1. Overview of State Hospital Licensing Survey Linda L. Foss PhD, RN Executive Director Clinical Care Facilities Office of Inspections and Investigations Department of Health Linda L. Foss Executive Director Clinical Care Facilities

2. Survey Process Regulatory Framework

3. Survey Purpose of survey is determine compliance with state licensing requirements State licensing requirements are minimum

4. What are we looking for?

5. Compliance

6. SurveyComponents Observations Interviews Record review

7. Washington Administrative Code Purpose and Applicability Licensing Patient Care Environment of Care Management Design, Construction Review, and Approval of Plans

8. Hospital Responsibilities Comply with RCW 70.41 Set up only the number of beds licensed Notify with 2 business days of completion accreditation survey Notify in writing of accreditation decision or status change in 30 days

9. Governance Informing patient of any unanticipated outcomes Establish and review governing authority policies Performance Plan Organizational Management Reporting Practitioners

10. Governance Approve an appoint medical staff Authenticated of orders by authorized practitioner Approve and Review Medical Staff bylaws

11. Criminal history, disclosure, and background inquiries Employee, Contractor, Volunteer, Student Access to Children under 16 Vulnerable adults Developmentally disable individuals

12. Patient Rights/Organizational Ethics Respect Dignity Confidentiality Privacy Complaint resolution, Spiritual care Communication Free from abuse and neglect

13. Patient Rights/Organizational Ethics Involved in care Right to refuse care Advised of unanticipated outcomes To be informed and agree with care Advanced directives Request DNR Right to donate organs Access protective services

14. New Definitions Victim of sexual assault" means a person is alleged to have been sexually assaulted and who presents as a patient. Vulnerable Adult-includes hospitalized adults.

15. Leadership Assessing patient and family satisfaction of services Posting Complaint Hotline Provide patient with written billing statements

16. Leadership Provide for safe haven for abandoned newborns Provide of organization wide performance improvement activities

17. Leadership Assign a nurse at the executive level Establish hospital wide patient care services

18. Adverse Events Reporting Process is now outlined in the WAC Reported to Linda Furkay PhD, RN Toll Free Hotline for Reporting Adverse Events 1-888-524-6257

19. Reportable Events Failure or facility system malfunction such as Heating, ventilation, fire alarm Water supply electrical Information management Must Notify DOH-Office of Inspections and Investigation.

20. Notification Who Linda Foss Phone 360-236- 2920 Fax number- 360-586-0123 linda.foss@doh. wa.gov linda.foss@doh. wa.gov What Type of event Date of event

21. Management of Human Resources Job descriptions Staff performance Assure qualified staff Supervision of staff State licensure, certification, registration TB screening

22. Education for staff Orientation Education Blood borne pathogen exposure control HIV Multi-drug resistant organisms

23. Qualified Staff License, registration certification Job description Orientation Performance evaluation Supervision Staff working within scope of practice Competency

24. Medical Staff Bylaws Verification Appointment Reappointment Delineated clinical privileges Reporting practitioner Assessment of performance

25. Management of Information Control access of patient information Confidential, secure, and integrity Medical record for every patient

26. Infection Control Program Education Policies Patient care practices Environmental management and housekeeping functions

27. Improving Organizational Performance Hospital Wide Periodically evaluated Interdisciplinary Includes one member of the board

28. Requirements for Food and Nutrition Services Linen and Laundry Services Pharmaceutical Services Laboratory, Imaging and other Diagnostic Services Safe Patient Handling Patient Care Services

29. Patient Care Units Surgical Anesthesia Recovery Care Obstetrical Neonate and Pediatrics Critical or Intensive Care Alcohol/Chemical Dependency Psychiatric Long-Term Emergency Dialysis

30. Patient Care Plan for Patient Care Assessment of Patient Standards of Care Qualified Staff Equipment

31. Patient Care All patient access to safe and appropriate care Adopt and implement P&P for patient care and nursing practice Individuals conducting business in hospital comply with P&P

32. Patient Care Services Provide personnel, space, equipment, reference materials, training A registered nurse available for consultation in the hospital at all times Policies and procedures around care process

33. Emergency Contraception 24/7 emergency care to victims of sexual assault Provide medically and factually accurate and unbiased written and oral information about emergency contraception

34. Safe Patient Handling Develop a policy Hazard assessment Annual performance evaluation of the program Annual staff training Procedures for hospital staff to follow Types of equipment

35. Management of Environment of Care Manage environmental hazards and risks, prevent accidents and injuries, and maintain safe conditions for patients, visitors, and staff.

36. Self-Assessment Tips.

37. Read the regulations

38. How are you meeting the regulations?

39. Where is the documentation that demonstrates compliance ?

40. Questions