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HomeMy WebLinkAboutC88-117 Medicare MOU with skilled nursingC C88- 117 -22 MOU - SNF, HHA AND HOF OCTOBER 21, 1988 MEDICARE MEMORANDUM OF UNDERSTANDING PRO MEDICARE AGREEMENTS WITH SKILLED NURSING FACILITIES, HOME HEALTH AGENCIES AND HOSPITAL OUTPATIENT DEPARTMENTS This Memorandum of Understanding is entered into this 1st day of April, 1989 by and between the Colorado Foundation for Medical Care, the Colorado Professional Review Organization, hereinafter referred to as the PRO, and EAGLE COUNTY NURSING SERVICE , to enumerate operational proce- dures that the above mentioned parties have agreed will be followed. I. BACKGROUND AND AUTHORITY In accordance with Section 9353(e) of the Budget Reconciliation Act of 1986, Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Hospital Outpatient Departments (HOPDs) are to maintain an agreement with the Professional Review Organization (PRO) regarding review of written beneficiary complaints regarding quality of care while the services were being reimbursed by Medicare, or for services which may otherwise be made under Title XVIII. The PRO will also review complaints received from and through the HCFA Region VIII office. Section 2030 of the PRO Manual requires that PROs review a sample of intervening care between readmissions that occur within thirty -one (31) days in PPS hospitals. Intervening care includes that provided to a Medicare beneficiary by a SNF, HHA, or HOPD when it is the primary source of care. The care includes that which is paid for by Medicare or that may be paid by Medicare. II. PRO RESPONSIBILITIES A. Beneficiary Complaints 1. Determine the inquirer is a Medicare beneficiary or representative of a Medicare beneficiary. 2. Determine that the services in question were provided in a Medicare certified facility even though the services may not be reimbursed by Medicare. 3. The services in question are covered by Medicare; regardless of whether they are covered for this particular beneficiary. 4. Determine that the complaint is a quality of care issue. All non - quality concerns and complaints that do not meet items #2 and #3 above are forwarded to the HCFA Regional Office with a copy to the beneficiary. -1- C FMC EFF: 4/1/89 MOU - SNF, HHA AND HOPD OCTOBER 21, 1988 5. Acknowledge the beneficiary by letter that the complaint has been received and the PRO is reviewing. 6. Request the medical record within fifteen (15) days of receipt of the complaint. The provider has thirty (30) days to provide the medical record. 7. Review the record within fifteen (15) days and refer to a physician advisor, if necessary. If there is no quality problem, the PRO will respond in writing to the beneficiary within five days following the disclosure of information, rules in 42 CFR 476.132. If there is a provider quality issue the PRO will continue with #8 below. If there is a physician problem, the PRO will continue with #9 below. If both physician and provider are identified as the source of the problem, both #8 and #9 will be followed. 8. Potential provider quality issues will be referred to the provider with a thirty day response time. The response will be reviewed by the physician advisor and a determination made if there is or is not a confirmed quality issue. The beneficiary will be informed of the outcome of this review. The provider will be provided a copy of the letter to the beneficiary thirty days before the letter is sent to the beneficiary. A copy of the provider's comments will be attached to the PRO's response. The PRO letter will indicate whether or not the care provided met professionally recognized standards of care. If the care did not meet these standards, the corrective action to be taken will be described in the letter. 9. Potential physician quality issue will be referred to the responsible physician with a thirty day response time. The response will be reviewed by a physician advisor and a determina- tion made if there is or is not a confirmed quality problem and a severity level assigned. The beneficiary will be notified that a thorough investigation of the complaint has been conducted and that corrective action will be taken if a problem is found. The physician will be sent a copy of the PRO response letter to the beneficiary fifteen days prior to the letter being sent to the beneficiary. 