TJC Survey Review December 2012 Findings Reminders Observations Jan. 2013

2 THANK YOU for your assistance with the personnel files during the Joint Commission PPR Survey! Nutrition; NRRU Care Coordination; Bio Engineering Speech Pathology; Pharmacy Radiology; GI Emergency Dept.; CT Rehab; Respiratory Medical Procedures Unit Nursing; Dialysis; Jules Stein (Four Specific Employee Names / Seven Specific Positions) HR File Review

3 Docs Reviewed During HR/Competency Interview  License Verification Printouts  Other Certifications, such as BLS, ACLS, PALS, MICN  Job Description  Performance Evaluations  Annual Education  Annual Competencies

4 Observations When Prepping Personnel Files o Needed some departments to complete performance evaluations and annual competencies the week of survey (or on interview morning) because not in file when we did the review. o While many files did contain the required license verification printout, the printout date was NOT ALWAYS completed prior to the last expiration of the license. o The only acceptable license verification is the timely printout from the Board website.  Copies of licenses cannot replace the verification printout from the Board website. They can be tampered with easily.  Late printouts that are past the license expiration date will not pass a surveyor’s inspection. It tells them we let someone work without verifying if a license is valid.

5Observations when Prepping Personnel Files o Some staff have multiple licenses listed on the Board website, such as RN, NP, and Public Health Nurse. Please print them all for the files! o It’s important the education requirements are accurate on JD. Required vs. Preferred. o While HR did review files during the week as surveyor spoke to staff, official list from surveyor did not come until morning of HR interview. Had only two hours to prepare all the files. So, very important keep up with due dates and get papers into files timely.

6 Going Forward... Upcoming Surveys:  Transplant Survey - open  Patient Safety Licensing Survey - open  WW TJC Survey – Summer 2013; Week of Aug. 16 th is Week 36. Same preparation process for all licensing visits:  Keep HR tracking up to date  Be aware of due dates and expiration dates  Complete forms timely  Review documents for completeness before entry and filing  Use HR Staff as a resource for forms, entry, and compliance