Question of the Month
Each month, The Center for Healthcare Accreditation selects a Question of the Month that is designed to highlight best practices, help organizations deal with common challenges, and encourage professional development. The question of the month requires no login, and allows you to submit questions at a time convenient to you.
If you would like to submit a question on any topic, please email us. Your question will be reviewed by our consulting experts. If you are a member, please contact your senior advisor for immediate response to your question(s). Please note, although the experts will try to answer as many questions as feasible, there is no guarantee that all questions will be answered. Your question may be edited for content.
2010
July
Our medical staff is having difficulty with focused professional practice evaluation related to licensed independent practitioners that do not perform surgical or other invasive procedures. Do you have any suggestions about what would be appropriate, how the review would take place and the number of reviews that would meet the requirement?
Your question is understandable, as many hospitals have difficulty with the medical staff standard requiring focused professional practice evaluation (MS.08.01.01) for those LIPs that do not perform procedures. The standard consists of two components for focused professional practice evaluation (FPPE). FPPE is to be performed when an individual initially requests privileges, and when issues impacting the provision of safe, quality patient care are identified. Because the standard requires the use of specific criteria for the second component of FPPE, we understand your question to be how FPPE is performed for initial privilege requests for non-proceduralists. For both components the organization has the liberty to determine what constitutes FPPE. Generally, for the first component, (FPPE for initial privileges) many organizations use retrospective record review of a set amount of LIPs cases over a given period of time or until an expressed amount of records (patient cases) have been reviewed. Remember, the organization gets to determine how best to perform FPPE, and for non-proceduralists, a review, conducted retrospectively of the practitioners care, can provide an adequate evaluation of technical, clinical and professional performance. The number of cases reviewed is entirely up to the organization, however, the medical staff should determine how many cases would be necessary to identify the practitioner's ability and performance; there is no required number. Additionally, there is no time frame required for the review, however, certainly the review should be completed during the practitioner's provisional period.
June
With the Joint Commission's removal of the Measure of Success (MOS) requirements for some of the "C" elements of performance (EPs), can we still use the clarification process for these EPs if they resulted in a Requirement for Improvement (RFI) during our accreditation survey?
Based on the April 28 release of its Online newsletter, Joint Commission made no mention of any change to the 90% success rate on audits for these EPs. So, the answer is yes. Remember that if you receive an RFI in these areas, you must still submit an Evidence of Standards Compliance or ESC to be accepted, although the 4 month-period monitoring requirement to maintain ESC or PPR compliance is eliminated. It's also important to note that in the Online publication, 11 of the MOS-removed EPs will become "A" category scoring elements effective July 1.
February
I am confused about PRN orders for restraint. I thought any type of PRN order for restraint was expressly forbidden by both CMS and TJC. However, now I’ve been told some types of PRN orders are “ok”. Is this true?
Yes, this is absolutely true. And, yes, there is much confusion over this issue. Under the Conditions of Participation §482.13(e)(6), states “Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN)”. However, the Interpretative Guidelines go on to state the following exceptions: “Geri chair”. If a patient requires the use of a Geri chair with the tray locked in place in order for the patient to safely be out of bed, a standing or PRN order is permitted. Given that a patient may be out of bed in a Geri chair several times a day, it is not necessary to obtain a new order each time.
Raised side rails. If a patient's status requires that all bedrails be raised (restraint) while the patient is in bed, a standing or PRN order is permitted. It is not necessary to obtain a new order each time the patient is returned to bed after being out of bed. Repetitive self-mutilating behavior. If a patient is diagnosed with a chronic medical or psychiatric condition, and the patient engages in repetitive self-mutilating behavior, a standing or PRN order for restraint to be applied in accordance with specific parameters established in the treatment plan would be permitted. Since the use of restraints to prevent self-injury is needed for these types of rare, severe, medical and psychiatric conditions, the specific requirements (1-hour face-to-face evaluation, time-limited orders, and evaluation every 24 hours before renewal of the order) for the management of violent or self- destructive behavior do not apply.”
So, for protective restraint and restraint for the violent and self-destructive patient, restraints that are most frequently used (limb restraints) may NOT be ordered on a PRN basis. However, for patients using Geri chairs with locked trays to protect the patient, for side rails raised to protect the patient from leaving the bed and for patients that require restraint to prevent repetitive self-mutilating behavior (this singular scenario would be the exception to the limb restraint statement), PRN restraint orders are allowed. To provide your hospital with maximum flexibility in the use of restraints, you may wish to conduct a risk assessment surrounding these issues and determine if your hospital uses Geri chairs or side rails for restraint (side rails used to prevent the patient from falling out of bed are not considered restraint. Side rails used to prevent the patient from getting out of bed or leaving the bed, are considered restraint), if so, you may wish to outline in policy when PRN orders for restraint using these devices are allowed. Hospitals without behavioral health units most probably will not need to deal with the patient that exhibits repetitive self-mutilating behavior; however behavioral health units are encouraged to discuss use of PRN restraint orders for this patient condition in your restraint and seclusion policy.
January
With the relaxation of the medication storage rules, can medications be left at the patient bedside?
Yes. The Conditions of Participation allow for drugs and biologicals to be stored in a secured area and to be locked when appropriate. Under §482.25(b)(2)(i) – CMS's Interpretative Guidelines state "all drugs and biologicals must be kept in a secure area, and locked when appropriate", with the guidelines going on to state critical care areas are generally actively staffed and provide care around the clock, therefore the critical area would be considered secure. This would extend to nonscheduled (non-controlled substances) which might be left at the patient's bedside. Should the patient have visitors, the nurse is still monitoring the patient and supervising the area, so technically, medications left at the bedside would be considered stored in a secure environment. However, the Interpretative Guidelines outline that hospitals should have polices and procedures ensuring limitation of entry and exit to areas such as ICUs and Labor and Delivery Units (another example area noted in the Interpretative Guidelines as a "secure" area for drug storage due to the 24/7 provision of care) where "cabinet locked" storage of non-controlled medications is not required. What is the key here? Description of limitation of access to visitors, patients and staff and identification of who may have access and why (which should be in accordance with job responsibilities, such as EVS personnel, etc.).
Note: All scheduled medications (narcotics) must be locked when stored. Leaving scheduled/controlled medication at the patient bedside is not considered locked.
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