1. TOP TEN DOH SURVEY CITATIONS
RANDY BENSON
Executive Director
WHS Health Care Quality Service
January 13, 2015

2. TOP TEN DOH SURVEY CITATIONS
The 2014 Top Ten “NO’s” From The Fire Marshal and Environment of Care Surveyors
10. Outdated Patient Supplies
9. Keys Left in Portable X-Ray Machines
8. Incompetent Employees

3. TOP TEN DOH SURVEY CITATIONS
Top Ten “No’s” (cont.)
7. Penetrations of Fire Walls
6. Keyboard Skins
5. Unsecured Sharps, Syringes and IV Fluid Bags
4. Compressed Gas Cylinder Sprayers

4. TOP TEN DOH SURVEY CITATIONS
Top Ten “No’s” (cont.)
3. Unsecured Confidential Paper In Cardboard Boxes Under Desks
2. Gaps at the Bottom of Hallway Fire Doors
1. EQUIPMENT PARKED IN A FIRE EVACUATION ROUTE HALLWAY

5. TOP TEN DOH SURVEY CITATIONS
Outdates: Violate hospital policy, QI standards, CMS patient safety standards, lack of attention to details
Keys: Unsafe practice (battering ram), violation of radiation safety standards
Lacking documentation of competency, serious HR citation, all employees (not just nursing staff)

6. TOP TEN DOH SURVEY CITATIONS
Fire Wall Penetrations: Violates hospital policy (Fire Marshal and EOC), lack of attention to detail
Keyboard Skins: Infection control violation, patient safety issue (CMS standard)
Unsecured Needles, Syringes and IV Fluids: Terrorism threat, theft, infection control, violates hospital policy

7. TOP TEN DOH SURVEY CITATIONS
Confidential paper: Violation of CMS HIPPA standards, legal issue, competency issue
Fire door gaps: smoke and fire barrier violation of Fire Marshal standards, patient safety, unsafe environment of care, lack of attention to detail
Equipment in Hallway: Fire Marshal standards violation, failure to comply with clear standard

8. TOP TEN DOH SURVEY CITATIONS
Other Issues:
Fire Drills
Dust on Window Sills: (All Things Related to Infection Prevention and Control)
Mandatory Signage: (Patient Safety and Provision of Care)
Disaster and Emergency Planning: The Soft Underbelly of Facility Operations (how responsive is the facility)
Food Contamination in the Kitchen

9. TOP TEN DOH SURVEY CITATIONS
QUESTIONS?

10. TOP TEN DOH SURVEY CITATIONS
Randy Benson Executive Director WHS Health Care Quality Service (HQS)