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25Aug, 2014
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Joint Commission/Medicare survey – Santa Ana, CA

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A pleasure of a surveyor who was open to different ideas of how to approach standards so was not stuck on only their “way” of doing things. A fresh take. Surveyor had some great sayings, such as: “Can’t accept if you don’t inspect” – Surveyor was referring to nurses receiving medications from someone else. This reduces medication error in terms of wrong medication, wrong dose, expired medication, etc. I’ve seen nurses accept expired medications in the middle of a survey and the surveyor asked to see the vial. Embarrassing. “(Medications) […]
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10Jul, 2014
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On-Site Medicare (follow-up) inspection Beverly Hills, CA

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Surveyor spent more time with the instrument and scrub techs than leadership. Techs MUST know CDC/AORN/WHO recommendations for specific procedures in cleaning, disinfection and sterilization. There must be justification for how instruments are prepared so KNOW manufacturers recommendations. If you mix solutions, know what the measurements are and have a specific method to ensure that those measurements are accurate. So, make marks in tubs and sinks and/or have measuring devices. Sometimes, the added cost of “ready-to-use” bacteriacidal/germicidal/fungicidal/tuberculocidal is worth it. At least around survey time!
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15Apr, 2014
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On-Site Initial Inspection/Joint Commission Marina Del Rey, CA

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Surveyors from all accreditation agencies and some county departments of health inspectors are opting for very open-ended question. They are asking things like: How do you handle data management? Tell me how you integrate infection control into your QAPI program? In addition, they are very open about questioning non-leaders in the Center about emergency procedures (evacuation routes, CPR roles). They want to make sure that not only the Administrator, Director of Nursing and Medical Director know important policies. They may ask non-leaders about when their last emergency drill was (they […]
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22Nov, 2013
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On-Site Initial inspection – San Diego, CA

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Another marathon. TJC surveyors are now big on asking open-ended questions. Of course, staff (nurses, techs and administrative types) are freaked out and respond as if they are being accused of abusing kittens. Then, the o-so-friendly surveyor says “I’m not trying to catch you doing something wrong”. Whatever. They have told me that they will seek out the newest, least experienced tech or nurse and ask them about emergency policies (evacuation, fire, etc) to see if they have been oriented. If they answer “I don’t know”, you are sunk. If […]
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15Nov, 2013
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On-Site Initial inspection – Pasadena , CA

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Ten hours later . . . What is a peer? TJC has no standard saying what a peer is, but their FAQ says: The definition of a peer is someone from the same discipline with essentially equal qualifications. So, an anesthesiologist who works ten years with an ophthalmologist and sees how he/she works every day cannot provide a peer reference. Yet, someone who is in the same specialty yet gets no closer than passing that same ophthalmologist in the hospital hallway, can provide a peer reference. “Look Alike” includes cap […]
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5Nov, 2013
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On-Site Medicare inspection – Huntington Beach, CA

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Know that your biological indicator works with your sterilizer!!! Many variations of Attest, for example, exist. It must be appropriate for your sterilizer. Sometimes we tell surgery centers about certain guidelines that are out there and not everyone believes us. But, if you have an “educated” surveyor, they will know that your glutaraldehyde or OPA must be at a certain temperature according to manufacturer’s instructions. First, know the temperature and second, have a method of monitoring it! If you hand-wash GI scopes, follow your policies and that of the manufacturer.
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4Oct, 2013
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On-Site Medicare inspection – Pasadena, CA

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What did the inspector focus on? Infection control first. Infection cheap MLB jerseys prevention second. Infection control third. Inspector talked about the fact that identifying tape on instruments was not allowed per AORN. In fact, AORN says it’s perfectly fine per 2009 guidelines. Know your “nationally recognized cheap jerseys guidelines and standards” or know where to find them quickly! Then you can beat back the uninformed inspector! Inspector said we needed to find the manufacturer’s recommendation that allowed double packaging (peel packs) for instruments. He said AAMI/ANSI didn’t allow this. […]
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