1. “The Stony Brook Way is My Way” New York State Department of Health Center for Medicaid Medicare Services [CMS] All Cause Corrective Action Stony Brook Medicine

2. DOH References of Deficiency: 1.Allegations of Sexual, Physical, or Psychological Abuse 2.Infection Control Practices 3.Intravenous Therapy and Blood Product Administration 4.HIPAA, as it relates to PHI Disclosure 5.Code Cart Standardization “The Stony Brook Way is My Way”

3. 1.Didactic education 2.Skills based training and Simulation 3.Attestation- confirmed completion 4.Validation- check performance 5.Outcomes- compliance IMPLEMENTATION /COMMUNICATION STRATEGY “The Stony Brook Way is My Way”

4. DOH for CMS Allegation survey 4/28/15 – 5/4/15 Finding related to process for investigation of patient complaints of Abuse & Neglect by a Staff member Actions: New Policy implemented prior to DOH exit (policy #RI 0057) Education to front line, managers, supervisors, directors & medical staff via PPs, LMS, and continuing through annual re-certifications and new employee orientation Abuse Complaint checklist to document actions CMS ALLEGATION SURVEY “The Stony Brook Way is My Way”

5. CMS document received evening of 6/3/2015 (on day 3 of TJC Survey) Follow up actions and clarification statements to be submitted by 6/15/2015 Requires 100% education : Medical Staff must complete to 100% by 6/15/2015 Requires 100% monitoring of responses to Abuse & Neglect complaints (13 to date since DOH visit) Requires feedback to Departments on Abuse & Neglect complaints Requires tracking & trending by department and individual CMS REPORT 5/13/2015 “The Stony Brook Way is My Way”

6. Infection Control is in Your Hands Administrative Policy on Isolation Precautions IC 0006 As soon as patients are identified as needing isolation: Yellow card / chart, dedicated stethoscope / thermometer All rooms must have a Personal Protection Equipment [PPE] cabinet in or in close proximity to the entryway Cabinets must be stocked with gowns, gloves, surgical masks, goggles and / or face shields All HCWs are responsible for following the isolation precautions delineated in the Hospital Policy and reminding other HCWs to do the same Families must be educated re: On hand hygiene practices and Patients isolation HEALTHCARE EPIDEMIOLOGY DEPARTMENT

7. Infection Control is in Your Hands All patients, regardless of status: inpatient outpatient observation Must be placed on the correct isolation precautions based upon: personal history clinical presentation isolation code on Banner Bar HEALTHCARE EPIDEMIOLOGY DEPARTMENT

8. Isolation Card (front) HEALTHCARE EPIDEMIOLOGY DEPARTMENT Infection Control is in Your Hands

9. Administrative Policy on Hand Hygiene IC 0003 Hand Hygiene is performed: Upon entering & exiting patient rooms Before and after any contact with patient / environment, regardless of +/- isolation status In between dirty and clean procedures Between separate portions of the physical exam re: clean vs dirty OK to foam when entering a C diff room, but must wash hands with SOAP / WATER upon exiting Families must be educated on hand hygiene practices DEPHEALTHCARE EPIDEMIOLOGY DEPARTMENT ORMATICS

10. Infection Control is in Your Hands Administrative Policy on Infection Control in patient transporting IC 0007 Patients on isolation must be transported using practices that minimize cross contamination If patient is on isolation, the transporter must: perform hand hygiene, don correct PPE identified on the isolation yellow card before entering room Bring clean transfer equipment into the room, transfer patient to stretcher or wheelchair as indicated cover patient with clean sheet remove isolation garb before exiting room, perform hand hygiene When transferring patient on occupied bed, wipe the side rails and all accompanying equipment with antimicrobial (purple) wipes, allowing for 2 minute dwell time prior to exiting the room HEALTHCARE EPIDEMIOLOGY DEPARTMENT

11. Infection Control is in Your Hands Health Care Providers are NOT to carry multi-dose vials in pockets or case (pharmacy policy modified): from patient to patient from room to room when used on a patient with an infection, discard after use Use single-dose containers whenever possible When single-dose dispensers are not available: maintain aseptic technique perform hand hygiene prevent tip of dispenser from touching the patient wipe down container with antimicrobial (purple) wipes in between every patient encounter and prior to returning it to the case. HEALTHCARE EPIDEMIOLOGY DEPARTMENT

12. SBU Hospital Infection Control Policies Hand Hygiene IC 0003 Multidrug Resistant Organisms (M-RO) IC 0010 Patient Care Equipment Cleaning IC 0013 Infection Control In Patient Transporting IC 0007 Isolation Precautions IC 0006 Prevention and Control of Clostridium defficile IC 0022 Prevention and Control of Clostridium defficile IC 0022 Prevention and Transmission of M. Tuberculosis infection IC 0011 Prevention and Transmission of M. Tuberculosis infection IC 0011 MM0012 Multiple Dose Vials, Multiple Use Containers IC0012 Standard Precautions HEALTHCARE EPIDEMIOLOGY DEPARTMENT Infection Control is in Your Hands

13. All consultants [MDs, NPs, PAs, etc] will notify primary nurse of their arrival prior to entering patient room in ED and on the Units: “I’m here to see patient ____. Is there anything I should know?” “The Stony Brook Way is My Way”

14. Audit and analysis of all IV and Blood Administration Policies Development of educational materials aligned with best practices and SBUH policies Development of Skills Training stations Development of Simulation scenarios Training of Auditors Systematic ongoing monitoring IV THERAPY AND BLOOD ADMINISTRATION “The Stony Brook Way is My Way”

15. Removed complete patient name from slave monitors Rolling computer carts: instructing and auditing for open EMRs with PHI on the screen Education on the proper communication of PHI, with instruction for sensitivity to the environment and other people: only permitted use of incidental disclosure HIPAA COMPLIANCE: PROTECTED HEALTHCARE INFORMATION “The Stony Brook Way is My Way”

16. All Pediatric and Adult Code Carts now include the appropriate Zoll Pads Pediatric Code Cart now contains two sets of Zoll Pads: Children less than 8 years of age and over 8 years of age All Code Carts now have consistent Code Cart checklists CODE CART STANDARDIZATION “The Stony Brook Way is My Way”

17. Accountability Attestation of all staff by 6/15/2015 Validation of training and education 6/15-6/20/2015 Remediation directives-as it occurs Behavior-Based Expectations- continuous ALL CAUSE CORRECTIVE ACTIONS “The Stony Brook Way is My Way”

18. Please sign and date the attestation faxed to you EMAIL to: Joyce.Klein@stonybrookmedicine.eduJoyce.Klein@stonybrookmedicine.edu Type your name - LAST NAME, FIRST NAME in the SUBJECT of email If you are unable to email, please fax to: 631-706-3329