Week 2 Team Assignment Research

Team Assignment:

Begin working on the Organizational Performance Management Table which is part of your Organizational Performance Management Paper assignment due in Week Four.

• Select specific organizations and research regulatory and accreditation standards that apply to your chosen organization types.• Complete Part 1 and 2 of the table.

Submit the completed parts of the table to show progress on your assignment due in Week Four.

Step 1:

Choose an organization(After reading the team forum I began research on a few organizations)

Step 2:

Task Division of this assignment

(Here is my suggestion on division)

Research: Narrow Research Down to be as “succinct” or clear and brief as possible:Part 1:Enter the surmised data into Felds for part 1Part 2:Enter the surmised data into Felds for part 1Edit for Grammar, run through Turn it In for Plagiarism & Final Submission

(I have completed the purple section)

Organizational Choices

Team,

Have any of you worked in an Emergency Room or Hospital? I have both, but I think long term care is the better choice. Hospital Administrator jobs are hard to find, where we are most needed is in long term care. Nursing home administrators are important and hard to find. We are all in the same courses, so we must all be taking the

same degree. I suggest we go with long term care. But I have done research for wither choice. Below is the summation of my findings.

The ResearchEmergency Rooms

Emergency Rooms are highly utilized health care organizations. The ER can vary in quality from hospital to hospital, and more and more “Urgent Care Centers” and “Free-standing Emergency Rooms” are opening. Emergency care is the most expensive to as opposed to preventive visits, check-ups, and sick visits to a private physician or clinic. Emergency Rooms are overcrowded and are perhaps the easiest place to breach HIPPA rules and experience significant risks of all types.

It is also the department in the hospital that gets the most complaints. Some ERs are more equipped than others to handle specific injuries or illnesses. For example, the hospital I worked in Mainland Medical Center has an accredited Chest Pain Center. The ER is highly efficient in treating heart attacks and strokes. Ben Taub Hospital in Houston, Texas has a great trauma center and handles gunshot wounds with success. Specialty Hospitals, such as MD Anderson have emergency rooms as well. MD Anderson is a Cancer Hospital, but patients receiving cancer care at MD Anderson can go to its Emergency Room for treatment, tailored to that patient. Cypress Creek Psychiatric Hospital also has a psychiatric emergency room.

Some hospitals are excellent in several aspects, and have very specialized units. Methodist Hospital has a pulmonary unit, where patients with Cystic Fibrosis and other lung diseases can get specialty care that they might not get from a local general hospital on a med/ surge unit. Methodist Hospital Emergency Room and the entire hospital for that matter are beautiful and full of luxurious opulence. Some Emergency Rooms are so much better than others that patients are life flighted to them, rather than the closest hospital in order to save their life. I saw Sara looked interested in the life flight aspect of ERs. Yet, the organization you suggested is an “ambulance transportation service” not an actual Emergency Room.

I worked in Emergency Room Hold Over. A small unit for only 5 patients who were in for observation or waiting for an empty bed. I would process physician orders, order lab work, order medications, etc. I would collect requested specimens, vital signs, and attach telemetry (heart monitors) as ordered. There is little room for error and inexperience in the ER. I had a less than competent nurse one evening, and I reported to her the patient had severe jaw pain, and this is important because it is a sign of Heart Attack. She did not page the physician, and the man was in fact having a heart attack.

When patients are only separated by a curtain, it is possible to hear every moan, cry, and word that is spoken. The patient in bed 7 can hear bed 8 being notified of his kidneys stones size and location, while bed 6 is listening to bed 5 receive the diagnosis of

a sexually transmitted disease. This is a terrible but solvable issue; Methodist hospital brings patients back to a small enclosed room in the ER, not behind curtains. Quality and Risk management in ERs is so significant.

Side note concerning Hospitals in General, Johns Hopkins University Hospital is the Number 1 rated hospital in the country. Here’s a list of the top 10 US hospitals from CNN.

