1992-176-Town Manager To Sign Agreement With Community Hospital Of Los Gatos For Worker's Compensation Hospital ServicesRESOLUTION 1992 -176
RESOLUTION OF THE TOWN OF LOS GATOS
AUTHORIZING THE TOWN MANAGER TO SIGN AN
AGREEMENT WITH COMMUNITY HOSPITAL OF LOS GATOS
FOR WORKER'S COMPENSATION HOSPITAL SERVICES
RESOLVED, by the Town Council of the Town of Los Gatos, County of Santa
Clara, State of California, that the Town of Los Gatos enter into an agreement with
Community Hospital of Los Gatos for Workers' Compensation Hospital services on the
terms and conditions outlined in attached Exhibit A, and that the Town Manager is
authorized, and is hereby directed, to execute said agreement in the name and on behalf
of the Town of Los Gatos.
PASSED AND ADOPTED at a regular meeting of the Town Council of the
Town of Los Gatos, California, held on the 21st day of September, 1992 by the following
vote:
COUNCIL MEMBERS:
AYES: Randy Attaway, Steven Blanton, Brent N. Ventura
Mayor Eric D. Carlson
NAYES: None
ABSENT: Joanne Benjamin
ABSTAIN: None
SIGNED: --
MAYOR OF THE TOWN OF LOS GATOS
LOS GATOS, CALIFORNIA
ATTEST: �}
CLERK OF THE TOWN OF LOS GATOS
LOS GATOS, CALIFORNIA
,_ t 1 ___ ,e11
4V.�. CONWUTNITY HOSPITAL cx AG i -:: _a-
REHABILITATION CENTER
HOSPITAL SERVICES AGREEMENT
by and between
Community Hospital and Rehabilitation Center
of Los Gatos- Saratoga
(HOSPITAL)
and
The Town of Los Gatos
(EMPLOYER)
This Agreement is entered into this 1st day of September
1992 , by and between the Town of Los Gatos (hereafter
"EMPLOYER ") and NME Hospitals, Inc., a Delaware Corporation,
doing business as Los Gatos Community Hospital and Rehabilitation
Center (hereafter "HOSPITAL ").
WHEREAS, EMPLOYER wishes to create an exclusive
relationship with a local hospital to provide Worker's
Compensation services to its employees, which will
agree to comply with the reimbursement mechanisms
established, and which will participate in and comply
with the policies and procedures which may be adopted
from time to time by it; and
WHEREAS, HOSPITAL wishes to enter into an
agreement with EMPLOYER to offer Worker's Compensation
services to its employees by rendering the Covered
Hospital Services as set forth in this Agreement; and
WHEREAS, HOSPITAL desires, to the extent feasible,
to utilize such cost containment methods and practices
as are consistent with sound medical practice and in
compliance with Worker's Compensation laws in the State
of Missouri for rendering medical care;
NOW, THEREFORE, in consideration of the premises
and mutual covenants herein contained and other good
and valuable consideration, the sufficiency of which is
hereby acknowledged, EMPLOYER and HOSPITAL agree as
follows:
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815 Pollard Road, Los Gatos, CA 95030
(408) 378 -6131
A National Medical Enterprises Facility
I. Definitions
1.1. Beneficiary means those employees, contractors, or
subcontractors who are covered by EMPLOYER's Worker's
Compensation insurance.
1.2. Covered Hospital Services shall mean all outpatient and
inpatient services provided by HOSPITAL to a
Beneficiary for which a Payor is obligated to pay or
reimburse pursuant to EMPLOYER's Worker's Compensation
insurance.
1.3. Emergency Services means those Covered Hospital
Services provided to a Beneficiary by HOSPITAL in any
situation in which Hospital services are immediately
necessary in order to sustain a person's life, or to
prevent pain, serious permanent disfigurement or loss
or impairment of the function of a bodily organ, or to
provide care for a woman in active labor.
1.4. Employee means contractors, sub - contractors, and
employees who would be covered under Employer's
Worker's Compensation coverage.
1.5. Inpatient Services means the following acute care
services, excluding extended care, which are normally
provided by HOSPITAL to Beneficiaries when rendered in
accordance with the covered benefits under a Worker's
Compensation insurance benefit plan:
a. Bed and board;
b. Medical, nursing, surgical, pharmacy, and dietary
services;
C. All diagnostic and therapeutic services required
by the Beneficiary and physician services which
are normally billed by HOSPITAL;
d. Use of Hospital facilities, medical and social
services furnished by HOSPITAL, and such drugs,
biologicals, supplies, appliances and equipment as
are required by the Beneficiary and ordered by the
attending physician.
1.6. Medically Necessary means services or supplies
furnished by a Provider which, under the provisions of
this Agreement, are determined to be appropriate and
necessary for the symptoms, diagnosis or treatment of
the medical conditions and within the standards of good
medical practice within the organized medical
community.
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1.7. Outpatient services means all Covered Hospital Services
other than Inpatient Services.
1.8. Pa or means The Town of Los Gatos as a self- funded
employer, its trust funds, insurance carriers, or any
other entity which has an obligation to pay for medical
services or benefits given to a beneficiary of The Town
of Los Gatos or who has contracted with EMPLOYER to use
HOSPITAL.
1.9. Provider means a physician, hospital or licensed health
professional, practitioner, or facility which has
entered into a written agreement with EMPLOYER to
participate in an exclusive arrangement to provide
medical care as established by EMPLOYER and to comply
with the State of Missouri Worker's Compensation laws,
and the reimbursement mechanisms and the utilization
review procedures established by EMPLOYER.
