensure that staff had informed them of the conditions to exit from seclusion immediately upon being placed into seclusion. l) Review facility policies and procedures that define early termination from seclusion. m) Review clinical records of persons who had been placed into seclusion to ensure documentation of their satisfactory physical condition upon release from seclusion and that the required therapeutic discussion of the seclusion is documented. n) Review the unit logbook to determine if any patients had been placed into seclusion at least twice in a 24-hour period. If so, review their clinical record to ensure the required treatment team meeting occurred and the elements to be addressed are documented. ST - HB071 - Pt Rights - RESTRAINTS Title Pt Rights - RESTRAINTS Statute or Rule 65E-5.180(10), FAC (h) Nothing herein shall affect the ability of emergency medical technicians, paramedics or physicians or any person acting under the direct medical supervision of a physician to provide examination or treatment of incapacitated persons in accordance with Section , F.S. Restraint means the immobilization of a person's body in order to restrict free movement or range of motion, whether by physical holding or by use of a mechanical device. For purposes of this chapter, restraint includes all applications of such procedures, specifically including emergency treatment orders and emergency medical procedures which include protective medical devices for ambulating safety, or furniture used to protect mobility-impaired persons from falls and injury. The use of walking restraints when used during transportation under the supervision of trained staff is not considered restraint. a) Review patient medical records of all patients for whom restraints have been used. b) Interview staff to determine if walking restraints are ever employed; if so, determine the conditions under which they are acceptable to the facility.

303 Page 303 of 399 ST - HB072 - Pt Rights-Restraints-Medical Devices c) Review clinical record to ensure the presence of a physician order for any restraint. d) Review facility policies and procedures to ensure that policies permit staff other than physicians to initiate restraint in an emergency situation. If such emergency initiation of restraint is permitted, review unit logbook to determine if restraint has been implemented on any current patients. Review those patient's clinical records to ensure that a verbal physician order was received within one hour and that a written order was signed within 24 hours. Also ensure that a RN or ARNP assessed the patient within 15 minutes if emergency restraint was initiated by other than a RN. e) Review any policy or procedure or committee meeting minutes to ensure the physician who has ordered restraints is authorized to do so. f) Review clinical records to ensure no physician order for restraint exceeds the period of time permit by rule. g) Review clinical records to ensure that any extension of restraint orders was reviewed by a physician or ARNP. h) Review policies and procedures to ensure that staff are required to search each patient for contraband when placed into restraints and that each patient is required to be medically evaluated for restraints. Review clinical records to ensure that staff have charted the documentation of these actions. i) Ensure each unit that uses restraint or seclusion maintains a logbook or similar registry. Examine the logbook to determine that it sequentially records all uses of restraint and other data required by rule. Examine clinical records to ensure the restraint events were documented. j) Review policies and procedures to ensure that the facility has informed its staff of restraint requirements. Review clinical records of persons placed in restraint to ensure each observation of patients is recorded, that the frequency of observation is no more than 15 minutes apart, and that one observation per hour is conducted by a nurse. Conduct interviews of patients who were restrained to ensure that they were offered the opportunity to drink, toilet, and have range of motion while in restraints. Observe the room in which restrained patients are held to ensure it is located outside the view of persons other than staff and that no obvious safety risks exist. k) Interview patients who had been restrained to ensure that staff had informed them of the conditions to exit from restraints immediately upon being placed into restraints. l) Review facility policies and procedures that define early termination from restraints. m) Review patient medical records of persons who had been placed into restraints to ensure documentation of their satisfactory physical condition upon release from restraints and that the required therapeutic discussion of the restraints is documented. n) Review patient medical records of patients who had been restrained to ensure that the patient's treatment plan was reviewed and revised as appropriate. Title Pt Rights-Restraints-Medical Devices Statute or Rule 65E-5.180(11), FAC

304 Page 304 of 399 (8) Use of Protective Medical Devices with Frail or Mobility Impaired Persons. (a) When ordering safety or protective devices such as posey vests, geri-chairs, mittens, and bed rails which also restrain, facility staff shall consider alternative means of providing such safety so that the person's need for regular exercise is accommodated to the greatest extent possible. (b) Where frequent or prolonged use of safety or protective devices is required, the person's treatment plan shall address debilitating effects due to decreased exercise levels such as circulation, skin, and muscle tone and the patient's need for maintaining or restoring bowel and bladder continence. (c) The treatment plan shall include scheduled activities to lessen deterioration due to the usage of such protective medical devices. Review patient medical records for provision of alternative methods utilized other than the protective devices. -Review the activity plan -Observe patients in activities -Review nursing assessments of patient skin, muscle tone, and bowel and bladder continence. ST - HB073 - Pt Rights/Supervision Title Pt Rights/Supervision Statute or Rule 65E-5.180(9), FAC (9) Elevated Levels of Supervision. Receiving and treatment facilities shall ensure that where one-on-one supervision is ordered by a physician, it shall be continuous and shall not be interrupted as a result of shift changes or due to conflicting staff assignments. Such supervision shall be continuous until documented as no longer medically necessary by a physician. -Review how one-on-one supervision is conducted -Review schedule of assigned staff -Observe patients who are on one-on-one supervision.

305 Page 305 of 399 ST - HB074 - Pt Rights - Right to Communicate Title Pt Rights - Right to Communicate Statute or Rule (5)(a)&(d), FS (a) Each person receiving services in a facility providing mental health services under this part [Chapter 394, Part I, F.S.] has the right to communicate freely and privately with persons outside the facility unless it is determined that such communication is likely to be harmful to the person or others. (d) Each facility shall establish reasonable rules governing visitors, visiting hours, and the use of telephones by patients in the least restrictive possible manner. Patients shall have the right to contact and to receive communication from their attorneys at any reasonable time. Review policies and procedures to ensure that all patients, regardless of age or stage of development, are assured of free and open communication by telephone, mail, and visitation, unless restricted for safety reasons. Review rules to ensure reasonableness as to patient right to communicate vs. hospital need to maintain order and provide scheduled treatment. ST - HB075 - Pt Rights - Communication Restriction Notice Title Pt Rights - Communication Restriction Notice Statute or Rule (5)(c), FS (c)...if a patient's right to communicate or to receive visitors is restricted by the facility, written notice of such restriction and the reasons for the restriction shall be served on the patient, the patient's attorney, and the patient's guardian, guardian advocate, or representative; and such restriction shall be recorded on the patient's clinical record with the reasons therefor. The restriction of a patient's right to communicate or to receive visitors shall be reviewed at least every 7 days. The Interview patients to determine if their ability to communicate with others outside the facility has at any time been restricted. If a patient's communication was restricted, verify that: 1.Full documentation of the extent and justified reasons for the restrictions are found in the patient medical record; 2.That the patient and others required by statute have been notified in writing; and 3. That reviews have been completed at least every seven days.

306 Page 306 of 399 right to communicate or receive visitors shall not be restricted as a means of punishment. ST - HB076 - Pt Rights - Communication Restrict-Recording Title Pt Rights - Communication Restrict-Recording Statute or Rule 65E-5.190(1), FAC (1) If the treatment team imposes any restrictions on whom patient person in a receiving or treatment facility may communicate, such restrictions and justification shall be recorded in the person's clinical record. Recommended form CF-MH 3049, Feb. 05, "Restriction of Communication or Visitors," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. Facility staff shall make competent adults aware that they have the ability to waive the confidentiality of their presence in a receiving or treatment facility and allowing all or specified individuals the person selects access to private and open communication with the person. Recommended form CF-MH 3048, Feb. 05, "Confidentiality Agreement," incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. Review clinical records to determine if any restrictions reported by patients during interviews are adequately justified. Use of recommended form "Restriction of Communication or Visitors" (CF-MH 3049). ST - HB077 - Pt Rights - Communication - Correspondence Title Pt Rights - Communication - Correspondence Statute or Rule (5)(b), FS

307 Page 307 of 399 (b) Each patient admitted to a facility under the provisions of this part shall be allowed to receive, send, and mail sealed, unopened correspondence; and no patient's incoming or outgoing correspondence shall be opened, delayed, held, or censored by the facility unless there is reason to believe that it contains items or substances which may be harmful to the patient or others, in which case the administrator may direct reasonable examination of such mail and may regulate the disposition of such items or substances. Interview patients and staff and review policies and procedures to determine that people have the right to send and receive unopened mail unless restricted. Determine if stationery and stamps are provided to patients by the facility if needed. ST - HB078 - Pt Rights - Visitors Title Pt Rights - Visitors Statute or Rule (5)(c), FS (c) Each facility must permit immediate access to any patient, subject to the patient's right to deny or withdraw consent at any time, by the patient's family members, guardian, guardian advocate, representative, Florida statewide or local advocacy council, or attorney, unless such access would be detrimental to the patient. Review facility policies to ensure that family, guardians, guardian advocates, HRAC/APD members, and attorney have immediate access to a person unless it is considered detrimental to the person or unless the person chooses not to see the person. Telephone the HRAC to determine whether they have free access to any patient at any time. See BA 074 for facility rules governing visitors and visiting hours. ST - HB079 - Pt Rights - Phones Access Title Pt Rights - Phones Access Statute or Rule (5)(a), FS

308 Page 308 of 399 (a) Each facility shall make available as soon as reasonably possible to persons receiving services a telephone that allows for free local calls and access to a long-distance service. A facility is not required to pay the costs of a patient's long-distance calls. The telephone shall be readily accessible to the patient and shall be placed so that the patient may use it to communicate privately and confidentially. The facility may establish reasonable rules for the use of this telephone, provided that the rules do not interfere with a patient's access to a telephone to report abuse pursuant to paragraph (e). Confirm availability of a private and toll-free telephone, particularly to report abuse. Interview patients and staff and review policies and procedures to determine that patients have the right to make and receive telephone calls. ST - HB080 - Pt Rights - Communication - Telephone Title Pt Rights - Communication - Telephone Statute or Rule 65E-5.190(2), FAC (2) Immediate access to a telephone shall be provided to each person requesting to call his or her legal counsel, Florida Abuse Registry, Florida Local Advocacy Council, or the Advocacy Center for Persons with Disabilities. Tour the units to ensure the presence of toll-free telephones available adjacent to the site where rights/advocacy information is posted. Patients should be able to dial the phone, rather than relying on staff to do so. The phone should be located far enough away from the nurse's station to permit privacy of conversation. The cord may be shortened to prevent the phone's use as a weapon. ST - HB081 - Pt Rights/Reporting Abuse Title Pt Rights/Reporting Abuse Statute or Rule (5)(e), FS (e) Each patient receiving mental health treatment in any facility shall have ready access to a telephone in order to Interview patients to confirm that staff has advised them of procedures for reporting abuse. Observe the location of a telephone available for reporting abuse and the posting of the Abuse Registry's telephone

309 Page 309 of 399 report an alleged abuse. The facility staff shall orally and in writing inform each patient of the procedure for reporting abuse and shall make every reasonable effort to present the information in a language the patient understands. A written copy of that procedure, including the telephone number of the central abuse hotline and reporting forms, shall be posted in plain view. number close to the phone. Tour the unit to view the posted abuse reporting procedure. ST - HB082 - Pt Rights/Personal Effects Title Pt Rights/Personal Effects Statute or Rule (6), FS (6) CARE AND CUSTODY OF PERSONAL EFFECTS OF PATIENTS - A patient's right to the possession of his or her clothing and personal effects shall be respected. The facility may take temporary custody of such effects when required for medical and safety reasons. A patient's clothing and personal effects shall be inventoried upon their removal into temporary custody. Copies of this inventory shall be given to the patient and to the patient's guardian, guardian advocate, or representative and shall be recorded in the patient's clinical record. This inventory may be amended upon the request of the patient or the patient's guardian, guardian advocate, or representative. The inventory and any amendments to it must be witnessed by two members of the facility staff and by the patient, if able. All of a patient's clothing and personal effects held by the facility shall be returned to the patient immediately upon the discharge or transfer of the patient from the facility, unless such return would be detrimental to the patient. If personal effects are not returned to the patient, the reason must be documented in the clinical record along with the disposition of the clothing and personal effects, which may be Review policies and procedures to ensure compliance with statute. Interview patients and staff to determine that patients have the right to retain their clothing and personal effects. Sample patient charts to confirm presence of the required inventory, witnessed by two staff and by the patient, if possible. Upon discharge or transfer, does the clinical record reflect that personal effects were returned to the patient, representative, or guardian advocate?

310 Page 310 of 399 given instead to the patient's guardian, guardian advocate, or representative. As soon as practicable after an emergency transfer of a patient, the patient's clothing and personal effects shall be transferred to the patient's new location, together with a copy of the inventory and any amendments, unless an alternate plan is approved by the patient, if able, and by the patient's guardian, guardian advocate, or representative. ST - HB083 - Pt Rights/Personal Effects Title Pt Rights/Personal Effects Statute or Rule 65E-5.200, FAC Each designated receiving and treatment facility shall develop policies and procedures governing what personal effects will be removed from persons for reasons of personal or unit safety, how they will be safely retained by the facility, and how and when they will be returned to the person or other authorized individual. Policies and procedures shall specify how contraband and other personal effects determined to be detrimental to the person will be addressed when not returned to the person or other authorized individual. An inventory of personal effects shall be witnessed by two staff and by the person, if able, at the time of admission, at any time the inventory is amended, and at the time the personal effects are returned or transferred. Recommended form CF-MH 3043, Feb. 05, "Inventory of Personal Effects," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C. of this rule chapter may be used for this purpose. Review policies and procedures to ensure the facility has developed sufficient procedures to meet the requirements. When personal effects are removed from a patient, the use of recommended form "Inventory of Personal Effects" (CF-MH 3043) is considered by the department to be sufficient. However, most facilities have modified the form to be more inclusive of the items the patient was allowed to retain.

311 Page 311 of 399 ST - HB084 - Pt Rights - Voting Title Pt Rights - Voting Statute or Rule (7), FS (7) VOTING IN PUBLIC ELECTIONS - A patient who is eligible to vote according to the laws of the state has the right to vote in the primary and general elections. ST - HB085 - Pt Rights - Voting Title Pt Rights - Voting Statute or Rule 65E-5.210, FAC The facility shall have voter registration forms and applications for absentee ballots readily available at the facility or in accordance with the procedures established by the supervisor of elections, and shall assure that each person who is eligible to vote and wishes to do so, may exercise his or her franchise. Each designated receiving and treatment facility shall develop policies and procedures governing how persons will be assisted in exercising their right to vote. Review policies to ensure the facility has procedures in place to assist patient in exercising their right to vote. It is unlikely that patients experiencing very short stays in a receiving facility will require access to voting. However, longer stay treatment facilities must actively extend this right to all patients whose competence has not been removed by a court. ST - HB086 - Pt Rights - Habeas Corpus - Petition for Writ Title Pt Rights - Habeas Corpus - Petition for Writ Statute or Rule (8), FS

312 Page 312 of 399 (8) HABEAS CORPUS - (a) At any time, and without notice, a person held in a receiving or treatment facility, or a relative, friend, guardian, guardian advocate, representative, or attorney, or the department, on behalf of such a person, may petition for a writ of habeas corpus to question the cause and legality of such detention and request that the court order a return to the writ in accordance with chapter 79. Each patient held in a facility shall receive a written notice of the right to petition for a writ of habeas corpus. (b) At any time, and without notice, a person who is a patient in a receiving or treatment facility, or a relative, friend, guardian advocate, representative, or attorney or the department, on behalf of such person, may file a petition in the circuit court where the patient is being held alleging that the patient is unjustly denied a right or privilege granted herein or that a procedure authorized herein is being abused. Upon filing of such a petition, the court shall have the authority to conduct a judicial inquiry and to issue any order needed to correct an abuse of the provisions of this part. (c) The administrator of any receiving or treatment facility receiving a petition under this subsection shall file the petition with the clerk of the court on the next court working day. (d) No fee shall be charged for the filing of a petition under this subsection. a) Sample clinical records for documentation that the patient had been given a notice of his/her right to file a petition. Use of recommended form "Notice of Right to Petition for Writ of Habeas Corpus or for Redress of Grievances" (CF-MH 3036) is considered by the department to be sufficient to document the required notice. b) If a petition had been filed, had it been provided to the clerk of the court within one working day? c) Interview staff to determine that they understand their responsibilities under the law. ST - HB087 - Pt Rights - Habeas Corpus- Notice of Rights Title Pt Rights - Habeas Corpus- Notice of Rights Statute or Rule 65E-5.220, FAC

313 Page 313 of 399 (1) Upon admission to a receiving or treatment facility, each person shall be given notice of his or her right to petition for a writ of habeas corpus and for redress of grievances. Recommended form CF-MH 3036, Feb. 05, "Notice of Right to Petition for Writ of Habeas Corpus or for Redress of Grievances," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. A copy of the notice shall be provided to the guardian, guardian advocate, representative, or the health care surrogate or proxy, and the person's clinical record shall contain documentation that the notice was provided. A petition form shall be promptly provided by staff to any person making a request for such a petition. Recommended form CF-MH 3090, Feb. 05, "Petition for Writ of Habeas Corpus or for Redress of Grievances," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. (2) Receiving and treatment facilities shall accept and forward to the appropriate court of competent jurisdiction a petition submitted by the person or others in any form in which it is presented. 1) Review clinical records to ensure that all patients admitted to a facility and other required persons have been notified of this right. Use of recommended form "Notice of Right to Petition for Writ of Habeas Corpus or for Redress of Grievances" (CF-MH 3036) is considered by the department to be sufficient to document the required notice. 2) Use of recommended form "Petition for Writ of Habeas Corpus or for Redress of Grievances" (CF-MH 3090) is considered by the department to be sufficient. ST - HB088 - Treatment and Discharge Planning Title Treatment and Discharge Planning Statute or Rule (11), FS (11) RIGHT TO PARTICIPATE IN TREATMENT AND DISCHARGE PLANNING - The patient shall have the opportunity to participate in Interview staff and patients to ensure that patients are informed of their right to participate in treatment, discharge planning, and selection of aftercare provider.

