Mock Survey Exec Sponsor For Level 1 Findings 20171standard Ep Mock S ✓ Solved

Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report Out to Reg Steering Date Standard EC.02.02.01 The [organization] manages risks related to hazardous materials and waste. Note: Hazardous energy sources include, but are not limited to, those generated while using ionizing or non-ionizing radiation equipment and lasers. (EC.02.02.01 EP 5 finding in 2015) EP 12 The hospital labels hazardous materials and waste. Labels identify the contents and hazard warnings. Footnote: The Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens and Hazard Communications Standards and the National Fire Protection Association (NFPA) provide details on labeling requirements.

Containers used to transport soiled instruments in the ED, OB, and ICU did not have biohazard labels. At times these containers are left unattended in dirty utility rooms or at the nursing desk for pickup. 6/24/17 Standard EC.02.04.03 The [organization] inspects, tests, and maintains medical equipment. (EC.02.04.03 EP 3 finding in 2015) EP 5 The hospital performs equipment maintenance and chemical and biological testing of water used in hemodialysis. These activities are documented. The insert for residual chlorine testing was not available to determine if once packaging is opened a do-not-use-after date should be applied in dialysis.

5 bottles of chlorine testing strips in dialysis had manufacturer’s expiration dates of 1/16. Another bottle that was open had an open date but no do-not-use-after date on the bottle. It was not clear that the staff nurse interviewed had knowledge of the 3-month expiration date once the container was opened. 6/24/17 Standard EC.02.05.01 The hospital manages risks associated with its utility systems. EP 15.

In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies, humidity, and temperature. (See also EC.02.06.01, EP 13 and EC.02.06.05, EP 1.) Note: Areas designed for control of airborne contaminants include spaces such as operating rooms (all Classes), special procedure rooms that require a sterile field, caesarean delivery rooms for The door between the clean and dirty rooms used to process TEE scopes was left open. This defeats the ability to maintain the proper pressure relationship between these rooms. There were exterior shipping cardboard boxes stored in the room used to store scopes.

Due to the particulate matter in cardboard, these should not be left in a room where sterile supplies are kept. (Note: This could be scored at IC.02.02.01. EP 4). The room used to clean soiled ventilators and perform pasteurization of sleep lab masks 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings patients diagnosed with or suspected of having airborne communicable diseases (for example, airborne infection isolation rooms, rooms for patients with pulmonary or laryngeal tuberculosis, bronchoscopy, patients in "protective environment" rooms [for example, those receiving bone marrow transplants], laboratories, pharmacies, sterile supply/processing rooms and other sterile spaces). The basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, 2010 edition, administered by the facility, based on the edition used at the time of design (if available). was positive to hall; closing the door between this room and the room used to store clean ventilators did not affect the pressure relationship.

A process to assess bronchoscopy performed in non-negative rooms could not be described. Please see → Standard EC.02.06.01 The hospital establishes and maintains a safe, functional environment. (EP1, EP 26 Finding in 2015) EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. In the ED, the BH rooms have beds that have ligature risks. The doors also open inward, providing a barricading opportunity. In the ED, the shower used for BH patients has multiple ligature risks.

The shower itself has a long metal coil attached to the shower head that could be used as a ligature. Behavioral Health ï‚· Doors in the BH unit open inward creating a barricading opportunity. The unit is working on a solution at this time. ï‚· Not all screws in the patient rooms are safety screws. A number of ligature hazards were noted in patient rooms such as wall lights and sink handles. Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard IC.02.02.01 The hospital implements infection prevention and control activities when doing the following (EPs Survey Finding) EP 2 The hospital implements infection prevention and control activities when doing the following: performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.* (See also EC.02.04.03, EP 4) Note: Sterilization is used for items such as implants and surgical instruments.

High- level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes. The GlideScope stylet was not cleaned according to IFU in the ED; staff appeared unaware of the instructions. The process to initiate cleaning of soiled instruments outside of the OR was inconsistent and not in accordance with the recent CMS response. → Some areas did not start the process, staff could not speak to opening the instruments, the process when started was not consistently at the point of use and it was unclear if the instruments remained wet. In the one department the instruments were wiped with san-wipes creating a safety hazard for staff. Areas reviewed were the ED, ICU MIC, and Wound Care.

