RANDY BENSON, PH.D. COMMON DOH SURVEY CITATIONS

Environment of Care and State Fire Marshal DOH is Very Busy DOH Was Running Days Behind Schedule All Teams Are Out and Getting Caught Up No Unusual Areas of Focus Infection Prevention and Control Continues To Be a Concern on the EOC Side

COMMON DOH SURVEY CITATIONS Infection Prevention and Control Staff Training on Infection Control and Blood Borne Pathogens, Several Citations: Generic But Not Facility Specific Training Failure To Identify the Infection Preventionist and How to Contact Them Failure to Reach 100% Competency Compliance in Previous Calendar Year.

COMMON DOH SURVEY CITATIONS Infection Prevention and Control (cont.) Food Service and Nutrition Separate Sink for Handwashing Failure to Wear Gloves and Hair Covering During Food Preparation Failure to Remove Gloves When Making Change Boxes of Food Products Setting On Floor in Storage Area Failure to Keep Continuous Temperature Logs of All Refrigerators and Freezers

COMMON DOH SURVEY CITATIONS Infection Prevention and Control (cont.) General Cleanliness Citations Dust (High, on Patient Care Equipment, In Patient Rooms) Cleaners and Disinfectants (When Surveyors Find Unusual Cleaners or Disinfectants in Facility, Have They Been Approved?) Use of Proper Hand Hygiene by Ancillary Staff When Entering and Exiting a Patient Room Proper Airflow to Prevent Infections (Dirty Utility Rooms, OR and OR Sub-sterile Areas)

COMMON DOH SURVEY CITATIONS Engineering Citations Firewall Penetrations Uneven Sidewalks/Trip Hazards Failure to Maintain Proper Logs of Elevator Inspections, PMs of Equipment That Is Not Biomedical, Failure to Document Generator Tests in Proper Timeframes Failure to Complete Annual EOC Management Report or Show That It Reached Administration/Board

COMMON DOH SURVEY CITATIONS HIPAA Citations Confidential Paper in Unprotected Containers (Cardboard Boxes) Unlocked HIPAA Shredding Paper Bins Too Much Patient Information on Nursing Station Whiteboard Failure To Get 100% Staff Competency Compliance With HIPAA Education

COMMON DOH SURVEY CITATIONS Fire Marshal Citations Hallway Fire Doors Fail to Close and Latch Fire Drills Not Conducted Often Enough, or Without Evaluation By All Staff/Departments Emergency Lighting in Stairwells Missing or Burned Out Penetration of Fire Walls Not All Fire Extinguishers Inspected Monthly Too Many HIPAA Shreddable Paper Bins Stored in a Not Fire Rated Area

COMMON DOH SURVEY CITATIONS Fire Marshal (cont.) HIPAA Shreddable Paper Bins Too Large (64 Gallon vs. 33 Gallon) Sprinkler Head Escucheon Missing Too Much Cardboard (for Recycling) Stored in a Not Fire Rated Area Violation of the 24” Rule Equipment Blocking Fire Evacuation Door Equipment Blocking Fire Evacuation Hallway Flammable Material Hanging on Fire Doors (CMS)

COMMON DOH SURVEY CITATIONS General Issues Bringing a Citation Inadequate Disaster and Emergency Response Plan (CMS Survey) Failure to do an Annual Risk Assessment Failure To Update the Plan At Least Every Three Years Failure to Exercise the Plan Failure to Document Competency of All Staff (HR Citation) Employed Contracted

COMMON DOH SURVEY CITATIONS QUESTIONS?

COMMON DOH SURVEY CITATIONS RANDY BENSON, Ph.D. HEALTHCARE QUALITY SERVICE (HQS) CONSULTANT