10. Corrective Action will be taken by the PRO when a confirmed physician and /or provider quality issue is identified. a. If the quality problem meets the definition of a gross and flagrant violation or a substantial violation in a substantial number of cases, the PRO Sanction Process will be initiated. (Refer to Section IV). -2- CFMC EFF: 4/1/89 MOU - SNF, HHA AND HOPD OCTOBER 21, 1988 b. If the quality problem has the potential to affect the care provided to other beneficiaries, the PRO will forward their findings to the HCFA Regional Office. C. Confirmed quality issues identified in SNFs, HHAs, or HOPDs will be added to the PRO profile data for intervening care. B. Intervening Care 1. The CFMC RN Review Coordinators will review and screen each medical record utilizing generic quality screens (refer to Attachment A). All review information will be documented on a review abstract. 2. Cases with a potential quality problem, as determined by the RN reviewer as a Level I quality problem in HHA screens 5 and 6, and outpatient surgery screens la, lc, 4 and 5 will be pended until the threshold of three cases per quarter or five cases per biquarter has been met (refer to Attachment B for definition of Severity Levels) and weighted severity scores. 3. All Level II and III cases and those Level I cases that have met the threshold will be referred to a physician advisor for assignment of severity level and determination of the source of the problem. The physician will consult with appropriate specialists or other health care practitioners as necessary to confirm the problem. 4. The provider and /or practitioner will be notified that a potential quality problem has been identified and be provided with thirty (30) days to respond and discuss the issue. The initial notification will include sufficient data so that the responsible party will clearly understand the identified problem and the severity of the problem. 5. The Physician Advisor will review the response(s) of the provider and /or practitioner and either confirm or not confirm the quality problem. The responsible party will receive a final determination notice of the outcome of this review. Where the PRO confirms a quality problem, the notice will include sufficient detail so that the responsible party will clearly understand the identified problem, what the appropriate action should have been in the case, the severity of the problem, and the action to be taken to resolve the quality problem, if appropriate. -3- CFMC EFF: 4/1/89 -AOU - SNF, HHA AND HOPD OCTOBER 21, 1988 6. The confirmed problems will be entered into the CFMC database for profiling by provider and practitioner. All cases determined to be a potential sanction for a "gross and flagrant" violation will be referred to the Statewide Quality Assurance Committee for possible sanction (refer to Section IV). 7. Profiles for all intervening care quality issues for provider issues will be profiled on a quarterly basis. The profiles will be reviewed by the Associate Medical Director for acute and long term care. The Associate Medical Director will review all profiles with a multidisciplinary committee of long term care providers and health care practitioners. Those providers who have reached the threshold of 25 points per quarter (refer to Attachment B, Severity Levels and Weighted Severity Scores) will be considered for referral to the Regional Office of HCFA for possible decertification as Medicare providers. 8. Physician profiles will be integrated with all other physician profile data according to the Weighted Severity Scoring. C. Confidentiality The PRO will adhere to the Colorado Foundation for Medical Care (CFMC) Confidentiality Policy (refer to Attachment C). III. PROVIDER RESPONSIBILITIES Health care facilities that submit claims for Medicare payment must cooperate in the conduct of PRO review. Facilities must: 1. Assure that copies of the medical records are furnished to the PRO within thirty (30) days of the request. 2. Provide patient care data and other pertinent data (including information on costs and charges) at the time the PRO is collecting information required to make its review determinations. For review of beneficiary complaints, all required information must be photocopied and delivered, without cost, to the PRO within thirty (30) days of the PRO's request. Reimbursement for photocopying of intervening care review records will be at the rate of $.0498 per page. 3. Provide written notices to Medicare beneficiaries at the time the beneficiaries begin receiving care for which Medicare payment is sought; that this care is subject to PRO quality review; and indicate the potential outcomes of that review. Refer to Attachment D for the necessary informational materials for distribution. -4- CFMC EFF: 4/1/89 �Ud' - SNF, HHA AND HOPD OCTOBER 21, 1988 4. All teaching /university system providers must provide to CFMC within thirty (30) days of signing the MOU a determination of "ownership" of the medical records in the outpatient department. Intervening care review is not performed in physicians offices. Therefore, physicians in a teaching /university system may be exempted from this review if the physician rather than the outpatient department is the custodian of the medical record. University /teaching system providers must determine ownership of records and notify the PRO of how this determi- nation was made along with a list of physicians whose records are retained by the outpatient department. 