314 Page 314 of 399 treatment and discharge planning and shall be notified in writing of his or her right, upon discharge from the facility, to seek treatment from the professional or agency of the patient's choice. ST - HB089 - Pt Rights/Posting Notices Title Pt Rights/Posting Notices Statute or Rule (12), FS (12) POSTING OF NOTICE OF RIGHTS OF PATIENTS - Each facility shall post a notice listing and describing, in the language and terminology that the persons to whom the notice is addressed can understand, the rights provided in this section. This notice shall include a statement that provisions of the federal Americans with Disabilities Act apply and the name and telephone number of a person to contact for further information. This notice shall be posted in a place readily accessible to patients and in a format easily seen by patients. This notice shall include the telephone numbers of the Florida local advocacy council and Advocacy Center for Persons with Disabilities, Inc. Observe the unit and observe the following posters/notices: Patient Rights APD Advocacy Center ADA Provisions Notices must be in simple language and located close to the telephone. ST - HB095 - Human Rights Advocacy Comm Title Human Rights Advocacy Comm Statute or Rule , FS Any facility designated by the department as a receiving or treatment facility must allow access to any patient and the Call the HRAC to determine if at any time, any member of the HRAC had a request to meet with a patient or to review a clinical record denied or delayed.

315 Page 315 of 399 clinical and legal records of any patient admitted pursuant to the provisions of this act by members of the Florida statewide and local advocacy councils. ST - HB096 - Pt's Representative - Voluntary Admissions Title Pt's Representative - Voluntary Admissions Statute or Rule (1), FS (1) VOLUNTARY PATIENTS - At the time a patient is voluntarily admitted to a receiving or treatment facility, the identity and contact information of a person to be notified in a case of an emergency shall be entered in the patient's clinical record. For voluntary patients, there should be an emergency contact listed in the patient's clinical record. No notice shall be made without the consent of the patient. Sample patient charts to confirm a representative has been designated for involuntary patients who have no guardian. ST - HB097 - Pt's Representative - Involuntary Admissions Title Pt's Representative - Involuntary Admissions Statute or Rule (2), FS 2) INVOLUNTARY PATIENTS - (a) At the time a patient is admitted to a facility for involuntary examination or placement, or when a petition for involuntary placement is filed, the names, addresses, and telephone numbers of the patient's guardian or guardian advocate, or representative if the patient has no guardian, and the patient's attorney shall be entered in the patient's clinical record. (b) If the patient has no guardian, the patient shall be asked to designate a representative. If the patient is unable or unwilling Confirm from patient clinical records that the representative selected by the facility (if the patient has not selected his/her own) is one of the seven permitted representatives and that the representative does not belong to one of the prohibited groups listed in paragraph (e). Ensure that the clinical chart documents the representative was notified by telephone or in person within 24 hours by the facility of the patient's admission.

316 Page 316 of 399 to designate a representative, the facility shall select a representative. (c) The patient shall be consulted with regard to the selection of a representative by the receiving or treatment facility and shall have authority to request that any such representative be replaced. (d) When the receiving or treatment facility selects a representative, first preference shall be given to a health care surrogate, if one has been previously selected by the patient. If the patient has not previously selected a health care surrogate, the selection, except for good cause documented in the patient's record, shall be made from the following list in the order of listing: 1. The patient's spouse. 2. An adult child of the patient. 3. A parent of the patient. 4. The adult next of kin of the patient. 5. An adult friend of the patient. 6. The appropriate Florida local advocacy council as provided in s (e) A licensed professional providing services to the patient under this part, an employee of a facility providing direct services to the patient under this part, a department employee, a person providing other substantial services to the patient in a professional or business capacity, or a creditor of the patient shall not be appointed as the patient's representative. ST - HB099 - Guardian Advocate - Petition for Appointment Title Guardian Advocate - Petition for Appointment Statute or Rule (1), FS (1) The administrator may petition the court for the appointment of a guardian advocate based upon the opinion of Review policies and procedures to ensure consistency with statute. Sample patient charts to ensure that a guardian advocate is requested for all patients determined by staff to be

317 Page 317 of 399 a psychiatrist that the patient is incompetent to consent to treatment. incompetent to consent to treatment. ST - HB100 - Guardian Advocate- Provision of Pet'n Copies Title Guardian Advocate- Provision of Pet'n Copies Statute or Rule 65E-5.230(1), FAC (1) A copy of the completed recommended form CF-MH 3106 "Petition for Adjudication of Incompetence to Consent to Treatment and Appointment of a Guardian Advocate," as referenced in subparagraph 65E-5.170(1)(d)2., F.A.C., or its equivalent, shall be given to the person, the person's representative if any, and to the prospective guardian advocate with a copy retained in the person's clinical record. Review the clinical records of patients who are believed to be incompetent to consent to treatment to ensure that a petition has been completed and filed with the court. "Petition for Adjudication of Incompetence to Consent to Treatment and Appointment of a Guardian Advocate" (CF-MH 3106) is considered by the department to be sufficient for this purpose. ST - HB101 - Guardian Advocate- Duties, Responsibilities Title Guardian Advocate- Duties, Responsibilities Statute or Rule (2), FS (2) A facility requesting appointment of a guardian advocate must, prior to the appointment, provide the prospective guardian advocate with information about the duties and responsibilities of guardian advocates, including the information about the ethics of medical decision making. Before asking a guardian advocate to give consent to treatment for a patient, the facility shall provide to the guardian advocate sufficient information so that the guardian advocate can decide whether to give express and informed Does the chart reflect that the staff provided the prospective guardian advocate with the required information? Does the chart reflect that the guardian advocate met with the patient and his/her physician in person if possible or by telephone if not prior to consenting to treatment? Does the chart contain a court order authorizing the guardian advocate to: consent to mental health treatment? Consent to medical treatment? (as applicable) consent to ECT? (as applicable)

318 Page 318 of 399 consent to the treatment, including information that the treatment is essential to the care of the patient, and that the treatment does not present an unreasonable risk of serious, hazardous or irreversible side effects. Before giving consent to treatment, the guardian advocate must meet and talk with the patient and the patient's physician in person, if at all possible, and by telephone, if not. The decision of the guardian advocate may be reviewed by the court, upon petition of the patient's attorney, the patient's family or the facility administrator. ST - HB102 - Guardian Advocate- Pre-Appointment Training Title Guardian Advocate- Pre-Appointment Training Statute or Rule (3), FS 65E-5.230(2), FAC (3), FS (3) Prior to a guardian advocate exercising his or her authority, the guardian advocate shall attend a training course approved by the court. The training course, of not less than 4 hours, must include, at minimum, information about the patient rights, psychotropic medications, diagnosis of mental illness, the ethics of medical decision making, and duties of guardian advocates. This training course shall take the place of the training required for guardians appointed pursuant to chapter 744. Review the clinical records of patients who have had a guardian advocate appointed by the court (usually at the same time as a hearing for involuntary placement). Look for a recommended form entitled "Certification of Guardian Advocate Training Completion (MH-CF 3120) or the form entitled "Completion of Guardian Advocate Training" taken from the Guardian Advocate Training & Resource Manual. The date of satisfactory training completion should be no later than the date the Guardian Advocate was asked to provide express and informed consent to treatment. 65E-5.230(2), FAC (2) The person's clinical record shall reflect that the guardian advocate has been appointed by the court and has completed the training required by Section (4), F.S., and further training required pursuant to a court order, prior to being asked to provide express and informed consent to treatment. Recommended form CF-MH 3120, Feb. 05, "Certification of

319 Page 319 of 399 Guardian Advocate Training Completion," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. ST - HB103 - Guardian Advocate-Auth to Consent to Treatmt Title Guardian Advocate-Auth to Consent to Treatmt Statute or Rule (6), FS (6) If a guardian with the authority to consent to medical treatment has not already been appointed or if the patient has not already designated a health care surrogate, the court may authorize the guardian advocate to consent to medical treatment, as well as mental health treatment. Unless otherwise limited by the court, a guardian advocate with authority to consent to medical treatment shall have the same authority to make health care decisions and be subject to the same restrictions as a proxy appointed under part IV of chapter 765. Unless the guardian advocate has sought and received express court approval in proceeding separate from the proceeding to determine the competence of the patient to consent to medical treatment, the guardian advocate may not consent to: (a) Abortion. (b) Sterilization. (c) Electroconvulsive treatment. (d) Psychosurgery. (e) Experimental treatments that have not been approved by a federally approved institutional review board in accordance with 45 C.F.R. part 46 or 21 C.F.R. part 56. The court must base its decision on evidence that the treatment or procedure is essential to the care of the patient and that the treatment does not present an unreasonable risk of serious, hazardous, or irreversible side effects. The court shall follow Review the clinical records of any patient for whom a Guardian Advocate has consented to non-psychiatric medical treatment. Ensure that the signed court order delegates the authority to consent to medical as well as mental health treatment. If extraordinary treatment, such as ECT has been authorized by the Guardian Advocate, ensure that a separately signed court order authorizing the Guardian Advocate to consent to the procedure is in the clinical record.

320 Page 320 of 399 the procedures set forth in subsection (1) of this section. ST - HB104 - Guardian Advocate - Copy Petition to Consent Title Guardian Advocate - Copy Petition to Consent Statute or Rule 65E-5.230(5), FAC (5) If a guardian advocate is required by s , F.S., or otherwise to petition the court for authority to consent to extraordinary treatment, a copy of the completed petition form shall be given to the person, a copy to the attorney representing the person, and a copy retained in the person's clinical record. Recommended form CF-MH 3108, Feb. 05, "Petition Requesting Court Approval for Guardian Advocate to Consent to Extraordinary Treatment," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. Any order issued by the court in response to such a petition shall be given to the person, attorney representing the person, guardian advocate, and to the facility administrator, with a copy retained in the patient's clinical record. Recommended form CF-MH 3109, Feb. 05, "order Authorizing Guardian Advocate to Consent to Extraordinary Treatment," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter, or other order used by the court may be used for such documentation. Review the clinical records of any patient for whom the Guardian Advocate has filed a petition for authority to consent to extraordinary treatment. Ensure that copies of the petition have been provided, as required by rule. Use of recommended form "Petition Requesting Court Approval for Guardian Advocate to Consent to Extraordinary Treatment" (CF-MH 3108) is considered by the department to be sufficient for such documentation. Any resultant court order should also be found in the clinical record prior to any consent for such extraordinary treatment. Use of recommended form "Order Authorizing Guardian Advocate to Consent to Extraordinary Treatment" (CF-MH 3109), or other order used by the court is considered by the department to be sufficient for such documentation. ST - HB105 - Guardian Advocate - Discharge Title Guardian Advocate - Discharge Statute or Rule (7), FS

321 Page 321 of 399 (7) The guardian advocate shall be discharged when the patient is discharged from an order for involuntary outpatient placement or involuntary inpatient placement or when the patient is transferred from involuntary to voluntary status. In reviewing clinical records, ensure that any consent for treatment provided by a Guardian Advocate is based upon a court order issued since the patient's most recent admission. Also ensure that no Guardian Advocate has authorized any treatment for a patient after the patient has been permitted to transfer from involuntary to voluntary status. Use of recommended form "Notification to Court of Patient's Competence to Consent to Treatment and Discharge of Guardian Advocate" (CF-MH 3121) for documentation is considered by the department to be sufficient. ST - HB106 - Guardian Advocate - Replacement Title Guardian Advocate - Replacement Statute or Rule 65E-5.230(3), FAC When a guardian advocate previously appointed by the court cannot or will not continue to serve in that capacity, and the person remains incompetent to consent to treatment, the facility administrator shall petition the court for a replacement guardian advocate. A copy of the completed petition shall be given to the person, the current guardian advocate, the prospective replacement guardian advocate, person's attorney, and representative, with a copy retained in the person's clinical record. Recommended form CF-MH 3106, "Petition for Adjudication of Incompetence to Consent to Treatment and Appointment of a Guardian Advocate," as referenced in subparagraph 65E-5.170(1)(d)2., F.A.C., may be used for this documentation if Parts I and II are completed. At any time a Guardian Advocate has not been reasonably available to discuss treatment planning options, ensure that the facility administrator or his/her designee has made efforts to involve the Guardian Advocate. If these efforts have been unsuccessful, ensure that the administrator has petitioned the court for a successor Guardian Advocate, providing copies of the petition to all required parties. Use of recommended form, "Petition for Adjudication of Incompetence to Consent to Treatment and Appointment of a Guardian Advocate" (CF-MH 3106) is considered by the department to be sufficient for this documentation if parts I and III are completed. ST - HB107 - Guardian Advocate - Discharge (Pt. Competenc) Title Guardian Advocate - Discharge (Pt. Competenc) Statute or Rule 65E-5.230(6), FAC

322 Page 322 of 399 (6) At any time a person, who has previously been determined to be incompetent to consent to treatment and had a guardian advocate appointed by the court, has been found by the attending physician to have regained competency to consent to treatment, the facility shall notify the court which appointed the guardian advocate of the patent's competence and the discharge of the guardian advocate. Recommended form CF-MH 3121, Feb. 05, "Notification to Court of Person's Competence to Consent to Treatment and Discharge of Guardian Advocate," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. In reviewing clinical records, the surveyor should recognize any documentation by a physician that a patient continuing to reside at the facility may be currently competent to provide express and informed consent or to transfer from involuntary to voluntary status. In such cases, the Guardian Advocate should be discharged by the facility administrator and the court so informed. Use of recommended form "Notification to Court of Patient's Competence to Consent to Treatment and Discharge of Guardian Advocate" (CF-MH 3121) for documentation is considered by the department to be sufficient. ST - HB108 - Health Care Surrogate or Proxy Title Health Care Surrogate or Proxy Statute or Rule 65E (1)- (5) & (7), FAC (1) During the interim period between the time a person is determined to be incompetent to consent to treatment by one or more physicians, pursuant to Section , F.S., and the time a guardian advocate is appointed by a court to provide express and informed consent to the patient's treatment, a health care surrogate designated by the patient, pursuant to Chapter 765, Part II, F.S., may provide such consent to treatment. (2) In the absence of an advance directive or when the health care surrogate named in the advance directive is no longer able or willing to serve, a health care proxy, pursuant to Chapter 765, Part IV, F.S., may also provide interim consent to treatment. 1) Due to the extended time between the patient's admission to a facility and the time at which a Guardian Advocate may be appointed by a court, it may be necessary for the patient to have treatment provided for which the patient is not competent to provide consent. In such cases, a health care surrogate designated through an advance directive or a health care proxy may be available to provide substituted judgment for the patient, i.e. that decision concerning treatment that the patient would have made had he or she been competent to do so. 3) Use of recommended form "Certification of Patient's Incompetence to Consent to Treatment and Notification of Health Care Surrogate/Proxy" (CF-MH 3122) is considered by the department to be sufficient for this purpose. 4) No authorization for treatment from a health care surrogate or proxy should be accepted by a facility until a physician has documented the patient's incapacity and a petition has been filed with the court.

323 Page 323 of 399 (3) Upon the documented determination that a patient is incompetent to make health care decisions for himself or herself by one or more physicians, pursuant to Section , F.S., the facility shall notify the surrogate or proxy in writing that the conditions under which he or she can exercise his or her authority under the law have occurred. Recommended form CF-MH 3122, Feb. 05, "Certification of Person's Incompetence to Consent to Treatment and Notification of Health Care Surrogate/Proxy," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. (4) If the surrogate selected by the person is not available or is unable to serve or if no advance directive had been prepared by the person, a proxy may be designated as provided by law. Recommended form CF-MH 3123, Feb. 05, "Affidavit of Proxy," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. (5) A petition for adjudication of incompetence to consent to treatment and appointment of a guardian advocate shall be filed with the court within two court working days of the determination of the patient's incompetence to consent to treatment by one or more physicians, pursuant to Section , F.S. Recommended form CF-MH 3106, "Petition for Adjudication of Incompetence to Consent to Treatment and Appointment of a Guardian Advocate," as referenced in subparagraph 65E-5.170(1)(d)2., F.A.C., may be used for this purpose. (7) Each designated receiving and treatment facility shall adopt policies and procedures specifying how its direct care and assessment staff will be trained on how to honor each person's treatment preferences as detailed in his or her advance directives. The person being served shall be provided information about advance directives and offered assistance in completing an advance directive, if willing and able to do so.

324 Page 324 of 399 ST - HB109 - Health Care Surrogate or Proxy Title Health Care Surrogate or Proxy Statute or Rule 65E (6), FAC (6) The facility shall immediately provide to the health care surrogate or proxy the same information required by statute to be provided to the guardian advocate. In order to protect the safety of the person, the facility shall make available to the health care surrogate or proxy the training required of guardian advocates and ensure that the surrogate or proxy communicate with the person and person's physician prior to giving express and informed consent to treatment. Review clinical records of patients for whom consent to treatment has been provided by a health care surrogate or proxy to ensure that the record includes documentation that same requirements of Guardian Advocates has been extended to the surrogate/proxy. ST - HB110 - Notices - Voluntary Patients Title Notices - Voluntary Patients Statute or Rule (1), FS (1) VOLUNTARY PATIENTS - Notice of a voluntary patient's admission shall only be given at the request of the patient, except that in an emergency, notice shall be given as determined by the facility. Review policies and procedures to ensure that notice of a voluntary patient's admission is only given at the request of the patient, unless there is an emergency.