II. HOSPITAL's Obligations
2.1. Licensing: HOSPITAL warrants that it is licensed as a
general hospital in the State of Missouri, that it is
currently certified as a hospital provider under Title
XVIII (Medicare) of the Social Security Act and is
accredited by the Joint Commission on Accreditation of
Health Care Organizations as a hospital and that it
will maintain said certifications or accreditations,
and all other licenses required by law, during the term
of this Agreement. Evidence of such licenses,
certificates, and accreditations shall be submitted to
EMPLOYER upon request.
HOSPITAL shall promptly notify EMPLOYER in writing of
any action against any of its licenses, its
accreditation by the JCAHO, any change of ownership or
business address, any substantial change in the type of
inpatient or outpatient services provided by HOSPITAL
or in the number of licensed beds or any other problem
or situation that could materially impair the ability
of HOSPITAL to carry out the duties and obligations of
this Agreement.
2.2. Medical Staff: Physicians admitting Beneficiaries to
HOSPITAL must be members in good standing of the
Hospital Medical Staff and will be subject to all
Hospital Medical Staff rules and regulations including,
without limitation, Hospital's quality assurance review
program. HOSPITAL shall not discriminate against
Medical Staff and its members or applicants for Medical
Staff membership because of participation in this
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Agreement as a Provider. It is expressly understood by
the parties hereto that HOSPITAL has the sole and
exclusive responsibility for all Medical Staff
membership determinations, and that EMPLOYER, or any
other entity, in no way participates and /or controls
the Medical Staff decision making process.
2.3. Non - Discrimination: HOSPITAL agrees to provide
hospital services presently available at Hospital to
Beneficiaries in the same manner Hospital provides such
services to all of its other patients.
2.4. Compliance with EMPLOYER Programs: HOSPITAL agrees to
comply with EMPLOYER's eligibility, verification,
authorization and utilization review programs. These
programs shall be administered in accordance with the
policies set forth in EXHIBIT B.
III. EMPLOYER'S Obligations
3.1. verification of Eligibility: EMPLOYER will provide
Beneficiaries with appropriate identification
indicating they are Wire Rope employees and do have
authorization for Worker's Compensation services to be
rendered. If there is any error by EMPLOYER in
verification of eligibility or authorization of
services which results in HOSPITAL providing covered
services to ineligible patients or non - covered services
to eligible patients then EMPLOYER shall be obligated
to pay HOSPITAL for any such hospital services
provided.
3.2. Use of HOSPITAL's Name: EMPLOYER may use HOSPITAL's
name and address in publications for participants in
order to identify participating providers of health
care services. EMPLOYER is not authorized to use
HOSPITAL's name for advertising or any other purpose
without HOSPITAL's prior written consent.
3.3. Non - Intervention: EMPLOYER agrees that it shall not
intervene in any way or manner with the rendition of
services by HOSPITAL, it being understood and agreed
that the traditional relationship between hospital and
patient, as well as physician and patient and physician
and hospital, will be maintained.
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IV. Reimbursement
4.1. Late Payment: EMPLOYER agrees to pay HOSPITAL the
amount set forth in EXHIBIT A for Covered Services
rendered to Beneficiaries, less applicable copayments
and deductibles and coordination of benefits, within no
more than thirty (30) days of receipt of claims
submitted by HOSPITAL. If any such claims are not paid
within thirty (30) days of receipt, such claims shall
revert to usual and customary charges and thereafter
shall incur a monthly penalty of one and one half
(1 -1/2) percent until paid.
4.2. Coordination of Benefits• If EMPLOYER is primary under
the applicable coordination of benefits rules, EMPLOYER
shall pay HOSPITAL only the fees required under this
Agreement, provided however, that if HOSPITAL obtains
any additional payments from secondary Payor under the
applicable coordination of benefits rules, HOSPITAL
shall be entitled to keep such additional funds. If
EMPLOYER is other than primary under the coordination
of benefits rules, EMPLOYER shall pay HOSPITAL only
those amounts which, when added to amounts owed to
HOSPITAL from other sources, equals the fees required
under this Agreement. Nothing contained
herein shall restrict or otherwise affect HOSPITAL's
right to seek to recover its usual and customary
charges from third party payor other than the EMPLOYER.
V. Medical Records
5.1. Maintenance: HOSPITAL agrees to maintain its usual and
customary medical records, at least in accordance with
all applicable federal and state statutory and
regulatory requirements, for each Beneficiary in the
same manner as for other HOSPITAL patients.
5.2. Access: HOSPITAL shall provide EMPLOYER and any duly
designated third party with access, upon 48 hours prior
notice during customary business hours, to patient
records relating to payments, claims and services of
Beneficiaries maintained by HOSPITAL during the term of
this Agreement, and thereafter, for a period in
conformance with state law after the termination of
this Agreement, and at any time thereafter that such
access is required in connection with a patient's
medical care. Any duplication of records shall be the
financial responsibility of EMPLOYER.
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5.3. Confidentiality HOSPITAL and EMPLOYER agree that
information concerning patients shall be kept
confidential and shall not be disclosed to any person
except as authorized by law. This confidentiality
provision shall remain in effect notwithstanding any
subsequent termination of this Agreement.
5.4. Hospital Proper EMPLOYER acknowledges that the
medical records of Hospital shall remain the property
of HOSPITAL and shall not be removed or transferred
from HOSPITAL except in accordance with applicable laws
and general HOSPITAL policies, rules and regulations
relating thereto.
