| 1. |
Review your medical equipment IFU’s for cleaning and disinfection.
- Are you following their recommendations?
- Does your staff know what to use and how to clean/disinfect your medical equipment?
Follow The CDC’s guidelines to cleaning and disinfecting. |
| 2. |
Conduct locked patient bathroom drills.
- Does your staff know how to access a locked patient bathroom door?
- Do you have a location for the key that is easily accessible?
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| 3. |
Review in detail your titration orders.
- Ensure that both the Pharmacists and Nurses understand all the required elements and have in place a robust, time-oriented clarification process to ensure orders are clarified without delay.
See our C&A Newsletter Article, Titration Orders – Are You Set for Safe Practice? |
| 4. |
Periodically review with your organization’s Department Directors, how to ensure their department or unit is survey ready every day.
- Establish a checklist that highlights the most problematic areas based upon your past surveys, results from mock surveys, and your internal rounding process.
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| 5. |
Review your process for auditing your Plans of Care/Care Plans/Treatment Plans.
- What are the current opportunities from your audits?
- How are you addressing any shortfalls?
- Are they individualized to the patient needs based on the patient’s assessment and diagnostic study results?
- Are Interventions for care and treatment based on those assessments?
- Are target dates for meeting the interventions set initially and revised per the patient’s condition?
See our C&A Newsletter Article, Treatment Planning |
| 6. |
Audit your process for cleaning and disinfecting reusable instruments/probes/scopes.
- How are you addressing initial debridement at the point of use?
- Are you transporting soiled devices in an appropriate container?
Follow CDC’s Recommendations for Disinfection and Sterilization in Healthcare Facilities |
| 7. |
Identify rooms greater than 50 square feet storing combustible materials to ensure they have a door closure device.
- Does the device permit the door latch to engage when the door is allowed to close on its own?
- Is storage more than 18 inches away from sprinkler heads?
- Is storage following your organization’s policy?
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| 8. |
Review your oxygen cylinder storage practices?
- Are the racks labeled according to your policy?
- Do you have intermingling of cylinders? (Full cylinders with Empty cylinders?)
- Are you checking for short fills or leaking tanks from your oxygen supplier?
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| 9. |
Determine that your organization’s generator remote annunciator is in a location under continual surveillance. A remote annunciator monitors the condition of a generator set from a remote location. It needs to be under continual surveillance to ensure immediate response in the event of genset malfunction or inadvertent operation. |
| 10. |
Test all patient call buttons and pulls (including those in restrooms).
- Are they functional?
- Do they annunciate in a location that is monitored?
- Do staff know where to respond in the event of an alarm?
- Are the pulls hanging freely and not wrapped around assist bars that may impede functioning?
- Are the pull cords made of material that can be cleaned (non-cloth)?
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| 11. |
Dedicate time to do a full unit sweep of every drawer, cabinet, closet, nook, and cranny. Remove any outdated supplies.
- Process any equipment that is no longer in use.
- Consolidate supplies to ensure efficient management.
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| 12. |
Conduct a wall-to-wall review of all work orders for painting and patching of worn or damaged walls, work surfaces.
- Ensure all damaged areas have had a work order submitted.
- Look under sinks and other areas that may have water damaged wood.
- Create a file or spreadsheet of all work orders for tracking purposes.
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