Hospitals: The Joint Commission, the organization that gives hospital accreditation, provides standards for patient safety including falls assessment and reduction. Failure by hospitals to implement these standards could jeopardize accreditation. Figure 5 summarizes the regulations and standards for falls prevention in Skilled Nursing Facilities, Home Health Agencies, Hospitals, and the Ambulatory Care Environment. The figure shows the absence of regulatory mechanisms or standards In the Ambulatory Care/Outpatient setting. Figure 5: Regulations, Policies, Tools and Standards Skilled Nursing Ambulatory Home Health Hospitals Facilities Care Risk Are included in the Best Practice to Standards by The Joint Commission Voluntary; Assessments MDS (Minimum Data provide a formal for hospital to assess patient fall risk, Existing Set) assessment and as multi-factor Falls Risk and implement falls reduction clinical part of a Assessment for all intervention. guidelines comprehensive patients over 65 from the assessment of each years old included in American resident. OASIS (Outcome and Geriatric Assessment Society and Information Set) others. Falls CMS: If resident is CMS recommends MA hospitals voluntarily report and Voluntary assessed as at risk for Falls Prevention publicly report patient falls and falls Performance falls, there must be a Interventions are with injury on the quality and safety Monitoring care plan that implemented as part website PatientCareLink, at addresses this risk. of the physician- www.patientcarelink.org Skilled nursing homes ordered Plan of Care are required to Hospitals are expected to report falls resident falls to that are Serious Reportable Events DPH. (SREs) as defined by the National Quality Forum (NQF) to the MA DPH. Websites for Nursing Home Home Health Hospital Compare: None Consumers Compare: includes falls Compare: quality and Includes Hospital Acquired incidence performance Conditions of falls and injuries measures for home health agencies PatientCareLink: voluntary posting of performance measures Medicare DPH may cite a facility CMS recommends a For Hospital Acquired Conditions None Certification/ for falls under formal multi-factor (HAC) of Falls and Trauma (Includes: Participation Accidents/Supervisions Falls Risk Assessment fracture, dislocation, intracranial during an annual for all patients over injury, crushing injury, burn, electric survey or as part of a 65 years old. This shock); hospitals cannot receive complaint, and they data is reported to additional payment from Medicare may assess civil the state using OASIS or charge Medicare patients for monetary penalties. tool as a condition treating these conditions. for Medicare participation. Staff Training Voluntary Voluntary Most hospitals require falls Voluntary
Hospitals: The Joint Commission, the organization that gives hospital accreditation, provides standards for patient safety including falls assessment and reduction. Failure by hospitals to implement these standards could jeopardize accreditation. Figure 5 summarizes the regulations and standards for falls prevention in Skilled Nursing Facilities, Home Health Agencies, Hospitals, and the Ambulatory Care Environment. The figure shows the absence of regulatory mechanisms or standards In the Ambulatory Care/Outpatient setting. Figure 5: Regulations, Policies, Tools and Standards Skilled Nursing Facilities Home Health Hospitals Ambulatory Care Risk Assessments Are included in the MDS (Minimum Data Set) assessment and as part of a comprehensive assessment of each resident. Best Practice to provide a formal multi-factor Falls Risk Assessment for all patients over 65 years old included in OASIS (Outcome and Assessment Information Set) Standards by The Joint Commission for hospital to assess patient fall risk, and implement falls reduction intervention. Voluntary; Existing clinical guidelines from the American Geriatric Society and others. Falls Performance Monitoring CMS: If resident is assessed as at risk for falls, there must be a care plan that addresses this risk. Skilled nursing homes are required to resident falls to DPH. CMS recommends Falls Prevention Interventions are implemented as part of the physician- ordered Plan of Care MA hospitals voluntarily report and publicly report patient falls and falls with injury on the quality and safety website PatientCareLink, at www.patientcarelink.org Hospitals are expected to report falls that are Serious Reportable Events (SREs) as defined by the National Quality Forum (NQF) to the MA DPH. Voluntary Websites for Consumers Nursing Home Compare: includes falls incidence Home Health Compare: quality and performance measures for home health agencies Hospital Compare: Includes Hospital Acquired Conditions of falls and injuries PatientCareLink: voluntary posting of performance measures None Medicare Certification/ Participation DPH may cite a facility for falls under Accidents/Supervisions during an annual survey or as part of a complaint, and they may assess civil monetary penalties. CMS recommends a formal multi-factor Falls Risk Assessment for all patients over 65 years old. This data is reported to the state using OASIS tool as a condition for Medicare participation. For Hospital Acquired Conditions (HAC) of Falls and Trauma (Includes: fracture, dislocation, intracranial injury, crushing injury, burn, electric shock); hospitals cannot receive additional payment from Medicare or charge Medicare patients for treating these conditions. None Staff Training Voluntary Voluntary Most hospitals require falls Voluntary
falls-prevention-phase-1-report.docx