Top FAQs Hospital Accreditation September 30, 2015 Donna Tiberi , RN, BS, MHA Standards Interpretation & Accreditation Manager
Objectives • Review of actual HFAP’s frequently asked questions (FAQs) • Increase awareness and understanding of Acute Care standard compliance 2
PLEASE NOTE Allied Health Professional requirements have been deleted from Chapter 2 and are now located in Chapter 3 – Medical Staff. 3
FAQs v We thought it would helpful to review frequently asked questions submitted by hospitals to provide clarification. v Often times accreditation organizations are told that there is inconsistency with their FAQ responses. Organizations report that they ask the same questions, but receive different answers. This can be true. However, one reason why FAQs are answered differently is because questions were phrased differently. It’s not uncommon for organizations to call in to AO’s many times or submit the same question multiple times for the same issue. Even one word can change the answer! v It’s important to remember that based on how a question is written or asked will determine how our Standards Interpretation department will respond to your question. 4
01. 00. 07 Governing Body Responsibilities Q: The Acute Care standard (01. 00. 07) requires that the governing board bylaws address the responsibilities for the physical plant. I do not understand how to implement this. Do I need a statement in the bylaws that speak to what our current process entails? 5
01. 00. 07 Governing Body Responsibilities Answer: v The bylaws of the governing body must state that the governing body is responsible for the "provision for the adequacy of the physical plant. " This statement establishes the role and responsibilities of the governing body to ensure a safe environment for patients, visitors, and staff. v It is the responsibility of the governing body to review safety reports, inspections, and other reports of the physical condition and take corrective action, including the release of funds as necessary. v Be sure the committee minutes at each level, especially the governing body, reflect the review of these reports and any corrective actions taken as indicated. v The Governing Body must have a mechanism in place for the review of the governance bylaws no less than every three (3) years, and must complete a performance evaluation of itself within the past 12 months. 6
01. 01 Categories Eligible for Appointment Mid-level Practitioners Q: The Acute Care standard states that the number of allied health professionals that may be supervised by a single physician is limited in some states. Where can I find the ratio so that I am within the state limitations? 7
01. 01 Categories Eligible for Appointment Supervision of Allied Health Practitioners Answer: v You may refer to your state's Advanced Nurse Practice Act and the Physician Assistant Practice Act to identify whethere is a limit. v Governing Body defines AHP requirements v Remember that this information must be made available to the surveyor at time of survey. 8
10. 01. 02 Information in Medical Records Q: The Acute Care standard (10. 01. 02) states that parts of the medical record that are the responsibility of the physician must be authenticated by the physician. The standard also stipulated that it is up to the institution to define the rules & regulations for authentication/delegation. Are all history & physicals (H&Ps) subject to co-signature? 9
10. 01. 02 Information in Medical Records Answer: v Medical staff policies identify those portions of the medical record, if any, that may be delegated to a non-physician practitioner. Medical staff policy, consistent with State law defines: The portions of the medical record that may be delegated to non-physician practitioners, such as: ü Medical History ü Physical Examination ü Progress Notes ü Operative Report ü Discharge Summary v The requirements for co-signature and/or authentication, consistent with State law for non-physician practitioners, especially: ü Nurse Practitioners ü Physician Assistants ü Certified Registered Nurse Anesthetists (CRNA) ü Certified Nurse Midwifes 10
03. 01. 15 Required Application and Reapplication: Information to be Reviewed Criminal Background Checks Q: What type of criminal background checks are required to run on employees? Per Indiana state law, we are required to obtain limited criminal background history. We are not obtaining: 1) social security trace; 2) county criminal check for all counties lived; 3) multi-state, multi jurisdiction search; and 4) all 50 states sex offender registries. During our last survey, we were not cited but were questioned about our searches. The surveyor mentioned that statewide searches are pulled differently than multi-state searches. Are our current searches acceptable? 11