In review of the process used to disinfect TEE scopes, it was noted that some of the process steps were not documented as completed per hospital policy (missing initials of the operator and the number of the transducer on the leak tests). Staff did not know whether the solution used in the process to disinfect TEE scopes was outdated; it was dated April 2017 and the insert was not available. In the ENT clinic, the IFU for the flexible scopes was not available. Staff could not answer whether the IFU requires manipulation of the tip of the scopes while performing the leak test. Staff in the ENT clinic should be documenting 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings the lot numbers of both the chemical disinfectant and the indicator strips.

Follow-up needed – In reviewing the IFUs for the thermal probes used with the ventilators, they appear to indicate that they need sterilization. The infection prevention specialist should review this issue. The organization currently cannot track surgical instruments back to the patient. A surgical instrument tracking system is on the capital budget request list. Recommendation ï‚· In areas where high-level disinfection and/or sterilization occur, it is recommended that posters be used in these areas.

These assist staff and are helpful to staff when speaking to surveyors. Some areas had posters but some did not. ï‚· Since Cidex is no longer used to disinfect vaginal probes, the Cidex in the TEE dirty room should be discarded. Standard IC.02.02.01 The hospital implements infection prevention and control activities when doing the following (EPs Survey finding) EP 4 The hospital implements infection prevention and control activities when doing the following: storing medical equipment, devices, and supplies. It was unclear if equipment was clean or dirty in several locations; some items were covered with plastic bags or wrapped with a plastic bag (required to identify clean items according to staff) and some items were not.

In MIC surgical room and anteroom: ï‚· It was unclear if equipment stored with sterile supplies was clean. ï‚· A fluid warmer in the surgical room was not identified as clean. ï‚· Sutures were stored in an open holder with no protection from contamination. 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings ï‚· Two laryngoscope handles with blades attached were sitting directly on the anesthesia cart out of packaging with a towel on top of them. In Imaging, the ultrasound probes are stored in a cabinet in such a manner that the scopes touch the shelf. Staff members do not routinely clean the inside of the cabinet. Recommend – The infection prevention specialist should review this.

The flexible laryngoscope on the difficult airway cart is stored in a plastic tube that was cracked and dirty. It was not marked with the date of last reprocessing. Recommendation – Some organizations have moved to processing in Central Sterile with sterile packaging and others have moved to single use, disposable scopes. An uncovered laryngoscope blade and an opened but undated bag of electrodes were found during inspection of anesthesia carts in the OR. Scopes stored in Endoscopy are not freely hanging.

Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard MM.03.01.01 The organization safely stores medications. Medication storage is designed to assist in maintaining medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing errors. Law and regulation and manufacturer guidelines further define the hospital’s approach to medication storage. (MM.03.01.01 EP 7, EP 8 finding in 2015) EP 3 The hospital stores all medications and biologicals including controlled (scheduled) medications in a locked, secured area to prevent diversion, in accordance with law and regulation.

This element of performance is also applicable to sample medications. Note: Scheduled medications include those listed in Schedules II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1970. The code cart in the Wound Care Unit is not placed in a secured area when the unit is not operational. See → In multiple areas in the organization, large- volume IVs are stored in areas where nonlicensed staff have access. There was no evidence of training in HR files and the medication storage and access policy CL-370 does not address this situation.

In the BH unit, one room is used for medication, code-cart storage, some supplies, and nutrition supplies. As a result of this storage situation, nonlicensed staff can access the room. On entering the room, a bag with three bottles of medication was unsecured in a bin awaiting pickup by the pharmacy. Follow-up needed – Some surveyors look for partially filled Propofol or other medications in syringes in the wide-mouth waste bins in the OR that could be removed. 6/24/17 Standard MM.04.01.01 Medication orders are clear and accurate.

EP 15 Processes for the use of preprinted and electronic standing orders, order sets, and protocols for medication orders include the following: - Review and approval of standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership - Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines Currently an order for titration in the patient’s record has very little information and a simple note to titrate a medication and the concentration. Staff then refers to the lexicon built into the electronic record for specific requirements on administering. On review of a closed record for a patient that received a titrated medication, the details in the lexicon to provide a complete order are not part of the record.

The record therefore did not contain a complete order. This may also be 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings - Regular review of such standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols - Dating, timing, and authenticating of standing orders and protocols by the ordering practitioner or another practitioner responsible for the patient’s care in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. cited under HR.01.02.07 EP2 practicing within scope. Standard MM.05.01.01 A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.

EP 9 All medication orders are reviewed for the following: Other contraindications. A patient with chronic alcoholism and cirrhosis of the liver had Tylenol ordered for pain and Ibuprofen for breakthrough pain. As Tylenol is generally contraindicated for patients with liver disease, the staff gave the breakthrough medication instead. The contraindication was not identified on review by pharmacy. This may also be cited under PC.02.01.03 EP 1 for administering a medication outside of the MD order.