Obtained From: http://www.cnn.com/2013/07/16/health/best-hospitals-ranking/index.html

1.Johns Hopkins Hospital in Baltimore2. Massachusetts General Hospital in Boston

Center determined to slash cancer deaths Robotic arm grasps the future3. Mayo Clinic in Rochester, Minnesota

4. Cleveland Clinic in Ohio5. UCLA Medical Center in Los Angeles

6. Northwestern Memorial Hospital in Chicago7. (tie) New York-Presbyterian University Hospital of Columbia and Cornell, New York

7. (tie) UCSF Medical Center in San Francisco9. Brigham and Women's Hospital in Boston

10. UPMC-University of Pittsburgh Medical Center in Pennsylvania(Auerbach, 2013)

The Required Research:

Part I

After you have completed your individual research on your chosen type of health care organization, collaborate with your Learning Team to complete this table. Then, refer to this table as you collaborate to write your paper. Include this table as an appendix to your paper.

Fill in the necessary information in each cell, but be as succinct as possible.

1. Provide names of or links to specific organizations. 2. Summarize key products or services provided by each type of organization 3. and identify the primary customers they serve.

Organization One Organization Two Organization Three

Texas Children’s Hospital The Methodist Hospital MD Anderson Cancer Center

Hospital Website: Hospital Website: Hospital Website:

http://www.texaschildrens.org/

http://www.houstonmethodist.org/default.cfm

http://www.mdanderson.org/

Emergency Room:http://www.texaschildrens.org/Locate/Departments-and-Services/Emergency-Center/

Emergency Room:http://www.houstonmethodist.org/er

Emergency Room:http://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/emergency-medicine/emergency-med-ec.html

Serves pediatric patients, leader in specialty care.

Serves all patients and provides specialty care.

Serves cancer patients with specialty services.

According to the website:

“Texas Children's Emergency Center provides a complete range of services to the greater Houston community, treating children with both medical and surgical emergencies.

As a Level 1 pediatric trauma center, the Emergency Center collaborates with pediatric surgical subspecialties in caring for children with a broad spectrum of traumatic injuries and also serves as a referral center for children who are victims of assault and other violent crimes. In addition, our urgent care center provides services for less severely ill children” (Texas Children’s Emergency Center, 2014).

“Texas Children's Emergency Center, the largest pediatric emergency center in South Central Texas, has 50 beds and 18 observation beds and is

According to the Website:

“Quality emergency care is now available outside of our primary hospital locations. What’s the difference between an urgent care center and a Methodist Emergency Care Center? We offer full medical services to all patients, regardless of age, ability to pay, or the acuity of their illness. Our physicians and staff are all trained in emergency medicine, and we are open 24/7. Urgent care centers typically care for only minor injuries and illnesses, are not open 24/7, do not participate with Medicare or Medicaid programs and often do not have physicians on staff. The Methodist Emergency Care Center is an emergency room that brings to each neighborhood the same high-quality care for which The Methodist Hospital is known”(Methodist Hospital, 2014).


“The MD Anderson Cancer Center Emergency Center is a unique facility that provides emergent and urgent treatment for established MD Anderson Cancer Center oncology patients as well as employees and visitors injured on the MD Anderson premises”(MD Anderson, 2014).

“Open 24 hours every day, the Emergency Center is staffed by a team of registered nurses, patient service coordinators, patient care assistants, mid-level providers and physicians from the Department of Emergency Medicine who have expertise in the treatment of cancer related emergencies”(MD Anderson, 2014).

“The Emergency Center

open 24 hours a day, 7 days a week. Seeing nearly 85,000 patients annually, the center is staffed by full-time, board-certified pediatric emergency medicine physicians and pediatric nurses, along with ancillary services such as child-life specialists, social workers, sexual abuse nurse examiners, Spanish translators and respiratory therapists”(Texas Children’s Emergency Center, 2014).

“Open 24 hours a day, 365 days a year.Treat patients of all ages.Co-pay: Hospital emergency room co-pay applies.Board-certified emergency medicine physicians/nurses.Treat all patients, regardless of ability to pay.Accepts Medicare and Medicaid patients.Full scope of emergency medical services” (Methodist Hospital, 2014).

features 44 rooms including those designated for isolation, code emergencies, and gynecologic emergencies. The Emergency Center provides service to approximately sixty patients per day with cancer related conditions and is an important safety net for MD Anderson patients. The Emergency Center takes great pride in treating MD Anderson patients with empathy, efficiency and expertise” (MD Anderson, 2014).