03. 01. 15 Required Application and Reapplication: Information to be Reviewed Answer: v HFAP is not prescriptive. Criminal background checks is often a state requirement and varies greatly, state to state. There are many types of searches to consider. Your human resources department should develop this policy in collaboration with the legal department. v The hospital will conduct criminal background investigations based on information provided in the application or as required by federal and state regulations 12
03. 01. 15 Required Application and Reapplication: Information to be Reviewed (continued ) v The hospital will conduct criminal background checks as allowed by State law for all potential new hires v This policy should establish how extensive the criminal background check will be in terms of: ü The number of years to be searched ü Whether the search will be limited to your state or beyond. Some facilities have implemented finger-printing for new employees, but again this is not an HFAP requirement ü Certain states have more extensive requirements for those employed in nursing homes, behavioral health or mental health facilities 13
03. 01. 15 Required Application and Reapplication Q: Employment verification from former employers has been increasingly difficult and a time consuming task. We would like to know what other means would meet the standard? We currently conduct skills checklists on clinical staff and all new hires have a background check. 14
03. 01. 15 Required Application and Reapplication Answer: v We would suggest developing a policy in collaboration with your legal department outlining your process for obtaining reference information. v This policy should specify the number of attempts that will be made to obtain references. Perhaps you will mail two requests and send a third as "certified mail. " v The policy should also outline documentation expectations, e. g. , "No response received from letter mailed on July 1, xxxx. Second letter mailed to xxxx on July 17, xxxx. " v Your facility may also consider the use of electronic means to request this information. For some facilities, this has been an effective means used by the Medical Staff officers to obtain references in a timely manner. 15
03. 01. 15 Required Application and Reapplication: Information to be Reviewed Answer: (continued) v At time of survey, your facility should be able to speak to the requirements established by your state and be able to explain your policy & procedures. v The hospital must be able to speak to the application request information regarding any criminal history 16
03. 01. 18 Temporary Privileges Q: What are the standard requirements for assigning temporary privileges to a physician? 17
03. 01. 18 Answer: Temporary Privileges v It is not permitted to grant temporary privileges until such time as the appointment or reappointment process can be completed. v All applicants requesting privileges must go through the entire credentialing and privileging process for approval. v For those that cannot wait, this means that an ad hoc or Medical Executive Committee meeting should be scheduled sooner than planned. 18
03. 01. 18 Temporary Privileges (continued) Answer: v The medical staff bylaws should clearly define the process for granting temporary privileges. Of course, your medical staff may prefer to wait until all 3 references before the application is submitted to the chief/department chair and CEO. Temporary privileges should be temporary and time-limited. v Inappropriate granting of temporary privileges could be a violation of the Acute Care standard (03. 01. 12) Uniform Application of Membership Criteria) that requires a uniform application of membership criteria. It is not permitted to grant temporary privileges until such time as the appointment or reappointment process can be completed. Please review the Acute Care standard (03. 01. 18) for additional information. v All applicants requesting privileges must go through the entire credentialing and privileging process for approval. For those that cannot wait, this means that an ad hoc or Medical Executive Committee meeting should be scheduled sooner than planned. 19
04. 00. 05 Competency Q: Can you provide a description of the scope of practice for Licensed Practical Nurses (LPNs)? 20
04. 00. 05 Competency Answer: v The scope of practice for LPNs is defined through your facility's policies & procedures and in accordance with your state law. v The job descriptions must reflect the scope of practice and how this individual will function within your organization, including supervision requirements in certain settings of care. 21
04. 00. 05 Code Blue Q: Is there a requirement for conducting a mock Code Blue (emergency code) exercise? There is a requirement for fire, but not sure about Code Blue. 22