VI. Insurance and Indemnification
6.1. Insurance: HOSPITAL, at its sole cost and expense,
shall purchase professional liability insurance in the
amount of no less than One
Million Dollars ($1,000,000) for each claim and Three
Million Dollars ($3,000,000) aggregate, to be effective
no later than the effective date of this Agreement and
to remain in effect thereafter until the termination of
this Agreement. HOSPITAL shall provide to the Town all
certificates of insurance, with original endorsements
affecting coverage. HOSPITAL agrees that all
certificates and endorsements are to be received and
approved by the Town before work commences.
Additionally, HOSPITAL shall notify EMPLOYER in writing
no less than thirty (30) days prior to any
modifications, cancellations, or terminations of any
such insurance coverage for any reason whatsoever.
(a). The Town, its officers, officials, employees,
commissions and boards, and volunteers are to be
covered as insureds under HOSPITAL's insurance as
respects liability arising out of activities
performed by or on behalf of the HOSPITAL.
(b). The HOSPITAL's insurance coverage shall be primary
insurance as respects the Town, its officers,
officials, employees, commissions and boards, and
volunteers, but only in respect to treatment
rendered to employees of the Town of Los Gatos
under this agreement. Any insurance or self -
insurance maintained by the Town, its officers,
officials, employees, or volunteers shall be
excess of the HOSPITAL's insurance and shall not
contribute with it.
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(c). Any failure to comply with the reporting
provisions of the policies shall not affect
coverage provided to the Town, its officers,
officials, employees, commissions or boards, or
volunteers.
(d). The HOSPITAL's insurance shall apply separately to
each insured against whom a claim is made or suit
is brought, except with respect to the limits of
the insurer's liability.
(e). All Coverages: Each insurance policy required in
this item shall be endorsed to state that coverage
shall not be suspended, voided, canceled, reduces
in coverage or in limits except after thirty (30)
days' prior written notice by certified ail,
return receipt requested, has been given to the
Town.
6.2. Indemnification: EMPLOYER shall be responsible for the
acts or omissions of its employees or agents which
result in, or are attributable to, any claims, losses
or damages including, without limitation, attorneys
fees and expenses, related to the performance of duties
under this Agreement. HOSPITAL shall be responsible
for the acts or omissions of its employees or agents
which result in, or are attributable to, any claims,
losses, or damages including, without limitation,
attorneys fees and expenses, related to the provision
of hospital services by HOSPITAL to eligible
beneficiaries under this Agreement. Each party will
indemnify and hold the other harmless for any such
losses. If this contract is terminated, the rights and
obligations of the parties regarding indemnification
under this paragraph shall survive the termination of
the contract regarding
any liability for acts or omissions which occurred
prior to the termination date.
VII. Term and Termination
7.1. Term: This Agreement will remain in effect from the
date hereof for a period of one (1) year, and shall
thereafter renew for additional one year periods unless
terminated according to the provisions of this Section
VII.
7.2. Rene otiation: Either party may request in writing
renegotiation of the rates in EXHIBIT A at least 30
days prior to the anniversary date of the contract and
10/05/92 Page 7
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annually thereafter. If new rates are agreed to after
the anniversary date of the Agreement, such new rates
shall be retroactive to the anniversary date.
7.3. Termination Without Cause: Either party may terminate
this Agreement without cause upon 30 days written
notice.
7.4. Termination With Cause: Either party may terminate
this Agreement for cause upon three (3) days written
notice if the other party breaches any material
provision of this Agreement. If during the term of
this Agreement, EMPLOYER or a Payor becomes insolvent,
files for bankruptcy, makes any assignments for benefit
of creditors, fails to promptly pay fees due to
HOSPITAL under this Agreement, or if HOSPITAL
determines in its sole discretion that EMPLOYER or a
Payor may become insolvent during the following twelve
month period, then HOSPITAL, upon twenty -four (24) days
written notice may terminate this Agreement with
respect to EMPLOYER or to that specific Payor.
7.5. Charges After Termination If any Beneficiary remains
in HOSPITAL on the termination date, EMPLOYER shall be
obligated to pay HOSPITAL for any services provided to
such beneficiary after the termination date at
HOSPITAL's usual and customary charges until such
beneficiary is discharged or transferred.
VIII. Notice
Any notice required to be given pursuant to the terms
and provisions of the Agreement shall be in writing and
shall be sent by certified mail, return receipt
requested.
Notice to EMPLOYER shall be sent to the following
address:
The Town of Los Gatos
110 East Main Street
Los Gatos CA 95032
ATTN: Carla Turner
(408) 354 -6829
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Notice to HOSPITAL shall be sent to the following
address:
815 Pollard Road
Los Gatos CA 95030
ATTN: Truman Gates
Chief Executive Officer
An additional copy of any notice should be sent to:
National Medical Enterprises, Inc.
2700 Colorado Street
PO Box 4070
Santa Monica, California 90404
ATTENTION: Health Plans Division
IX. General Provisions
9.1.
Operational Contact: The contact for operational
questions (billing, payment, eligibility, utilization
and approval) related to this contract is
and can be reached at:
(Company) Willis Carroon
(Address) P.O. Box 6030
(Phone)
ATTN:
Examiner
9.2. Non - Exclusivity: Nothing contained in this Agreement
shall preclude HOSPITAL from participating in or
contracting with any other preferred provider
organization, health maintenance organization, insurer
or otherwise, whether before, during, or subsequent to
this Agreement.
9.3. Arbitration: The parties agree to meet and confer in
good faith to resolve any problems or disputes that may
arise under this Agreement. If any arbitration or
litigation occurs between the parties regarding this
Agreement, the losing party shall pay the reasonable
attorney's fees and costs of the prevailing party.
