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Overview of State Hospital Licensing Survey
Linda L. Foss PhD, RNExecutive Director Clinical Care FacilitiesOffice of Inspections and Investigations
Department of Health
Linda L. Foss
Executive Director
Clinical Care Facilities
• Survey Process• Regulatory Framework
Survey• Purpose of survey is determine
compliance with state licensing requirements
• State licensing requirements are minimum
What are we looking for?
Compliance
Survey Components • Observations
• Interviews
• Record review
Washington Administrative Code • Purpose and
Applicability• Licensing• Patient Care• Environment of Care
Management
• Design, Construction Review, and Approval of Plans
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
Governance• Informing patient
of any unanticipated outcomes
• Establish and review governing authority policies
• Performance Plan• Organizational
Management• Reporting
Practitioners
Governance• Approve an
appoint medical staff
• Authenticated of orders by authorized practitioner
• Approve and Review Medical Staff bylaws
Criminal history, disclosure, and background inquiries
• Employee,• Contractor,• Volunteer, • Student
Access to• Children under 16 • Vulnerable adults• Developmentally
disable individuals
Patient Rights/Organizational Ethics
• Respect • Dignity• Confidentiality• Privacy• Complaint
resolution,
• Spiritual care• Communication• Free from abuse
and neglect
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
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.
Leadership• Assessing patient and family satisfaction
of services• Posting Complaint Hotline• Provide patient with written billing
statements
Leadership • Provide for safe haven for abandoned
newborns • Provide of organization wide
performance improvement activities
Leadership• Assign a nurse at the executive level
• Establish hospital wide patient care services
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
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.
Notification • Who• Linda Foss • Phone 360-236-
2920• Fax number-
360-586-0123• linda.foss@doh.
wa.gov
• What• Type of event• Date of event
Management of Human Resources
• Job descriptions• Staff performance• Assure qualified staff• Supervision of staff• State licensure, certification, registration• TB screening
Education for staff • Orientation • Education
Blood borne pathogen exposure control HIV
Multi-drug resistant organisms
Qualified Staff
• License, registration certification
• Job description• Orientation• Performance
evaluation
• Supervision • Staff working within
scope of practice• Competency
Medical Staff Bylaws • Verification• Appointment• Reappointment• Delineated clinical
privileges
• Reporting practitioner
• Assessment of performance
Management of Information • Control access of patient information• Confidential, secure, and integrity • Medical record for every patient
Infection Control Program • Education• Policies• Patient care practices • Environmental management and
housekeeping functions
Improving Organizational Performance
• Hospital Wide • Periodically evaluated• Interdisciplinary • Includes one member of the board
Requirements for• Food and Nutrition
Services• Linen and Laundry
Services• Pharmaceutical
Services
• Laboratory, Imaging and other Diagnostic Services
• Safe Patient Handling
• Patient Care Services
Patient Care Units • Surgical • Anesthesia• Recovery Care• Obstetrical• Neonate and
Pediatrics• Critical or Intensive
Care
• Alcohol/Chemical Dependency
• Psychiatric• Long-Term• Emergency• Dialysis
Patient Care• Plan for Patient Care• Assessment of
Patient• Standards of Care
• Qualified Staff• Equipment
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
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
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
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
Management of Environment of Care• Manage environmental hazards and
risks, prevent accidents and injuries, and maintain safe conditions for patients, visitors, and staff.
Self-Assessment Tips.
Read the regulations
How are you meeting the regulations?
Where is the documentation that demonstrates
compliance?
Questions