325 Page 325 of 399 ST - HB111 - Notices - Involuntary Patients Title Notices - Involuntary Patients Statute or Rule (2), FS (2) INVOLUNTARY PATIENTS. (a) Whenever notice is required to be given under this part, such notice shall be given to the patient and the patient's guardian, guardian advocate, attorney, and representative. 1. When notice is required to be given to a patient, it shall be given both orally and in writing, in the language and terminology that the patient can understand, and if needed, the facility shall provide an interpreter for the patient. 2. Notice to a patient's guardian, guardian advocate, attorney, and representative shall be given by United States mail and by registered or certified mail with the receipts attached to the patient's clinical record. Hand delivery by a facility employee may be used as an alternative, with delivery documented in the clinical record. If notice is given by a state attorney or an attorney for the department, a certificate of service shall be sufficient to document service. (b) A receiving facility shall give prompt notice of the whereabouts of a patient who is being involuntarily held for examination, by telephone or in person within 24 hours after the patient's arrival at the facility, unless the patient requests that no notification be made. Contact attempts shall be documented in the patient's clinical record and shall begin as soon as reasonably possible after the patient's arrival. Notice that a patient is being admitted as an involuntary patient shall be given to the Florida local advocacy council no later than the next working day after the patient is admitted. (c) The written notice of the filing of the petition for involuntary placement must contain the following: a) Review policies and procedures to ensure that notice of an involuntary patient's whereabouts are given to specified persons by telephone or in person within 24 hours of arrival at the facility unless it is documented that the patient requested no notice be made. Sample patient medical records to verify that notice was made and that all contact attempts were documented. Notices to the patient should be given orally and in writing in the language and terminology that the person understands. If someone is hard of hearing or deaf, have interpreters been used? b) Has the notice has been either hand delivered to the patient, guardian, guardian advocate, representative, and attorney or sent by US mail and certified or registered mail with receipts contained in the chart? d) A treatment facility is generally a state operated mental hospital rather than a community-based receiving facility. e) Are notices of transfer and discharge provided as required?

326 Page 326 of Notice that the petition has been filed with the circuit court in the county in which the patient is hospitalized and the address of such court. 2. Notice that the office of the public defender has been appointed to represent the patient in the proceeding, if the patient is not otherwise represented by counsel. 3. The date, time, and place of the hearing and the name of each examining expert and every other person expected to testify in support of continued detention. 4. Notice that the patient, the patient's guardian or representative, or the administrator may apply for a change of venue for the convenience of the parties or witnesses or because of the condition of the patient. 5. Notice that the patient is entitled to an independent expert examination and, if the patient cannot afford such an examination, that the court will provide for one. (d) A treatment facility shall provide notice of a patient's involuntary admission on the next regular working day after the patient's arrival at the facility. (e) When a patient is to be transferred from one facility to another, notice shall be given by the facility where the patient is located prior to the transfer. ST - HB115 - Clinical Records, Confidential Title Clinical Records, Confidential Statute or Rule (1)-(2), FS 65E-5.250(1), FAC (1)-(2), FS (1) A clinical record shall be maintained for each patient. The record shall include data pertaining to admission and such other information as may be required under rules of the department. A clinical record is confidential and exempt from the provisions of s (1). Unless waived by express and 1) A "Clinical Record" means all parts of the record required to be maintained and includes all medical records, progress notes, charts, and admission and discharge data, and all other information recorded by a facility which pertains to the patient's hospitalization and treatment. Review policies and procedures to ensure compliance with statute. Examine patient charts to ensure they are marked "confidential." 3) Review charts to see if releases of information are present when they are requested. Confirm there is no release of

327 Page 327 of 399 informed consent, by the patient or the patient's guardian or guardian advocate or, if the patient is deceased, by the patient's personal representative or the family member who stands next in line of intestate succession, the confidential status of the clinical record shall not be lost by either authorized or unauthorized disclosure to any person, organization, or agency. (2) The clinical record shall be released when: (a) The patient or the patient's guardian authorizes the release. The guardian or guardian advocate shall be provided access to the appropriate clinical records of the patient. The patient or the patient's guardian or guardian advocate may authorize the release of information and clinical records to appropriate persons to ensure the continuity of the patient's health care or mental health care. (b) The patient is represented by counsel and the records are needed by the patient's counsel for adequate representation. (c) The court orders such release. In determining whether there is good cause for disclosure, the court shall weigh the need for the information to be disclosed against the possible harm of disclosure to the person to whom such information pertains. (d) The patient is committed to, or is to be returned to, the Department of Corrections from the Department of Children and Family Services, and the Department of Corrections requests such records. These records shall be furnished without charge to the Department of Corrections. information unless a competent patient has provided consent or consent has been given by a guardian or a guardian advocate unless information is needed under one of the specified exceptions. 65E-5.250(1), FAC Except as otherwise provided by law, verbal or written information about a patient shall only be released when the competent person or a duly authorized legal decision-maker such as guardian, guardian advocate, or health care surrogate or proxy provides consent to such release. When such information is released, a copy of a signed authorization form

328 Page 328 of 399 shall be retained in the person's clinical record. Recommended form CF-MH 3044, Feb. 05, "Authorization for Release of Information," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used as documentation. Consent or authorization forms may not be altered in any way after signature by the person or other authorized decision-maker nor may a person or other authorized decision-maker be allowed to sign a blank form. ST - HB117 - Clinical Records - Release of Confid. Info Title Clinical Records - Release of Confid. Info Statute or Rule (3), FS (3) Information from the clinical record may be released in the following circumstances: (a) When a patient has declared an intention to harm other persons. When such declaration has been made, the administrator may authorize the release of sufficient information to provide adequate warning to the person threatened with harm by the patient. (b) When the administrator of the facility or secretary of the department deems release to a qualified researcher as defined in administrative rule, and aftercare treatment provider, or an employee or agent of the department is necessary for treatment of the patient, maintenance of adequate records, compilation of treatment data, aftercare planning, or evaluation of programs. For the purpose of determining whether a person meets the criteria for involuntary outpatient placement or for preparing the proposed treatment plan pursuant to s , the clinical record may be released to the state attorney, the public defender or the patient's private legal counsel, the court, and to

329 Page 329 of 399 the appropriate mental health professionals, including the service provider identified in s (6)(b)2, in accordance with state and federal law. ST - HB118 - Clinical Records, Confidential Title Clinical Records, Confidential Statute or Rule (9), FS (9) Nothing in this section is intended to prohibit the parent or next of kin of a person who is held in or treated under a mental health facility or program from requesting and receiving information limited to a summary of that person's treatment plan and current physical and mental condition. Release of such information shall be in accordance with the code of ethics of the profession involved. This section of the law does not require information be provided to parent or next of kin, but does permit it to occur without patient consent if the professional releasing the permitted information believes it to be within his or her code of ethics. Interview staff to ensure their understanding of this provision. ST - HB120 - Clinical Records, Confidential-Right to Waive Title Clinical Records, Confidential-Right to Waive Statute or Rule 65E-5.250(2), FAC (2) Facility staff shall inform each person that he or she has the right to waive, in writing, the confidentiality of his or her presence in a receiving or treatment facility and to communicate with all or a group of individuals as specified by the person. Recommended form CF-MH 3048, Feb. 05, "Confidentiality Agreement," as referenced in subsection 65E-5.190(1), F.A.C., may be used for this purpose. If patient rights materials signed by the patient at admission do not include the required notice, review policies to ensure the facility has procedures in place to inform patients at some early time in their hospitalization. Interview patients to ensure they know their right to have open access initiated by others outside the facility. Limiting contact to only those who know an access code is prohibited without the consent of the patient.

330 Page 330 of 399 ST - HB121 - Clinical Records, Confidential - Pt. Access Title Clinical Records, Confidential - Pt. Access Statute or Rule (10), FS (10) Patients shall have reasonable access to their clinical records, unless such access is determined by the patient's physician to be harmful to the patient. If the patient's right to inspect his or her clinical record is restricted by the facility, written notice of such restriction shall be given to the patient and the patient's guardian, guardian advocate, attorney, and representative. In addition, the restriction shall be recorded in the clinical record, together with the reasons for it. The restriction of a patient's right to inspect his or her clinical record shall expire after 7 days, but may be renewed, after review, for subsequent 7-day periods. Interview patients to determine if they know they have the right to access their own clinical records, unless restricted by a physician. If any patients indicate they have requested, but been denied, access to their records, review the clinical record to determine if the required procedures had been followed and required documentation is present. If access to the clinical record is restricted, verify that there is written notice in the clinical record with the reasons for the restriction. The reason for the restriction should be given to the person, the person's guardian, guardian advocate, representative and attorney. Patient charts should be sampled to ensure that any restriction to accessing one's own record is documented and that the restriction is reviewed and renewed at least every 7 days. Staff should be interviewed to determine if they know how to respond to patient requests for accessing their record. ST - HB122 - Clinical Records, Confidential-Restrict Acces Title Clinical Records, Confidential-Restrict Acces Statute or Rule 65E-5.250(4), FAC (4) When a person's access to his or her clinical record or any part of his or her record is restricted by written order of the attending physician, such restriction shall be documented in the person's clinical record. If the request is denied or such access is restricted, a written response shall be provided to the person. Recommended form CF-MH 3110, Feb. 05, "Restriction of Person's Access to Own Record," which is Review clinical records of patients who state that requested access to the record had been denied. Use of recommended form "Restriction of Patient Access to Own Record" (CF-MH 3110) is considered by the department to be sufficient for such documentation.

331 Page 331 of 399 incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for such documentation. ST - HB123 - Clinical Records, Confidential - Pol & Proced Title Clinical Records, Confidential - Pol & Proced Statute or Rule 65E-5.250(5), FAC (5) Each receiving facility shall develop detailed policies and procedures governing release of records to each person requesting release, including criteria for determining what type of information may be harmful to the person, establishing a reasonable time for responding to requests for access, and identifying methods of providing access that ensure clinical support to the person while securing the integrity of the record. Policies and procedures should specify in detail how reasonable access to a patient's own record will be assured. This should include what records will be released, to whom, when, where, and how. ST - HB124 - Clinical Records, Confidential - Alteration Title Clinical Records, Confidential - Alteration Statute or Rule (11), FS (11) Any person who fraudulently alters, defaces, or falsifies the clinical record of any person receiving mental health services in a facility subject to this part, or causes or procures any of these offenses to be committed, commits a misdemeanor of the second degree, punishable as provided in s or s Review of patient charts should include observation of methods of correcting mistakes in charting to ensure that medical records are not altered or defaced in any way. Use of "white-out" or eradication of errors is unacceptable; a simple line drawn through the error, with the date/time and person's initials and credentials who made the entry is acceptable.

332 Page 332 of 399 ST - HB125 - Transportation To A Receiving Facility Title Transportation To A Receiving Facility Statute or Rule (1)(j), FS (1) TRANSPORTATION TO A RECEIVING FACILITY (j) The nearest receiving facility must accept persons brought by law enforcement officers for involuntary examination. Interview law enforcement officials to determine if the facility has, at any time, declined to accept a patient brought for involuntary examination. ST - HB130 - Voluntary Admissions - Auth To Recv Patients Title Voluntary Admissions - Auth To Recv Patients Statute or Rule (1)(a), FS (1) AUTHORITY TO RECEIVE PATIENTS - (a) A facility may receive for observation, diagnosis, or treatment any person 18 years of age or older making application by express and informed consent for admission or any person age 17 or under for whom such application is made by his or her guardian. If found to show evidence of mental illness, to be competent to provide express and informed consent, and to be suitable for treatment, such person 18 years of age or older may be admitted to the facility. A person age 17 or under may be admitted only after a hearing to verify the voluntariness of the consent. Review policies and procedures to ensure compliance with statute especially regarding limitation of voluntary status to persons who are competent to provide express and informed consent for admission and treatment. Any admission of a person under the age of 18 requires an application for admission by the minor's guardian (usually the biological parent). In the absence of an application by the minor's guardian, a judicial hearing is required. The minor's concurrence with the voluntary admission is also required; in the absence of such, the admission must be handled under the involuntary examination provisions.

333 Page 333 of 399 ST - HB131 - Voluntary Admission - Application Forms Title Voluntary Admission - Application Forms Statute or Rule 65E-5.270(1), FAC (1) Recommended form CF-MH 3040, "Application for Voluntary Admission," as referenced in paragraph 65E (1)(b), F.A.C., may be used to document an application of a competent adult for admission to a receiving facility. Recommended form CF-MH 3097, Feb. 05, "Application for Voluntary Admission - Minors," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter, may be used to document a guardian's application for admission of a minor to a receiving facility. Recommended form CF-MH 3098, Feb. 05, "Application for Voluntary Admission - State Treatment Facility," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter, may be used to document an application of a competent adult for admission to a state treatment facility. Any application for voluntary admission shall be based on the patient's express and informed consent. Use of the following recommended forms, properly completed, is considered by the department to be sufficient to document an application for voluntary admission: "Application for Voluntary Admission" (CF-MH 3040) for a competent adult to a receiving facility; "Application for Voluntary Admission z Minors" (CF-MH 3097) for a guardian's application for admission of a minor to a receiving facility; or "Application for Voluntary Admission - State Treatment Facility" (CF-MH 3098) for a competent adult for admission to a state treatment facility. Review records to ensure that one of the above forms are in the clinical records of each patient considered at any time to be on voluntary status. Interview patients to ensure that they were not coerced into voluntary status and that they appear able to make well-reason, willful and knowing decisions. ST - HB132 - Voluntary Admits - Assess Ability to Consent Title Voluntary Admits - Assess Ability to Consent Statute or Rule (1)(b), FS (1) AUTHORITY TO RECEIVE PATIENTS - Review facility records to ensure that the specified types of people have been admitted voluntarily only after their

334 Page 334 of 399 (b) A mental health overlay program or mobile crisis response service or a licensed professional who is authorized to initiate an involuntary examination pursuant to s and is employed by a community mental health center or clinic must, pursuant to district procedure approved by the respective district administrator, conduct an initial assessment of the ability of the following persons to give express and informed consent to treatment before such persons may be admitted voluntarily: 1. A person 60 years of age or older for whom transfer is being sought from a nursing home, assisted living facility, adult day care center or adult family-care home, when such person has been diagnosed as suffering from dementia. 2. A person 60 years of age or older for whom transfer is being sought from a nursing home pursuant to s (12). 3. A person for whom all decisions concerning medical treatment are currently being lawfully made by the health care surrogate or proxy designated under chapter 765. ability to provide express and informed consent has been assessed by an authorized service or professional while the patient is still at his or her licensed residence. 2. The notice of emergency discharge or transfer must have been given to the resident's legal guardian or representative by telephone or in person, prior to the transfer, if possible. The resident is still entitled to a hearing on the transfer or discharge. 3. The statute doesn't specify that this group of persons must be from a facility licensed under Ch. 400, F.S. However, since the entire paragraph relates to licensed facilities, one can presume this was the legislature's intent. Further, the Baker Act prohibits a health care surrogate or proxy from consenting to the provision of mental health treatment for a voluntary patient; requiring that the patient be discharged or transferred to involuntary status. ST - HB133 - Voluntary Admission - Document Assessment Title Voluntary Admission - Document Assessment Statute or Rule 65E-5.270(3), FAC (3) Documenting the assessment of each person pursuant to Section (1)(b), F.S., shall be done prior to moving the person from his or her residence to a receiving facility for voluntary admission. Recommended form CF-MH 3099, Feb. 05, "Certification of Ability to Provide Express and Informed Consent for Voluntary Admission and Treatment of Selected Persons from Facilities Licensed under Chapter 400, F.S.," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter and used for this purpose. Review the clinical records of persons who have been admitted to the receiving facility from a licensed facility. Ensure that the assessment was conducted by an authorized organization prior to the patient's removal from the facility. Use of recommended form "Certification of Ability to Provide Express and Informed Consent for Voluntary Admission and Treatment of Selected Persons Pursuant to s (1), F.S." (CF-MH 3099) is considered by the department to be sufficient.

335 Page 335 of 399 ST - HB134 - Voluntary Admission-Adjudicated Incapacitated Title Voluntary Admission-Adjudicated Incapacitated Statute or Rule (1)(c), FAC (1) AUTHORITY TO RECEIVE PATIENTS - (c) When an initial assessment of the ability of a person to give express and informed consent to treatment is required under this section, and a mobile crisis response service does not respond to the request for an assessment within 2 hours after the request is made or informs the requesting facility that it will not be able to respond within 2 hours after the request is made, the requesting facility may arrange for assessment by any licensed professional authorized to initiate an involuntary examination pursuant to s who is not employed by or under contract with, and does not have a financial interest in, either the facility initiating the transfer or the receiving facility to which the transfer may be made. Ensure that the assessor used by the sending facility was an authorized professional and one without any conflict of interest and that the service designated by DCF was unable to respond within the two-hour time frame. ST - HB135 - Volunt Admit - Incapacitated Persons Title Volunt Admit - Incapacitated Persons Statute or Rule (1)(d), FS (1) AUTHORITY TO RECEIVE PATIENTS - (d) A facility may not admit as a voluntary patient a person who has been adjudicated incapacitated, unless the condition of incapacity has been judicially removed. If a facility admits as a voluntary patient a person who is later determined to have Review policies and procedures and patient charts to confirm that persons who have been adjudicated incapacitated by the court are only admitted on an involuntary basis. Patients, if admitted on voluntary status, who have a health care surrogate or proxy currently making health care decisions for them cannot have such surrogates or proxies give consent to their mental health treatment and must be admitted on an involuntary status.

336 Page 336 of 399 been adjudicated incapacitated, and the condition of incapacity had not been removed by the time of the admission, the facility must either discharge the patient or transfer the patient to involuntary status. ST - HB136 - Volunt Admit - Incapacitated Persons Title Volunt Admit - Incapacitated Persons Statute or Rule (1)(e), FS (1) AUTHORITY TO RECEIVE PATIENTS - (e) The health care surrogate or proxy of a voluntary patient may not consent to the provision of mental health treatment for the patient. A voluntary patient who is unwilling or unable to provide express and informed consent to mental health treatment must either be discharged or transferred to involuntary status. Verify through review of clinical records that no voluntary patients have an authorization for treatment provided by a health care surrogate or proxy. If the chart reflects that a surrogate or proxy had been consenting to the patient's medical treatment immediately prior to the patient's admission on a voluntary basis to psychiatric care, but the patient is currently considered competent to consent to his or her own treatment, determine the circumstances under which the patient's competency to consent had been restored. ST - HB137 - Doc. of Competence to Consent Title Doc. of Competence to Consent Statute or Rule (1)(f), FS (1) AUTHORITY TO RECEIVE PATIENTS - (f) Within 24 hours after admission of a voluntary patient, the admitting physician shall document in the patient's clinical record that the patient is able to give express and informed consent for admission. If the patient is not able to give express and informed consent for admission, the facility shall either discharge the patient or transfer the patient to involuntary Review patient charts to ensure that the admitting physician has documented in the record, within 24 hours after admission, that the person is able to provide express and informed consent.