04. 00. 05 Answer: Competency Code Blue v HFAP standards are not prescriptive. There is no standard that speaks to hospital codes. However, the Acute Care standard (04. 00. 05) speaks to staff competency per hospital policy. v Staff must be qualified and competent to perform their duties as assigned. Conducting a mock "Code Blue" may be one example your facility has defined as a policy to ensure staff competence via practice. v If staff is required to be certified in Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS), Basic Life Support (BLS), etc. , the staff must also maintain certification every two years as required per certification. Again, there is no HFAP requirement for conducting a mock Code Blue. 23
04. 00. 09 Evaluation of Competence Q: The Acute Care standard (04. 00. 09) indicated that competence evaluations should be at least on an annual basis. Our organization is considering a change in the timeline, but will maintain on an annual basis. With this change, some evaluations may be earlier or later than the last evaluation. Is this acceptable? 24
04. 00. 09 Evaluation of Competence Answer: v. Yes, such proposed changes would be acceptable. However, be sure to memorialize your plan and the details of all changes. v. Also, be sure to document these changes in your Leadership meeting minutes. 25
04. 00. 09 Evaluation of Competence Q: Our leadership staff is considering allowing Cath Lab Technicians to insert Peripherally Inserted Central Catheters (or PICC lines). Is there a standard requirement about who should be inserting intravenous lines? 26
04. 00. 09 Evaluation of Competence Answer: v Your facility defines the duties and responsibilities of each discipline through a job description. v The Acute Care standard (04. 00. 09) requires that staff must be competent in knowledge, skills and ability to perform their responsibilities. v There must be an objective process performed at defined intervals for assessing and evaluating the competence of all employees. v As long as your staff have completed appropriate training and passed competency assessments, staff may perform procedures or services within their scope of practice and in accordance with hospital policy, state law & regulations. 27
04. 00. 10 New Employee Orientation & 04. 00. 11 Required Orientation Curriculum Q: Are hospital-employed physicians and hospitalists held to the same standard for orientation and ongoing educational requirements? 28
04. 00. 10 New Employee Orientation & 04. 00. 11 Required Orientation Curriculum Answer: v The Acute Care standards (04. 00. 10 and 04. 00. 11) require orientation for all employees, including hospital-employed physicians and non-employed physicians (hospitalists). v Orientation for non-employed physicians may be modified; however, it must include all elements defined in the standard (04. 00. 11). Orientation may be provided by either the medical staff office, physician services department, or the human resources department. v Your facility should have a policy that outlines the orientation plan for your physicians. The orientation provided is to be documented in the credentials files for each physician. 29
04. 00. 10 New Employee Orientation Contract Employee Records Q: What is required of an employee file, and maintaining proper documentation for a contracted employee? 30
04. 00. 10 Answer: New Employee Orientation Contract Employee Records v The facility is responsible to ensure that all employees, including contracted employees, are competent. Maintenance of such competence is in the design of your facility’s policy & procedures. v Competency assessment is an ongoing process. The facility will define the competencies to be assessed annually, and those competencies to be assessed at shorter defined time intervals. v The facility is also responsible to provide contracted employees an orientation to the facility. v The orientation curriculum addresses specific information and individual scope of service. You may review the following Acute Care standards for more detail: 01. 06, 04. 00. 05, 04. 00. 09, 04. 00. 10, 04. 00. 11, and 04. 00. 12. 31
07. 01. 02 & 24. 01. 16 Infection Control Q: Does HFAP require the same titers and immunizations for volunteers as for in-house employees? If so, please provide the related references. 32
07. 01. 02 & 24. 01. 16 Answer: Infection Control v Yes, volunteers must meet the same requirements. See Acute Care standard (24. 01. 16), Infection Control, item D, states that "employee health policies regarding infectious diseases and specifically those infected or ill employees, including contract workers and volunteers, must not render food service and/or must not report to work. " See - Acute Care standard (07. 01. 02) Infection Prevention. Explanation: Measures to evaluate staff and volunteers exposed to patients with infections and communicable disease. 33