5. The CFMC may be requesting photocopies of medical records in order to comply with the HCFA requirements for PRO re- review by an outside agency. The CFMC will contact your facility, in writing, to request the necessary records. IV. SANCTIONS Section 1154 of the Social Security Act (the Act) provides that health care practitioners and any other persons (including hospitals or other health care facilities, organizations or agencies) who furnish health care items or services for which payment may be made (in whole or in part) by the Medicare program have certain obligations. These obligations are to assure that the services or items: a. will be provided economically and only when, and to the extent they are medically necessary; b. will be of a quality which meets professionally recognized standards of health care; and C. will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by the CFMC in the exercise of its duties and responsibilities. In carrying out its Title XVIII duties and functions, the CFMC is to determine whether any person or practitioner may have violated Section 1154(a) Obligations. -5- CFMC EFF: 4/1/89 MOU - SNF, HHA AND HOPD OCTOBER 21, 1988 THIS MEMORANDUM OF UNDERSTANDING between the Colorado Foundation for Medical Care and EAGLE COUNTY NURSING SERVICE shall be effective April 1, 1989 through September 30, 1992. IN WITNESS WHEREOF, the aforegoing has been duly executed the day and year indicated above. COLORADO FOUNDATION FOR MEDICAL CARE r� By tA,. L President Date: -6- EAGLE COUNTY NURSING SERVICE Skilled Nursing Facility/Home Health Agency and /or Hospital Outpatient Department THE COUNTY OF EAGLE, STATE OF COLORADO, By and Through Its Board of County Commj" oners By: n By: I rt/ // Chief of Medical Staff Date: CFMC EFF: 4/1/89 Generic Oua Ytv Screens- 1. Intake assessment Debar ATTACHMENT .A a. Adequate assessment of medical, physical, psychological and social condition of the patient. b. Adequate assessment of OPD as appropriate setting to meet the patient's needs. 2. Appropriate and timely interventions a. Appropriate diagnostic and therapeutic services provided based on patient's condition and /or needs. b. Abnormal results of diagnostic services addressed and resolved or the record explains why they are unresolved. c. Reassessment of patient's medical, physical, psychological and social needs with referrals to other disciplines as necessary. 3. Specialty Therapies a. Restorative need identified and addressed through assessment, plan implementation and evaluation. b. Presence of therapy plan of care and documentation of therapist's compliance with plan. 4. Patient teaching a. Assessment of patient's educational needs with development and evaluation of a goal- oriented plan. b. Monitoring of patient's compliance with prescribed medical program. 5. Death within 48 hours of admission to hospital as ascertained from the hospital record. 6. Issues related to provision of patient care. a. Presence of critical inciftnt with resultant injury or untoward effect. 1. Serious life- threatening complications as a result of inadequate care. 2. Major adverse drug reactions or medication error. IV -31 ' gage 2 b. Presence of temperature elevation of 101 degrees oral (rectal 102 degrees) without intervention. c. Presence of B.P. reading of less than 85 or greater than 180 systolic or less than 50 or greater than 110 diastolic without intervention. d. Presence of pulse less than 50 (or 45 if the patient is on a beta blocker), or greater than 120 without intervention. e. Purulent or bloody drainage from wound. f. Indication of an infection following an invasive procedure or dressing change. 7. Documented plan for appropriate followup care or discharge. S. In the judgment of the professional reviewer, are there any other events /patterns of care that resulted in adverse outcomes that should be evaluated? No Yes Explain IV -32 .O 7 7 1-f O r Lij C J W ✓ L A CZ .61 W c •� N aar w O�r .Ai v noo O 2 S W N W CF Z O C F a a 4 a L V t C h C C, IV -33 L O. O L ✓ N ✓ C ✓ L A 0. W 9 ✓ C • ✓ d ✓ 0 W L L W W W L M L ✓ C W 9 V_ w C W L A M N A a 0< C c ✓ C O V A C 0 M O •O Q L L w CL v 0 CM u e 01 O O N Y- O O L O L. ✓ 9 C a I S O r ✓ co co !