“Emergency Center services for established patients include care for:

non-urgent to emergency conditionstreatment-related side effectscancer related emergencies and non-cancer related emergenciescomorbiditiesfluid and electrolyte replacementurgent blood product administrationPatients receive triage, medical screening and evaluation. Consultative services are also available” (MD Anderson, 2014).

Part II4. Outline the overall content of the major regulations, accreditation requirements,

and other standards that affect each organization.

5. Provide the title, section, parts, or subparts or the numbering system and so on of the specific regulations or accreditation requirements.

For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11


Texas Children’s Hospital The Methodist Hospital MD Anderson Cancer Center

Medicare/Medicaid State Operations Manual Publication 100-07

Medicare/Medicaid State Operations Manual - Survey Protocol, Regs and Interpretive Guidelines

Appendix A

Federal Regulations - Conditions of Participation for Hospitals

42 CFR 482

Federal Regulations - Prospective Payment System (PPS)

42 CFR 412

Federal Regulations - Special Responsibilities in Emergency Cases

42 CFR 489See section 20 & 24

Federal Regulations - Critical Access Hospital Conditions of Coverage

42 CFR 485See section 608

Federal Regulations - Swing Bed 42 CFR 482See section 66

Retrieved From: http://www.dshs.state.tx.us/hfp/rules.shtm#hosp_gen(Texas Department of Health & Human Services, 2014).

All three organizations are Hospital Emergency Rooms Hospitals have specific regulations, and governing agencies. All 3 are certified at the state and federal levels.

Hospital Regulatory Agencies:

I) Texas Department of Aging and Disability Services (DADS)

Monitors Skilled Nursing Care and Employability in the State.

http://www.access.gpo.gov/nara/cfr/waisidx_00/42cfr482_00.html





https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/index.html?redirect=/SurveyCertificationGenInfo/



http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11

Hospitals that provide SNF services are subject to SNF regulations within that unit.

Texas DADS is the agency that certifies employability and records misconduct of licensed employees. Any employee providing patient care must be DADS licensed. (Nurses, Nurse Aides)

Employability Check: http://www.dads.state.tx.us/providers/employability/

Misconduct Registry: http://www.dads.state.tx.us/providers/NF/credentialing/emr/index.html

Sanction Database: http://www.dads.state.tx.us/providers/NF/credentialing/sanctions/index.cfm

Texas Administrative Codes:http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=3&ti=40&pt=1

(Texas Department of Aging & Disability Services, 2014)

II) Joint commission on accreditation of health care organizations (JACHO)

Joint Commission Accreditation

“Joint Commission accreditation can be earned by many types of health care organizations, including hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services”(Joint Commision.org, 2014). “Types of accredited hospitals include:

General Children’s Long Term Acute Care (LTACH) Oncology Psychiatric Rehabilitation Specialty (Cardiac, Orthopedic, Surgical)”

(Joint Commision.org, 2014).

JACHO only gives accreditation to hospitals that are CMS Certified. (See CMS section for more info)

JACHO certifies and inspects hospitals for compliance and quality, below is an excerpt from the JACHO website elaborating on the survey (or inspection) process. (2014)

Obtained From:

http://www.jointcommission.org/about/jointcommissionfaqs.aspx#298 “Joint Commission surveyors visit accredited health care organizations a minimum of once every 39 months (two years for laboratories) to evaluate standards compliance. This visit is called a survey. All regular Joint Commission accreditation surveys are unannounced” (Joint Commision.org, 2014).

“Joint Commission surveyors are highly trained experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other health care professionals. The Joint Commission is the only health care accrediting body that requires its surveyors be certified” (Joint Commision.org, 2014).

“During the survey, surveyors select patients randomly and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care, and often speak to the patients themselves” (Joint Commision.org, 2014).

