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Salem Hospital Plan of Correction 6-11-12

Salem Hospital Plan of Correction 6-11-12

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Published by Statesman Journal
Salem Hospital Plan of Correction 6-11-12
Salem Hospital Plan of Correction 6-11-12

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Published by: Statesman Journal on Mar 31, 2013
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08/03/2013

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Plan
of
Correction
OHA,
Health Care Regulation
&
Quality ImprovementCenters for Medicare and Medicaid ServicesProvider Number
38-0051
Complaint Number
#s
OR7583 and
OR
7617
RESPONSE TO PREFIX
TAG
A
131
CFR
482.13(b)(2) PATIENT
RIGHTS:
INFORMED
CONSENT
The patient or his/her representative has the right
to
make informed decisions regarding his/her care.This
STANDARD
is
not
met
as
evidenced by 1
of
3 pediatric patients who received anesthesia services,
it
was determined
that
the hospital failed
to
ensure the patient representative's right
to
be
fully informed
of
the patient's health status, including the outcome and treatments provided during recovery fromanesthesia services.
Plan
of
Correction:
1.
Develop an Anesthesia policy describing the communication processes needed whenunanticipated outcomes or adverse events occur in children undergoing anesthesia, even
if
the risk
of
the occurrence
or
event was discussed
in
the informed consent process(Procedure, Alternatives, Risk and Benefits (PARQ).
2.
Achieve approval
of
the policy from the Vice-President
of
Surgical Services and theAnesthesia Section by 8/10/2012.
3.
Educate all applicable physicians and clinical staff by 8/24/2012 prior
to
policyimplementation on
that
date.
4.
Finalize metrics and monitoring plan in collaboration with Anesthesia Section and nursingstaff and implement monitoring by 8/27/2012. Suggested metrics include:
a.
Track and analyze unanticipated outcomes and take appropriate actions
as
needed.b.
#
of
times communication with family/representatives
is
documented when
PACU
recovery
is
>90 minutes/total number
of
cases with recovery time
of
>90 minutes(pediatric cases). Target:
95%
c.
Monitoring will occur until target
is
reached and sustained for 2 months, and thenrandomly thereafter.d. Results
to
be
reported
to
Anesthesia Section Chief and Vice President SurgicalServices monthly
Responsible Parties:Section Chief, AnesthesiaVice President, Surgical ServicesTime of Completion:
As
noted above
RESPONSE TO PREFIX
TAG
A
1003
CFR
482.52(b)(2)
ANESTHESIA
RECORD
A pre-anesthesia evaluation
is
completed and documented by
an
individual qualified
to
administeranesthesia, performed within 48 hours prior
to
surgery or a procedure requiring anesthesia services.This
STANDARD
is
not met
as
the hospital failed
to
fully develop and implement
an
anesthesia policyand procedure
to
ensure a pre-anesthesia evaluation was completed and documented within 48 hours,
1
 
Plan
of
Correction
OHA,
Health Care Regulation
&
Quality ImprovementCenters for Medicare and Medicaid ServicesProvider Number
38-0051
Complaint Number
#s
OR7583 and
OR
7617
and that that the evaluation was dated and timed
to
show
that
it
occurred prior
to
induction
of
anesthesia.A routine audit
of
anesthesiologist documentation was done
in
February, 2012. The results were sharedwith the Anesthesia Section Chief who coached the Anesthesia members
to
comply with the regulatoryrequirements
for
documentation
of
pre-anesthesia evaluations, and the need
to
ensure that the note wastimed. A second audit was completed in July which showed improved performance.
Plan
of
Correction:
1.
Develop a Medical Staff policy for performance and documentation
of
a pre-anesthesiaevaluation
2.
Achieve approval
of
the policy from the Anesthesia Section and the Medical ExecutiveCommittee by 8/10/2012.
3.
Educate all applicable practitioners prior
to
policy implementation date
of
8/24/2012.4. Monitor for compliance beginning 8/27/2012. Metrics are:
a.
Sample size: 1 case per credentialed anesthesiologist per month
b.
Number
of
pre-anesthesia evaluations documented/Total number
of
casesin
sample.Target: 100%
c.
Number
of
pre-anesthesia evaluations dated and timed/total number
of
cases in
sample.Target: 100%d. Monitoring will focus on anesthesiologists who cannot achieve and sustain performance
at
target.
5.
The Anesthesia Section Chief will continue
to
have one-to-one conversations with individualanesthesiologists who are
not
compliant with documentation requirements.
6.
Continued non-compliance following the discussion with the Section Chief will be handledthrough the Contract Management process.
Responsible Party: Anesthesia Section ChiefVice President, Surgical ServicesDate
of
Completion:
As
noted above
RESPONSE TO
TAG
A
1005
CFR
482.52(b)(3)
POST-ANESTHESIA EVALUATION
A post-anesthesia evaluation
is
completed and documented by
an
individual qualified
to
administeranesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services.This
STANDARD
is
not
met
as
the hospital failed
to
fully develop and implement its anesthesia policies
to
ensure a post-anesthesia evaluation was completed no later than 48 hours after surgery
as
required.A routine audit
of
anesthesiologist documentation was done
in
February, 2012. The results were sharedwith the Anesthesia Section Chief who coached the Anesthesia members
to
comply with the regulatoryrequirements for documentation
of
pre-anesthesia evaluations, and the need
to
ensure that the note wastimed. A second audit was completed
in
July which showed improved performance.
Plan
of Correction:
2
 
Plan
of
Correction
OHA,
Health Care Regulation
&
Quality ImprovementCenters for Medicare and Medicaid ServicesProvider Number
38-0051
Complaint Number
#s
OR7583 and OR
7617
1.
Develop a Medical Staff policy for performance and documentation
of
a post-anesthesiaevaluation
2.
Achieve approval
of
the policy from the Anesthesia Section and the Medical ExecutiveCommittee by 8/10/2012.
3.
Educate all applicable practitioners prior
to
policy implementation date
of
8/24/2012.4. Monitor for compliance beginning 8/27/2012. Metrics are:
a.
Sample size: 1 case per credentialed anesthesiologist per month
b.
Number
of
post-anesthesia evaluations documented{fotal number
of
cases in
sample.Target: 100%
c.
Number
of
post-anesthesia evaluations dated and timed/total number
of
cases
insample. Target: 100%d. Monitoring will focus on anesthesiologists who cannot achieve and sustain performance
at
target.
5.
The Anesthesia Section Chief will continue to have one-to-one conversations with individualanesthesiologists who are not compliant with documentation requirements.
6.
Continued non-compliance by specific anesthesiologists will
be
handled through the ContractManagement process.
Responsible Party: Anesthesia Section ChiefVice-President, Surgical ServicesDate
of
Completion:
As
noted above
RESPONSE TO TAG A
9999
OAR
333-505-0030{3)(d) ORGANIZATIONHospital policies which required
that
a hospital adopt, maintain, and follow written patient care policiesthat include all patient care services provided by the hospital.
Plan
of
Correction:
Refer
to
Tags A 1003 and A 1005
as
stated above.
OAR
333-505-0033 PATIENT
RIGHTS
Requires that a hospital comply with the requirements for patient rights set out
in
42
CFR
482.13
Plan
of
Correction:
Refer
to
Tag A
131as
stated above.
3

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