337 Page 337 of 399 status pursuant to subsection (5). ST - HB138 - Doc of Competence - Form Title Doc of Competence - Form Statute or Rule 65E-5.270(1)(a), FAC (1) (a) Recommended form CF-MH 3104, "Certification of Person's Competence to Provide Express and Informed Consent," as referenced in paragraph 65E-5.170(1)(c), F.A.C., may be used to document the competence of a person to give express and informed consent to be on voluntary status. The original of the completed form shall be retained in the person's clinical record. Review clinical records to verify that a physician has certified a voluntary patient's competence to consent within 24 hours of the patient's admission or prior to permitting an involuntary patient to convert to voluntary status. Use of recommended form "Certification of Patient's Competence to Provide Express and Informed Consent" (CF-MH 3104) is considered by the department to be sufficient to document the competence of a person to give express and informed consent to be a voluntary patient. ST - HB139 - Notice of Right to Discharge Title Notice of Right to Discharge Statute or Rule (3), FS (3) NOTICE OF RIGHT TO DISCHARGE - At the time of admission and at least every 6 months thereafter, a voluntary patient shall be notified in writing of his or her right to apply for a discharge. Review clinical records to ensure that voluntary patients are notified at the time of their admission and at least every 6 months thereafter of their right to apply for a discharge.

338 Page 338 of 399 ST - HB140 - Volunt Admit - Right to Request Discharge Title Volunt Admit - Right to Request Discharge Statute or Rule 65E-5.270(2), FAC (2) Persons on voluntary status shall be advised of their right to request discharge. Recommended forms CF-MH 3051a, Feb. 05, "Notice of Right of Person on Voluntary Status to Request Discharge from a Receiving Facility," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter, or CF-MH 3051b, Feb. 05, "Notice of Right of Person on Voluntary Status to Request Discharge from a Treatment Facility," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter and used to document the giving of such advice. A copy of the notice or its equivalent shall be given to the person and to the person's parent if a minor, with the original of each completed application and notice retained in the person's clinical record. Review clinical records to verify that the patient has been notified of his or her right to request discharge. Use of recommended forms "Notice of Voluntary Patient's Right to Request Discharge from a Receiving Facility" (CF-MH 3051a) or "Notice of Voluntary Patient's Right to Request Discharge from a Treatment Facility" (CF-MH 3051b) is considered by the department to be sufficient to document the giving of such advice. ST - HB141 - Discharge of Voluntary Patient Title Discharge of Voluntary Patient Statute or Rule (2)(a)-(b), FS (2) DISCHARGE OF VOLUNTARY PATIENTS - (a) A facility shall discharge a voluntary patient: 1. Who has sufficiently improved so that retention in the facility is no longer desirable. A patient may also be Review policies and procedures to ensure consistency with statute. Sample clinical records of discharged patients to ensure that patients are discharged within 24 hours when they are determined to be sufficiently improved or when they have revoked consent to admission/treatment or requested discharge, unless the request is rescinded or the person is transferred to involuntary status.

339 Page 339 of 399 discharged to the care of a community facility. 2. Who revokes consent to admission or requests discharge. A voluntary patient or a relative, friend, or attorney of the patient may request discharge either orally or in writing at any time following admission to the facility. The patient must be discharged within 24 hours of the request, unless the request is rescinded or the patient is transferred to involuntary status pursuant to this section. The 24-hour time period may be extended by a treatment facility when necessary for adequate discharge planning, but shall not exceed 3 days exclusive of weekends and holidays. If the patient, or another on the patient's behalf, makes an oral request for discharge to a staff member, such request shall be immediately entered in the patient's clinical record. If the request for discharge is made by a person other than the patient, the discharge may be conditioned upon the express and informed consent of the patient. (b) A voluntary patient who has been admitted to a facility and who refuses to consent to or revokes consent to treatment shall be discharged within 24 hours after such refusal or revocation, unless transferred to involuntary status pursuant to this section or unless the refusal or revocation is freely and voluntarily rescinded by the patient. ST - HB142 - Transfer To Voluntary Status Title Transfer To Voluntary Status Statute or Rule (4), FS (4) TRANSFER TO VOLUNTARY STATUS - An involuntary patient who applies to be transferred to voluntary status shall be transferred to voluntary status immediately, unless the patient has been charged with a crime, or has been involuntarily placed for treatment by a court The process begins immediately but the actual transfer from involuntary to voluntary status requires that a physician or clinical psychologist first examine the patient to certify competence to provide express and informed consent. Review patient clinical records and interview patients to see if there are methods in place to accomplish patient transfer to voluntary status, when requested and only when patient is competent to provide well-reasoned, willing, and knowing decisions about his or her medical and mental health treatment.

340 Page 340 of 399 pursuant to s and continues to meet the criteria for involuntary placement. When transfer to voluntary status occurs, notice shall be given as provided in s ST - HB143 - Transfer to Voluntary Status Title Transfer to Voluntary Status Statute or Rule 65E-5.270(1)(b), FAC (1) (b) Recommended form CF-MH 3104, "Certification of Person's Competence to Provide Express and Informed Consent," as referenced in paragraph 65E-5.170(1)(c), F.A.C., may be used to document a person applying for transfer from involuntary to voluntary status is competent to provide express and informed consent. The original of the completed form shall be filed in the person's clinical record. A change in legal status must be followed by notice sent to individuals pursuant to Section , F.S. If a patient is transferred from involuntary to voluntary status, use of recommended form "Certification of Patient's Competence to Provide Express and Informed Consent" (CF-MH 3104) is considered by the department to be sufficient to document a person applying for transfer is competent to provide express and informed consent. ST - HB144 - Transfer to Involuntary Status Title Transfer to Involuntary Status Statute or Rule (5), FS (5) When a voluntary patient, or an authorized person on the patient's behalf, makes a request for discharge, the request for discharge, unless freely and voluntarily rescinded, must be communicated to a physician, clinical psychologist, or psychiatrist as quickly as possible, but not later than 12 hours after the request for discharge is made. If the patient meets the Review policies and procedures to ensure consistency with statute. Determine how and when the treating professional is notified when a person on voluntary status requests discharge. Interview staff and review clinical records to assure that a person who refuses or revokes consent to treatment is discharged within 24 hours unless transferred to involuntary status. If transferred to involuntary status, confirm that the petition was filed with the court within 2 working days.

341 Page 341 of 399 criteria for involuntary placement, the administrator of the facility must file with the court a petition for involuntary placement, within 2 court working days after the request for discharge is made. If the petition is not filed within 2 court working days, the patient shall be discharged. Pending the filing of the petition, the patient may be held and emergency treatment rendered in the least restrictive manner, upon the written order of a physician, if it is determined that such treatment is necessary for the safety of the patient or others. ST - HB145 - Volunt Admit - Refusal of Treatment Title Volunt Admit - Refusal of Treatment Statute or Rule 65E-5.270(4), FAC (4) If a competent adult or the guardian of a minor refuses to consent to mental health treatment, the person shall not be eligible for admission on a voluntary status. A person on voluntary status who refuses to consent to or revokes consent to treatment shall be discharged from a designated receiving or treatment facility within 24 hours after such refusal or revocation, unless the person is transferred to involuntary status or unless the refusal or revocation is freely and voluntarily rescinded by the person. When a person refuses or revokes consent to treatment, facility staff shall document this immediately in the person's clinical record. Recommended form CF-MH 3105, Feb. 05, "Refusal or Revocation of Consent to Treatment," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. Should a competent person withdraw his or her refusal or revocation of consent to treatment, the person shall be asked to complete Part II of recommended form CF-MH 3105, "Refusal or Revocation of Consent to Treatment," and the original shall be retained in the Review clinical records of patients admitted on a voluntary basis to ensure that a valid consent to treatment has been signed by a competent adult patient or the guardian of a minor. Review progress notes to determine if the patient had ever refused consent to treatment. If so, recommended form "Refusal or Revocation of Consent to Treatment" (CF-MH 3105) should have been completed. The facility should have discharged the patient within 24 hours unless the patient withdrew the refusal to consent, in which case, the patient shall be asked to complete Part II of recommended form "Refusal or Revocation of Consent to Treatment" (CF-MH 3105).

342 Page 342 of 399 person's clinical record. ST - HB146 - Voluntary Admit - Request for Discharge Title Voluntary Admit - Request for Discharge Statute or Rule 65E-5.270(5), FAC (5) An oral or written request for discharge made by any person following admission to the facility shall be immediately documented in the person's clinical record. Recommended forms CF-MH 3051a, "Notice of Right of Person on Voluntary Status to Request Discharge from a Receiving Facility," as referenced in subsection 65E-5.270(2), F.A.C., or CF-MH 3051b, "Notice of Right of Person on Voluntary Status to Request Discharge from a Treatment Facility," as referenced in subsection 65E-5.270(2), F.A.C., may be used for this purpose. This form may also be completed by a relative, adult friend, or attorney of the person. Interview voluntary patients to determine if they know they have the right to request discharge and if, at any time, had requested discharge from the facility. If so, review their clinical record to ensure that request was documented. Use of recommended forms "Notice of Voluntary Patient's Right to Request Discharge from a Receiving Facility" (CF-MH 3051a) or, "Notice of Voluntary Patient's Right to Request Discharge from a Treatment Facility" (CF-MH 3051b) is considered by the department to be sufficient. ST - HB147 - Voluntary Admission Title Voluntary Admission Statute or Rule 65E-5.270(6), FAC (6) When a person on voluntary status refuses treatment or requests discharge and the facility administrator makes the determination that the person will not be discharged within 24 hours from a designated receiving or treatment facility, a petition for involuntary inpatient placement or involuntary outpatient placement shall be filed with the court by the In each case where a voluntary patient is transferred to involuntary status following refusal of treatment or request for discharge, ensure that a petition for involuntary placement has been initiated. Use of recommended form "Petition for Involuntary Placement" (CF-MH 3032) is considered to be sufficient. The petition must be initiated and filed with the court within the allowable timeframes.

343 Page 343 of 399 facility administrator. Recommended form CF-MH 3032, "Petition for Involuntary Inpatient Placement," as referenced in subparagraph 65E-5.170(1)(d)1., F.A.C., or recommended form CF-MH 3130, "Petition for Involuntary Outpatient Placement", as referenced in subparagraph 65E-5.170(1)(d)2., F.A.C., may be used for this purpose. The first expert opinion by a psychiatrist shall be obtained on the petition form within 24 hours of the request for discharge or refusal of treatment to justify the continued detention of the person and the petition shall be filed with the court within 2 court working days after the request for discharge or refusal to consent to treatment was made. ST - HB150 - Involuntary Exam - Criteria Title Involuntary Exam - Criteria Statute or Rule (1), FS (1) CRITERIA - A person may be taken to a receiving facility for involuntary examination if there is reason to believe that is the person has a mental illness and because of his or her mental illness: (a) 1. The person has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination; or 2. The person is unable to determine for himself or herself whether the examination is necessary; and (b) 1. Without care or treatment, the person is likely to suffer from neglect or refuse to care for himself or herself; such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services; or 2. There is substantial likelihood that without care or treatment

344 Page 344 of 399 the person will cause serious bodily harm to himself or herself or others in the near future, as evidenced by recent behavior. ST - HB151 - Involuntary Exam - Initiation Title Involuntary Exam - Initiation Statute or Rule (2)(a) FS (2) INVOLUNTARY EXAMINATION - (a) An involuntary examination may be initiated by any one of the following means: 1. A court may enter an ex parte order stating that a person appears to meet the criteria for involuntary examination, giving the findings on which that conclusion is based. The ex parte order for involuntary examination must be based on sworn testimony, written or oral. If other less restrictive means are not available, such as voluntary appearance for outpatient evaluation, a law enforcement officer, or other designated agent of the court, shall take the person into custody and deliver him or her to the nearest receiving facility for involuntary examination. The order of the court shall be made a part of the patient's clinical record. No fee shall be charged for the filing of an order under this subsection. Any receiving facility accepting the patient based on this order must send a copy of the order to the Agency for Health Care Administration on the next working day. The order shall be valid only until executed or, if not executed, for the period specified in the order itself. If no time limit is specified in the order, the order shall be valid for 7 days after the date that the order was signed. 2. A law enforcement officer shall take a person who appears to meet the criteria for involuntary examination into custody and deliver the person or have him or her delivered to the nearest receiving facility for examination. The officer shall Review patient charts to verify that a copy of an ex parte order, a law enforcement report, or a certificate of a mental health professional is present and completed by an authorized person. 1. The ex parte order for involuntary examination, with attached document giving the findings, shall accompany the patient to the receiving facility and be retained in the patient's clinical record. 2. Mandatory form "Report of Law Enforcement Officer Initiating Involuntary Examination (CF-MH 3052a) shall accompany the patient to the nearest receiving facility for retention in the patient's clinical record. 3. Mandatory form "Certificate of Professional Initiating Involuntary Examination" (CF-MH 3052b) shall expire seven days after the certificate is signed, unless the patient has been taken into custody and delivered to a receiving facility. The certificate is valid throughout the state. The completed certificate shall accompany the patient to a receiving facility and be retained in the person's clinical record. Copies of court orders, reports and certificates required to be submitted to the Agency for Health Care Administration, should be sent to the Baker Act Reporting Center at the Florida Mental Health Institute, which collects these on the Agency's behalf. Review clinical records to ensure that the initiating documents are sent to the BA Reporting Center on the next working day. References - Section , F.S.: (2) "Clinical psychologist" means a psychologist as defined in s (7) with 3 years of postdoctoral experience in the practice of clinical psychology, inclusive of the experience required for licensure, or a psychologist employed by a facility operated by the United States Department of Veterans Affairs that qualifies as a receiving or treatment facility under this part. (4) "Clinical social worker" means a person licensed as a clinical social worker under chapter 491. (21) "Physician" means a medical practitioner licensed under chapter 458 or chapter 459 who has experience in the diagnosis and treatment of mental and nervous disorders or a physician employed by a facility operated by the United States Department of Veterans Affairs which qualifies as a receiving or treatment facility under this part. (23) "Psychiatric nurse" means a registered nurse licensed under part I of chapter 464 who has a master's degree or a doctorate in psychiatric nursing and 2 years of post-master's clinical experience under the supervision of a physician.

345 Page 345 of 399 execute a written report detailing the circumstances under which the person was taken into custody, and the report shall be made a part of the patient's clinical record. Any receiving facility accepting the patient based on this report must send a copy of the report to the Agency for Health Care Administration on the next working day. 3. A physician, clinical psychologist, psychiatric nurse, mental health counselor, marriage and family therapist, or clinical social worker may execute a certificate stating that he or she has examined a person within the preceding 48 hours and finds that the person appears to meet the criteria for involuntary examination and stating the observations upon which that conclusion is based. If other less restrictive means are not available, such as voluntary appearance for outpatient evaluation, a law enforcement officer shall take the person named in the certificate into custody and deliver him or her to the nearest receiving facility for involuntary examination. The law enforcement officers shall execute a written report detailing the circumstance under which the person was taken into custody. The report and certificate shall be made a part of the patient's clinical record. Any receiving facility accepting the patient based on this certificate must send a copy of the certificate to the Agency for Health Care Administration on the next working day. (36) "Marriage and family therapist" means a person licensed as a marriage and family therapist under chapter 491. (37) "Mental health counselor" means a person licensed as a mental health counselor under chapter 491. ST - HB153 - Involuntary Exam - Forms Distribution Title Involuntary Exam - Forms Distribution Statute or Rule 65E-5.280(5), FAC (5) In order for the department to implement the provisions of Section (2)(e), F.S., and to ensure that the Agency for Health Care Administration will be able to analyze the data it receives pursuant to that section, designated receiving These forms include: Recommended form "Ex Parte Order for Involuntary Examination" (CF-MH 3001) or other order provided by the court, Mandatory form "Report of Law Enforcement Officer Initiating Involuntary Examination" (CF MH 3052a),

346 Page 346 of 399 facilities shall forward copies of each recommended form CF-MH 3001, "Ex Parte Order for Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C., or other order provided by the court, mandatory form CF-MH 3052a, "Report of Law Enforcement Officer Initiating Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C., mandatory form CF-MH 3052b, "Certificate of Professional Initiating Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C., accompanied by mandatory form CF-MH 3118, Sept. 06, "Cover Sheet to Agency for Health Care Administration," which is hereby incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter to: BA Reporting Center, FMHI-MHC 2737, Bruce B. Downs Boulevard, Tampa, Florida Mandatory form "Certificate of Professional Initiating Involuntary Examination" (CF-MH 3052b), Regardless of which of the above three methods was used to initiate the involuntary examination, the form must be accompanied by the mandatory form "Cover Sheet to Agency for Health Care Administration" (CF-MH 3118). ST - HB154 - Involuntary Exam-Initiation-Report Prepared Title Involuntary Exam-Initiation-Report Prepared Statute or Rule (2)(b), FS (2)(b) A person shall not be removed from any program or residential placement licensed under chapter 400 or chapter 429 and transported to a receiving facility for involuntary examination unless an ex parte order, a professional certificate, or law enforcement officer's report is first prepared. If the condition of the person is such that presentation of a law enforcement officer's report is not practicable before removal, the report shall be completed as soon as possible after removal, but in any case before the person is transported to a receiving facility. A receiving facility admitting a person for involuntary examination who is not accompanied by the required ex parte order, professional certificate, or law enforcement officer's report shall notify the Agency for Health Ensure that the facility notifies AHCA by certified mail on the next working day if a facility or service licensed under s.400 F.S. sends a person on involuntary status to a receiving facility without an order/report/certificate. Inquire as to whether the chapter 400 facility routinely sends such patients to hospital emergency rooms for involuntary examinations to be initiated, rather than carrying out their legal responsibilities. AHCA staff responsible for the licensure and survey of chapter 400 facilities should be notified of the failure of such facilities to abide by the Baker Act requirements.

