(Dec. 22, 2023) – This week, the Kansas Department of Health and Environment provided the Kansas Hospital Association and hospital risk managers the following information.
- The following new forms (implemented on Sept. 7, 2023) are now available on KHDE's website at https://www.kdhe.ks.gov/580/Medical-Care-Facilities.
- Risk Manager Change Notification Form
- Confidential Quarterly Report Form
- Facility or Individual Report of Adverse Finding Form
- KDHE Risk Management Plan Checklist
- Trends Revealed from Risk Management Survey
- Documentation of investigations did not include findings, conclusions, recommendations, actions taken and results of actions taken [KAR 28-52-1(c)]
- Risk Management documentation was not labeled as "confidential and privileged" [KSA 65-4925]
- Separate standard-of-care determinations were not made for each involved provider and each clinical issue [KAR 28-52-4(b)]
- Each standard-of-care determination was not dated and signed by an appropriately credentialed clinician authorized to review patient care incidents on behalf of the designated committee [KAR 28-52-4(c)]
- Results of the primary review (primary standard-of-care determinations) were not documented [KAR 28-52-4(c)]
- Standard-of-care determinations were not approved (finalized) by the designated Risk Management Committee [KAR 28-52-4(c)]
- Annual Risk Management Plan Submission Reminder:
- The annual governing body review/approval of the Risk Management Plan should coincide with your facility's license renewal. The preferred timeframe is 60-90 days before license renewal and the plan must be submitted to kdhe.riskmanagement@ks.gov no later than 60 days before license renewal. We want to ensure the Risk Management Plan is as current as possible at the time of license renewal. If you are unsure of when your facility’s license renewal date is, please contact Kelly Rivera.
- The position(s) of the Risk Management Committee(s) should be clearly noted on your plan’s organizational chart.
- All patient services, including those services provided by outside contractors or consultants, must be periodically reviewed and evaluated in accordance with the plan.
If you have any questions, please contact Kelly Rivera, CPTA, Risk Management Program Coordinator Health Facilities Program, Acute and Continuing Care, Bureau of Facilities and Licensing, KDHE.
--Ron Marshall