� C C WOW C O a r N C N I N O A r �r A c G LO e N L O W z O C A w a I. ✓r �Y. q N O A++6 O C E q NL NLL W j L. -w 40 N 0 0 7 Y W W 0 U'G C9 Na w. 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Adequate assessment of HHA's capacity to provide the services required for recovery or maximum restoration of function. Assessment to include: History Physical assessment /functional limits /impairment Activities of daily living Psycho - social (cognitive and affective) Caregiver Review of medications Nutritional needs Environmental risks b. Adequate assessment of physical environment and capability of caregiver to provide care in the home. c. Adequate assessment of patient before or at time of entry and source of referral to HHA. 2. Appropriate and timely interventions a. Presence of temperature elevation of 100 degrees oral (rectal 101 degrees) or presence of hypothermia without physician notification within 4 hours from the. time detected. b. Presence of B.P. reading of less than 85 or greater than 180 systolic or less than 50 or greater than 110 diastolic without physician notification within 4 hours from the time detected. c. Presence of pulse less than 50 (or 45 if the patient is on a beta blocker) or greater than 120 without physician notification within 4 hours from the time detected. d. Presence of other significant changes in signs and symptoms without physician notification within 4 hours from time detected. Examples: mental status (re: changes in cognitive function or behavior) loss of function signs and symptoms of CHF, etc. e. Appropriate diagnostic services provided on physician's orders. f. Abnormal results of diagnostic services addressed and resolved or the record explains why they are unresolved. g. Appropriate intervention if significant change in social support system, including environment. h. Appropriate reporting of abuse /neglect. 1. Timely reporting to physician of lack of family and /or patient compliance. IV -36 Page 2 - --- r -- -- 3. Adequacy of restorative care a. Specialty therapies. 1) Restorative need identified and addressed through assessment, plan implementation and evaluation. 2) Presence of therapy plan of care and documentation of therapist's compliance with plan. 3) Presence of patient education. b. Nursing instructions 1) Presence of patient education plan and documentation of nursing compliance with the plan. 2) Documentation in the nursing care plan of coordination of services (interdisciplinary followup and reinforcement). 3) Continual reassessment of patient's needs with referrals to other disciplines as necessary. 4. Deaths within 48 hours of transfer to hospital as ascertained from the hospital record. '5. Possible indications of secondary infections a. Temperature elevation greater than 2.degrees after 72 hours of start of care. b. Indication of an infection following an invasive procedure. `6. Issues related to patient care after the home health start of care a. Presence of incident with resultant injury or untoward effect. b. Presence of decubitus ulcer. c. Presence of life- threatening complications. d. Adverse drug reaction or medication error. e. Evidence of inappropriate planning and administration of patient care. f. Responsibility for termination of care only when services are no longer required. 7. Documented plan for appropriate followup care and discharge summary to physician(s) of record. B. In the judgment of the professional reviewer, are there any other events /patterns of care that resulted in adverse outcomes that should be evaluated? No Yes _ Explain ' PRO reviewer is to record the failure of the screen, but need not refer potential severity level I quality problems to physician reuiovor until a nattern emeraes. 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O •••.� N 10 Ur- •• Cr O N 0Y ii N 10 N.0 m r ✓ N A=•r'i' V•� N •9Y 0•r• t L C• j L ..• 'O AV Q = C N AY L u•� V Y✓ 10 A 10A 616 �t A•• At ✓ OL.Oz Be ✓ 0 ✓. N r 'C✓YU 0Y 10 C 10 OuL.A6A Litt NNa 10 N AY••• 0•� 0u10 Z C• 10 92 u9 X 0 O ma JL a v C C C r A N u Ol�rt ✓Y r 10 10 +�••' A OA20 Y r Lr ✓0101016 0 9✓ L �! N YYA rp N ��11 Cr O • A1010 ` rr N N y10 r LCAC OZL a6 GO1✓ L 04- 40 Crr ` )107 1016 6M10'O ri0• 10 !%N ✓ •Y.O CL O V 10 NaC u •� r A OG Z••• 10N 10 Ol>r C 10100 i rw 10'O OM•t L✓ N6 O *6t AL 10 10 6610 •r•N i A G ••� i N O C OY 10r Y C Lt AC 10 A A L .•• L 3 Y i A 01 V i IA 660 IL 2-4 01 C 16r 10 V iM L O 10 09 6 Yrr 610�Y N 10 L p C•�W 6 y O O Z rr L C Ca 6N V NZ N C - 0•� Ara 10 A 0 m 0A 0 10 10 610• L L ai< NO =00 LL E L 1010 Or rr N ✓ i •0✓ AZ N r u 6Y C L' V ✓Q ✓101010 0A•� r 0r u10E =!:S.