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From the Desk of Lisa Thomas, BSN
The twelve states being surveyed by state surveyors
are sharing their survey findings. For certain, the
surveyors are looking for compliance. Organizations
who have had stellar licensure or accreditation
surveys historically are being cited with multiple paged
deficiency reports! Surveys are with two and three
surveyors and are lasting two full days.
The twelve states undergoing surveys now include:
Arkansas, Florida, Indiana, Kansas, Maine, Maryland,
Michigan, New Jersey, North Carolina, Oregon, Utah
and Wyoming.
The remaining 38 states will start in October! Are you
prepared?
If you'd like to share your survey results in order to
assist others prepare, please submit to
lisat@excellentiagroup.com and
cathy@excellentiagroup.com
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Greetings!
If you have been attending our Infection Control
webinars, you will find this newsletter issue an
important addendum to the information that you have
already received from us regarding CMS Infection
Control Changes and upcoming audits.
If you have not yet registered for one of our webinars, I
encourage you to check us out and register today.
This will be the perfect opportunity to ask questions of
our Infection Control consultant that you may not be
able to get answered easily from other sources.
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| HOT SPOTS |
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Hot Spots identified by the organization's claim state
the surveyors are directly observing and interviewing
the following:
- 'White glove' inspection of ALL ASC areas
with focus on high dusting, (tops of sterilizers, blanket
warmers, booms, towers, etc.) Roofs, drains, ceiling
tiles, wall dings, storage rooms, med gas storage, etc
are being included,
- CRNA's/Anesthesia's role from
participation in the "Time Out", to involvement with
narcotic procurement, to chain of command process
with anesthesiologist/surgeon, to how the
determination of an individual patient anesthetic plan
is made,
- Pharmaceutical practices including
drawing up, labeling and administration of
medications,
- HR files for current health screening
results and current licensures, &
- 'Training' and documentation for the
training of the Infection Control Nurse is being
reviewed. Surveyors vary in their interpretation of what
will suffice for 'training'.
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