“Joint Commission accreditation does not begin and end with the on-site survey. It is a continuous process. Every time a nurse double-checks a patient’s identification before administering a medication, every time a surgical team calls a" time out" to verify they agree they’re about to perform the correct procedure, at the correct site, on the correct patient, they live and breathe the accreditation process. Every three months, hospitals submit data to the Joint Commission on how they treat conditions such as heart attack care and pneumonia – data that is available to the public and updated quarterly on qualitycheck.org. Every year, organizations evaluate their ongoing standards compliance through a periodic performance review. Joint Commission accreditation is woven into the fabric of a health care organization’s operations” (Joint Commision.org, 2014).

“The Joint Commission’s state-of-the-art standards focus on patient safety and quality of care. The Joint Commission standards are updated regularly to reflect the rapid advances in health care and medicine. The hospital accreditation standards number more than 250, and address everything from patient rights and education, infection control, medication management, and preventing medical errors, to how the hospital verifies that its doctors, nurses, and other staff are qualified and competent, how it prepares for emergencies, and how it collects data on its performance and uses that data to improve itself” (Joint Commision.org, 2014).

Read More about JACHO:

Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2013http://www.jointcommission.org/improving_americas_hospitals_the_joint_commissions_annual_report_on_quality_and_safety_2013/

Hospital Accreditation:

http://www.jointcommission.org/accreditation/hospitals.aspx 2014 Accreditation Requirements:

http://www.jointcommission.org/standards_information/hap_requirements.aspx National Quality Improvement Goals

http://www.jointcommission.org/about/jointcommissionfaqs.aspx#618 National Patient Safety Goals

http://www.jointcommission.org/about/jointcommissionfaqs.aspx#324

Texas Department of Health and Human Services (DHHS)

The following comes from the Department of Health and Human Services.

A list of regulations for Texas Hospitals. (2014)

Obtained from: http://www.dshs.state.tx.us/hfp/rules.shtm#hosp_gen

Hospitals- General

Hospital Licensing State Regulations 25 TAC §133 PDF file 1060KB

Hospital Compliance with House Bill 1376 PDF

file 152KB

Helpful Tools Preamble

87KBFinal Fact

Sheet

32KBTHA Comments82KBRevision 134KB

List A, Procedures Requiring Full Disclosure of

Specific Risks and Hazards

25 TAC §601

List B, Procedures Requiring No Disclosure of

Specific Risks and Hazards

25 TAC §601

Information for Sexual Assault Patients Click here to link

Preadmission Screening and Resident Review

(PASRR) Redesign – Implementation May 24, 2013

Additional Information to Preadmission Screening

and Resident Review (PASRR) Redesign (REVISED

7/24/13)

PASRR Letter

to Facilities

PASRR

UPDATE

7/17/13

PASRR Resources

Brochure

Informational Material Concerning Vaccinations Against Influenza Virus and Pneumococcal

Diseases Click here to link

DSHS Position Statement Regarding the Use of Alcohol-Based

Surgical Skin Preparations

9/28/2004 PDF

File88KB

NPI Update (10/2/2006) PDF File 13KB

Medicare/Medicaid State Operations Manual Publication

100-07

Medicare/Medicaid State Operations Manual -

Survey Protocol, Regs and Interpretive Guidelines

Appendix A


42 CFR 482


42 CFR 412


42 CFR

489See

sections 20 &

24


42 CFR

485See

section 608

Federal Regulations - Swing Bed 42 CFR

482See

section 66

Free Standing Emergency Room Regulations

Freestanding Emergency Medical Care Facilities

Freestanding Emergency Medical Care Facilities 25 TAC §131 PDF File 688KB

Information for Sexual Assault Patients

Information Sheet for Patients -- This brochure contains information for patients presenting with

psychiatric symptoms in Emergency Departments, regarding their rights, relevant laws and

processes. (pdf 30KB)

A Guide for Laboratories Performing CLIA Non-waived Testing in Free-Standing Emergency Care

Facilities (pdf 471KB)

Guidance Regarding the Location of Dressing Rooms near the Diagnostic Radiographic(X-ray)