07. 02. 04 Preparing, Assembling, Wrapping, Storage of, & Distribution of Sterile Equipment & Supplies Q: Is there a standard that address storage of sterile instruments? What is the recommended temperature for all sterile storage areas? 34
07. 02. 04 Preparing, Assembling, Wrapping, Storage of, & Distribution of Sterile Equipment & Supplies Answer: v The Acute Care standard (07. 02. 04) addresses the requirements for storage and distribution of sterile equipment. You may also want to review the CDC, AORN, AMII guidelines as well for additional information. The following link will also provide you with some additional insight as well: http: //www. infectioncontroltoday. com/articles/2011/05/infection-control-and-the-centralsterile-supply-department. aspx. v The recommended temperature for all sterile storage areas is 24°C (75°F). These areas require at least 4 air exchanges per hour in a controlled relative humidity that does not exceed 70%. Sterile items should be stored on or in designated shelving, counters or containers. v Sterile items should be stored: 18" below the ceiling (or level of sprinkler head) because adequate space is needed for air circulation and to ensure the effectiveness of sprinkler systems. 8 -10" above the floor to prevent contamination during cleaning and 2" for outside walls because of condensation that may form on interior surfaces of outside walls. v The bottom shelf should be solid or contain a physical barrier between the shelf and the floor. Heavy instruments packages should not be stacked due to the possibility of compression. Outside shipping containers and corrugated cardboard boxes are exposed to unknown and potentially high microbial contamination and should never be allowed in the sterile storage area. 35
10. 01 Content of the Record Q: What is required in terms of documentation in the medical records for short stays? 36
10. 01 Content of the Record Answer: v The medical record must reflect the patient's entire care during his/her inpatient or outpatient treatment. v The medical record must contain information to justify admission, continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and treatment services. 37
10. 01. 02 Information in Medical Records Q: Does HFAP recognize the ability of mid-level practitioners, such as Physician Assistants (PAs), to co-sign for physicians that have delegated the performance of medical service to this individual? 38
10. 01. 02 Information in Medical Records Answer: v Yes - HFAP recognizes the ability of mid-level practitioners cosign for physicians. v Medical staff policies identify those portions of the medical record, if any, that may be delegated to a non-physician practitioner. v Under standard 10. 01. 02 it states that the Medical staff policy, consistent with State law defines the portions of the medical record that may be delegated to nonphysician practitioners, such as: ü ü ü Medical History Physical Examination Progress Notes Operative Report Discharge Summary Also refer to standard 30. 00. 10 History & Physical. 39
10. 01. 02 Information in Medical Records (continued) Answer: v The requirements for co-signature and/or authentication, must be consistent with State law for non-physician practitioners, especially: ü ü Nurse Practitioners Physician Assistants Certified Registered Nurse Anesthetists (CRNA) Certified Nurse Midwifes 40
10. 01. 05 Pre-printed Orders, Order Sets & Protocols Q: In regards to the Acute Care standard (10. 01. 05), item #3, what is the required frequency for reviewing preprinted orders, order sets and protocols? 41
10. 01. 05 Pre-printed Orders, Order Sets & Protocols Answer: v All medication standing orders or routine protocols are subject to annual review and/or revision v All protocols and practice guidelines for patient care must be reviewed on an annual basis to ensure all information is up-to -date with current practice guidelines. The Medical standing orders and protocols are to be reviewed by the professional medical staff via its committee structure 42
10. 01. 18 Discharge Summary Q: Is it a requirement to have a list (or template) of what to include in a discharge summary? 43
10. 01. 18 Answer: Discharge Summary v Your facility should have a policy approved by the medical staff that outlines the expectations for the discharge summary, including timeliness for completion and content. Please refer to the Acute Care standard (10. 01. 18) Discharge Summary, for the entire requirement. The medical records must contain a discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. v The discharge summary requirement would include outpatient records. For example: 1. The outcome of the treatment, procedures, or surgery 2. The disposition of the case 3. Provisions for follow-up care for an outpatient surgery patient or an emergency department patient who was not admitted or transferred to another hospital *Discharge summaries must be completed within 7 days of discharge. The medical record must be completed with in 30 days. 44
