Hospital Regulatory Issues

Bud PateDirector of West Coast Operations

Hospital Regulatory Considerations

State Department of Health / Licensing CMS Conditions of Participation Accreditation Rules

State DHS

The Bad News Regulations are incomplete, dated and inflexible

The Good News There’s a “get out of jail free” card: Title 22 sections 70741

and 70737

22 CCR 70741: Disaster and Mass Casualty Program

This section provides a mechanism for the planned and appropriate use of staff and space for the unusual situation

If appropriately written and implemented (with notification to DHS via 70737), the DMC / Emergency Preparedness plan allows the hospital to do what is necessary while maintaining continuous compliance with the regulations.

Is Approval Necessary?

No, just notification. 22 CCR 70737

However, communication (and the approach to communication) should be excellent and ongoing Refer to mass casualty program

Remember to notify CMS if: Overflow into distinct part: e.g. SNF or Rehabilitation Unit. Keep track of beginning and end

Expectations for the Disaster and Mass Casualty Program

Best reference is JCAHO … post-Katrina update to standards

Incident Command

Define Overflow locations Separation of flow Temporary / volunteer staffing

JCAHO July 1, 200

HR.1.35 Non-LIP Volunteers MS.4.110 LIP Volunteer EC.4.10 Drills