Common DOH Survey Citations Common DOH Survey Citations Environment of Care and State Fire Marshal DOH is Very Busy DOH Was Running 4560 Days Behind Schedule All Teams A re Out and Getting Caught Up ID: 475333
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Slide1
Randy Benson, Ph.D.
Common DOH Survey CitationsSlide2
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
A
re Out and Getting Caught Up
No Unusual Areas of Focus
Infection Prevention and Control Continues To Be a Concern on the EOC SideSlide3
Common DOH Survey Citations
Infection Prevention and Control
Staff Training on Infection Control and Blood Borne Pathogens, Several Citations:
Generic But
N
ot Facility Specific Training
Failure To Identify the Infection Preventionist and How to Contact Them
Failure to Reach 100% Competency Compliance in Previous Calendar Year.Slide4
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 FreezersSlide5
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)Slide6
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/BoardSlide7
Common DOH Survey Citations
HIPAA Citations
Confidential Paper in Unprotected Containers (Cardboard Boxes)
Unlocked HIPAA Shredding Paper Bins
T
oo Much Patient Information on Nursing Station Whiteboard
Failure To Get 100% Staff Competency Compliance With HIPAA EducationSlide8
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 AreaSlide9
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)Slide10
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
ContractedSlide11
Common DOH Survey Citations
QUESTIONS?Slide12
Common DOH Survey Citations
RANDY BENSON, Ph.D.
HEALTHCARE QUALITY SERVICE (HQS)
CONSULTANT
rbenson117@comcast.net
509 951-4878