15. 01. 03 Complaints and Grievances Q: If the governing body has delegated the process for resolution of complaints and grievances to a committee or department, does that committee or department need to report back to the governing body? 45
15. 01. 03 Answer: Patient Grievances v Yes, the committee for complaints/grievances would need to report back to the governing body. Communication reporting should always go up to all leadership levels. v Please remember that the hospital's governing body is responsible for the effective operation of the grievance process. This includes the hospital's compliance with all of the CMS grievance process requirements. v A written complaint is always considered a grievance and information obtained from patient satisfaction surveys usually does not meet the definition of a grievance. v Data collected regarding patient grievances, as well as other complaints must be incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program. 46
18. 00. 10 Conscious Sedation Q: When performing conscious sedation, the nurse providing the sedation is also monitoring the patient and should not be the circulating nurse. Is this correct? 47
18. 00. 10 Moderate Sedation: Assisting With the Procedure Answer: v Yes, this is correct. Standard 18. 00. 10 states that the proceduralist shall have an assistant assigned whenever moderate sedation is administered; this assistant may be another physician, RN, LPN/LVN, or technician. v The "monitoring" RN may be counted as the "RN planning and supervising nursing care” for the patient. v During survey the surveyors will review to determine that policy requires moderate sedation cases to have a minimum of two (2) staff: one (1) to monitor one (1) to assist the physician v The nurse administering sedation cannot be the nurse assisting with the procedure or be the circulating nurse in the room. v Please review the Acute Care standard (18. 00. 08 Moderate Sedation) for additional information 48
19. 00. 13 Qualified Personnel Q: What staffing qualifications are required to assist and provide moderate sedation during a bronchoscopy? 49
19. 00. 13 Qualified Personnel Staff Qualifications/Competency Answer: v Your medical staff will need to define the qualifications for staff that can assist with patients receiving moderate sedation. v Hospitals are expected to regularly reassess staff competency and to provide periodic training needed to keep staff skills up-to-date. v The hospital must document training completion dates and evidence of satisfactory competence. v Staff that complete training but cannot demonstrate satisfactory competence must not be permitted to use radiologic equipment and/or administer procedures v The qualifications should be written in either the job description or approved policy. It is recommended that the education department prepare a training program with a post-test to ensure competency. Both training program and post-test must be submitted to the director of anesthesia for approval. You may review the Acute Care standards (19. 00. 13/20. 07/15. 02. 30) for additional information. v The Association of peri. Operative Registered Nurses (AORN) is a valuable resource and may offer examples: (https: //www. aorn. org/education/curriculum/confidence-based_learning/moderate_sedation. aspx ). Also, the American Society of Anesthesiologists (ASA) website provides guidelines relative to moderate sedation. 50
25. 01. 03 Security of Medications Q: Our crash cart and Omni medication system is located in an alcove by the nurses' station. Do they have to be behind locked doors? 51
25. 01. 03 Security of Medications Answer: v The crash cart and Omni medication system must be maintained in an area that allows for sufficient staff traffic to notice anyone attempting to access cart when not authorized. v Staff must be able to view the cart from the station or floor area. It is recommended that your facility conduct a risk assessment to determine potential unauthorized access to the cart. 52
30. 05 Surgical Privileges Q: Does a hospital-employed First Assist need to be credentialed and privileged? 53
