News You Can Use

July’s compliance tip is focused on deficiencies cited during a survey when surveyors are not able to determine that the organization has developed and implemented an antibiotic stewardship program. Specific challenge areas include the education and training of both staff and medical staff and the incorporation of the program into the QAPI process. The CMS Regulation has been included here as a reference.

The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program.

1. An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership;
2. The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings;

1. The governing body must ensure all of the following:
   1. Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities.
   2. All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with hospital QAPI leadership.
2. The infection preventionist(s)/infection control professional(s) is responsible for:]
   6. Communication and collaboration with the antibiotic stewardship program.
3. The leader(s) of the antibiotic stewardship program is responsible for:
   1. The development and implementation of a hospital-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics.
   2. All documentation, written or electronic, of antibiotic stewardship program activities.
   3. Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as with the hospital’s infection prevention and control and QAPI programs, on antibiotic use issues.
   4. Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.

CIHQ encourages organizations to evaluate their programs in order to identify compliance issues and develop and implement a plan to eliminate the potential for a deficiency to be cited during survey.

The following resources are provided to CIHQ accredited organization as well as ARS member to assist with compliance to this regulation:

ARS provides accredited hospitals will the following in order to assist with compliance to this regulation:

• #3025 – Policy – Antibiotic Stewardship Program
• #1127 – Form – Antibiotic Stewardship Program Monitoring Evaluation Form
• #3014 – Tool – Antibiotic Stewardship – Physician and Staff Information Sheet
• #3016 – Tool – Antibiotic Stewardship Guideline for Management of Clostridium Difficile Toxin
• #3017 – Tool – Antibiotic Stewardship Guideline for Treatment of Community Acquired Pneumonia
• #1131 – Tool – Antibiotic Stewardship Guideline for Treatment of Skin and Soft Tissue Infections
• #1132 – Tool – Antibiotic Stewardship Guideline for Treatment of Urinary Tract Infections

On May 22, 2023 CMS published the approval of the CIHQ Critical Access Accreditation Program. This was the initial application and is applicable from June 1, 2023 to June 1, 2027. CIHQ is extremely grateful to the facilities that acted as our pilot survey and to Frio Regional Hospital that graciously allowed us to conduct our observation survey with CMS in attendance. You can find this exciting announcement in the Register at https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services

CIHQ Applications to CMS as an Accrediting Organization and Expansion of Accreditation Programs - Update CIHQ is expanding its accreditation programs to Acute Psychiatric Hospitals. The application process has been completed and approved. The final decision to accept the application was published in the Federal Register on May 22, 2023. We are excited about welcoming Acute Psychiatric Hospitals to the CIHQ family of accredited organizations. You can find this exciting announcement in the Register at https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services

• Next steps will be the standards and process review. We have completed the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
  • Griffin Memorial Medical Center
  • SD Human Services Center
  • Adventist Health Vallejo
  • East End Behavioral Health Hospital
  • Glendora Hospital – A College Behavioral Health Hospital
• A virtual office review will be conducted from June 21 – 23, 2023
• An observation survey (dates to be determined) will be conducted
• Publication in the Federal Register will occur on or by October 19, 2023

CIHQ analyzes findings cited during accreditation surveys in order to track and trend the top findings. We do this primarily to evaluate whether or not ARS is supplying sufficient and effective resources to assist our facilities with compliance. This also guides the decision to add more tools and resources in order to facilitate compliance. This tracking is also used to evaluate the quality and consistency of how standards are applied and cited.

Below are the top condition-level deficiencies cited during the first half of 2023.

CIHQ Standard Number	Title	Level of Severity	Percentage Cited at Condition-Level
CE-18	Fire Drills	Condition *Note this standard is cited when condition-level deficiencies are cited regardless of the standard cited	34%
CE-19	Inspection & Testing of Life Safety Systems	Condition	17%
CE-15	Compliance to the NFPA Life Safety Code	Condition	17%
MM-28	Administration of Medications	Condition	14%
IC-07	Disinfection & Sterilization Practices	Condition	14%
CE-14	Emergency Powered Battery Lighting	Condition	14%
NS-03	Delivery of Nursing Care	Condition	11%
IC-03	Infection Control Prevention & Control Policies	Condition	11%
RB-01	Rehabilitation Services	Condition	9%

Below are the top standard-level deficiencies cited during the first half of 2023.

CIHQ Standard Number	Title	Level of Severity	Percentage of Surveys Cited at Standard-Level
CE-15	Compliance to the NFPA Life Safety Code	Standard	83%
MR-05	Minimum Content of the Medical Record	Standard	74%
IC-03	Infection Prevention & Control Policies	Standard	69%
CE-21	Compliance to the NFPA Health Care Facilities Code	Standard	66%
CE-10	Management of Utilities	Standard	65%
CE-13	Testing of Emergency Power Systems	Standard	63%
CE-03	Provision of a Safe Environment	Standard	60%
HR-04	Management of Contract/Volunteer Staff	Standard	42%
HR-03	Competency of Staff	Standard	40%
GL-04	Leadership Responsibilities	Standard	40%

 

CIHQ’ own Billy Kinch will be presenting at ASHE as part of the 60th Annual Conference & Technical Exhibition. This conference brings the entire healthcare facilities management profession together for discussion-based sessions and innovative networking opportunities. This is the first time we CIHQ has been invited to speak at ASHE; Billy will provide an update on CIHQ’ adventures and share top findings in the physical environment.

Healthcare and community care professionals from across the continuum attend CareForum every year because it offers unmatched opportunities to learn from the industry’s top experts and gain skills to take back to their organizations and put into action. CareForum is attended by more than 1,000 healthcare executives and leaders from various end markets across health and community care.

CIHQ to Speak at WellSky’s Care Forum
Richard Curtis, CEO was accepted to speak at WellSky’s Care Forum in Austin, September 10-13. He’s speaking on Monday, September 11th on Collaborating with the Medical Staff for Successful Regulatory Compliance.

CIHQ appreciates the work of rehabilitation hospitals, and will be attending AMRPA’s conference October 15-18, 2023 in Dallas. AMRPA hosts an IRF Boot Camp before the conference to provide rehabilitation managers and medical directors with fundamental knowledge.

The conference program will focus on innovative strategies to keep rehabilitation professionals ahead of the curve and providing the highest quality of care, advocacy efforts in the interest of inpatient rehabilitation hospitals and units, outpatient rehabilitation centers, and other rehabilitation providers.