Hospital Panel Says Major Issues Remain at Alta Bates By RICHARD BRENNEMAN

Friday August 12, 2005

Though the shaky accreditation status of the Alta Bates-Summit hospitals has been upgraded one level, the hospitals have a lot to do before they can win a clean bill of health. 

That’s the word Thursday from JCAHO—the Joint Commission on Accreditation of Hospital Organizations. 

Without accreditation by the private agency, the Alta Bates-Summit hospitals in Berkeley and Oakland can’t received federal payments for treating Medicare and Medicaid patients, often a big share of hospital revenues. 

In a survey released in November, JCAHO issued a preliminary denial of accreditation, which placed the hospitals on notice that they would lose accreditation unless major changes were made. 

In a review released earlier this month, the organization raised the hospitals’ status to conditional approval. 

“The Joint Commission will conduct a special follow-up survey in four to six months,” said JCAHO spokesperson Mark Forstneger. “The report will be issued two to four weeks after the survey is completed.” 

While JCAHO ruled that the hospital had corrected four of the deficiencies uncovered in the 2004 survey, they said the majority of findings had still not been corrected. 

The unresolved issues include insuring that: 

• Patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital. 

• Informed consent is obtained. 

• Patient-specific information is readily accessible to those involved in the medication management system. 

• Medications are properly and safely stored throughout the organization. 

• Medication orders are written clearly and transcribed accurately.  

• All prescriptions or medication orders are reviewed for appropriateness.  

• The hospital responds appropriately to actual or potential adverse drug events and medication errors. 

• The hospital defines in writing the time frame(s) for conducting the initial assessment(s). 

• Any use of restraint is initiated pursuant to either an individual order or an approved protocol, the use of which is authorized by an individual order. 

• Operative or other procedures and/or the administration of moderate or deep sedation or anesthesia are planned.  

• The hospital takes action to prevent or reduce the risk of nosocomial (hospital caused) infections in patients, staff, and those who come into the organization. 

• The hospital has a complete and accurate medical record for every patient assessed or treated. 

• Designated qualified personnel accept and transcribe verbal orders from authorized individuals. 

In the case of long-term care patients, the hospitals must insure: 

• The resident receives education and training specific to the resident's needs and as appropriate to the care, treatment, and services provided.  

• Pain is assessed in all long-term care residents. 

The four allegations removed last Friday were: 

• Managing drugs returned to the hospitals’ pharmacies. 

• Assessing pain in all short-term care patients. 

• Developing plans for the care, treatment and provision of services in accordance with the patient’s needs, strengths, limitations, goals, and 

• Placing time limits on verbal or written orders to restrain or isolate patients.›