Room in a Freestanding Emergency Medical Care (FEMC) Facility

Freestanding Emergency Medical Care Facilities 25 TAC §131 PDF File 688KB

HEALTH AND SAFETY CODE

TITLE 4. HEALTH FACILITIES

SUBTITLE B. LICENSING OF HEALTH FACILITIES

CHAPTER 254. FREESTANDING EMERGENCY MEDICAL CARE FACILITIES

SUBCHAPTER A. GENERAL PROVISIONS

http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.254.htm

Hospitals- Special

Hospital Licensing State Regulations 25 TAC §133 PDF

file1060KB

Hospital Compliance with House Bill 1376 PDF file 152KB

Helpful Tools Preamble

87KBFinal Fact

Sheet

32KBTHA

Comments

82KBRevisio

n134KB

Information for Sexual Assault Patients Click here to link

Preadmission Screening and Resident Review (PASRR)

Redesign – Implementation May 24, 2013

Additional Information to Preadmission Screening and

Resident Review (PASRR) Redesign (REVISED 7/24/13)

PASRR Letter to

Facilities

PASRR UPDATE

7/17/13

PASRR

Resources

Brochure

Informational Material Concerning Vaccinations Against Influenza Virus and Pneumococcal

Diseases Click here to link

NPI Update (10/2/2006) PDF File13KB

Medicare/Medicaid State Operations Manual Publication 100-

07

Medicare/Medicaid State Operations Manual - Survey Protocol, Regs and Interpretive Guidelines

Appendix A


42 CFR 482


42 CFR 412


42 CFR 489See

section 20 & 24


42 CFR 485See

section 608

Federal Regulations - Swing Bed 42 CFR 482See

section 66

(Texas Department of Health & Human Services. 2014).

Texas DHS Licensing Rules for Hospitals are found in Title 25 Texas Administrative Code Chapter 133.

III) Centers for Medicare & Medicaid (CMS)

CMS covers 100 million people through Medicare & Medicaid. CMS Strives to increase the health of Americans while reducing costs. CMS enforces and implements health care legislation CMS reduces fraud, waste, and abuse of federal health programs A facility must be CMS certified if they wish to accept Medicare and Medicaid

insurance for reimbursement. CMS has many regulations for both payments and quality of care. Must be Accredited to become CMS certified

“CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. CMS also ensures that the standards of accrediting organizations recognized by CMS (through a process called "deeming") meet or exceed the Medicare standards set forth in the CoPs / CfCs”(CMS.gov, 2014).

The following is an excerpt from the CMS Website. (2014)

Obtained From: http://www.cms.gov/Medicare/Provider-Enrollment-and Certification/CertificationandComplianc/Hospitals.html

“Accredited Hospitals - A hospital accredited by a CMS-approved accreditation program may substitute accreditation under that program for survey by the State Survey Agency. Surveyors assess the hospital's compliance with the Medicare Conditions of Participation (CoP) for all services, areas and locations covered by the hospital's provider agreement under its CMS Certification Number (CCN)”CMS.gov, 2014).

“Although the survey generally occurs during daytime working hours (Monday through Friday), surveyors may conduct the survey at other times. This may include weekends and times outside of normal daytime (Monday through Friday) working hours. When the survey begins at times outside of normal work times, the survey team modifies the survey, if needed, in recognition of patients' activities and the staff available”CMS.gov, 2014).

“All hospital surveys are unannounced. Should an individual or entity (hospital) refuse to allow immediate access upon reasonable request to either a State Agency, CMS surveyor, a CMS-approved accreditation organization, or CMS contract surveyors, the hospital's Medicare provider agreement may be terminated. The CMS State Operations Manual (SOM) provides CMS policy regarding survey and certification activities”CMS.gov, 2014).

Read More: State Operations Manual Appendix A - Survey Protocol, Regulations and

Interpretive Guidelines for Hospitals http://www.cms.gov/RegulationsandGuidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

Revised Appendix A, “Interpretive Guidelines for Hospitals”http://www.cms.gov/RegulationsandGuidance/Guidance/Transmittals/downloads/R37SOMA.pdf

Hospital Outpatient Regulations and Noticeshttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html

Hospitalshttp://www.cms.gov/Medicare/ProviderEnrollmentandCertification/CertificationandComplianc/Hospitals.html

Critical Access Hospitalshttp://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/CAHs.html

(I suggest Long Term Care.)