347 Page 347 of 399 Care Administration of such admission by certified mail no later than the next working day. The provisions of this paragraph do not apply when transportation is provided by the patient's family or guardian. ST - HB155 - Involuntary Exam- Notify AHCA Title Involuntary Exam- Notify AHCA Statute or Rule 65E-5.280(6), FAC (6) If a patient is delivered to a receiving facility for an involuntary examination from any program or residential placement licensed under the provisions of chapter 400, F.S., without an ex parte order, the mandatory form CF-MH 3052a, "Report of Law Enforcement Officer Initiating Involuntary Examination" as referenced in subsection 65E-5.260(1), F.A.C., or mandatory form CF-MH 3052b, "Certificate of Professional Initiating Involuntary Examination" as referenced in subsection 65E-5.260(1), F.A.C., the receiving facility shall notify the Agency for Health Care Administration by the method and timeframe required by Section (2)(b), F.S. The receiving facility may use recommended form CF-MH 3119, Feb. 05, "Notification of Non-Compliance with Required Certificate," as referenced in subsection 65E-5.270(7), F.A.C., for this purpose. Review the clinical record for each patient referred to the facility from a chapter 400 licensed facility. The record should include one of the following three forms, completed prior to the patient's removal from the chapter 400 facility: Recommended form "Ex Parte Order for Involuntary Examination" (CF-MH 3001) or other order provided by the court, Mandatory form "Report of Law Enforcement Officer Initiating Involuntary Examination" (CF-MH 3052a), or Mandatory form "Certificate of Professional Initiating Involuntary Examination" (CF-MH 3052b) The receiving facility's use of recommended form "Notification of Non-Compliance with Required Certificate" (CF-MH 3119) sent to the BA Reporting Center is considered by the department to be sufficient for AHCA notification. ST - HB156 - Involuntary Exam- Clinical Record Title Involuntary Exam- Clinical Record Statute or Rule 65E-5.280(7), FAC

348 Page 348 of 399 (7) Documentation that each completed form was submitted in a timely way shall be retained in the person's clinical record. Review the clinical records of patients presented to a receiving facility for involuntary examination. Each patient's chart, regardless of the length of time retained at the facility, should include documentation that AHCA, through the BA Reporting Center, was properly notified in a timely way. ST - HB157 - Involuntary Exam Title Involuntary Exam Statute or Rule (2)(f), FS (2)(f) A patient shall be examined by a physician or clinical psychologist at a receiving facility without unnecessary delay and may, upon the order of a physician, be given emergency treatment if it is determined that such treatment is necessary for the safety of the patient or others. The patient may not be released by the receiving facility or its contractor without the documented approval of a psychiatrist, a clinical psychologist, or, if the receiving facility is a hospital, the release may also be approved by an attending emergency department physician with experience in the diagnosis and treatment of mental and nervous disorders and after completion of an involuntary examination pursuant to this subsection. However, a patient may not be held in a receiving facility for involuntary examination longer than 72 hours. Review patient charts to ensure that patients are examined by a physician or a clinical psychologist without unnecessary delay and that they are not released from the facility without the documented approval of a psychiatrist or clinical psychologist. Once the involuntary examination has been initiated, the patient's agreement to be voluntary does not eliminate the requirement for the examination to be performed by the physician or clinical psychologist. ST - HB158 - Involuntary Examination - Examination Defined Title Involuntary Examination - Examination Defined Statute or Rule 65E-5.100(7), FAC

349 Page 349 of 399 (7) Examination means the integration of the physical examination required under Section (2), F.S., with other diagnostic activities to determine if the person is medically stable and to rule out abnormalities of thought, mood, or behavior that mimic psychiatric symptoms but are due to non-psychiatric medical causes such as disease, infection, injury, toxicity, or metabolic disturbances. Examination includes the identification of person-specific risk factors for treatment such as elevated blood pressure, organ dysfunction, substance abuse, or trauma. While a clinical psychologist can perform part of the legally required examination, the process of ruling out non-psychiatric medical causes of the symptoms requires medical expertise. ST - HB159 - Involuntary Exam Title Involuntary Exam Statute or Rule 65E (1), FAC The involuntary examination is also known as the initial mandatory involuntary examination: (1) Whenever an involuntary examination is initiated by a circuit court, a law enforcement officer, or a mental health professional as provided in Section (2), F.S., an examination by a physician or clinical psychologist must be conducted and documented in the person's clinical record. The examination, conducted at a facility licensed under Chapter 394 or 395, F.S., must contain: (a) A thorough review of any observations of the person's recent behavior; (b) A review of mandatory form CF-MH 3100, "Transportation to Receiving Facility", as referenced in subsection 65E-5.260(2), F.A.C., and recommended form CF-MH 3001, "Ex Parte Order for Involuntary Examination", Review medical records for a complete medical exam for involuntary patients; which is a face-to face examination.

350 Page 350 of 399 as referenced in subsection 65E-5.260(1), F.A.C., or other form provided by the court, or mandatory form CF-MH 3052a, "Report of Law Enforcement Officer Initiating Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C., or mandatory form CF-MH 3052b, "Certificate of Professional Initiating Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C. (c) A brief psychiatric history; and (d) A face-to-face examination of the person in a timely manner to determine if the person meets criteria for release. ST - HB160 - Involuntary Exam - Clinical Record Title Involuntary Exam - Clinical Record Statute or Rule 65E (5), FAC (5) All results and documentation of all elements of the initial mandatory involuntary examination shall be retained in the person's clinical record. Review the clinical record of patients presented to the facility for involuntary examination to ensure that the required documentation is present. ST - HB161 - Involuntary Exam Title Involuntary Exam Statute or Rule 65E (6), FAC (6) If the patient is not released or does not become voluntary as a result of giving express and informed consent to admission and treatment in the first part of the involuntary examination, the person shall be examined by a psychiatrist to Review clinical records to verify that patients who are admitted on involuntary status are examined by a psychiatrist, if not earlier released or transferred to voluntary status following certification by a physician. If not released, use of recommended, "Application for Voluntary Admission" form (CF-MH 3040) or recommended form "Application for Voluntary Admission - Minors" (CF-MH 3097) will be considered by the department to be

351 Page 351 of 399 determine if the criteria for involuntary inpatient or involuntary outpatient placement are met. sufficient if the patient wishes to apply for voluntary admission. If not released and the patient wishes to transfer from involuntary to voluntary status, use of recommended form "Certification of Patient's Competence to Provide Express and Informed Consent" (CF-MH 3104) documenting the patient is competent to provide express and informed consent, will be considered by the department to be sufficient. ST - HB163 - Involuntary Exam Title Involuntary Exam Statute or Rule 65E (7), FAC (7) After the initial mandatory involuntary examination, the person's clinical record shall include: (a) An intake interview; (b) The mandatory form CF-MH 3100, "Transportation to Receiving Facility," as referenced in subsection 65E-5.260(1), F.A.C., and recommended form CF-MH 3001, "Ex Parte Order for Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C., or other form provided by the court, or mandatory form CF-MH 3052a, "Report of Law Enforcement Officer Initiating Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C., or mandatory form CF-MH 3052b, "Certificate of Professional Initiating Involuntary Examination," as referenced in subsection 65E-5.260(1), F.A.C.; and (c) The psychiatric evaluation, including the mental status examination or the psychological status report. Review clinical records to verify the required forms are included. ST - HB164 - Involuntary Exam - Actions Req Within 72 Hrs Title Involuntary Exam - Actions Req Within 72 Hrs Statute or Rule (2)(i), FS

352 Page 352 of 399 (2)(i) Within the 72 hour examination period or, if the 72 hours ends on a weekend or holiday, no later than the next working day thereafter, one of the following actions must be taken, based on the individual needs of the patient: 1. The patient shall be released, unless he or she is charged with a crime in which case the patient shall be returned to the custody of a law enforcement officer; 2. The patient shall be released, subject to the provisions of subparagraph 1., for voluntary outpatient treatment; 3. The patient, unless he or she is charged with a crime, shall be asked to give express and informed consent to placement as a voluntary patient, and if such consent is given the patient shall be admitted as a voluntary patient; or 4. A petition for involuntary placement shall be filed in the circuit court when outpatient or inpatient treatment is deemed necessary. When inpatient treatment is deemed necessary, the least restrictive treatment consistent with the optimum improvement of the patient's condition shall be made available. When a petition is to be filed for involuntary outpatient placement, it shall be filed by one of the petitioners specified in s (3)(a). A petition for involuntary inpatient placement shall be filed by the facility administrator. Review clinical records to determine that patients determined not to meet the criteria for involuntary placement are released from the facility on a timely basis; no more than 72 hours from arrival at a receiving facility. Review policies and procedures and patient charts to determine that the receiving facility ensures that no patient is detained in excess of 72 hours unless a competent patient has given informed consent to voluntary admission and signed recommended form entitled "Application for Voluntary Admission" (CF-MH 3040) or the administrator has filed a Petition for Involuntary Placement (CF-MH 3032). ST - HB165 - Notice of Release Title Notice of Release Statute or Rule (3), FS (3) NOTICE OF RELEASE - Notice of the release shall be given to the patient's guardian or representative, to any person who executed a certificate Review policies and procedures to ensure compliance with statute. Sample clinical records to confirm presence of recommended form "Notice of Release or Discharge" (CF-MH 3038) is used to inform patients, guardians and representatives, guardian advocates, persons who executed a certificate

353 Page 353 of 399 admitting the patient to the receiving facility, and to any court which ordered the patient's evaluation. admitting the patient to the receiving facility and to the court which ordered the patient's examined. ST - HB166 - Involuntary Exam/E.M.S. Title Involuntary Exam/E.M.S. Statute or Rule 65E-5.280(4)(c), FAC (4)(c) The 72-hour involuntary examination period set out in Section (2)(f), F.S., shall not be exceeded. In order to document the 72-hour period has not been exceeded, recommended form CF-MH 3102, Feb. 05, "Request for Involuntary Examination After Stabilization of Emergency Medical Condition," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for this purpose. The form may be sent by fax, or otherwise, to promptly communicate its contents to a designated receiving facility at which appropriate medical treatment is available. In order to document the 72-hour period has not been exceeded, use of recommended form "Request for Involuntary Examination After Emergency Medical Services" (CF-MH 3102) is considered by the department to be sufficient. The form may be sent by fax, or otherwise, to promptly communicate its contents to the receiving facility to which the patient will be sent, at which appropriate medical treatment is available. ST - HB170 - Involuntary Placement Title Involuntary Placement Statute or Rule (2) FS (2) ADMISSION TO A TREATMENT FACILITY - A patient may be retained by a receiving facility or involuntarily placed in a treatment facility upon the recommendation of the administrator of the receiving facility where the patient has been examined and after adherence to Review the patient's clinical record to make sure the petition was filed promptly in the court in the county where the person is located. Sample clinical records to ensure that the recommended form "Petition for Involuntary Placement" (CF-MH 3032) was completed by both experts and by the administrator within the 72-hour period. Document that the "Petition for Involuntary Placement" was filed with the court within the permitted 72 hours period,

354 Page 354 of 399 the notice and hearing procedures provided in s The recommendation must be supported by the opinion of a psychiatrist and the second opinion of a clinical psychologist or another psychiatrist, both of whom have personally examined the patient within the preceding 72 hours, that the criteria for involuntary inpatient placement are met. However, in a county that has a population of fewer than 50,000, if the administrator certifies that a psychiatrist or clinical psychologist is not available to provide the second opinion, the second opinion may be provided by a licensed physician who has postgraduate training and experience in diagnosis and treatment of mental and nervous disorders or by a psychiatric nurse. Any second opinion authorized in this subsection may be conducted through a face-to-face examination, in person or by electronic means. Such recommendation shall be entered on an involuntary inpatient placement certificate that authorizes the receiving facility to retain the patient pending transfer to a treatment facility or completion of a hearing. or if the 72 hours ends on a weekend or holiday, no later than the next working day thereafter. ST - HB171 - Petition/Involuntary Placement Title Petition/Involuntary Placement Statute or Rule (3), FS (3) PETITION FOR INVOLUNTARY INPATIENT PLACEMENT - The administrator of the facility shall file a petition for involuntary inpatient placement in the court in the county where the patient is located. Review patient charts to ensure petitions are filed promptly in the court of the county where the person is located. It is suggested that the surveyor call the clerk of the court and the judge to determine the receiving facility's compliance in practice.

355 Page 355 of 399 ST - HB172 - Involuntary Placement Title Involuntary Placement Statute or Rule 65E-5.290, FAC (1) If a person is retained involuntarily after an involuntary examination is conducted, a petition for involuntary inpatient placement or involuntary outpatient placement shall be filed with the court by the facility administrator within the 72-hour examination period, or if the 72 hours ends on a weekend or legal holiday, the petition shall be filed no later than the next court working day thereafter. Recommended form CF-MH 3032, "Petition for Involuntary Inpatient Placement," as referenced in subparagraph 65E-5.170(1)(d)1., F.A.C., or recommended form CF-MH 3130, "Petition for Involuntary Outpatient Placement", as referenced in subparagraph 65E-5.170(1)(d)2., F.A.C., or other forms adopted by the court may be used for this purpose. A copy of the completed petition shall be retained in the patient's clinical record. (2) Each criterion alleged must be substantiated by evidence. (3) Use of recommended form CF-MH 3021, Feb. 05, "Notice of Petition for Involuntary Placement," as referenced in subparagraph 65E-5.285(1)(b)7., F.A.C., or other form used by the court, when properly completed, will satisfy the requirements of Section , F.S. A copy of that completed form, or its equivalent, shall be retained in the person's clinical record. Whenever potential involuntary inpatient placement in a state treatment facility is proposed, a copy of the completed notice form shall also be provided to the designated community mental health center or clinic for purposes of conducting a transfer evaluation. (4) Recommended form CF-MH 3113, Feb. 05, "Notice to Court - Request for Continuance of Involuntary Placement (1) Use of recommended form "Petition for Involuntary Placement" (CF-MH 3032) is considered by the department to be sufficient. (2) Use of recommended form "Notice of Petition for Involuntary Placement" (CF-MH 3021) when properly completed, is considered by the department to satisfy the requirements of s , F.S. (3) Use of recommended form "Notice to Court Request for Continuance of Involuntary Placement Hearing" (CF-MH 3113) is considered by the department to be sufficient. (4) Use of recommended form "Application for Appointment of Independent Expert Examiner" (CF-MH 3022) is considered by the department to be sufficient to request the expert examiner. (5) Use of recommended form "Notification to Court of Withdrawal of Petition on Involuntary Placement" (CF-MH 3033) is considered by the department to be sufficient. (6) Use of recommended form "Order for Involuntary Placement" (CF-MH 3008) or other order used by the court, is considered by the department to be sufficient for this purpose.

356 Page 356 of 399 Hearing," as referenced in paragraph 65E-5.285(2)(b), F.A.C., may be used by the counsel representing a person in requesting a continuance. A completed copy of the form used shall be provided to the facility administrator for retention in the person's clinical record. (5) Recommended form CF-MH 3022, Feb. 05, "Application for Appointment of Independent Expert Examiner," as referenced in paragraph 65E-5.285(2)(c), F.A.C., may be used to request the expert examiner. (6) Recommended form CF-MH 3033, Feb. 05, "Notification to Court of Withdrawal of Petition on Involuntary Inpatient or Outpatient Placement," as referenced in paragraph 65E-5.285(2)(d), F.A.C., may be used if the facility administrator seeks to withdraw the petition for involuntary placement prior to the hearing. The facility shall retain a copy in the person's clinical record. When a facility withdraws a petition for involuntary inpatient placement, it shall notify the court, state attorney, attorney for the person, and guardian or representative by telephone within 1 business day of its decision to withdraw the petition, unless such decision is made within 24 hours prior to the hearing. In such cases, the notification must be made immediately. In all cases involving potential involuntary inpatient placement in a state treatment facility, a copy of the notification form shall also be provided to the designated community mental health center or clinic responsible for conducting a transfer evaluation. (9) If the court concludes that the person meets the criteria for involuntary inpatient placement pursuant to Section , F.S., it shall prepare an order. Recommended form CF-MH 3008, "Order for Involuntary Inpatient Placement," as referenced in paragraph 65E (1)(b), F.A.C., or other order used by the court, may be used for this purpose. This signed order shall be given to the person, guardian, guardian advocate or representative, counsel for the person, state attorney, and administrator of the receiving or treatment facility, with a copy of the order retained in the person's clinical record.

357 Page 357 of 399 ST - HB173 - Procedure/Involuntary Placement Title Procedure/Involuntary Placement Statute or Rule (7)(b), FS (7)(b) If the patient continues to meet the criteria for involuntary inpatient placement, the administrator shall, prior to the expiration of the period during which the treatment facility is authorized to retain the patient, file a petition requesting authorization for continued involuntary inpatient placement. The request shall be accompanied by a statement from the patient's physician or clinical psychologist justifying the request, a brief description of the patient's treatment during the time he or she was involuntarily placed, and an individualized plan of continued treatment. Notice of the hearing shall be provided as set forth in s If at the hearing the administrative law judge finds that attendance at the hearing is not consistent with the best interests of the patient, the administrative law judge may waive the presence of the patient from all or any portion of the hearing, unless the patient, through counsel, objects to the waiver of presence. The testimony in the hearing must be under oath, and the proceedings must be recorded. "Petitions for Continued Involuntary Placement" are rarely filed by receiving facility administrators, since the patient would have had to exceed the maximum period of the court order, usually six months. However, petitions filed with the state Division of Administrative Hearings should be filed at least 25 days prior to the person's expiration of the order for involuntary placement or for a person involuntarily placed while as a minor who is about to reach the age of 18. Review clinical records to see if hearings for continued involuntary placement are conducted for people who remain at the facility. Check clinical records of patients who are involuntarily placed to see the petitions are present requesting continued authorization for involuntary placement and that the petitions are accompanied by the person's clinical psychologist or physician noting what the person's treatment and continued response to treatment has been documented. ST - HB174 - Involuntary Placement - Continued Placemt Title Involuntary Placement - Continued Placemt Statute or Rule 65E-5.300(1), FAC

358 Page 358 of 399 (1) In order to request continued involuntary inpatient placement, the treatment facility administrator shall, prior to the expiration of the period during which the treatment facility is authorized to retain the person, file a request for continued placement. Recommended form CF-MH 3035, Feb. 05, "Petition Requesting Authorization for Continued Involuntary Inpatient Placement," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used as documentation of that request. The petition shall be filed with the Division of Administrative Hearings within 20 days prior to the expiration date of a person's authorized period of placement or, in the case of a minor, the date when the minor will reach the age of majority. The petition shall contain the signed statement of the person's physician or clinical psychologist justifying the request and shall be accompanied by the following additional documentation: (a) Evidence justifying the request by the physician or clinical psychologist for involuntary inpatient placement, including how the person meets each of the statutorily required criteria; (b) A brief summary of the person's treatment during the time he or she was placed; and (c) An individualized treatment plan. Use of recommended form "Petition Requesting Authorization for Continued Involuntary Placement" (CF-MH 3035) is considered by the department to be sufficient as documentation of the request. ST - HB175 - Procedure/Involuntary Placement Title Procedure/Involuntary Placement Statute or Rule (7)(e), FS (7)(e) If continued involuntary inpatient placement is necessary for a patient admitted while serving a criminal Review clinical records of such patients to ensure that petitions were filed with the Division of Administrative Hearings in a timely manner.