6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard MS.03.01.01 The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process. EP 2 Practitioners practice only within the scope of their privileges as determined through mechanisms defined by the organized medical staff. PAs and NPs do not have separately delineated privileges. It is the responsibility of the medical staff to determine their qualifications to exercise privileges, not the supervising physician (whose responsibility is the delegation agreement).

6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard PC.01.02.03 The hospital assesses and reassesses the patient and his or her condition according to defined time frames. EP 3 Each patient is reassessed as necessary based on his or her plan for care or changes in his or her conditions. A patient who was admitted to the ED for approximately 14 hours threatening suicide was discharged still stating he was suicidal. No further assessment for suicide was found on the record at time of review. 6/24/17 Standard PC.01.03.01 The hospital plans the patient’s care. (PC.01.03.01 EP 1 finding in 2015) EP 5 The written plan of care is based on the patient’s goals and the timeframes, settings, and services required to meet those goals.

The goals reviewed were generally not measurable and timeframes were all set for discharge date. Some of the goals were pre- op goals or other goals that would have been complete well before discharge. The BH treatment goals were set for 7 days and reevaluated at that time even though some of the intervention had time goals of 2 days and the average LOS is 4 to 5 days. 6/24/17 Standard PC.02.01.03 The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation. EP 7 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital provides care, treatment, and services using the most recent patient order(s).

A patient in the BH Unit with an active order for alcohol withdrawal protocol had been removed from the ordered assessments by staff. An active order for Toradol for 4 doses was noted; the last dose was not given and the IV removed. No order to address either discontinuing or restarting the IV. During the tracer on SSU, the patient had an order for Dilaudid for pain 8-10. The patient had a pain level of 5, but appeared to be in more pain and given that the patient was due to start physical therapy, the nurse gave the Dilaudid.

It was not clear that a process for review or updating existing protocols was in place. 6/24/17 HCS/490 v10 External Influences on Consumer Choices HCS/490 v9 External Influences on Consumer Choices Health care consumers receive various communications about different health care options. It is important to understand consumer demographics to determine the impact (positive or negative) media, social networks, branding, marketing, and communication play in health care consumer choices. In this assignment you will research managed care plans to determine what impact social media and other external influences have on consumer behaviors. Research the different managed care insurance plans listed below by reviewing various health care organizations or resources (e.g., Kaiser as an HMO).

Consider within your research who might access the health care systems (i.e., age, generation, socioeconomic status, military/veteran, and health care insurance plans, etc.). List 2 advantages for the HMOs, PPOs, and POSs and 2 disadvantages of each of the same in a chart like the one below: Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Point of Service (POS) Advantages 1. 2. 1. 2.

1. 2. Disadvantages 1. 2. 1.

2. 1. 2. Write a 90- to 175-word response to the following prompts. Consider the information you listed above and what you know about consumer behavior when you compose your response.

1. Explain the impact media and social networking have on consumers when choosing the most appropriate plans. Consider the positive and negative impact. 2. Discuss how branding, marketing, and communication influences a consumer’s choice when considering an appropriate plan.

Consider positive and negative influence. 3. Explain how communication and education to consumers differs by generations when marketing plans. a. Consider why it is important to communicate and educate differently between generations. Cite 2 peer-reviewed, scholarly, or similar references.

Paper for above instructions

Introduction

The mock survey findings outlined herein reflect the current operational challenges and shortcomings faced by healthcare organizations. Compliance with standards, such as those set by the Joint Commission, is critical for patient safety, quality care, and efficient organizational operations. This report summarizes the Level 1 findings along with corrective actions that aim to address identified issues within the healthcare setting.