Long Term Care

Long Term Care is essentially nursing home care. Nursing Homes are ideally competent facilities hired to care for loved ones for people who cannot do so at home. Grandmothers, Sisters, Uncles, Fathers, people in their last stages of life, should be cared for with the utmost respect, dignity, and quality. The industry is ridden with fraud, waste, and abuse. The industry can be better, especially if people like us research and do the work to make it so.

After you have completed your individual research on your chosen type of health care organization, collaborate with your Learning Team to complete this table. Then, refer to this table as you collaborate to write your paper. Include this table as an appendix to your paper.

Fill in the necessary information in each cell, but be as succinct as possible.

6. Provide names of or links to specific organizations. Summarize key products or services provided by each type of organization and identify the primary customers they serve.


Park Manor Skilled Nursing Facility (Chain)

Southwest LTC (Gulf Health Care) (Chain)

WCTS Health Care(Bayou Pines Care Center) (Chain)

Website:http://www.parkmanor-conroe.com/

Website:http://www.swltc.com/ghc-texascity.html

Website:http://bayoupinescarecenter.webs.com/

Serves patients needing Skilled Nursing Care (SNF)




“Our facility is certified to deliver skilled nursing care. Unlike many skilled nursing centers, we are equipped with advanced technologies and specialized resources for patients needing Intravenous therapy, Physical therapy, Speech therapy, Occupational therapy, Wound care, Pulmonary Care and many other treatments and services. Whatever your particular recovery regimen may entail, our caregivers seamlessly work together to deliver quality individualized care” (Park Manor, 2014).


“Patients and their families are included in the important decision-making process of care planning. And we encourage patients to pursue interests, and activities that encourage a meaningful, fulfilling lifestyle” (Southwest LTC, 2014).

“Our team of health care professionals is led by a licensed administrator and includes our medical director, consultant pharmacist and consultant dietician. From the director of nurses and our rehabilitation staff, to the activity director and social worker, our staff works to address the special needs of each patient” (Southwest LTC,2014).


“Services We Provide

24-hour skilled nursing care.

Clinical Laboratory and Diagnostics X-ray, on site as needed.

Physical, Occupational, and Speech therapy on site.

Podiatry services, on site as needed

Mental health services.

All resident meals

“Our rehabilitation unit features a separate focus. Our fully-equipped, rehabilitation gym is staffed by physical therapists, occupational therapists and speech therapists. While many of our patients are able to return home, our goal is to get every patient functioning at their highest level and capability” (Southwest LTC, 2014).

“Our Services Rehabilitative Care 24-hour Skilled Nursing

and Intermediate Care Post Stroke Program Rehabilitation Services

Post Total Joint Replacement

Wound Care Program Specialized Skin & Wound Care

Respite/Vacation Program

IV Therapyo Pain

Managemento Dementia

Related Programming

o Cognitive & Perceptual Retraining

o Podiatry Services”(Southwest LTC, 2014).

served family style, allowing residents to select portion and choice of foods.

Resident kitchen available for residents' use 24 hours stocked with convenient foods that can be easily prepared using microwave or toaster oven.

Activities for residents daily.

Beauty and Barber shop in a spa setting.

Daily housekeeping and on-site laundry.

Cable and Telephone hookup available in all resident rooms.

All electric beds which can be lowered to 7 inches from floor for resident safety eliminating the need for restraint.

For additional resident security, all night stands come equipped with one lockable drawer” (Bayou Pines Care Center, 2014).

7. Outline the overall content of the major regulations, accreditation requirements, and other standards that affect each organization. Provide the title, section, parts, or subparts or the numbering system and so on of the specific regulations or accreditation requirements.

For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11

“Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs”(CMS.gov, 2014)


MS-

1446-PFY 2014 Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities

20

14

CMS-

1446-F

CMS-1446-F Prospective Payment System and Consolidated Billing for Skilled Nursing

Facilities for FY 2014

20

14

CMS-

1446-

CN

Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing

Facilities for FY 2014; Correction

20

14

CMS-

1446-

CN2



20

14

CMS-

1446-

CN3



20

14

CMS-

1432-N


Facilities for FY 2013; Notice

20

13

CMS-

1351-P


Facilities; Disclosures of Ownership and Additional Disc losable Parties Information

20

12

CMS-

1351-

CN

Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing


20

12

CMS-

1351-F


Facilities for FY 2012

20

12

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations.html

(CMS.gov, 2014).