359 Page 359 of 399 sentence, but whose sentence is about to expire, or for a patient involuntarily placed while a minor but who is about to reach the age of 18, the administrator shall petition the administrative law judge for an order authorizing continued involuntary inpatient placement. ST - HB176 - Discharge/Involuntary Patients Title Discharge/Involuntary Patients Statute or Rule (1), FS (1) POWER TO DISCHARGE - At any time a patient is found to no longer meet the criteria for involuntary placement, the administrator shall: (a) Discharge the patient, unless the patient is under a criminal charge, in which case the patient shall be transferred to the custody of the appropriate law enforcement officer. (b) Transfer the patient to voluntary status on his or her own authority or at the patient's request, unless the patient is under criminal charge or adjudicated incapacitated; or (c) Place an improved patient, except a patient under a criminal charge, on convalescent status in the care of a community facility. Review policies and procedures to ensure compliance with the statute. Review closed patient charts to ensure the patients were discharged appropriately. c) a "community facility" is defined in the Baker Act as any community service provider contracting with the department to furnish substance abuse or mental health services under part IV of this chapter. ST - HB177 - Discharge/Involuntary Patients Title Discharge/Involuntary Patients Statute or Rule 65E-5.320, FAC A receiving or treatment facility administrator shall provide Use of recommended form "Notice of Release or Discharge" (CF-MH 3038) is considered by the department to be

360 Page 360 of 399 prompt written notice of the discharge of patient person on involuntary status to the person, guardian, guardian advocate, representative, initiating professional, and circuit court, with a copy retained in the person's clinical record. Recommended form CF-MH 3038, "Notice of Release or Discharge," as referenced in paragraph 65E-5.280(7)(e), F.A.C., may be used as documentation of such notice. If the discharge occurs while a court hearing for involuntary placement or continued involuntary placement is pending, all parties including the state attorney and attorney representing the person, shall be given telephonic notice of the discharge by the facility administrator or his or her designee. sufficient to document such notice. ST - HB178 - Transfer/Patient Among Facilities Title Transfer/Patient Among Facilities Statute or Rule , FS (1) TRANSFER BETWEEN PUBLIC FACILITIES (a) A patient who has been admitted to a public receiving facility, or the family member, guardian, or guardian advocate of such patient, may request the transfer of the patient to another public receiving facility. A patient who has been admitted to a public treatment facility, or the family member, guardian, or guardian advocate of such patient, may request the transfer of the patient to another public treatment facility. Depending on the medical treatment of mental health treatment needs of the patient and the availability of appropriate facility resources, the patient may be transferred at the discretion of the department. If the department approves the transfer of an involuntary patient, notice according to the provisions of s shall be given prior to the transfer by the transferring facility. The department shall respond to the request for transfer within 2 working days after receipt of Review policies and procedures to ensure compliance with statutes permitting transfer of patients between receiving and treatment facilities. Sample closed clinical records of patients who have been transferred to confirm prior approval of the patient's transfer by the facility that received the person. Are time lines met? Verify that the transfer to the facility occurred as planned. Emergency access to care is also governed by chapter 395, F.S.

361 Page 361 of 399 the request by the facility administrator. (b) When required by the medical treatment or mental health treatment needs of the patient or the efficient utilization of a public receiving or public treatment facility, a patient may be transferred from one receiving facility to another, or one treatment facility to another, at the department's discretion, or, with the express and informed consent of the patient or the patient's guardian or guardian advocate, to a facility in another state. Notice according to the provisions of s shall be given prior to the transfer by the transferring facility. If prior notice is not possible notice of the transfer shall be provided as soon as practicable after the transfer. (2) TRANSFER FROM PUBLIC TO PRIVATE FACILITIES A patient who has been admitted to a public receiving or public treatment facility and has requested, either personally or through his or her guardian or guardian advocate, and is able to pay for treatment in a private facility shall be transferred at the patient's expense to a private facility upon acceptance of the patient by the private facility. (3) TRANSFER FROM PRIVATE TO PUBLIC FACILITIES (a) A patient or the patient's guardian or guardian advocate may request the transfer of the patient from a private to a public facility, and the patient may be so transferred upon acceptance of the patient by the public facility. (b) A private facility may request the transfer of a patient from the facility to a public facility, and the patient may be so transferred upon acceptance of the patient by the public facility. The cost of such transfer shall be the responsibility of the transferring facility. (c) A public facility must respond to a request for the transfer of a patient within 2 working days after receipt of the request. (4) TRANSFER BETWEEN PRIVATE FACILITIES

362 Page 362 of 399 A patient in a private facility or the patient's guardian or guardian advocate may request the transfer of the patient to another private facility at any time, and the patient shall be transferred upon acceptance of the patient by the facility to which transfer is sought. ST - HB179 - Transfer/Patient Among Facilities Title Transfer/Patient Among Facilities Statute or Rule 65E-5.310, FAC (1) Recommended form CF-MH 3046, Feb. 05, "Application for and Notice of Transfer to Another Facility," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used to request the transfer of a person to another receiving or treatment facility. This application, or its equivalent, shall be completed and filed with the facility administrator or designee. A copy of the completed application shall be retained in the person's clinical record. (2) The administrator of the facility or designee at which the person resides shall, without delay, submit an application for transfer to the administrator of the facility to which a person has requested transfer. Upon acceptance of the person by the facility to which the transfer is sought, the administrator of the transferring facility or his or her designee shall mail the statutorily required notices to the person, the person's attorney, guardian, guardian advocate or representative, retaining a copy in the person's clinical record. Recommended form CF-MH 3046, "Application for and Notice of Transfer to Another Facility," as referenced in subsection 65E-5.310(1), F.A.C., may be used for this documentation. (3) If the proposed transfer of a person originates with the administrator of the facility or his or her designee or with the (1) Use of recommended form "Application for and Notice of Transfer to Another Facility" (CF-MH 3046) is considered by the department to be sufficient. (2) Use of recommended form "Application for and Notice of Transfer to Another Facility" (CF-MH 3046) is considered by the department to be sufficient for this documentation. (3) Use of recommended form "Application for and Notice of Transfer to Another Facility" (CF-MH 3046) will be considered by the department to be sufficient for this purpose. (4) Review policies and procedures to ensure that a copy of the patient's clinical record and other relevant documents are transferred with the patient to another facility. (5) Review policies and procedures to ensure that patient safety and care during transport is addressed.

363 Page 363 of 399 treating physician a notice of transfer is required. The notice shall be completed by the administrator or designee of the transferring facility, after acceptance of the person by the facility to which he or she will be transferred, with copies provided prior to the transfer to those required by law, with a copy retained in the person's clinical record Recommended form CF-MH 3046, "Application for and Notice of Transfer to Another Facility," as referenced in subsection 65E-5.310(1), F.A.C., may be used for this purpose. (4) All relevant documents including a copy of the person's clinical record, shall be transferred prior to or concurrent with the person to the new facility. (5) Each facility shall develop and implement policies and procedures for transfer that provide for safety and care during transportation. ST - HB185 - Minors; Admission & Placement Title Minors; Admission & Placement Statute or Rule (2), FS (2) A person under the age of 14 who is admitted to any hospital licensed pursuant to chapter 395 may not be admitted to a bed in a room or ward with an adult patient in a mental health unit or share common areas with an adult patient in a mental health unit. However, a person 14 years of age or older may be admitted to a bed in a room or ward in the mental health unit with an adult if the admitting physician documents in the case record that such placement is medically indicated or for reasons of safety. Such placement shall be reviewed by the attending physician or a designee or on-call physician each day and documented in the case record. Review policies and procedures to confirm compliance with statute. Review clinical records and also observe where people are sharing common areas to ensure that minors under 14 years of age are not sharing common areas with adults. Review clinical records of patients age 14 or older who are sharing a room or ward with an adult to ensure that the placement is documented initially and on a daily basis by the physician as medically necessary.

364 Page 364 of 399 ST - HB190 - Access/Emergency Svcs. & Care Title Access/Emergency Svcs. & Care Statute or Rule (6), FS (6) RIGHTS OF PERSONS BEING TREATED - A hospital providing emergency services and care to a person who is being involuntarily examined under the provisions of s shall adhere to rights of patients specified in part I of chapter 394 and the involuntary examination procedures provided in s , regardless of whether the hospital, or any part thereof, is designated as a receiving or treatment facility under part I of chapter 394 and regardless of whether the person is admitted to the hospital. ST - HB191 - Emergency Medical Conditions Title Emergency Medical Conditions Statute or Rule (2)(g), FS (2) INVOLUNTARY EXAMINATION - (g) A person for whom an involuntary examination has been initiated who is being evaluated or treated at a hospital for an emergency medical condition specified in s must be examined by a receiving facility within 72 hours. The 72-hour period begins when the patient arrives at the hospital and ceases when the attending physician documents that the patient has an emergency condition.

365 Page 365 of 399 ST - HB192 - Emergency Medical Conditions Title Emergency Medical Conditions Statute or Rule (2)(g) FS (2) INVOLUNTARY EXAMINATION - (g)...if the patient is examined at a hospital providing emergency medical services by a professional qualified to perform an involuntary examination and is found as a result of that examination not to meet the criteria for involuntary outpatient placement pursuant to s (1) or involuntary inpatient placement pursuant to s (1), the patient may be offered voluntary placement, if appropriate, or released directly from the hospital providing emergency medical services. The finding by the professional that the patient has been examined and does not meet the criteria for involuntary inpatient placement or involuntary outpatient placement must be entered into the patient's clinical record. Nothing in this paragraph is intended to prevent a hospital providing emergency medical services from appropriately transferring a patient to another hospital prior to stabilization provided the requirements of s (3)(c) have been met. ST - HB193 - Emergency Medical Conditions Title Emergency Medical Conditions Statute or Rule (2)(h), FS (2)(h) One of the following must occur within 12 hours after

366 Page 366 of 399 the patient's attending physician documents that the patient's medical condition has stabilized or that an emergency medical condition does not exist: 1. The patient must be examined by a designated receiving facility and released; or 2. The patient must be transferred to a designated receiving facility in which appropriate medical treatment is available. However, the receiving facility must be notified of the transfer within 2 hours after the patient's condition has been stabilized or after determination that an emergency medical condition does not exist. ST - HB194 - Emergency Medical Conditions Title Emergency Medical Conditions Statute or Rule 65E-5.280(4)(a), FAC (4) Emergency Medical Conditions - (a) Recommended form CF-MH 3101, Feb. 05, "Hospital Determination that Person Does Not Meet Involuntary Placement Criteria," which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used to document the results of the examination prescribed in Section (2)(g), F.S. Use of recommended form "Emergency Medical Services' Determination that Person Does Not Meet Involuntary Placement Criteria" (CF-MH 3101) is considered by the department to be sufficient. ST - HZ800 - Applicability; Definitions Title Applicability; Definitions Statute or Rule , 59A , 59A (1)

367 Page 367 of , F.S. The provisions of this part apply to the provision of services that require licensure as defined in this part and to the following entities licensed, registered, or certified by the agency, as described in chapters 112, 383, 390, 394, 395, 400, 429, 440, 483, and 765: (1) Laboratories authorized to perform testing under the Drug-Free Workplace Act, as provided under ss and (2) Birth centers, as provided under chapter 383. (3) Abortion clinics, as provided under chapter 390. (4) Crisis stabilization units, as provided under parts I and IV of chapter 394. (5) Short-term residential treatment facilities, as provided under parts I and IV of chapter 394. (6) Residential treatment facilities, as provided under part IV of chapter 394. (7) Residential treatment centers for children and adolescents, as provided under part IV of chapter 394. (8) Hospitals, as provided under part I of chapter 395. (9) Ambulatory surgical centers, as provided under part I of chapter 395. (10) Mobile surgical facilities, as provided under part I of chapter 395. (11) Health care risk managers, as provided under part I of chapter 395. (12) Nursing homes, as provided under part II of chapter 400. (13) Assisted living facilities, as provided under part I of chapter 429. (14) Home health agencies, as provided under part III of chapter 400. (15) Nurse registries, as provided under part III of chapter 400. (16) Companion services or homemaker services providers, as provided under part III of chapter 400.

368 Page 368 of 399 (17) Adult day care centers, as provided under part III of chapter 429. (18) Hospices, as provided under part IV of chapter 400. (19) Adult family-care homes, as provided under part II of chapter 429. (20) Homes for special services, as provided under part V of chapter 400. (21) Transitional living facilities, as provided under part V of chapter 400. (22) Prescribed pediatric extended care centers, as provided under part VI of chapter 400. (23) Home medical equipment providers, as provided under part VII of chapter 400. (24) Intermediate care facilities for persons with developmental disabilities, as provided under part VIII of chapter 400. (25) Health care services pools, as provided under part IX of chapter 400. (26) Health care clinics, as provided under part X of chapter 400. (27) Clinical laboratories, as provided under part I of chapter 483. (28) Multiphasic health testing centers, as provided under part II of chapter 483. (29) Organ, tissue, and eye procurement organizations, as provided under part V of chapter , F.S. As used in this part, the term: (1) "Agency" means the Agency for Health Care Administration, which is the licensing agency under this part. (2) "Applicant" means an individual, corporation, partnership, firm, association, or governmental entity that submits an application for a license to the agency. (3) "Authorizing statute" means the statute authorizing the

369 Page 369 of 399 licensed operation of a provider listed in s and includes chapters 112, 383, 390, 394, 395, 400, 429, 440, 483, and 765. (4) "Certification" means certification as a Medicare or Medicaid provider of the services that require licensure, or certification pursuant to the federal Clinical Laboratory Improvement Amendment (CLIA). (5) "Change of ownership" means: (a) An event in which the licensee sells or otherwise transfers its ownership to a different individual or entity as evidenced by a change in federal employer identification number or taxpayer identification number; or (b) An event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a licensee is in any manner transferred or otherwise assigned. This paragraph does not apply to a licensee that is publicly traded on a recognized stock exchange. A change solely in the management company or board of directors is not a change of ownership. (6) "Client" means any person receiving services from a provider listed in s (7) "Controlling interest" means: (a) The applicant or licensee; (b) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or (c) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member. (8) "License" means any permit, registration, certificate, or license issued by the agency. (9) "Licensee" means an individual, corporation, partnership,

370 Page 370 of 399 firm, association, governmental entity, or other entity that is issued a permit, registration, certificate, or license by the agency. The licensee is legally responsible for all aspects of the provider operation. (10) "Moratorium" means a prohibition on the acceptance of new clients. (11) "Provider" means any activity, service, agency, or facility regulated by the agency and listed in s (12) "Services that require licensure" means those services, including residential services, that require a valid license before those services may be provided in accordance with authorizing statutes and agency rules. (13) "Voluntary board member" means a board member or officer of a not-for-profit corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services on the board of directors, and has no financial interest in the corporation or organization. 59A , F.A.C. (1) "Address of record" means the location that is printed on the license and is the address at which the provider is licensed to operate. In the event a license displays multiple locations including branch offices, satellite offices, or off-site locations, the address of record is the main or principle office address. (2) "Agency notification" or "Agency request" means the Agency sends notification by: (a) Mail or personal delivery to the address of record for a licensee or applicant, (b) Mail to an alternative mailing address if requested by the licensee or applicant, or (c) Electronic mail if an electronic mail address has been provided. (3) "Days" means calendar days. (4) "Management company" means an entity retained by a licensee to administer or direct the operation of a provider.

371 Page 371 of 399 This does not include an entity that serves solely as a lender or lien holder. 59A (1), F.A.C. (1)(a) "Arrest Report" means the detailed narrative written by the arresting law enforcement officer explaining the circumstances of the arrest. (b) "Disposition" means the sentencing or other final settlement of a criminal case which shall include, regardless of adjudication, a plea of nolo contendere or guilty, or a conviction by a judge or jury. (c) "Disqualifying Offense" means any criminal offense prohibited in Section , or (5), F.S. (d) "Exemption from Disqualification" means an exemption granted by the Agency following a review of the Application for Exemption, AHCA Form , October 2009, hereby incorporated by reference, and an informal hearing, if appropriate, during which the individual must present clear and convincing evidence to support a reasonable belief that he or she has been rehabilitated and does not present a danger to the health, safety, and welfare of the patient or individual as described in Section , F.S. (e) "FBI" means the Federal Bureau of Investigation. (f) "FDLE" means the Florida Department of Law Enforcement. (g) Level 1 Screening" means an assessment of the criminal history record obtained from the FDLE to determine whether screened individuals have any disqualifying offenses pursuant to Section or (5), F.S. An analysis and review of court dispositions and arrest reports may be required to make a final determination. (h) "Level 2 Screening" means an assessment of the criminal history record obtained through a fingerprint search through the FDLE and FBI to determine whether screened individuals have any disqualifying offenses pursuant to Section or

372 Page 372 of (5), F.S. An analysis and review of court dispositions and arrest reports may be required to make a final determination. ST - HZ802 - License or Application Denial; Revocation Title License or Application Denial; Revocation Statute or Rule , FS (1) In addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: (a) False representation of a material fact in the license application or omission of any material fact from the application. (b) An intentional or negligent act materially affecting the health or safety of a client of the provider. (c) A violation of this part, authorizing statutes, or applicable rules. (d) A demonstrated pattern of deficient performance. (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. (2) If a licensee lawfully continues to operate while a denial or revocation is pending in litigation, the licensee must continue to meet all other requirements of this part, authorizing statutes, and applicable rules and must file subsequent renewal applications for licensure and pay all licensure fees. The provisions of ss (1) and (3)(c) shall not apply to renewal applications filed during the time period in which the litigation of the denial or revocation is pending until that litigation is final.