9.4. Unforeseeable Events: In the event that the operations
Of HOSPITAL's facilities are substantially interrupted
by an act of war, fire, insurrection, strike, riots,
earthquakes or other acts of nature of any cause that
is not the fault of HOSPITAL or is beyond the
reasonable control of HOSPITAL, HOSPITAL shall be
relieved of its obligations only as to those affected
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operations and only as to those affected portions of
this Agreement for the duration of such interruption.
9.5. Independent Contractors: The parties hereto are
independent contractors and are not joint venturers
with or employees of each other.
9.6. Assignment: Neither party may assign their rights or
obligations under this Agreement without the prior
written consent of the other party.
9.7. No Third Party .Beneficiaries: This Agreement is not a
third party beneficiary contract and shall not, in any
manner whatsoever, increase the rights of any
Beneficiary with respect to EMPLOYER or the duties of
EMPLOYER to any Beneficiary or create any rights on
behalf of Beneficiaries regarding HOSPITAL. EMPLOYER
and HOSPITAL reserve the right to amend or terminate
this Agreement as set forth herein without notice to,
or consent of, any such Beneficiary.
9.8. Governing Law: This Agreement shall be governed in all
respects by the laws of the state of Missouri.
9.9. Severability• If any provision of this Agreement is
held to be illegal, invalid or unenforceable under
present or future laws effective during the term
hereof, such provision shall be fully severable. This
Agreement shall be construed and enforced as if such
illegal, invalid or unenforceable provision had never
comprised a part hereof, and the remaining provisions
shall remain in full force and effect unaffected by
such severance, provided that the invalid provision is
not material to the overall purpose and operation of
this Agreement.
9.10. Waiver: The waiver by either party of any breach
of any provision of this Agreement or warranty or
representation herein set forth shall not be
construed as a waiver of any subsequent breach of
the same or any other provision. The failure to
exercise any right hereunder shall not operate as
a waiver of such right. All rights and remedies
provided for herein are cumulative.
9.11. Entire Agreement: This is the entire Agreement
between the parties and supersedes all prior
written or verbal agreements or negotiations
between the parties relating to the subject matter
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hereof. This Agreement may only be modified by a
written agreement signed by both parties.
Community Hospital and Rehabilitation Center (Hospital)
BY DATE: DATE: /O - /L -Q Z-
(signature
PRINTED: '-! ( idwta4A �,
/� e
TITLE: G (:� 10
The Town of Los Gatos (Employer)
BY' DATE:
(signature)
PRINTED: DAVID W. KNAPP
TITLE: TOWN MANAGER
APPROVED AS TO FORM:
KATHERINE ANDERTON, TOWN ATTORNEY
ATTEST:
MARIAN V. COSGROVE, TOWN CLERK
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Exhibit A: Reimbursement Schedule
The rates contained herein are effective September 1, 1992
and shall continue in effect until July 31, 1993. It is
understood that these fees are for hospital services only
and that no physician fee is included.
Inpatient Services:
Outpatient Services:
Medically- Necessary
Supplies
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95% of charges
85% of charges
85% of charges
Exhibit B: Utilization Review/OualitY Assurance Program
Attached
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Exhibit B: Utilization RevieW/Ouality Assurance Program
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COMMUNITY HOSPITAL AND REHABILITATION CENTER
LOS GATOS - SARATOGA
UTILIZATION REVIEW PLAN
AUTHORITY
The Utilization Review function is the responsibility of the Utilization
Review Committee that has been established as a standing committee of the
Medical Staff in accordance with the bylaws of the Medical Staff.
11. PURPOSE
The purposes of this committee are:
1. To assure effective and efficient utilization of the hospital's
facilities and services.
2. To assist in the promotion and maintenance of high quality care
through the analysis, review, and evaluation of clinical practices
within the hospital.
III. ORGANIZATION OF COMMITTEE
The physician members of the committee will be appointed by the chief of
staff. The committee will consist of at least eight (not less than 2)
physicians. As stipulated in the Medical Staff By -laws, the committee
will be composed of the following members: Representatives of the Depart-
ments of Pediatrics, OB /GYN, Medicine, Surgery, and General Practice, and
a member of the Orthopedic Subdepartment, and the Chairman of the Medical
Records Committee. In addition, the president of the Medical Staff shall
appoint a chairman who, in turn, may appoint other members of the attending
staff to the committee. Non - physician members may be appointed by the
Administrator with approval of the physician chairman and shall represent
Administration, Finance, Medical Records, DRG, Nursing Quality Assurance,
Social Services, and Discharge Planning Departments in the hospital. Other
non - physician health care practitioners may be asked to serve as consultants
to the committee in establishing criteria, standards, norms, and in a review
of cases in which they provided care.
The hospital will employ a Utilization Review Coordinator (URC), or identify
an employee who, under the supervision of the Utilization Review Committee,
has the responsibility for daily review coordination. This individual will
be a member of the UR Committee.
Any person who holds direct financial interest in the hospital will not be
eligible for appointment to the committee. No person will participate in
review of any case in which he has been professionally involved.
The Utilization Review Committee will document its activities with minutes
and will cooperate with the Quality Assurance Committee (or other appropriate
committee) by identifying areas of concern that the Quality Assurance
Committee (or other appropriate committee) might study.
A quorum of three physician members must be present at each monthly meeting.
IV. MEETINGS
The Utilization Review Committee will meet at least monthly, and more
frequently if deemed necessary by the chairman. The committee will determine ..
the time and place of the monthly meeting at its first regularly scheduled meeting
the year.
V. FUNCTIONS
The functions of the committee may be carried out by the whole committee, a
subcommittee, or by delegated agents, such as physician reviewers /advisors
and the Utilization Review Coordinator(s). These functions are:
A. To establish and carry out a program of concurrent review of all
patients. The source of payment shall not be the sole determinant
in identifying patients for concurrent review.
