Compliance Monitoring Division
Frequently Asked Questions
From CAH Training February 23-24, 2005
MDH and Chicago Regional Office
Q: Regarding C-0207 on personnel; can you clarify what it means that the doctor, PA, or NP with ER training needs to be available on-site within 30 minutes.
- Q: Does it mean that a patient needs to be seen in 30 minutes?
A: Our interpretation is that the hospital policy must be that the physician can be at the hospital within 30 minutes of being called in. It does not mean 30 minutes after the patient presents, or that the patient must be seen within 30 minutes. This condition of participation covers availability of staff, not medical practice. If state or your hospital regulations cover who must do triage, you should use those rules to cover your practice. To be a CAH, a physician or other practitioner must be able to be at the hospital within 30 minutes of being called in. The surveyors should look for documentation that the practitioner has been on-call and is available on site within 30 minutes.
- Q: What if the physician is on-site?
A: Then he is available within 30 minutes.
Q: Regarding C-0210 on the number of beds:
- Q: If a sick baby is in a bassinette without the mother, is that bed counted in the bed count?
A: Yes. A newborn baby in a bassinette with the mother is not included in the bed count. But if the baby comes back to the hospital to receive services, the bassinette is counted in the bed count.
- Q: If labor and delivery beds are excluded from the 25 bed count what about birthing rooms?
A: Beds used exclusively for observation of labor and delivery are not counted but if the woman stays in the bed after delivery, it is counted. Since birthing rooms are designed for the woman to stay during labor and after delivery, they are included in the bed count.
- Q: What about patient in outpatient bed, for example for same day surgery?
A: If it is a regulation hospital bed in the area or vicinity of hospital patient care, it would be counted. If it is a recliner type bed or a gurney, it is not counted.
- Q: If your facility conducts sleep studies, does the bed used in the sleep study count towards the 25-bed limit?
A: Yes, if it is a hospital type bed in the vicinity of hospital services it is counted. If it is not a regular hospital bed--e.g. a home-type bed, it is not counted.
- Q: What about the co-mingling of observation beds with inpatient beds?
A: Co-mingling of observation beds with inpatient beds is allowed and CMS will be sending this out in writing soon. However, observation patients on regular hospital beds will be counted against the 25 bed limit, unless the observed patient is on a gurney or a recliner.
Q: Regarding C-0260—physician review and signature of all midlevel practitioner records:
- Q: Do all records need to be reviewed and signed by physician?
A: March 7, 2005: CMS has decided that in states where mid-level practitioners are allowed to act as independent practitioners, in accordance with State law, we will allow that 25% of outpatient medical records and 100% of inpatient medical records in a CAH receive medical review and signature.http://www.cms.hhs.gov/physicians/prit/issues.asp#cah
- Q: What if the midlevel doesn't work at the hospital but orders a test to be done at the hospital? For example,
if a mid-level orders a catscan for a patient being seen outside the hospital in an independent clinic, does a physician have to sign the orders for the test
in order for the CAH to bill Medicare?
- Q: What about when a mid-level orders an admit for observation?
A: Yes, but this is required under C- 0211which states that observation status must be medically necessary and that an MD order is required.
Q: Regarding C-0272 requiring that policies be reviewed by a group of professional personnel including one member that is not a member of the CAH staff: Who should that person be? Could it be the director of nursing of the attached nursing home?
A: That person should be someone not employed by the hospital or connected in a way that would present a conflict of interest. Since this group is reviewing patient care policies, it would be wise to have someone with a healthcare background. It does not have to be a doctor or nurse; it could be a Podiatrist or a Dentist or other professional. It could be the director of the attached nursing home if it is clear that he or she is not on the staff of the hospital—it depends on how the hospital's policies and procedures define who is and who is not a staff member.
Q: Regarding C-0276 - pharmacists review of medication administration: How does this work when most CAHs have part-time pharmacists and are unable to review first dose to the patient?
A: If your pharmacy arrangement is adequate for you needs and you have policies and procedures that cover how patients are covered and how drugs are monitored, that's what the surveyors will look at. You should have policies and procedures that cover and define what emergent, urgent and routine medication means. Tele-pharmacy may be a part of your plan—the pharmacist does not have to be on site to review medication dosing.
Q: Regarding Background checks for pool nurses. Can hospital accept background checks done by the company with which the hospital contracts?
A: Yes, if the contractor provides that background check and/or can provide that evidence to the hospital, the hospital need not repeat the background checks.