• 1010 i'OYV 10u >10 A10100lOA r �L 0:;: NLA 1010 2— NLN•.• i 3,16 3- 3% 10 L� C Ar 10 0 10 A• Gr2 1 16 ALZ.0 t 0 r 0 10 i�w 6A >�•M F•r O C Ow OO ZY` A 10 O yy HOii VE OaAA�► ! F�AV <6Y76S66 T y y Y V• ` A A N G A° Ye L. °u•+ °VA M .°u1yECO t°.10. A M mat+ A A � 3,,N i u 610V i u Y _ N 10 A•A !►C As AY 9 7 NG` G6 dC G1 W•L6 CY C7 VC L rd L ° O C O44 O A 0✓ O+t C C_ N C C C 4yC� N A C 10N •Y •• A N Y 1. M✓ N Y i N f NA 10 r L •� V 60 0 10 L 640 N 0 i L 6Y M 0C••• 0100 0100 0iA C 016 C Z••` N Z L C Z L C Z 16 V W Z✓ W C Co C Q » C Z Z Z�, G 1 i N C I C i Y 1 C 0) .I• p AA r 6 OA — L i Im •• to L 10 C ..• C 6y. A N 6 Q1Y• 10 r 7 ii° - CL wnC.0 y L r V L A° x 0 O A L L.G m A in— Z L M9++ '� i Q L L I Y Y LN 09a w• Cs1lr� GN m " C� °•> 10 N Z w°• N y10LY y L A•� C C GAN A a. C L 10 1461 E N r C cob 7 1 14 O OM LL b OAi rr rG A 9 V O O AY 10 '7C 1: 041 y qm L a 0 10 Y 00 A 41 10 C A V L G 0 L "A A L N "16 C i A YGi 4) LO 10 ✓ pA tO .Ci10A16> a01C u r ✓4a1V1010 L L 3.44 > +a yw 0 0 O C LZPO 10 0 d 6 u to W CY OLO Or`N U r+6 ✓OAa Z IV -41 .Skilled Nursina �acil I. Compare hospital discharge summary and admission assessment to SNF to determine appropriateness of discharge to SNF and appropriateness of admission to and continued stay in that SNF. If SNF was unable to provide the care determined to be appropriate, was there documentation to initiate and provide safe, appropriate care within 24 hours? 2. In assessing the following elements, judge whether there was an appropriate notification, response and further evaluation process initiated within 4 hours for A -D and 24 hours for E -J. A. Medication 1) Polypharmacy (more than 7 drugs) 2) Drug regime review 3) Drug renewal 4) Prescribed administration 5) Errors B. Vital Signs 1) Temperature of 101'F oral (102'rectal) 2) B.P. ( 85 or > 180 systolic or c 50 or > 110 diastolic. 3) Pulse ( 50 (45 if the patient is on a beta blocker), or > 120. C. Fall with injury or untoward effect D. Indication of an infection following an invasive procedure E. Hydration and nutrition F. Sudden onset of confusion or change of mental status. G. Mobility 1) Decrease in ADL 2) New Contractures 3) Ability to transfer H. Pressure Sores I. Inappropriate use of restraints J. Elimination 1) Change in continence 2) Change in urinary output 3) Diarrhea or constipation IV -42 .Page 2 3. Abnormal results of diagnostic services addressed and resolved or the record explains why they are unresolved. 4. If appropriate, were the following disciplines addressed by an assessment, plan of care, ongoing evaluation and discharge plan? A. O.T. B. P.T. C. S.T. D. Social Service E. Physician F. Nursing G. Dietary Care 5. Deaths following transfer to hospital as ascertained from the hospital record. 6. In the judgment of the professional reviewer, are there any other events /patterns of care that resulted in adverse outcomes that should be evaluated? No Yes Explain IV -43 00 P7 a O O � 1 7 n T u w W C1 C 'M L 7 Z V r r N W Z J W O N W W OL N H J Ci u M W Z Y Y H 7 O M O > V V t d C V F C 49 C t IV -44 L W 4'uA N a01 A L W •� r •.• 11��}1 r p lW. `•Y r Y.L Y q r p y LLO'N M a Y Y w Q 41 W • •� W A r 1� C C O CIW Lp� V c H• O. a+ -� CL 0.ZA %--'a 34 >4 O. OA I.000.^ YLL �dlp L A Cr. W 41 Y O I E �P -0 ..N. m N 7 >•�t pCa1A W +•� W WV WL 74" W> >� .Ca1O w J Lo C41 W 0' V r• Op r- w o.W� 'L • A C Jt N W W L •� Y O L O A 4- O.O C a61A 41 O. a1 NN a+EO +I W oY. —3 w O. O C W N O. p••� O >1 L W CIO O Y - --a NOM N•�01.GNN •O. L•..p NAWL 3AA N a1 Qlbi C 344 C a A N O..0 W 0 0 a+ 41 W C O O.•� s A s O A >� A +� ++ t I. L C, 41 L •- > W p O. #A • A N O W A •� p L .� ..• 7 p C 10 O. a1 A ++!►• u L> O C W W ++ i O N •.• O A W � L •:I4 Q. S V o L�'> W dsi L'>'N CM 0 IL LY A W L >�WwC WO. YL O. NY •- dCWLLU W• fl Al NY. 41 CYY 4W OM W OO O I� •- > C •- i 41 41. rr N — C .0 N O.Vfa1O L CMCIW NN C Y O•�O.L .0 O. 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L O N •r W O� + O r W O m6N w LA�C W OCa c p W w 06 WL •r A OV 41 W > d L C C l N v 11 C L L N A W O. V L W W W 2p N 1 • A ZA aN ei�0 !►OI ON O •r ON u O. c W W A W L r > OuL . �NPvN't i N •C N C O N - •. L O L L L L O.p p O• .—a; O O. O A CjNwip Q. L6 ••N> MW t Q iIf u N N N IV -44 ci us c N w o- el L 1111 C i►.+ Cc w. c w 1 v l 34 V- -j a•r L 1 M 01C rCWM Y Y 0.4-42 j_ ` L aA N 7L�Y t C O+'!L IL Ca w O «. H OCr Y r. •.. L• w•r ws 01Y A++ N A Cd v 7 rC rN�Y N> L O w N•r u O �r w L •7 A Y — A 7 G O L GO t••7w Y O M •rr C .0 N G Y w C C• O O C Y 01 Y OL YYO G LO.WY 7 L M Aa 7LN 0 AMC !r! O ++ Y O► N r OA O a w.0 C Y LL aa4+•�r -Y 7 r !� ++ �t L a Aa00 L .2 •r 0 •A �+O YaN y. . 7 L L•• G w i L L Y ••- • Y OI N •.