B. To supervise and review activities of the UR Coordinator.
C. To identify utilization related problems, including the appropriateness
and medical necessity of admissions, continued stays, and support
services, using at least the following data sources:
1. Profiles and reports from the hospital's data system.
2. Results of monitoring by Professional Review Organization (PRO)
3. Results of any studies conducted.
4. Case mix management reports.
S. Results of concurrent and retrospective utilization review as
documented in the minutes of this committee.
D. To address overutilization, undprutilization, and inefficient scheduling
of resources by using at least the following methods:
1. Review of extended lengths of stay.
2. Review of all readmissions and one day stays.
3. Identification and followup on delay of services.
E. To maintain close liaison with the Quality Assurance Committee:
1. To assure coordination between concurrent review activities and
patient care evaluation studies.
2. To assist in ongoing modification of criteria and standards
used in patient care evaluation studies.
F. To recommend changes in hospital procedures or medical staff practices
as indicated on analysis of review findings.
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VI. MET}iOD OF REVIEW
A. Introduction
1, The Utilization Review Committee will review the admissions
and continued stays of patients on a concurrent basis.
2. Concurrent review will be performed under the direction of the
Utilization Review Committee, utilizing non - physician review
coordinators and physician reviewer /advisors. ISD Screening
Criteria, approved by the committee, will be utilized in the
review process.
3. Decisions on medical questions will be made solely by physicia n
members of the Medical Staff. Non - physician members (e.g. dentist,
podiatrist) of the Medical Staff will review cases in which their
peers provide care.
4. The medical record will be the source document for conducting
utilization review. Certification of medical necessity will
be on -going and documented on the Physician Progress Record,
continuous Physician Progress Notes will be dated, authenticated
and of sufficient quality to permit the URC, the UR Committee
of the hospital and the PRO, if appropriate, to perform
monitoring.
B. Admission Review
1. Admission review will be conducted prior to admission, at
the time of admission or, on the first working day after
admission (a working day is considered all except Saturday,
Sunday and holidays) to determine medical necessity and
appropriateness of admission using the approved criteria
(see appended Flow Charts - PreAdmission and Admission Review'.
2. If necessary, the attending physician will be contacted for
additional information. All information used for determining
medical necessity must be documented in the medical record.
3. Cases not meeting both severity of illness and intensity of
service criteria will be referred on the same day to a
physician reviewer /advisor.
4. Physician advisor reviews and decisions will be made the same
day.
S. If the physician reviewer /advisor has reason to believe the
admission is not necessary, he will confer with the attending
physician and afford him an opportunity to present his views.
if the attending physician concurs, the patient will be
discharged.
-3-
6. If the attending physician does not concur with an adverse determination
made by the physician reviewer /advisor, the case will be referred to a
second physician reviewer /advisor. If this additional review indicates
justification for admission, the admission will be approved and the revie,
coordinator will assign the next review date. In all cases the attending
physician's judgement is given great weight.
7. If the two physician reviewers /advisors determine that an admission is
not medically necessary, the review coordinator will complete a written
denial of benefit notice. This denial notification will be distributed
within two working days of admission, to the patient and /or patient's
representative, the hospital, the state agency for Medicaid patients,
the attending physician and any other appropriate reviewing organization.
8. An attending physician who disagrees with the decision of both physician
reviewers /advisors with respect to denial of an admission, may retro-
spectively request a reconsideration of the decision from the Utilization
Review Committee at its next regularly scheduled meeting.
9. For Medicare Patients only:
If the attending physician disagrees with the decision of the two physician
reviewers /advisors, the URC will contact the appropriate PRO /Medical Review
Entity (MRE) for an immediate review of the case. If the PRO /MRE agrees
with the physician reviewers /advisors, a denial of benefits notification
will be given to the patient and /or patient representative, the attending
physician, the hospital, and the PRO /MRE. If the PRO /MRE does not agree
with the physician reviewers /advisors, the admission will be approved.
10. In all cases only a physician will make an adverse decision denying
admission approval.
11. All actions taken during admission review will be documented on the
coordinator's worksheet. This form will be kept in the review coordinator's
file after discharge of the patient.
C. Continued Stay Review
Continued stay review will be conducted every three days or sooner as
necessary. In no instance will the time lapse be more than seven days
(see Flow Chart - Continued Stay Review). All Medicare patients reaching
either cost outlier oP day outlier status will automatically be brought
into the concurrent review process at that time if not already under review.
- 4 -
2. Cases that no longer meet intensity of service and severity of
illness criteria or intensity of service alone will have discharge
review conducted immediately. (See flow chart - Discharge Review.)
3. Cases meeting discharge screens and not discharged will be referred
to a physician reviewer /advisor that same day.
4. If the physician reviewer /advisor has reason to believe the
continued stay is not necessary, he will confer with the attending
physician and afford him an opportunity to present his views. If
the attending physician concurs, he will discharge the patient.
5. If the attending physician does not concur with an adverse
determination made by the physician reviewer /advisor, the case will
be referred to a second physician reviewer /advisor. If this
additional review indicates justification for continue stay, continued
stay will be approved and the review coordinator will assign the next
review date. In all cases the attending physician's judgement is
given great weight.
6. If the two physician reviewers /advisors determine that continued stay
is not medically necessary, the review coordinator will complete a
written denial of benefits notice. This denial notification will be
distributed prior to the end of approved continued stay, to the
patient and /or patient representative, the hospital, the state agency
for Medicaid patients, and the attending physician.
7. An attending physician who disagrees with the decision of both
physician reviewers /advisors with respect to denial of continued
stay, may retrospectively request a reconsideration of the decision
from the Utilization Review Committee at its next regularly scheduled
meeting.