30. 05 Answer: Surgical Privileges, RN first assistants Yes, the first assistant must be credentialed and privileged, whether employed by the hospital, a physician or other entity, or a contracted provider. v The First Assist, also known as Certified Surgical First Assistant CSFA) v Must be considered a medical professional who assists surgeons during surgeries. v The practitioner is individually credentialed based on their own individual qualifications. You may wish to refer to the Acute Care manual standard (30. 05) for more detail on Allied Health Practitioner categories. If the hospital utilizes RN First Assistants, surgical PA, or other non-MD/DO surgical assistants, the hospital must establish criteria, qualifications and a credentialing process to grant specific privileges to individual practitioners based on each individual practitioner’s compliance with the privileging/credentialing criteria and in accordance with Federal and State laws and regulations. This would include surgical services tasks conducted by these practitioners while under the supervision of an MD/DO. 54
30. 05 Surgical Privileges Q: Does hospital-employed Surgical Assistants and Surgical Technicians need to be credentialed through the medical staff process? 55
30. 05 Answer: Surgical Privileges v Your facility may choose to use either the medical staff or human resources department process in accordance with federal and state laws & regulations. Your facility must: v Have medical staff approved qualifications that details the expectations regarding education, training, experience, certification/license as appropriate to the position. v Have medical staff approved privileges that detail the surgical tasks that are appropriate for the position. This may be in the form of either a job description or list of privileges. v Have a process to credential/validate the qualifications of the individual, including education, training, experience, certification/license as appropriate to the position. v Have a process for the ongoing evaluation of competency of the individual. Should your facility determine these individuals are to go through the medical staff credentialing process, they must follow the same procedures as the medical staff personnel. 56
30. 05 Surgical Privileges Answer: continued v Credentialing and privileging criteria requirements apply to all categories of practitioners utilized in the facility. The granting of surgical privileges is a function of governance upon the recommendation of the Professional Medical Staff. Initial and revised / renewed privileges are copied to the surgical services. v Requirements apply to all categories of practitioners utilized in the facility. The granting of surgical privileges is a function of governance upon the recommendation of the Professional Medical Staff. Initial and revised / renewed privileges are copied to the surgical services v If the hospital utilizes RN First Assistants, surgical PA, or other non-MD/DO surgical assistants, the hospital must establish criteria, qualifications and a credentialing process to grant specific privileges to individual practitioners based on each individual practitioner’s compliance with the privileging/credentialing criteria and in accordance with Federal and State laws and regulations. This would include surgical services tasks conducted by these practitioners while under the supervision of an MD/DO. v When practitioners whose scope of practice for conducting surgical procedures requires the direct supervision of an MD/DO surgeon, the term “supervision” would mean the supervising MD/DO surgeon is present in the same room, working with the same patient. 57
30. 01. 00 Condition of Participation: Medical Leadership for Anesthesia Services Q: We were informed that hospitals will be cited for not having an Anesthesia Rescue Capacity policy. What needs to be included in this policy for compliance? 58
30. 01. 00 Condition of Participation: Medical Leadership for Anesthesia Services Answer: v The hospital must demonstrate that its emergency services are integrated into its other departments. The integration must be such that the hospital can immediately make available the full extent of its patient care resources to assess and render appropriate care for an emergency patient. v A facility must be able to respond to any life threatening patient emergency based on hospital services provided in accordance with their patient population (i. e. , neonatal, pediatrics, adults etc. ). 59
30. 01. 00 Condition of Participation: Medical Leadership for Anesthesia Services continued Answer: Rescue Capacity: Because the level of sedation of a patient receiving anesthesia services is a continuum, it is not always possible to predict how an individual patient will respond. Further, no clear boundary exists between some of these services. Hence, hospitals must ensure that procedures are in place to rescue patients whose level of sedation becomes deeper than initially intended, for example, patients who inadvertently enter a state of Deep Sedation/Analgesia when Moderate Sedation was intended. “Rescue” from a deeper level of sedation than intended requires an intervention by a practitioner with expertise in airway management and advanced life support. v The qualified practitioner corrects adverse physiologic consequences of the deeperthan intended level of sedation and returns the patient to the originally intended level of sedation. (Rescue capacity is not only required as an essential component of anesthesia services, but is also consistent with the requirements. 60