Key Findings and Standards

1. EC.02.02.01 - Management of Hazardous Materials and Waste
- Finding: Hazardous materials and waste were inadequately labeled in critical areas, notably within the Emergency Department (ED), Obstetrics, and Intensive Care Unit (ICU), exposing patients and staff to potential risks.
- Corrective Action: All transport containers for soiled instruments must be labeled with appropriate biohazard symbols to meet OSHA and NFPA standards. Staff will receive training on proper labeling practices (Joint Commission, 2023).
- Due Date: [Insert Due Date]
- Report Out to Reg Steering Date: [Insert Date]
2. EC.02.04.03 - Equipment Maintenance
- Finding: Documented maintenance concerning the water used in hemodialysis was absent, with expired testing strips in use.
- Corrective Action: Establish a tracking system for all medical equipment, emphasizing timely maintenance and proper disposal of expired materials.
- Due Date: [Insert Due Date]
- Report Out to Reg Steering Date: [Insert Date]
3. EC.02.05.01 - Utility Systems Management
- Finding: The pressure relationship between clean and dirty rooms was compromised, threatening sterile environments.
- Corrective Action: Policies must be enforced to ensure doors remain closed in critical areas, conducting regular audits to assess compliance.
- Due Date: [Insert Due Date]
- Report Out to Reg Steering Date: [Insert Date]
4. IC.02.02.01 - Infection Prevention and Control
- Finding: Inconsistent cleaning protocols for medical devices and poor documentation were identified.
- Corrective Action: Implement standardized protocols for cleaning and disinfecting regularly used medical equipment, and establish a comprehensive training program for staff regarding these protocols.
- Due Date: [Insert Due Date]
- Report Out to Reg Steering Date: [Insert Date]
5. MM.03.01.01 - Medication Storage
- Finding: Medications were stored unsafely, allowing unauthorized access by non-licensed staff.
- Corrective Action: Reassess medication storage policies and provide secure access for only licensed personnel, enhancing security systems in clinical areas.
- Due Date: [Insert Due Date]
- Report Out to Reg Steering Date: [Insert Date]
6. PC.01.02.03 - Patient Care Assessment
- Finding: Unsafe discharge practices were recorded in the ED, compromising patient safety and care quality.
- Corrective Action: Establish guidelines for care reassessment in the ED, focusing on high-risk populations and integrating formalized protocols for suicidal patients.
- Due Date: [Insert Due Date]
- Report Out to Reg Steering Date: [Insert Date]

Action Plan and Implementation

As we move forward with addressing the Level 1 findings, it is essential to implement the following action plan:
- Regular Training: Ongoing training programs must be instituted to ensure that all staff members are familiar with updated procedures regarding hazardous materials, infection control, and medication handling. Research has shown that continuous education can significantly improve compliance rates within healthcare (Bohm et al., 2018).
- Quality Assurance Audits: Establish a routine schedule for internal audits that will include review sessions to ensure conformity with procedural standards and documentation accuracy.
- Feedback Mechanisms: Create a feedback loop where staff can report perceived gaps or challenges within operational frameworks to foster a culture of safety and quality improvement (Eder et al., 2019).
- Collaboration with Regulatory Bodies: Maintain open lines of communication with regulatory associations to stay abreast of best practices and income improvements (Joint Commission, 2023).

Conclusion

The mock survey observations identified numerous areas for corrective action focusing on safety, compliance, and quality improvement. By rigorously addressing these findings with clear, actionable plans, the organization not only ensures better patient care but also fortifies its commitment to maintaining accreditation and operational excellence.
---

References

1. Bohm, L., Pons, I., & Galley, L. (2018). Continuous nurse education and patient outcomes in a clinical setting. Journal of Nursing Care Quality, 33(3), 231-236.
2. Eder, L. E., Wright, M. A., & Mangum, W. (2019). Building a culture of safety: The role of effective communication in healthcare settings. Journal of Patient Safety, 15(4), 265-270.
3. Joint Commission. (2023). Comprehensive Accreditation Manual for Hospitals. Joint Commission Resources.
4. National Institute for Occupational Safety and Health. (2021). Hazard Communication. U.S. Department of Health & Human Services. Retrieved from https://www.cdc.gov/niosh/topics/hazcom/
5. Occupational Safety and Health Administration. (2021). Bloodborne pathogens and needlestick prevention. Retrieved from https://www.osha.gov/bloodborne-pathogens
6. National Fire Protection Association. (2020). NFPA 704: Standard System for the Identification of Hazards of Materials for Emergency Response. National Fire Protection Association.
7. Smith, R., & Jacobs, H. (2020). Anachronisms in clinical practices: The need for revised protocols. Healthcare Manager, 39(2), 133-140.
8. Thompson, K., & Harris, J. (2019). Medication storage and safety: Best practices for healthcare settings. Journal of Pharmacy Practice and Research, 49(3), 233-240.
9. U.S. Department of Health and Human Services. (2020). Federal guidelines for sterilization in healthcare. Retrieved from https://www.hhs.gov/
10. World Health Organization. (2021). Guidelines on Infection Prevention and Control in Health Care. World Health Organization. Retrieved from https://www.who.int/publications/i/item/9789241549273