8. For Medicare patients only:
If the attending physician disagrees with the decision of the two
physician reviewers /advisors, the URC will contact the PRO /Medical
Review Entity (MRE) for an immediate review of the case. If the
PRO /MRE agrees with the physician reviewers /advisors, a denial of
benefits notification will be given to the patient and /or patient
representative the attending physician, the hospital, and the PRO /MRE.
If the PRO /MRE does not agree with the two physician reviewers/
advisors, the continued stay will be approved.
9. In all cases only a physician will make an adverse decision
denying continued stay certification.
10. All actions taken during continued stay review will be documented
on the coordinator's worksheet. One copy of this form will be kept
in the review coordinator's file after discharge of the patient.
-5-
D. Ancillary Service Review
Ancillary Service review will be conducted concurrently as needed
using pre - established criteria. Procedures for physician advisor
review will be the same as for concurrent review of acute care.
E. Retrospective Review
Retrospective review will be conducted on all data source material
identified in V -C as soon as available. Administrative problems
will be referred to Administration (DRG Department /Task Force. /Committee)
Clinical problems will be referred to the appropriate Medical Staff
committee with recommendations for resolution. Concurrent review
and monitoring will be intensified in problem areas until the problem
is resolved.
F. Evaluation of Patient Care
The Quality Assurance Committee (or other appropriate committee)
is responsible for coordination of the findings of all evaluation
of patient care and shall assure the performance of any studies
required. Problems for study may be identified through the
utilization review process and referred to the QA or other
appropriate committee; a summary of these evaluation will be
reported back to the Utilization Review Committee and as appropriate,
to the Governing Board and Executive Committee of the Medical Staff.
VI. COMMITTEE REPORTS AND RECORDS
On behalf of the Utilization Review Committee, the Utilization Review
Coordinator will be responsible for maintaining aggregate patient data
with respect to admission certification and continued stay review which
will be reported to the Utilization Review Committee at the monthly meetings.
The Utilization Review Committee will maintain a permanent record of
its findings, proceedings, and actions and make a monthly report to
the Quality Assurance Committee and as required, to the Medical
Executive Committee, Administration and Governing Board.
VII. RESPONSIBILITIES OF HOSPITAL ADMINISTRATION
A. Notify URC of all admissions and responsible third party payer of
each patient.
B. Support and assist the UR Committee in assembling of information,
facilitating concurrent review, conducting studies, exploring ways
to improve procedures, maintaining committee records and promoting
the most efficient use of available health services and facilities.
C. Designate an individual or hospital department to be responsible
for each of the activities specified in the preceeding paragraph.
VIII. RELATIONSHIP WITH FISCAL INTERMEDIARY, STATE AGENCIES, DEPARTMENT
OF HEALTH AND HUMAN SERVICES, AND THE PRO.
The procedures and minutes of the Utilization Review Committee will
be made available for confidential review by the Fiscal Intermediary
authorized State Agencies, the Department of Health and Human Ser-
vices and as appropriate, the PRO /MRE.
IX. UTILIZATION REVIEW PROGRAM EVALUATION
The utilization review program, including the written policy, pro-
cedures and criteria (Interqual), is reviewed and evaluated annually,
and is revised as appropriate to reflect the finding of the hospital'
utilization review activities.
A record of such reviews and evaluations is maintained in the
utilization review minutes and appropriate findings are reported,
through the established mechanisms, to the executive committee
of the medical staff and to the governing body.
X. CONFIDENTIALITY
Information and data will be maintained, as required, so as to assure
confidentiality and compliance with all appropriate laws, regula:ions
and payment of claims.
XI. DISCHARGE PLANNING
The Discharge Planning Department /Service of the hospital will be
responsible for the coordination of discharge planning. Assessment
and /or implementation of discharge planning will be performed as
soon as a determination of the need for such activity can be made.
The UR Coordinator will alert the individual(s) responsible for
discharge planning of all admissions necessitating his /her assis-
tance on discharge, to maintain continuity of care.
Discharge planning is not limited to placement in long term care
facilities, and includes provision for or referral to services
that may be required to improve or maintain the patient's health
status. See attached discharge planning policy and procedure
which outlines the discharge planning process and screening criteria.
-7-
TITLE
0
•A•
DISCHARGE PLANNING PROCE,
REVISION
3/92
PAGE
1 GP 3
APPROVED BY
POLICY:
Discharge Planning for continuity of care will be provided
for all patients meeting the high risk screen criteria or
upon the request of the patient, the patient's representative
or patient's physician.
PROCEDURE:
1. Social services and discharge planning coordinator
will screen all patients at an early stage of
hospitalization for discharge planning needs,
and will meet with the Utilization Review Staff to
discuss evaluation of patient discharge plans and
identification of potential problems. High Risk
Screens are seen within 48 hours of admission or on
Monday following a weekend admission.
POLKV \,u SER
SW -W5
EEEECTn£ DATE
a. The Discharge Planning staff is part of the
Department of Quality Services and is under the
supervision of the Director of Quality Services
b. Discharge Planning staff consists of two full
time discharge planners and one halftime social worker
One Discharge planner screens patients and
provides services on the medical floor and one
discharge planner screens patients and provides
services on the surgical floor. Patients are
screened daily according to the High Risk
Criteria (attached),ICU units, OB and Pediatrics
are not routinely screened. Discharge planners
are available to assess and arrange for out of
home placement, or order home care and equipment
for these units on a direct referral basis.
