PIN CAH CMS Standards Review

Conference Call Notes

Call: Sept 28, 2010

Tag C 278, cont: Designation of Infection Control Officer

Pioneer: APIC refers to this individual as an “Infection Preventionist” (IP)

  • Have an Authority Statement for the IP, approved by medical staff which

- authorizes the IP to take cultures in specific circumstances

- recommend any closures of wings/floors/facility to control spread of infection

- always working collaboratively with the chief of the medical staff and/or CEO

  • Reports status to medical staff and QI/QA program; include in annual eval of CAH program
  • Recent deficiencies on state survey related to questions about the IC Committee:

- did not have a policy describing the committee or its work

- did not include a medical staff member as lead

- questioned whether or not the committee including dietary and housekeeping

- wanted to know how the facility monitors HAIs and sorts by the location where the HAI identified

- wanted to know the surveillance method they use

- wanted to know what expert guidelines for the program are being followed

Tag C 279: Dietary Services

Dillon: Dietary Manager oversees all Dietary services

  • Manager participates in the monthly quality meetings and their internal CoP/standards meetings
  • The RD monitors diets, looks for potential drug-food interactions,etc; works w/ pharmacy on TPN and other special dietary therapy needs
  • Pharmacy mixes their TPN

Pioneer: as with all other departments, Dietary services does both quarterly and an annual quality report

  • The quarterly dept quality report feeds into the CAH Annual Program Evaluation
  • Only recently contracted for an RD; he does monthly visits to review menus, special diets, etc

Tag C 280, 281: Rehabilitation Services

St John’s, Libby: manager evaluates the quality of care and reports to the quality committee quarterly

  • Manager participates in the monthly quality meetings and their internal CoP/standards meetings
  • The RD monitors diets, looks for potential drug-food interactions,etc; works w/ pharmacy on TPN and other special dietary therapy needs
  • Pharmacy mixes their TPN

North Valley: use contracted services for inpatients and swing beds

  • Contractor monitors patient goals achieved, quality of care
  • Contractor is an active member of the quality and department managers teams; in essence, functions like an employee of the facility

Next Call:Wed, Nov 17, 2:00 pmTag C 282 through C 293

- lab

- radiology

- contracted services

NOTES:

** The October CAH Standards Review is cancelled due to the PIN Regional Meetings taking place

** The November CAH Standards Review call is rescheduled to Nov 17 to avoid conflict with Thanksgiving vacations

1