373 Page 373 of 399 (3) An action under s or denial of the license of the transferor may be grounds for denial of a change of ownership application of the transferee. (4) In addition to the grounds provided in authorizing statutes, the agency shall deny an application for a license or license renewal if the applicant or a person having a controlling interest in an applicant has been: (a) Convicted of, or enters a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, chapter 893, 21 U.S.C. ss , or 42 U.S.C. ss , unless the sentence and any subsequent period of probation for such convictions or plea ended more than 15 years prior to the date of the application; (b) Terminated for cause from the Florida Medicaid program pursuant to s , unless the applicant has been in good standing with the Florida Medicaid program for the most recent 5 years; or (c) Terminated for cause, pursuant to the appeals procedures established by the state or Federal Government, from the federal Medicare program or from any other state Medicaid program, unless the applicant has been in good standing with a state Medicaid program or the federal Medicare program for the most recent 5 years and the termination occurred at least 20 years prior to the date of the application. ST - HZ803 - License Required; Display Title License Required; Display Statute or Rule , FS (1) It is unlawful to provide services that require licensure, or operate or maintain a provider that offers or provides services that require licensure, without first obtaining from the agency a license authorizing the provision of such services or the Check to see that the license is for the facility and location where it is displayed. Contact the appropriate licensure unit if there are questions about the license. If applicable, check to make sure the category of testing being done is reflected on the license, the ownership given on the face of the license is accurate, that the location of the facility is the address printed on the license, and that the

374 Page 374 of 399 operation or maintenance of such provider. (2) A license must be displayed in a conspicuous place readily visible to clients who enter at the address that appears on the license and is valid only in the hands of the licensee to whom it is issued and may not be sold, assigned, or otherwise transferred, voluntarily or involuntarily. The license is valid only for the licensee, provider, and location for which the license is issued. (3) Any person who knowingly alters, defaces, or falsifies a license certificate issued by the agency, or causes or procures any person to commit such an offense, commits a misdemeanor of the second degree, punishable as provided in s or s Any licensee or provider who displays an altered, defaced, or falsified license certificate is subject to the penalties set forth in s and an administrative fine of $1,000 for each day of illegal display. license is properly displayed. Look at Z0827 Unlicensed Activity , F.S. as unlicensed activity should be cited if there has been a change of ownership, or for clinical laboratories, testing outside of the specialty/subspecialties printed on the license are being performed. Regarding Nursing Homes, refer to (2) which states: Separate licenses shall be required for facilities maintained in separate premises, even though operated under the same management. However, a separate license shall not be required for separate buildings on the same grounds. Regarding Labs, refer to 59A-7.021(3) which states: Separate licensure shall be required for all laboratories maintained on separate premises, as defined under subsection 59A-7.020(27), F.A.C., including mobile laboratory units, even though operated under the same management. Separate licensure shall not be required for separate buildings on the same or adjoining grounds. ST - HZ806 - Change of Address Title Change of Address Statute or Rule 59A , FAC (2) Any request to amend a license must be received by the Agency in advance of the requested effective date as detailed below. Requests to amend a license are not authorized until the license is issued. (a) Requests to change the address of record must be received by the Agency 60 to 120 days in advance of the The licensure unit handles change of address, but surveyors may find that the provider has moved and therefore could cite this.

375 Page 375 of 399 requested effective date for the following provider types: 1. Birth Centers, as provided under Chapter 383, F.S.; 2. Abortion Clinics, as provided under Chapter 390, F.S.; 3. Crisis Stabilization Units, as provided under Parts I and IV of Chapter 394, F.S.; 4. Short Term Residential Treatment Units, as provided under Parts I and IV of Chapter 394, F.S. 5. Residential Treatment Facilities, as provided under Part IV of Chapter 394, F.S.; 6. Residential Treatment Centers for Children and Adolescents, as provided under Part IV of Chapter 394, F.S.; 7. Hospitals, as provided under Part I of Chapter 395, F.S.; 8. Ambulatory Surgical Centers, as provided under Part I of Chapter 395, F.S.; 9. Nursing Homes, as provided under Part II of Chapter 400, F.S.; 10. Hospices, as provided under Part IV of Chapter 400, F.S.; 11. Homes for Special Services as provided under Part V of Chapter 400, F.S.; 12. Transitional Living Facilities, as provided under Part V of Chapter 400, F.S.; 13. Prescribed Pediatric Extended Care Centers, as provided under Part VI of Chapter 400, F.S.; 14. Intermediate Care Facilities for the Developmentally Disabled, as provided under Part VIII of Chapter 400, F.S.; 15. Assisted Living Facilities, as provided under Part I of Chapter 429, F.S.; 16. Adult Family-Care Homes, as provided under Part II of Chapter 429, F.S.; 17. Adult Day Care Centers, as provided under Part III of Chapter 429, F.S. (b) Requests to change the address of record must be received by the Agency 21 to 120 days in advance of the requested effective date for the following provider types: 1. Drug Free Workplace Laboratories as provided under

376 Page 376 of 399 Sections and , F.S.; 2. Mobile Surgical Facilities, as provided under Part I of Chapter 395, F.S.; 3. Health Care Risk Managers, as provided under Part I of Chapter 395, F.S.; 4. Home Health Agencies, as provided under Part III of Chapter 400, F.S.; 5. Nurse Registries, as provided under Part III of Chapter 400, F.S.; 6. Companion Services or Homemaker Services Providers, as provided under Part III of Chapter 400, F.S.; 7. Home Medical Equipment Providers, as provided under Part VII of Chapter 400, F.S.; 8. Health Care Services Pools, as provided under Part IX of Chapter 400, F.S.; 9. Health Care Clinics, as provided under Part X of Chapter 400, F.S., including certificate of exemption; 10. Clinical Laboratories, as provided under Part I of Chapter 483, F.S.; 11. Multiphasic Health Testing Centers, as provided under Part II of Chapter 483, F.S.; 12. Organ and Tissue Procurement Agencies, as provided under Chapter 381, F.S. (c) All other requests to amend a license including but not limited to services, licensed capacity, and other specifications which are required to be displayed on the license by authorizing statutes or applicable rules must be received by the Agency 60 to 120 days in advance of the requested effective date. This deadline does not apply to a request to amend hospital emergency services defined in Section (2), F.S. (3) Failure to submit a timely request shall result in a $500 fine.

377 Page 377 of 399 (4) A licensee is not authorized to operate in a new location until a license is obtained which specifies the new location. Failure to amend a license prior to a change of the address of record constitutes unlicensed activity. (5) The licensee shall return the license certificate to the Agency upon the rendition of a final order revoking, cancelling or denying a license, and upon the voluntary discontinuance of operation. ST - HZ809 - Proof of Financial Ability to Operate Title Proof of Financial Ability to Operate Statute or Rule 59A (3)(e),&(7), (7), A (3)(e) FAC "Financial instability" means the provider cannot meet its financial obligations. Evidence such as the issuance of bad checks, an accumulation of delinquent bills, or inability to meet current payroll needs shall constitute prima facie evidence that the ownership of the provider lacks the financial ability to operate. Evidence shall also include the Medicare or Medicaid program's indications or determination of financial instability or fraudulent handling of government funds by the provider (7) FS "Controlling interest" means: (a) The applicant or licensee; (b) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest This standard would be used by surveyors if evidence of financial instability is found and the licensee or any controlling interest in the licensee withholds information from the surveyor. The financial schedules and documentation of correction of the financial instability are submitted to the AHCA Home Care Unit <or other licensing unit> in the state office and reviewed by AHCA state office financial reviewers in the Financial Analysis Unit. Further administrative action may be taken by the state office. This standard applies to the following provider types: Nursing Home Facilities, as specified in Part II, Chapter 400, F.S.; Assisted Living Facilities, as specified in Part I, Chapter 429, F.S.; Home Health Agencies, as specified in Part III, Chapter 400, F.S.; Hospices, as specified in Part IV, Chapter 400, F.S.; Adult Day Care Centers, as specified in Part III, Chapter 429, F.S.; Prescribed Pediatric Extended Care Centers, as specified in Part VI, Chapter 400, F.S.; Home Medical Equipment Providers, as specified in Part VII, Chapter 400, F.S.; Intermediate Care Facilities for the Developmentally Disabled, as specified in Part VIII, Chapter 400, F.S.; Health Care Clinics, as specified in Part X, Chapter 400, F.S.; The standard applies to Nurse Registries as specified in 59A (7) which states:

378 Page 378 of 399 in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member FS (8) Upon application for initial licensure or change of ownership licensure, the applicant shall furnish satisfactory proof of the applicant's financial ability to operate in accordance with the requirements of this part, authorizing statutes, and applicable rules. The agency shall establish standards for this Statutes purpose, including information concerning the applicant's controlling interests. The agency shall also establish documentation requirements, to be completed by each applicant, that show anticipated provider revenues and expenditures, the basis for financing the anticipated cash-flow requirements of the provider, and an applicant's access to contingency financing. A current certificate of authority, pursuant to chapter 651, may be provided as proof of financial ability to operate. The agency may require a licensee to provide proof of financial ability to operate at any time if there is evidence of financial instability, including, but not limited to, unpaid expenses necessary for the basic operations of the provider. (9) A controlling interest may not withhold from the agency any evidence of financial instability, including, but not limited to, checks returned due to insufficient funds, delinquent accounts, nonpayment of withholding taxes, unpaid utility expenses, nonpayment for essential services, or adverse court action concerning the financial viability of the provider or any other provider licensed under this part that is under the control of the controlling interest. A controlling interest shall notify the agency within 10 days after a court action to initiate An application for renewal of a license shall not be required to provide proof of financial ability to operate, unless the applicant has demonstrated financial instability at any time, pursuant to Section , F.S., in which case AHCA shall require the applicant for renewal to provide proof of financial ability to operate by submitting information as described in 59A (7)(b), F.A.C. and documentation of correction of the financial instability, to include evidence of the payment in full of any bad checks, delinquent bills or liens and all associated fees, costs, and changes related to the instability. If complete payment cannot be made, evidence must be submitted of partial payment along with a plan for payment of any liens or delinquent bills. If the lien is with a government agency or repayment is ordered by a federal, state, or district court, an accepted plan of repayment must be provided. If the licensed nurse registry has demonstrated financial instability as outlined above at any time the AHCA will request proof of financial ability to operate. None of the Hospital Unit Programs nor the Lab Unit Programs would have this requirement.

379 Page 379 of 399 bankruptcy, foreclosure, or eviction proceedings concerning the provider in which the controlling interest is a petitioner or defendant. Any person who violates this subsection commits a misdemeanor of the second degree, punishable as provided in s or s Each day of continuing violation is a separate offense. 59A (7) FS (7) If an applicant or licensee has shown signs of financial instability, as provided in Section (9), F.S., at any time, the Agency may require the applicant or licensee to provide proof of financial ability to operate by submission of: (a) AHCA Form , July 2009, Proof of Financial Ability Form, that includes a balance sheet and income and expense statement for the next 2 years of operation which provide evidence of having sufficient assets, credit, and projected revenues to cover liabilities and expenses, and (b) Documentation of correction of the financial instability, including but not limited to, evidence of the payment of any bad checks, delinquent bills or liens. If complete payment cannot be made, evidence must be submitted of partial payment along with a plan for payment of any liens or delinquent bills. If the lien is with a government agency or repayment is ordered by a federal or state court, an accepted plan of repayment must be provided. ST - HZ812 - Change of Ownership Title Change of Ownership Statute or Rule (5),FS, , FS (5), F.S. "Change of ownership" means: (a) An event in which the licensee sells or otherwise transfers This tag may be cited for unreported changes of ownership.

380 Page 380 of 399 its ownership to a different individual or entity as evidenced by a change in federal employer identification number or taxpayer identification number; or (b) An event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a licensee is in any manner transferred or otherwise assigned. This paragraph does not apply to a licensee that is publicly traded on a recognized stock exchange. A change solely in the management company or board of directors is not a change of ownership , F.S. Whenever a change of ownership occurs: (1) The transferor shall notify the agency in writing at least 60 days before the anticipated date of the change of ownership. (2) The transferee shall make application to the agency for a license within the timeframes required in s (3) The transferor shall be responsible and liable for: (a) The lawful operation of the provider and the welfare of the clients served until the date the transferee is licensed by the agency. (b) Any and all penalties imposed against the transferor for violations occurring before the date of change of ownership. (4) Any restriction on licensure, including a conditional license existing at the time of a change of ownership, shall remain in effect until the agency determines that the grounds for the restriction are corrected. (5) The transferee shall maintain records of the transferor as required in this part, authorizing statutes, and applicable rules, including: (a) All client records. (b) Inspection reports. (c) All records required to be maintained pursuant to s , if applicable.

381 Page 381 of 399 ST - HZ815 - Background Screening; Prohibited Offenses Title Background Screening; Prohibited Offenses Statute or Rule , (2), , F.S. (1) Level 2 background screening pursuant to chapter 435 must be conducted through the agency on each of the following persons, who are considered employees for the purposes of conducting screening under chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest if the agency has reason to believe that such person has been convicted of any offense prohibited by s For each controlling interest who has been convicted of any such offense, the licensee shall submit to the agency a description and explanation of the conviction at the time of license application. (e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor's employer or the licensee. Employees and independent contractors hired or contracted before August 1, 2010, have until 2015 to obtain Level 2 screening. The rescreening should be done according to the schedule in (5)(c),F.S. included in this standard. Persons already hired or under contract before August 1, 2010 would have received level 1 screening. Employees and contractors who do not meet the background screening requirements cannot be retained in a direct care capacity, unless an exemption from disqualification has been approved by AHCA or the Department of Health (when a licensed or certified health care professional or certified nursing assistant). The employee or contractor with a disqualifying offense must have a copy of an exemption [granted by either DOH or AHCA] in their personnel file before the employee or contractor can be hired. There is a new staggered schedule: (a) Individuals for whom the last screening was conducted on or before December 31, 2004, must be rescreened by July 31, (b) Individuals for whom the last screening conducted was between January 1, 2005, and December 31, 2008, must be rescreened by July 31, (c) Individuals for whom the last screening conducted was between January 1, 2009, through July 31, 2011, must be rescreened by July 31, An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. Individuals may be provisionally employed in positions requiring background screening. They may be in training or orientation, but may NOT have access to residents/patients until the background screening process is completed

382 Page 382 of 399 (2) Every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward the person's fingerprints to the Federal Bureau of Investigation for a national criminal history record check. If the fingerprints of such a person are not retained by the Department of Law Enforcement under s (2)(g), the person must file a complete set of fingerprints with the agency and the agency shall forward the fingerprints to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national criminal history record check. The fingerprints may be retained by the Department of Law Enforcement under s (2)(g). The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person fingerprinted. (3) All fingerprints must be provided in electronic format. Screening results shall be reviewed by the agency with respect to the offenses specified in s and this section, and the qualifying or disqualifying status of the person named in the request shall be maintained in a database. The qualifying or disqualifying status of the person named in the request shall be posted on a secure website for retrieval by the licensee or designated agent on the licensee's behalf. An employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. If an individual is in the Clearinghouse and are working then they must be on that provider's employee roster within 10 days of their hire date. The same for once a person is no longer working for that provider. If they are in the Clearinghouse then their status in the employee roster must be updated within 10 days of a change. Surveyor Probes: Level 2 includes FDLE and FBI screening. Staff who do not have access to client property, funds, or living areas or who do not have contact with clients are not required to be screened. If an employee or contractor's responsibility requires him or her to have contact with clients, a Level 2 background screening is required. Was the employee or contractor hired on or after August 1, 2010? Does the licensee have evidence of contractor and employee screening? (4) In addition to the offenses listed in s , all persons required to undergo background screening pursuant to this part or authorizing statutes must not have an arrest awaiting final disposition for, must not have been found guilty of, regardless

383 Page 383 of 399 of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated delinquent and the record not have been sealed or expunged for any of the following offenses or any similar offense of another jurisdiction: (a) Any authorizing statutes, if the offense was a felony. (b) This chapter, if the offense was a felony. (c) Section , relating to Medicaid provider fraud. (d) Section , relating to Medicaid fraud. (e) Section , relating to domestic violence. (f) Section , relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems. (g) Section , relating to false and fraudulent insurance claims. (h) Section , relating to patient brokering. (i) Section , relating to criminal use of personal identification information. (j) Section , relating to obtaining a credit card through fraudulent means. (k) Section , relating to fraudulent use of credit cards, if the offense was a felony. (l) Section , relating to forgery. (m) Section , relating to uttering forged instruments. (n) Section , relating to forging bank bills, checks, drafts, or promissory notes. (o) Section , relating to uttering forged bank bills, checks, drafts, or promissory notes. (p) Section , relating to fraud in obtaining medicinal drugs. (q) Section , relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony.

