News and Views for Healthcare Accreditation Professionals

Archive for January, 2012

Repeat INDIRECT finding results in follow up survey

An AFS rule has now been re-established.  If an organization receives a repeat finding for an indirect standard at a triennial survey that had previously been found on the previous survey, a 45 day follow up survey will occur.

Effective January 1, 2012, The Joint Commission has reinstated a 2011 decision rule (AFS02) in the Accreditation with Follow-up Survey category for all accreditation programs, as well as the corresponding decision rule (CFR02, which was CFR06) in the Certification with Review category for all certification programs. The rule is:
AFS02: The organization demonstrates systemic patterns, trends, and repeat findings primarily with indirect impact standards.
This triggers a follow up survey.  Once you promise its fixed, it must remain fixed.

Privileging REQUIRED by CMS for Rehabilitation

Traditionally TJC surveyors have generally NOT looked for privileges for physicians who order therapy in outpatient rehabilitation centers.  CMS just released in the November COP release.  Note that if the hospital bills for the outpatient rehabilitation center under the hospital CCN, it is both surveyable, and CMS would expect privileges to be granted.  I have asked John Herringer if TJC surveyors will look for this.  I will update the blog when I get his response.

(Rev. 72, Issued: 11-18-11, Effective: 11-18-11, Implementation: 11-18-11)
§482.56(b) Standard: Delivery of Services
Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws.

Interpretive Guidelines §482.56(b)
Rehabilitation services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient. The practitioner must have medical staff privileges to write orders for these services.

This is the reply from John Herringer at SIG

For rehab if this is a new CMS requirement then the
practitioner will need to be privileged. We have always
required privileging for any outpatient services requiring medication
administration or blood administration as required by CMS.
It was not required for diagnostic testing and previously not
for therapy services.
The requirement would apply to any setting included in the scope
of the hospital survey.

The time is NOW to say no to Multi-dose vials

Both AORN and ASA have voiced in writing opinions against the continued use of multi-dose vials in the operating room.  ASA has gone so far as to say they should be banished from the entire operating room environment.  Now that two professional organizations have advocated against their use, can regulations be far behind?  Also as a matter of medico-legal liability, it would be difficult to defend the practice in light of these recommendations.

It is really a time consuming task, that is prone to non-compliance, to use MDVs in a completely sterile manner.  Also the 28 day beyond use dating requirement is not being followed.   Old literature stated that contamination was not so much an issue of inappropriate entry (or time that the vial was opened) but of the number of times a rubber stopper was punctured.  Rubber material was frequently found floating in the medication vial.

So while a MDV can still be used because that is all we have, it should be used as a SINGLE dose vial.  If there is a medication shortage of one of these medications or expense is an issue, pharmacy should dispense the medication as single doses as is now frequently done with succinylcholine.