All three organizations are Long Term Care/Skilled Nursing Facilities Skilled Nursing Facilities have specific regulations, and governing agencies. All 3 are certified at the state and federal levels.

I) Texas Department of Aging and Disability Service (DADS) State Level

“The DADS Regulatory Services division regulates:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS1250416.html







http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1432-N.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1432-N.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1446-CN3.html






http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1446-CN.html



http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1446-F.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1446-F.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1446-P.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-of-SNF-Federal-Regulations-Items/CMS-1446-P.html

Nursing facilities Intermediate care facilities for persons an intellectual disability Adult day care facilities Assisted living facilities Home health care providers Hospice providers Intellectual disabilities waiver providers

DADS Regulatory Services needs the following professionals on our survey teams:

Registered nurses Dieticians and nutritionists Social workers Architects Qualified mental retardation professionals Life Safety Code specialists Engineers” (DADS Regulatory Services, 2014)

Nursing Facility Requirements for Licensure and Medicaid Certification Handbookhttp://www.dads.state.tx.us/handbooks/nfr-lmc/

Texas DADS is the agency that certifies employability and records misconduct of licensed employees. Any employee providing patient care must be DADS licensed. (Nurses, Nurse Aides)

Employability Check: http://www.dads.state.tx.us/providers/employability/

Misconduct Registry: http://www.dads.state.tx.us/providers/NF/credentialing/emr/index.html

Sanction Database: http://www.dads.state.tx.us/providers/NF/credentialing/sanctions/index.cfm

Texas Administrative Codes:http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=3&ti=40&pt=1

DADS also monitors facility level inspections and regulations. These regulations can be found here:

http://www.dads.state.tx.us/handbooks/nfr-lmc/

II) Centers for Medicaid & Medicare (CMS) Federal Level

CMS covers 100 million people through Medicare & Medicaid.

CMS Strives to increase the health of Americans while reducing costs.

CMS enforces and implements health care legislation CMS reduces fraud, waste, and abuse of federal health programs

CMS started to regulate skilled nursing facilities because of the regulations in the criteria. Skilled nursing facilities are part of the federal certification criteria for nursing homes. Centers of Medicare and Medicaid started to regulate skilled nursing facilities to also help with how these facilities are getting paid by Medicare and Medicaid. "Section 4432(a) of the BBA of 1997 modified how payments are made for any Medicare skilled nursing facilities. SNF goes from being paid for a reasonable cost basis or low volume prospectively determined rates. Now they are getting paid by on the basics of prospective payment systems of (PPS)" (CMS.gov, 2014)

A Skilled Nursing Facility (SNF) is a 24 hour health care providing facility. The SNF will provide constant care for patients who are admitted for a short term or long term basis. SNF patients are typically elderly, disabled, mentally ill, or in need of rehabilitation for a variety of conditions. If a patient needs long term custodial care or short term rehabilitation services a SNF nursing home, rehab center, or hospital with a “swing bed policy” are the providers of care.

CMS along with state agencies monitor SNF providers and ensure compliance with their imposed standards of care. CMS also regulates alternatives to SNF such as Home Health Agencies, Assisted Living Facilities, and Personal Care Homes with similar evaluation and monitoring procedures. Nursing is a profession that has evolved dramatically over the years, yet the need to provide skilled nursing care for the elderly and disabled has not changed. Nursing Homes are commonly low paying employers that offer little or no benefits for the employees. The tasks and duties are very repetitive and can cause great care staff to become burnt out. Additionally, staffing shortages and high turnaround rates can lead to hiring staff that are not empathetic enough to provide quality care to residents. Whatever the real reason, the elderly and disabled are often the victim of abuse, neglect, theft, and even fraud on behalf of the care facility. Therefore, skilled nursing facilities must be under strict regulation by local and federal governments to combat the issues and hold people accountable.

“Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs”(CMS.gov, 2014). This means that if a SNF provider wants to receive patients who have Medicare or Medicaid coverage, they must follow all rules and submit to an inspection and survey by CMS and state agencies annually or at the time of complaint.

“To certify a SNF or NF, a state surveyor completes at least one Life Safety Code (LSC) survey and one Standard Survey annually” (CMS.gov, 2014). However, when deficiencies are found, these surveys turn into investigations requiring provider action to correct any issues found. “Skilled nursing facilities are licensed, regulated, and certified by a number of agencies at both the state and federal levels, including the state Department of Public Health, the Department of Health and Human Services’(DHHS) and the Centers for Medicare and Medicaid Services (CMS.gov, 2014). This is in addition to the local and state regulating agencies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Department of Aging and Disability Services (DADS), all these agencies have separate, but intersecting dominions

of control concerning SNF care and provision” (CMS.gov, 2014). CMS also publishes a five star quality rating system on certified SNF providers, rating their performance and ability to provide high quality care.

“If a SNF provider receives a deficiency on an evaluation survey, depending on the nature of the problem, CMS can take penalizing action against the nursing home” Medicare.gov, 2013). CMS has many options when it comes to reprimanding deficient facilities. “CMS can impose a large fine, deny payment, assign a temporary manager, or install a State monitor” (Medicare.gov, 2014). In the event a SNF provider chooses to ignore or is unable to the correct its complications or violations, CMS subsequently terminates its certification contract with the SNF provider.

III) Joint commission on accreditation of health care organizations (JACHO)

Joint Commission Accreditation“Joint Commission accreditation can be earned by many types of health

care organizations, including hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services”(JointCommision.org, 2014).

“Types of accredited hospitals include:

General Children’s Long Term Acute Care (LTACH) Oncology Psychiatric Rehabilitation Specialty (Cardiac, Orthopedic, Surgical)”

(Joint Commision.org, 2014).

Reference

Auerbach, R. (2013). Top 10 hospitals in the United States. CNN. Retrieved from

http://www.cnn.com/2013/07/16/health/best-hospitals-ranking/index.html

Bayou Pines Care Center. (2009). Bayou Pines Care Center. Retrieved from

http://bayoupinescarecenter.webs.com/

CMS.gov. (2014). List of SNF Federal Regulations. Retrieved from

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/List-

of-SNF-Federal-Regulations.html

Houston Methodist Hospital. (2014). Houston Methodist Emergency Care Centers.

Retrieved from http://www.mdanderson.org/education-and-research/departments-

programs-and-labs/departments-and-divisions/emergency-medicine/emergency-

med-ec.html

Joint commission on accreditation of health care organizations (JACHO). (2014). the

Joint Commission. Retrieved from http://www.jointcommission.org/

MD Anderson Cancer Center. (2014). Emergency Center. Retrieved from

http://www.mdanderson.org/education-and-research/departments-programs-and-

labs/departments-and-divisions/emergency-medicine/emergency-med-ec.html

Medicare.gov. (2014). Skilled nursing facility (SNF) care. Retrieved from

http://www.medicare.gov/coverage/skilled-nursing-facility-care.html

Park Manor Skilled Nursing Facility. (2014). Park Manor of Conroe. Retrieved from

http://www.parkmanor-conroe.com/

Southwest LTC. (2012). Gulf Health Care Center. Retrieved from

http://ww.swltc.com/ghc-texascity.html

Texas Children's Hospital. (2014). Emergency Center. Retrieved from

http://www.texaschildrens.org/Locate/Departments-and-Services/Emergency-

Center/

Texas Department of Health & Human Services. (2014). Rules and Regulations -- Health

Facility Program. Retrieved from

http://www.dshs.state.tx.us/hfp/rules.shtm#hosp_gen

Texas DADS Website. (2014). Texas Department of Aging & Disability Services

(DADS). Retrieved from http://www.dads.state.tx.us/

Texas Department of Aging & Disability Services. (2014). Culture Change: Regulatory

Services. Retrieved from

http://www.dads.state.tx.us/culturechange/experts/regulatoryservices.html

Documents

Week 2 Team Assignment Research