384 Page 384 of 399 (5) A person who serves as a controlling interest of, is employed by, or contracts with a licensee on July 31, 2010, who has been screened and qualified according to standards specified in s or s must be rescreened by July 31, 2015 in compliance with the following schedule. If, upon rescreening, such person has a disqualifying offense that was not a disqualifying offense at the time of the last screening, but is a current disqualifying offense and was committed before the last screening, he or she may apply for an exemption from the appropriate licensing agency and, if agreed to by the employer, may continue to perform his or her duties until the licensing agency renders a decision on the application for exemption if the person is eligible to apply for an exemption and the exemption request is received by the agency within 30 days after receipt of the rescreening results by the person. The rescreening schedule shall be: (a) Individuals for whom the last screening was conducted on or before December 31, 2004, must be rescreened by July 31, (b) Individuals for whom the last screening conducted was between January 1, 2005, and December 31, 2008, must be rescreened by July 31, (c) Individuals for whom the last screening conducted was between January 1, 2009, through July 31, 2011, must be rescreened by July 31, (6) The costs associated with obtaining the required screening must be borne by the licensee or the person subject to screening. Licensees may reimburse persons for these costs. The Department of Law Enforcement shall charge the agency for screening pursuant to s (3). The agency shall establish a schedule of fees to cover the costs of screening. (7)(a) As provided in chapter 435, the agency may grant an exemption from disqualification to a person who is subject to

385 Page 385 of 399 this section and who: 1. Does not have an active professional license or certification from the Department of Health; or 2. Has an active professional license or certification from the Department of Health but is not providing a service within the scope of that license or certification. (b) As provided in chapter 435, the appropriate regulatory board within the Department of Health, or the department itself if there is no board, may grant an exemption from disqualification to a person who is subject to this section and who has received a professional license or certification from the Department of Health or a regulatory board within that department and that person is providing a service within the scope of his or her licensed or certified practice. (8) The agency and the Department of Health may adopt rules pursuant to s (1) and to implement this section, chapter 435, and authorizing statutes requiring background screening and to implement and adopt criteria relating to retaining fingerprints pursuant to s (2). (9) There is no unemployment compensation or other monetary liability on the part of, and no cause of action for damages arising against, an employer that, upon notice of a disqualifying offense listed under chapter 435 or this section, terminates the person against whom the report was issued, whether or not that person has filed for an exemption with the Department of Health or the agency , F.S. (1) If an employer or agency has reasonable cause to believe that grounds exist for the denial or termination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record that indicates noncompliance with the standards in this chapter. It

386 Page 386 of 399 is the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification is proof of mistaken identity. (2)(a) An employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the agency as provided under s (b) If an employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. (c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to s (d) An employer may hire an employee to a position that requires background screening before the employee completes

387 Page 387 of 399 the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. (3) Any employee who refuses to cooperate in such screening or refuses to timely submit the information necessary to complete the screening, including fingerprints if required, must be disqualified for employment in such position or, if employed, must be dismissed. (4) There is no unemployment compensation or other monetary liability on the part of, and no cause of action for damages against, an employer that, upon notice of a conviction or arrest for a disqualifying offense listed under this chapter, terminates the person against whom the report was issued or who was arrested, regardless of whether or not that person has filed for an exemption pursuant to this chapter (2), F.S. "Employee" means any person required by law to be screened pursuant to this chapter, including, but not limited to, persons who are contractors, licensees, or volunteers. ST - HZ816 - Background Screening -Affidavit of Compliance Title Background Screening -Affidavit of Compliance Statute or Rule (2)(a-c), FS Until the person's background screening results are retained in the clearinghouse created under s , the agency may accept as satisfying the requirements of this section, proof of Is AHCA Recommended Form , August 2010, Affidavit of Compliance with Background Screening Requirements, in the employee's personnel file? Or, does the employee have a similar document attesting under penalty of perjury that they are in compliance with Chapter 435, F.S.

388 Page 388 of 399 compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health, the Department of Elderly Affairs, the Agency for Persons with Disabilities, the Department of Children and Family Services, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651, provided that: (a) The screening standards and disqualifying offenses for the prior screening are equivalent to those specified in s and this section; (b) The person subject to screening has not had a break in service from a position that requires level 2 screening for more than 90 days; and (c) Such proof is accompanied, under penalty of perjury, by an affidavit of compliance with the provisions of chapter 435 and this section using forms provided by the agency. ST - HZ817 - Minimum Licensure Requirement - Inform AHCA Title Minimum Licensure Requirement - Inform AHCA Statute or Rule (3-4) FS; 59A (1) FAC , F.S. In addition to the licensure requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license. (3) Unless otherwise specified in this part, authorizing statutes, or applicable rules, any information required to be reported to the agency must be submitted within 21 calendar days after the report period or effective date of the Refer to s , F.S. regarding the Exemptions for this regulation. Regarding Nursing Homes, note that the closing of a nursing facility ( (4)(a)) must comply with (1), F.S. instead which states: (1) Whenever a licensee voluntarily discontinues operation, and during the period when it is preparing for such discontinuance, it shall inform the agency not less than 90 days prior to the discontinuance of operation. The licensee also shall inform the resident or the next of kin, legal representative, or agency acting on behalf of the resident of the fact, and the proposed time, of such discontinuance and give at least 90 days' notice so that suitable arrangements may be made for the transfer and care of the resident. In the event any resident has no such person to represent him or her, the licensee shall be responsible for securing a suitable transfer of the resident before the discontinuance of operation.

389 Page 389 of 399 information, whichever is earlier, including, but not limited to, any change of: (a) Information contained in the most recent application for licensure. (b) Required insurance or bonds. The agency shall be responsible for arranging for the transfer of those residents requiring transfer who are receiving assistance under the Medicaid program. (4) Whenever a licensee discontinues operation of a provider: (a) The licensee must inform the agency not less than 30 days prior to the discontinuance of operation and inform clients of such discontinuance as required by authorizing statutes. Immediately upon discontinuance of operation by a provider, the licensee shall surrender the license to the agency and the license shall be canceled. (b) The licensee shall remain responsible for retaining and appropriately distributing all records within the timeframes prescribed in authorizing statutes and applicable rules. In addition, the licensee or, in the event of death or dissolution of a licensee, the estate or agent of the licensee shall: 1. Make arrangements to forward records for each client to one of the following, based upon the client's choice: the client or the client's legal representative, the client's attending physician, or the health care provider where the client currently receives services; or 2. Cause a notice to be published in the newspaper of greatest general circulation in the county in which the provider was located that advises clients of the discontinuance of the provider operation. The notice must inform clients that they may obtain copies of their records and specify the name, address, and telephone number of the person from whom the copies of records may be obtained. The notice must appear at least once a week for 4 consecutive weeks. 59A , F.S. Provider location. A licensee must maintain proper authority for operation of the provider at the address of record. If such

390 Page 390 of 399 authority is denied, revoked or otherwise terminated by the local zoning or code enforcement authority, the Agency may deny or revoke an application or license, or impose sanctions. ST - HZ818 - Minimum Licensure Requirement - Client Notice Title Minimum Licensure Requirement - Client Notice Statute or Rule (5) FS In addition to the licensure requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license. Refer to s , F.S. regarding the Exemptions for this regulation. (5)(a) On or before the first day services are provided to a client, a licensee must inform the client and his or her immediate family or representative, if appropriate, of the right to report: 1. Complaints. The statewide toll-free telephone number for reporting complaints to the agency must be provided to clients in a manner that is clearly legible and must include the words: "To report a complaint regarding the services you receive, please call toll-free (phone number)." 2. Abusive, neglectful, or exploitative practices. The statewide toll-free telephone number for the central abuse hotline must be provided to clients in a manner that is clearly legible and must include the words: "To report abuse, neglect, or exploitation, please call toll-free (phone number)." 3. Medicaid fraud. An agency-written description of Medicaid fraud and the statewide toll-free telephone number for the central Medicaid fraud hotline must be provided to clients in a manner that is clearly legible and must include the words: "To report suspected Medicaid fraud, please call toll-free (phone number)."

391 Page 391 of 399 The agency shall publish a minimum of a 90-day advance notice of a change in the toll-free telephone numbers. (b) Each licensee shall establish appropriate policies and procedures for providing such notice to clients. ST - HZ819 - Minimum Licensure Req - Financial Viability Title Minimum Licensure Req - Financial Viability Statute or Rule (9) FS In addition to the licensure requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license. Refer to s , F.S. regarding the Exemptions for this regulation. (9) A controlling interest may not withhold from the agency any evidence of financial instability, including, but not limited to, checks returned due to insufficient funds, delinquent accounts, nonpayment of withholding taxes, unpaid utility expenses, nonpayment for essential services, or adverse court action concerning the financial viability of the provider or any other provider licensed under this part that is under the control of the controlling interest. A controlling interest shall notify the agency within 10 days after a court action to initiate bankruptcy, foreclosure, or eviction proceedings concerning the provider in which the controlling interest is a petitioner or defendant. Any person who violates this subsection commits a misdemeanor of the second degree, punishable as provided in s or s Each day of continuing violation is a separate offense.

392 Page 392 of 399 ST - HZ821 - Reporting Requirements; Electronic Submission Title Reporting Requirements; Electronic Submission Statute or Rule 59A , FAC (1) During the two year licensure period, any change or expiration of any information that is required to be reported under Chapter 408, Part II or authorizing statutes for the provider type as specified in Section (3), F.S., during the license application process must be reported to the Agency within 21 days of occurrence of the change, including: (a) Insurance coverage renewal, (b) Bond renewal, (c) Change of administrator or the similarly titled person who is responsible for the day-to-day operation of the provider, (d) Annual sanitation inspections, (e) Fire inspections, (f) Approval of revisions to emergency management plans. Regarding 59A (1)(f), this does not apply to Home Care Unit programs since there is a different process through the Department of Health in chapter 400 Part III & IV, F.S. Regarding 59A (2), this only applies to nursing homes and assisted living facilities. (2) Electronic submission of information. (a) The following required information must be reported through the Agency's Internet site at 1. Nursing homes: a. Semi-annual staffing ratios required pursuant to Section (1)(o), F.S., and Rule 59A-4.103, F.A.C. b. Adverse incident reports required pursuant to Sections (7) and (8), F.S., and Rule 59A-4.123, F.A.C. c. Liability claim reports required pursuant to Section (10), F.S., and Rule 59A-4.123, F.A.C. 2. Assisted living facilities: a. Adverse incident reports required pursuant to Sections (3) and (4), F.S., and Rule 58A , F.A.C.

393 Page 393 of 399 b. Liability claim reports required pursuant to Section (5), F.S., and Rule 58A , F.A.C. (b) The licensee must retain the receipt issued from the Internet site indicating that their transaction was accepted. (c) If the Agency's Internet site is temporarily out of service, the required reports may be submitted by mail or facsimile as follows: 1. Semi-annual staffing ratios and liability claim reports are sent to the Agency for Health Care Administration, Central Systems Management Unit, 2727 Mahan Drive, MS 47, Tallahassee, FL or facsimile to (850) Adverse incident reports are sent to the Agency for Health Care Administration, Florida Center for Health Information and Policy Analysis, 2727 Mahan Drive, MS 16, Tallahassee, FL or facsimile to (850) ST - HZ824 - Right of Inspection; Inspection Reports Title Right of Inspection; Inspection Reports Statute or Rule , FS; 59A , FAC , F.S. (1) An authorized officer or employee of the agency may make or cause to be made any inspection or investigation deemed necessary by the agency to determine the state of compliance with this part, authorizing statutes, and applicable rules. The right of inspection extends to any business that the agency has reason to believe is being operated as a provider without a license, but inspection of any business suspected of being operated without the appropriate license may not be made without the permission of the owner or person in charge unless a warrant is first obtained from a circuit court. Any application for a license issued under this part, authorizing statutes, or applicable rules constitutes permission for an

394 Page 394 of 399 appropriate inspection to verify the information submitted on or in connection with the application. (a) All inspections shall be unannounced, except as specified in s (b) Inspections for relicensure shall be conducted biennially unless otherwise specified by authorizing statutes or applicable rules. (2) Inspections conducted in conjunction with certification, comparable licensure requirements, or a recognized or approved accreditation organization may be accepted in lieu of a complete licensure inspection. However, a licensure inspection may also be conducted to review any licensure requirements that are not also requirements for certification. (3) The agency shall have access to and the licensee shall provide, or if requested send, copies of all provider records required during an inspection or other review at no cost to the agency, including records requested during an offsite review. (4) A deficiency must be corrected within 30 calendar days after the provider is notified of inspection results unless an alternative timeframe is required or approved by the agency. (5) The agency may require an applicant or licensee to submit a plan of correction for deficiencies. If required, the plan of correction must be filed with the agency within 10 calendar days after notification unless an alternative timeframe is required. (6)(a) Each licensee shall maintain as public information, available upon request, records of all inspection reports pertaining to that provider that have been filed by the agency unless those reports are exempt from or contain information that is exempt from s (1) and s. 24(a), Art. I of the State Constitution or is otherwise made confidential by law. Effective October 1, 2006, copies of such reports shall be retained in the records of the provider for at least 3 years following the date the reports are filed and issued, regardless of a change of ownership.

395 Page 395 of 399 (b) A licensee shall, upon the request of any person who has completed a written application with intent to be admitted by such provider, any person who is a client of such provider, or any relative, spouse, or guardian of any such person, furnish to the requester a copy of the last inspection report pertaining to the licensed provider that was issued by the agency or by an accrediting organization if such report is used in lieu of a licensure inspection. 59A , F.A.C. (1) When regulatory violations are identified by the Agency: (a) Deficiencies must be corrected within 30 days of the date the Agency sends the deficiency notice to the provider, unless an alternative timeframe is required or approved by the Agency. (b) The Agency may conduct an unannounced follow-up inspection or off-site review to verify correction of deficiencies at any time. (2) If an inspection is completed through off-site record review, any records requested by the Agency in conjunction with the review, must be received within 7 days of request and provided at no cost to the Agency. Each licensee shall maintain the records including medical and treatment records of a client and provide access to the Agency. (3) Providers that are exempt from Agency inspections due to accreditation oversight as prescribed in authorizing statutes must provide: (a) Documentation from the accrediting agency including the name of the accrediting agency, the beginning and expiration dates of the provider's accreditation, accreditation status and type must be submitted at the time of license application, or within 21 days of accreditation. (b) Documentation of each accreditation inspection including the accreditation organization's report of findings, the provider's response and the final determination must be submitted within 21 days of final determination or the provider is no longer exempt from Agency inspection.

396 Page 396 of 399 ST - HZ827 - Unlicensed Activity Title Unlicensed Activity Statute or Rule , FS (1) A person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or hold out to the public that he or she holds a license for other than that for which he or she actually holds the license. (2) The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an action for an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency. (3) It is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense. (4) Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of This tag can be cited in conjunction with Z0803 License Required; Display, F.S. License required when the provider is offering services not authorized and printed on the face of the license, when the licensed owner is not operating and it is being operated by another entity that is not licensed to operate. It may also be cited if the Agency has notified the provider to cease unlicensed activity and the provider continues to operate.

397 Page 397 of 399 noncompliance. (5) When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation. (6) In addition to granting injunctive relief pursuant to subsection (2), if the agency determines that a person or entity is operating or maintaining a provider without obtaining a license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules. (7) Any person aware of the operation of an unlicensed provider must report that provider to the agency. ST - HZ829 - Moratorium; Emergency Suspension Title Moratorium; Emergency Suspension Statute or Rule , FS (1) The agency may impose an immediate moratorium or emergency suspension as defined in s on any provider if the agency determines that any condition related to the provider or licensee presents a threat to the health, safety, or welfare of a client. (2) A provider or licensee, the license of which is denied or revoked, may be subject to immediate imposition of a moratorium or emergency suspension to run concurrently with licensure denial, revocation, or injunction.

398 Page 398 of 399 (3) A moratorium or emergency suspension remains in effect after a change of ownership, unless the agency has determined that the conditions that created the moratorium, emergency suspension, or denial of licensure have been corrected. (4) When a moratorium or emergency suspension is placed on a provider or licensee, notice of the action shall be posted and visible to the public at the location of the provider until the action is lifted. ST - HZ830 - Emergency Management Planning Title Emergency Management Planning Statute or Rule , FS (1) A licensee required by authorizing statutes to have an emergency operations plan must designate a safety liaison to serve as the primary contact for emergency operations. Four of the Home Care programs have major state laws that have extensive emergency management requirements - home health agencies, hospices, nurse registries and home medical equipment providers - and their associated regulation sets have specific standards. (2) An entity subject to this part may temporarily exceed its licensed capacity to act as a receiving provider in accordance with an approved emergency operations plan for up to 15 days. While in an overcapacity status, each provider must furnish or arrange for appropriate care and services to all clients. In addition, the agency may approve requests for overcapacity in excess of 15 days, which approvals may be based upon satisfactory justification and need as provided by the receiving and sending providers. (3)(a) An inactive license may be issued to a licensee subject to this section when the provider is located in a geographic area in which a state of emergency was declared by the Governor if the provider: 1. Suffered damage to its operation during the state of emergency.

399 Page 399 of Is currently licensed. 3. Does not have a provisional license. 4. Will be temporarily unable to provide services but is reasonably expected to resume services within 12 months. (b) An inactive license may be issued for a period not to exceed 12 months but may be renewed by the agency for up to 12 additional months upon demonstration to the agency of progress toward reopening. A request by a licensee for an inactive license or to extend the previously approved inactive period must be submitted in writing to the agency, accompanied by written justification for the inactive license, which states the beginning and ending dates of inactivity and includes a plan for the transfer of any clients to other providers and appropriate licensure fees. Upon agency approval, the licensee shall notify clients of any necessary discharge or transfer as required by authorizing statutes or applicable rules. The beginning of the inactive licensure period shall be the date the provider ceases operations. The end of the inactive period shall become the license expiration date, and all licensure fees must be current, must be paid in full, and may be prorated. Reactivation of an inactive license requires the prior approval by the agency of a renewal application, including payment of licensure fees and agency inspections indicating compliance with all requirements of this part and applicable rules and statutes. (4) Licensees providing residential or inpatient services must utilize an online database approved by the agency to report information to the agency regarding the provider's emergency status, planning, or operations.