Survey Readiness Tips – Healthcare Accreditation & Regulatory Compliance

C&A’s Top 12 Survey Readiness Tips for 2022

In keeping with Courtemanche & Associate's traditions, this year’s December Newsletter includes our Top Survey Readiness  suggestions.

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?
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.
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?
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?
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)?
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.
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.

Happy Holidays!

Please reach out with questions or service needs you may have.

We look forward to hearing from you!

From all of us at Courtemanche & Associates, we wish you a healthy, safe, and productive New Year

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