- •� O •r u L p r C Q. r A O L• 6 L7 Y A g L L O > Y -r C rM- •rr .O L L 44', C M c Cy •r YNY j a> 41 OYWL•r 7 a OM Y 7 dY A N a C7 G .OYltr N >.L G Y. N N L••- 7 O N A Y wa Aw w •W r ■ •w r NNY Or •r 0 A 4sM N�- +jYY NO C C N L i aa N a L N r YY2 YCY L L w A N O T •L ' r Y 1NwO• Yw Y y Y C Y t •rr OO rNY C Y CwrJ0 •w N C 9 Y Y �•- Y ■w L L 2 N a w t 0•• 1 _ �• L C LLw C O OO O r C �O Y NY wL0 Nr Y + �wA w . o G` Y C w w w Y Y.— CC 7 J w w+a� 7v PO • A 7 Nw G L O CO C O T •�YA ' Y r•+ -�ua Lw a LLwL O a a73 C Y N o \ N soL YN c C oL• Yw Y >%O Y YY r A L7 wC Nw G — CYN a www C 2CNC r •.- 7 Y r Y L O C N O O C N V Y7— r- Y••r N " Y Y A+ MV O a L A wT xaY uwWOL O A7 a C W.". Y L Y L N Y9w O L C OA L L Yw• . W Y 0 z Y L C N01 L N 0.04- O G7 N O N GL a Y z CL Aft x C V 7. N C L r a r7 w L O Ly L L 7► L Ot a OL L Y � W fa Y Y 010 Y46r cLYw0L L Z G L O Z GV 3 N J+ w a•r L•r u C 0- 1N N N D O A Y O o •N dL w •• Y C V 41— L G a N N OY O O L N C Y•r r N Y Y 9 Y L Y ' , 10 Y rrr-� A r ssI C T GA V G -c A. . O N 09 us c N w o- d. L C w. u G O V- -j M L L O Y aY i �y w O «. H 7 O C G •N N •� M N Y C M O L M N N L O L N N Y N V O Y. C L M Aa am O Y A h ti Z Y L Y w O L Cw Y C ar C >4V a Gi C a,u Go 60 A GY OI M L Y 11 o •rA •rAL •TALC COIY �. OW W Cm LC Y•.- YL YL •r 41 G= Y C N 7 L N O U N L 7 Y N •r Y N O •r Y C NL O •r NL O L r G C Y N N N 7AV Y L ?�N a,w •.• !►w— a• V L y L YL rY L L w C wC 'A'O LL y L O - 77 G G •a G -A W V _ �• 01w N L N Nw Nwr •r L N •Y w O aw -o •Y -Yr -Yr a -Y O N 7 J L L L M Nw 4; O Nw O•-• N•r N+► Y 'LO A Y N Y O YON Y O N w• Y 111 N Y O OC OLC O r •.- CAY ar OC C A O C N O O C N V O C N Y — C Ga C N N " •W -w NY MV N ..- MY NL Y••- L Y L Y L N Y L NO. Y N•r Y L MOf W NYG NNO N01 M017 N019 UIwN L z TY L O L O L L O Ly L L 7► L Ot O 7 L W fa L O L O. C Qr 7L d Z GL L Z G L O Z GV O Z Gus Z GG Z G C O c N w o- d. L C w. u G O w eYs V O �y 16 i N Y O CL •c Z z N A Z am te to ; c Y. C L M Aa C O c N d. L C w. u G O w V O �y 16 O CL •c V V N am te to ; c Y. C JON I O L 7 Cc O L ^ oa s.°+ #A ua ac o Y we ce ICi N •crw r r O L YYc • cc O C Y GN 0101 w LuN IIC4 L. CC LL 7 a 7 V Y 40 41 AaYu W V Z NL 7c d cW W O — N N N N N N IV -45 N9 w O !rf y r V W a 01 c N L Z V r Y H W Z M J W O N Z W W O: V N H J u OL Z LAJ W J •\ N 1ri!% Y cc 1 Ct7C NL - Y 4A 170 C 1 7 Y ]L a Y 1- ++ r• 0 7 C Y M a 3%.- A L W O + "a LO V 3 C7 !#0 tYO C YN • O • $- L A O Y � Y .! O a r+ r+ 7 0 N N - i L Y> C c 0 r L N ►• D YC O- A C4 \ O YY7c r► L YY . � r ► V q wtt a L N LO CO 7 L O r r •% L YCSri + dL C A Y YC wY • C Y 1 du O Y t • Y CZ .- .61 304 L Y X N •�L C W u Y M Vr+YA C 7 A• -N+t Y N • �+ 440 A NrC Oa•L Y L C 7 SO "A 06 t L N ,.a wr+• C rN ir 0I dY 00 0 Nq Y++O u 01Y>OC•U O O L 0 0 A 0'M V. q j r+ Y C N !► a a a a V u 0++0 7 N Y Y Cr• - N C Y N rr• C.0 d •+ dq Y N Vt ,at 7Yt•- OOa >r+CN W—c Y A YCL I-V �Mr C ` A ••M >4 2040 .+ G S.� a AM co YjaY OqC Y•- fa1 0a•- L .m O t !, N t r• .0 C 0' d a Y +•� •� 0 C r• YA N a 4040 d N 0.2 V N d++ 0•. r L C ■ O !6A N 40 Yi OL i + N a r Ct d u 0 c Yd 0 L r• AA d N N C Y r1 Y r+ r+ 0 u N L N L or 40 -4000 L. AYtaq a%- C O Y7 > V OL Y r L Y Lr+,tr+YYO Na r•t j00 7 Olr Cat C 09 Y Y 3• W A ♦+ Cc r V L aCIO r+YN Zt aW&1 1.c Z Y iO r0rY! rC + t • -j r C Nrd Y a4+ad+•- O 7 co L Z L rPr a a L L L u 3, r•r•t C Nwr Y O .0 O Y ON j a ar•wY OriaVe +a O ONCa w O uN N • wY- +r•Nr• 440E M •01 g}L r�MY!►O'A Y r•CCYL r u C !►L Y O !+Y• 1. ur• Yr•r Y N r• O Y O d A u*9- .YZ •uL NO Cr• 8. W*. NY .UCY •jr1a Yr+•- 2++O7!+C+�• rY.Ya 7 r ON L .W 40 N V W C Y L Y V•7 u C777 da V do N C00160 .A'Aa•- • OY•••.•AACQ Lu OA r 7� YOC++d�04NNUY O: >.0 a� GY d Y Cr Y N s Y Nrr• O MOIL. A N L YW 0 C.7 Y O d.0 N Y •- u •t Y N 0 c Y\ V da q 44 C Y7 Vw N a.,.= L Y•.• NMar Y O Y 44 r E L O N YZ7 Y 0 Y i a Y YLt Yr a .CL• .CAC{. 9 t7r OCrr�r�ACNL F• Cr+4644 !-M i-uA a ra .rr N 7 A YrNA •?? u .+ a • —4, N cm c L AaLT. r.•N7 L L Y fl Cr• C O O L V OL N Gu Y d ++ !► N 0 'W c N Y .0 Y r r 3%0 dYrr L C Ol a a q L O1L a• L u V LA •LO V9NNA r •� CL t Y A Y Y •` Y r+VL NOLN ■ ■ C7 V L7 L( C O Z Z O N a c d• iA Vf N N •r i► q Y Nr• a N d • L CL Y Y L, L L0 YaN L L N' 0.21 L* .W Y r+ JL.OY Z+=+CM W W Y C C O q r .- r• M Y Y70d N o Z C GCp Z Z Yd Q. Y X i r• we 4040 N Y a r - -N.CYY prr7r Y L N!•. L 17 1 1 A Lm / Y O C Y C V Y c A Y 7 q g N c 4 t c o� w•- N Y 40 _a r� q� L Ol 7YL Y - NEQtq YCL CN ZL.Jriva x L L YYNCZ • - •- A qL r+0Ca00 W W7YA LCN• - u #A -W L. to 3 W Or• O 7 .L Y •- Y O N 314 S. Y V u W Y! ++ A &P 34 jrNO1•- L7•- - N O• Y Y> N Y dN C9 a' Ola > Y UI Y r�NLt a0 C +�YLLL I u 7 • r N• C L Y a Y Y u +r N C C WY. 47 No qi L u >d N •- 7 3% a- A Y a O r r► 7 N to Y> 6 c •L 7 L r rr o%. a7 Y LL! j 24AC a r-a 7C O - Y Y r• d Ofia u 0 • O w 1 0 .. C 0 r N O 0V O c •- F• F• F- u %► •- ".