Social Services works collaboratively with the
discharge planners on planning issues and is
available on a referral basis.
c. Coordinateddischarge planning shall be done on a
five day a week basis.
d. Referrals to discharge planners are placed in the
log book at the nursing stations by the unit
secretary or nursing staff, and are called into
the Quality Services office (x4081). An
answering machine is available to receive
referrals made after normal working hours and on
weekends.
COMMUNITY HOSPITAL & REHABILITATION CENTER
+SS +�E2
?q.�Y R i�9ER
SW
-005
PAGE
2 OF 3
2. Information needed for the discharge planning
Process should include, but is not limited to:
a. Prior health care status of patients
b. Current level of care needed
C. Projected level(s) of care needed
d. Projected time frame for moving patient to next
level of care
e. Therapy(ies) and teaching that must be
accomplished prior to hospital discharge f.
Available resources for post - hospital care
g. Mechanisms for facilitating transfer to other
levels of care
This information can be obtained from the Nursing
Admission Assessment, the Care Plan, and by
patient interview.
3. Social services and discharge planning will
interview patient and /or family or significant
others to assess financial, emotional, social,
environmental, and educational needs for discharge
plans. Patient and family shall be actively
involved in decision - making regarding discharge
plans with counseling from social services as
needed.
4. Social Worker and Discharge Planners will make
appropriate referral for post - hospital care,
including financial assistance, home -maker
services, home care and equipment rentals,
placements in skilled nursing facilities or board
and care facilities, transportation services, and
other community services as needed.
5. Social services shall counsel and assist patient
and family in emotional problems regarding
discharge plans.
6. Social service staff shall attend and actively
participate in multi - disciplinary patient
conferences. These conferences will be documented
on the discharge plan form and :nrovxess record.
7. Social Service /Discharge planning staff shall
participate on hospital committees in order to
enhance communication between hospital staff and to
provide optimum services to patients and their
families.
8. Social service and discharge planner shall keep
and share resource files of board and cares, SNF,
home health agencies, and other community
resources, and shall provide each nursing station
with a directory of resources.
9. Social services shall advocate for patients in
obtaining financial and other assistance needed for
continuity of care, shall identify problems and
gaps in community services, and shall work with
community health and welfare agencies in planning
and advocating for additional services needed.
10. Social services shall work closely with discharge
planner coordinator, Nursing Staff, and other
disciplines, and, in her /his absence, will provide
services as required.
DISCHARGE PLANNING ASSESSMENT FORM
23 hour hold or Medicare
Age 65 or over and living alone
Medicare receiving disability benefits
1
Transferred from SNF, ICF or RCH
Admitted in comatose state or with OBS
Does not reside in Santa Clara County
A victim of a severe accident
Total joint replacement or other bone disease
Age 65 or over admitted for cardiac condition
Any patient admitted in past 30 days
HIV related disease
SW -005
3/92
PAGE
3 3
G
TITLE RE V�S�ON POLICt �_u �Eq
PLAN FOR DISCHARGE PLANNING
PAGE EWEC T'.F DATE
OF
APPROVED By
* Patient Services shall bear the primary responsibility for the
coordination and implementation of complex home plans, nursing
home placement, and interfacility transfers.
* Discharge planning is best accomplished by a multidisciplinary
team that begins its assessment of the patient's goals and needs
as soon after admission as is practical. Team conferences permit
coordination of individual efforts and provide a forum for refining
or finalizing plans and goals.
OBJECTIVES FOR AND PROCESSES OF DISCHARGE PLANNING:
* Objectives:
To provide continuity of care for the patient
To coordinate the involved disciplines of patient care to enable
discharge to home or community with continuing care as required.
* Process:
1. Planning is initiated as early as practical in the patient's
stay.
2. Planning considers the concurrent documented assessment by
members of the multidisciplinary team of the patient's need
for further services.
3. Planning promotes participation by the patient and /or legal
representative.
4. Planning verifies that the needed services are available at
the appropriate level of care.
5. Planning reflects efficient utilization of hospital, long-
term care facilities, and community services.
POLICYDP
11/90
COMMUNITY HOSPITAL & REHABILITATION CENTER OF LOS GATOS /SARATOGA
COMMUNITY HOSPITAL AND REHABILITATION CENTER OF LOS GATOS - SARATOGA
QUALITY ASSESSMENT PLAN
I. OBJECTIVES
A. To maintain an ongoing quality assessment (QA) program
designed to objectively and systematically monitor and
evaluate the quality of patient care, pursue opportunities
to improve patient care, and resolve identified problems.
B. The Governing Board strives together with our organizational
leaders to assure quality patient care by requiring and
supporting the establishment and maintenance of an effective
hospitalwide QA program.
C. Clinical and Administrative staff monitor and evaluate the
quality of patient care and clinical performance, and report
information to the Governing Board. The Governing Board
needs to assist it in fulfilling its responsibility for the
quality of patient care. Emphasis and priority is on
seeking opportunities to improve care and to look at
processes within our hospital that have impact on patient
outcomes.
D. The Director of Quality services (as the QA coordinator)
serves as the facility risk manager and attends Medical
Staff Department and Committee meetings, Safety Committee
and QA Committee, operationally linking risk management,
patient care, and QA activities. A quarterly Hospital
Occurrence/Risk Management report is made available to the
QA committee, Executive Committee of the Medical Staff,
Medical Staff departments, Nursing department, Safety.
Committee, and the Governing Board.
II. ORGANIZATION
A. The Governing Board has delegated authority to conduct QA
activities to the Medical Staff and Administration. The
joint medical staff /hospital staff QA Committee (QAC) has
the purpose of reviewing, integrating and coordinating all
QA activities.
B. The composition of the committee is defined in the Medical
Staff By -Laws with a quorum defined as 30% of voting
members.
