1. Weekly Survey Prep Tip 9/30/13 Staying Survey Ready

2. Surveyors will look very critically at the environment in which we care for our patients Cleanliness/organization of the facility - all areas (including mechanical/electrical closets, EVS closets) Storage of equipment/supplies; separation of clean from soiled; no storage on floors or within 18” of the ceiling All egress routes must be clear No obstructions near fire doors, fire alarm pull stations or extinguishers; no storage in hallways – remember 8 ft. clearance rule Remove paper signs on doors & walls (along with the tape) Remove all expired drugs or medical supplies Proper oxygen storage Patient Rights Signage Survey Prep Tip 9-30-13

3. Surveyors will look very critically at the environment in which we care for our patients No drinks or food at work stations No door wedges White boards: contain current information Confidentiality of patient information Medication security Medication storage: Pyxis, med carts, IV carts, etc. Needle/Syringe security Clean utility room/Soiled utility room Refrigerator cleanliness/temperature monitoring – documentation of corrective actions Patient food – identification, expiration dates Crash cart checks; Eye wash station checks All linen carts must be covered Infection Control – isolation practices (PPE & hand washing) Survey Prep Tip 9-30-13

4. Surveyors will review our documentation Open chart reviews Date, time, signature for all medical record entries Verbal orders signed within 24 hours PRN orders complete with an indication Assessments / Reassessments IPOC up-to-date (reflects patient’s current status) Restraints Pain Management Medication Management / Administration Blood Transfusions Wound Care Patient Education Point of Care Testing Closed chart reviews Survey Prep Tip 9-30-13

5. Surveyors may ask staff questions about the following topics Communication with non-English speaking patients Hand-offs: SBAR, Ticket-to-Ride Adverse Drug Reactions Authority to turn off medical gas valves Negative Pressure Rooms Role in a Fire; drills, evacuation Role in a Disaster Phone Outages; Computer downtime Smoking Policy MSDS What to do for suspected abuse Ethical Consults PI activities to improve patient care and patient satisfaction Your competence to perform your job Survey Prep Tip 9-30-13

6. Key Reminders Surveyors will interview patients All employees must wear their ID badge All employees must wash their hands upon entering and exiting patients’ rooms All employees must wear PPE when applicable All employees must have current licenses, certifications, vaccines (such as Hepatitis B & Influenza) & PPD’s A current evaluation and annual mandatory competencies Current BCLS (applicable to specific job descriptions) Survey Prep Tip 9-30-13

7. Questions??? Ask your manager or supervisor. Survey Prep Tip 9-30-13