- C &R.- O qf� f u Y•C > L•-7 r•." O Q, Y O a Od1/fN d N N N a c L Y N L7 N LG. L Ar• d0 N 0n• lu; t O t Y Y Y Y I Or r O ar N Cr• C +.fit r+w Lr+Yr+ C N7 Q, 4A r Eva A asmC.1G q O Yr+r• a I O C X Y �• O Lr• >r Y O C Lt a 0t O CAYL r+w.0 dYd Or+ wdMdNr+ Z A 14 �O IV -46 1 • Generic Quality Screens - Outpatient Surgery 1. Adequacy of pre - operative assessment *a. Appropriate and timely history and physical examination completed and results in chart /record, with evaluation note by the operating surgeon, the note is to include information about the operative site. b. Laboratory, EKG and xrays (necessary /relevant for the procedure being performed) completed with reports available at the time of surgery. *c. Vital signs taken and recorded prior to surgery. d. Abnormal results or diagnostic services, vital signs, addressed and resolved or the record explains why they are unresolved. 2. Appropriate and timely interventions during surgery for significant and sustained deviations or adequate explanation. a) BP b) Pulse c) Respiratory difficulty and /or decrease in PO-2 d) Blood loss e) Abnormal temperature 3. Issues related to the provision of post- operative care a) Absence of temperature elevation 101 degrees oral (rectal 102 degrees). b) Absence of BP reading of less than 85 or greater than 180 systolic or less than 50 or greater than 110 diastolic without intervention/ c) Absence of pulse less than 50 (or 45 if the patient is on a beta blocker), or greater than 120 without interventions. d) Absence of Respiratory difficulty or observance of hypoxia. e) No Abnormal bloody drainage from wound. f) No serious life - threatening complications as a result of Inadequate care. g) No major adverse drug reactions or medication error. h) No Significant change in mental status. *4. Appropriate documented discharge plan with provisions for follow -up care. *5. Adequate patient education. IV -47 SEVERITY LEVEL WEIGHT c C', ATTACHMENT B SEVERITY LEVELS AND WEIGHTED SEVERITY SCORES Severity Level #1 - Definition: A quality problem where there is no potential for significant harm and no significant adverse outcome occurred due to quality problems. Severity Level #2 - Definition: A quality problem exists when there is potential for significant harm but there was no serious adverse outcome due to the quality problem. Severity Level #3 - Definition: A quality problem exists when there is both potential for serious harm and a serious adverse outcome resulted from the quality problem. Level I 1 Level II 5 Level III 25 CFMC EFF: 4/1/89 I• CONFIDENTIALITY POLICY COLORADO FOUNDATION FOR MEDICAL CARE INTRODUCTION ATTACHMENT C The purpose of the Data and Information System operated by the Colorado Foundation for Medical Care /CFMC is to supply the Foundation and other organizations within its patient care review system the information needed to.assess patient care in Colorado. To satisfy these objectives, the system collects, stores, analyzes and reports information which relates to: 1) the efficient operation and management of the review system 2) the description and evaluation of the effect of the review system on the quality of medical care, and 3) the description and evaluation of the effect of the review system on the utilization of services and facilities used to provide that care. The operation of this information system requires the collection and storage of sensitive data about individual patients, health care practitioners and health care facilities. The purpose of this plan is to describe the policies by which the CFMC guards the security and confidentiality of this sensitive information for the protection of the individuals and institutions from which these data are gathered. The plan includes the CFMC policy in eight specific areas: A. Limitation on Data Acquisition (Collection) and Storage B. Structure and Operation of the Confidentiality System C. Public Knowledge of the Data System D. Provisions for Access to Personal Data E. Access to Information by Those Within the CFMC Review System F. General Policy on Disclosure Outside the CFMC Review System G. Release of Public data H. Release of Private data Page l of 6 4/17/85 H. CMFC Deliberations Internal CFMC discussions pertaining to review or sanctions, predenial letters and correspondence from the attending physician to the physician advisor regarding predenial letters, and minutes of meetings, notes, comments, or other forms of recording. I. Public Data and Information Any data collected by the CFMC in compliance with its contractual agreements with the federal or state governments. J. Private