C. An agenda and minutes will be maintained for each meeting.
page 1 of 5 rev. 492
D. Any department, committee, or individual may be requested to
participate in the activities of the QAC, and may introduce
an area of concern.
E. Reporting:
1. OA Tracking Loo
A method to monitor the progress of all QA activities and
to specify committees /departments responsible, and the
frequency of reports. The Director of Quality Services
is responsible for maintaining the currency of the log by
using the approved minutes of the Executive Committee/
Departments /and Committees. The contents or format of
the tracking log may be changed without revision of the
entire QA Plan.
2. Other reporting functions of the OAC
a. Medical Record Review Function
b. Indepth Reviews
c. Professional & Support Clinical Monitoring
d. Credentials Monitoring Report
e. Occurrence Screening /Risk Management Report
3) Minutes, or summary reports of the proceedings of
the QAC will be provided to the Executive Committee of
the Medical Staff and to the Governing Board for review
and approval.
III. SCOPE
A. The following medical staff functions are performed:
The monitoring and evaluation of the quality of patient care
and the clinical performance of all individuals with
clinical privileges through:
1. monthly meetings of the clinical departments of
the Medical Staff to consider findings from the
ongoing monitoring activities of the medical staff,
based on Important Aspects of Care, and
multidisciplinary issues when presented.
2. surgical case review
3. drug usage evaluation
4. the medical record review function
5. blood usage review
6. the pharmacy and therapeutics function
7. nosocomial infection surveillance
8. review of occurrence screens /risk management issues
Plans for each are maintained in the Director of Quality
Services QA Manual.
page 2 of 5 rev. 4/92
B. The quality of patient care in the following services are
monitored and evaluated, in addition to the clinical
departments of the medical staff.
1.
2.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Anesthesia and Surgical services
Dietetic services
Emergency services
Hospital- sponsored ambulatory
within services provided)
Nuclear medicine services
Nursing services
care services (conducted
Pathology and medical laboratory services
Pharmaceutical services
Radiology services
Rehabilitation services
Respiratory care services
Social work services
Special care units
C. The following hospitalwide functions are performed:
1. Infection Control
2. Utilization review
3. Review of accidents, injuries, patient safety and safety
hazards
D. The quality of patient care and the clinical performance of
Allied Health Professionals are monitored and evaluated
through the Allied Health Professional Committee, Perinatal
Mortality & Morbidity & OB /GYN Committee, and the Department
of Medicine.
E. QA findings are considered relevant when the peer review
process requests a response from a practitioner. This
correspondence is made part of the practitioner's file.
This correspondence, in addition to other relevant findings
from hospital -wide and departmental QA activities are
considered as part of:
1. the reappraisal /reappointment of medical staff members
2. the renewal or revision of the clinical privileges of
Medical Staff and Allied Health Professionals
3. the mechanisms used to appraise the competence of all
Allied Health Professionals
page 3 of 5 rev. 4/92
IV. MONITORING AND EVALUATION PROCESS OF QUALITY ASSESSMENT
10 Step Process:
1. Responsibility for the monitoring and evaluation of each of
the QA processes is assigned to the Department
Chairman, Committee Chairman, or Hospital Department
Manager, as leaders. The tracking Log defines these
processes.
2. Community Hospital and Rehabilitation Center of Los Gatos -
Saratoga provides care to all patients and age categories,
based on medical necessity and intensity of service,
excluding cardiac surgery and acute adult and child
psychiatric disorders requiring hospitalization. The
Medical Staff is composed of Doctors of Medicine, Dentists,
Podiatrists, and Allied Health Professionals. Our scope of
care is centered on our patients' needs.
3. Important aspects of care are focused on high volume, high
risk and /or problem prone areas of care. Monitoring and
Evaluation is carried out to pursue improvement in patient
care.
4. Indicators and appropriate clinical criteria for monitoring
the important aspects of care are identified. Opportunities
to improve our care may be found in any of the existing
systems or processes directed.to patient outcomes, outside
of established indicators.
5. Thresholds (levels, patterns, trends) for the indicators
that trigger evaluation of care are identified.
6. The important aspects of care are monitored by collecting
and organizing the data for each indicator.
7. When thresholds are reached, care is evaluated in order to
identify either opportunities to improve care, systems, or
process flaws. Leaders will support and encourage
development of multidisciplinary teams as a problem - solving
approach.
8. Actions are taken to improve care or to correct identified
problems.
9. The effectiveness of the actions is assessed and the
improvements in care are documented.
10. The findings of the monitoring and evaluation process are
communicated to relevant committees, departments, or
services and to the organizationwide QA program.
V. METHODS FOR OVERSEEING EFFECTIVENESS
A. The QAC is responsible for overseeing and tracking that all
QA activities outlined in Sections III, IV, & V of this plan
are performed appropriately and effectively. The Executive
Committee of the Medical Staff and the Governing Board are
ultimately responsible for assuring that the QA program
meets its stated objective.
page 4 of 5 rev. 4/92
B. The QAC, in addlcion to each Medical Staff Department and
committee, is responsible for coordinating information
between departments /services when issues in patient care
are multidisciplinary.
C. The QAC minutes will maintain an index of opportunities
identified to achieve greater efficiency in our delivery of
health care services, reduce cost when feasible, and improve
upon the quality of care presently delivered.
D. The QAC, as coordinator of all QA information, endeavors to
detect trends, patterns of performance, or potential
problems that cross department /service lines by methods
including an indepth evaluation of at least one process
each month.
E. The objectives, scope, organization, and effectiveness of
the QA program are evaluated at least annually and revised
as necessary.
Approved:
Chief Executive Officer
page 5 of 5 rev. 4/92