COMMON DOH SURVEY CITATIONS RANDY BENSON PH D

COMMON DOH SURVEY CITATIONS RANDY BENSON, PH. D.

COMMON DOH SURVEY CITATIONS • Environment of Care and State Fire Marshal • • • DOH is Very Busy DOH Was Running 45 -60 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 rbenson 117@comcast. net 509 951 -4878