Data and Information Any data collected by the CFMC in compliance with it's private contractual agreements. K. Sanction Proceedings Procedures under Section 1157 and 1160 of the Social Security Act, for Imposition of Sanctions Upon Care Providers. L. Contracting Agencies Any federal, state, or private agencies, organizations, or businesses with whom CFMC contracts. M. CFMC Business The performance of review, monitoring, evaluation and other activities related to contractual or administrative functions of the Foundation. POLICY The following is the Colorado Foundation for Medical Care Confidentiality Policy as approved by the Board of Directors. Maintenance of procedures to implement this policy is the duty of the Foundation staff with the concurrence of the CFMC Data Security Officer or his designee. A. Limitation on Data Acquisition (Collection) and Storage 1. The CFMC or any agent, organization or institution acting on its behalf as a collector, processor and /or reviewer of information shall limit the collection of data and information to that deemed reasonably necessary or desirable for the purpose of performing CFMC business. 2. Protection of Data Systems must be established to prevent unauthorized access to CFMC data. Page 3 of 6 4/17/85 D. E. F. Provisions for Access to Personal Data 1. Health Care Providers To Their Own Records Subject to restrictions on disclosure of CFMC deliberations, health care providers must be allowed access to, and receive copies of their individual CFMC data and information. 2. Patient Access to One's Own Records Subject to restrictions on disclosure of CFMC deliberations and to state and federal law, a patient or his legally designated representative must be allowed access, upon request, to his /her own CFMC data and information. When a patient requests access to CFMC data and information, the physician of record must be notified in writing at least fifteen working days prior to patient access. The patient will not be required to obtain physican authorization to gain access to his individual CFMC data and information nor can the physician prevent patient access to the data and information, except as provided for by federal and state law. However, if upon receiving notification of intended patient access, a physician of record objects to the release of such information without clarification, the CFMC must provide his clarification along with the information if provided by the date of release. Access to Information by Those Within the CFMC Review System 1. Limitation on Data Access Each component of the CFMC Review System will have access only to that CFMC information and data necessary to carry out its functions within the System. 2. Authorized Access: Requirements An individual officer or employee of a component of the CFMC Review System may not be authorized access to confidential CFMC data and information until that individual: a. has completed the CFMC training program in the handling of such data and information pursuant to paragraph B.4 above, and, b. has signed a CFMC attestation statement. General policy on Disclosure Outside the CFMC Review System 1. Disclosure to Contracting Agencies Contracting agencies shall have access to all data generated pertinent to their contract. Page 5 of 6 4/17/85 ATTACHMENT D Colorado .Foundation for AN IMPORTANT MESSAGE TO MEDICARE BENEFICIARIES Medical Care The Omnibus Reconciliation Act (OBRA) Sections 9353 (c and e) Bldg. 2 Suite 400 requires a review of all written complaints from Medicare 6825 E. Tennessee Ave. beneficiaries about the quality of care they have received. Mailing Address: P.O. Box 17300 Denver, Colorado W217 These complaints about the quality of care can be in hospitals, skilled nursing facilities, hospital outpatient departments, (303) 321 - 8642 ambulatory surgery centers or home health agencies. This review is to be carried out by Peer Review Organizations. Peer Review Organizations (PROs) are groups of doctors who are paid by the Federal Government. Peer Review Organizations will respond to your request and inform you of the outcome of that review and any corrective action taken. If you have a complaint about the quality of care you have received as a Medicare beneficiary, place your complaint in writing and send to: COLORADO FOUNDATION FOR MEDICAL CARE ATTENTION: REVIEW OPERATIONS P.O. BOX 17300 DENVER, COLORADO 80217 If you have questions regarding payment of your bill, charges on your bill or questions about whether services are paid by Medicare, they should be directed to: BLUE CROSS AND BLUE SHIELD OF COLORADO MEDICARE PROVIDER UNIT 700 BROADWAY STREET DENVER, COLORADO 80273