30. 01. 03 Moderate Sedation Q: The Acute Care standard (30. 01. 03) limits privileges only to a list of providers that can administer deep sedation. In our emergency department (ED), the physicians are credentialed to give deep sedation and to supervise. Our registered nurses are also trained to give IV deep sedation in unusual circumstances. Is this practice acceptable? 61
30. 01. 03 Moderate Sedation Answer: (Conscious Sedation) The Acute Care standard (30. 01. 03) requires that anesthesia is furnished in a wellorganized manner and limited to qualified individuals. Anesthesia services must be delivered in a manner that is consistent with the needs and the resources of the hospital. v Should your facility determine, as appropriate, to administer IV deep sedation in the ED or areas other than surgery, the ED physicians must be granted privileges approved by the medical executive committee and the governing body. The ED physician requesting this privilege must demonstrate competency. v The credentials committee, with input from the director of anesthesia, is responsible to determine the training requirements and the method to be used to evaluate competency. v Facilities will define competency, training requirements, and methods to evaluate all staff that is permitted to administer sedation of any type. Competency is to be reassessed with each reappointment. 62
Employee Education File Retention Q: How long should we keep educational records on staff education requirements, e. g. , education on restraints or CPR? 63
Employee Education File Retention Answer: v HFAP has no standard regarding the length of time for saving these staff education files. You may want to seek direction from your facility's Risk Management and/or legal counsel regarding the preferred practice. You may also wish to contact your state to obtain additional information as some states may have retention requirements. You may wish to review Civil Rights Act of 1964 and FLSAse below: ü Under the Civil Rights Act of 1964, Title VII, and the ADA, employers with at least fifteen employees must retain applications and other personnel records relating to hires, rehires, tests used in employment, promotion, transfers, demotions, selection for training, layoff, recall, terminations of discharge, for one year from making the record or taking the personnel action. - See more at: http: //corporate. findlaw. com/human-resources/the-how-long-must-employers-retain-employeerecords. html#sthash. t. Fnv 4 QFG. dpuf ü 2015 - Under the FLSA, the record-keeping requirements are either two years or three years depending on the type of record involved: - See more at: http: //corporate. findlaw. com/humanresources/the-how-long-must-employers-retain-employee-records. html#sthash. t. Fnv 4 QFG. dpuf 64
Direct Access Law Q: Does HFAP have state-specific guidelines for states that allow direct access (without a physician order)to physical therapy? 65
Direct Patient Access Law Answer: v HFAP will survey to ensure compliance to state law & regulations for physical therapy access. v Some states do not allow direct access and require a physician's order, plan, and signature to proceed with treatment v Some states allow for up to 21 days of care within scope of PT practice guidelines to provide services before obtaining physician order and signatures. v You may wish to refer to the following website: 2015 - http: //www. apta. org/uploaded. Files/APTAorg/Advocacy/State/Issues/Direct_Access/Direct. Acce ssby. State. pdf. ( please review 31. 00. 11 Orders for Outpatient Services). 66
Monitoring End Tidal CO 2 Q: Is there a requirement for monitoring End Tidal CO 2 levels during moderate sedation? 67
Monitoring End Tidal CO 2 Answer: HFAP standards are not prescriptive; however, your facility is required to follow current ASA (American Society of Anesthesiologists) practice guidelines to ensure patient care is delivered in a safe and effective manner. You may wish to review the ASA guidelines and other information at: • • • www. asahq. org/For-Members/Standards-Guidelines-and-Statements. aspx www. ncbi. nlm. nih. gov/pmc/articles/PMC 3167153; www. dremed. com/medical_equipment_news/meet-new-asa-standards-with-waveline-touch-monitors 68
QUESTIONS? Please submit questions to: Donna Tiberi Standard Interpretation Dtiberi@hfap. org or info@hfap. org or Please call 312 -202 -8073 69
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