Compass
Safety
Misc
Grievances
HIPAA
100
What is the Compass mission statement?
To deliver superior mental health care services at the partial hospitalization and intensive outpatient levels.
100
What would you do in the case of a fire? Bonus points for acronym we use in event of fire :)
Evacuate all staff & patients via nearest exit; proceed across Revere to 5 Revere Drive (One Northbrook Place) Directors transport attendance sheet & account for all patients. RACE- Rescue, Alarm, Confine, Extinguish
100
What do we do if patients have any legal concerns?
We have a referral list of mental health lawyers that is kept on the Common drive.
100
Where can you go to make a report about anything?
1.) During daily rounds re: patient care 2.) Anytime w/ the treatment team 3.) Anonymously in the staff suggestion boxes in the copy room 4.) Can request a mtg. at any time w/ Ann, Marla, Claudia or David. 5.) JCAHO (can report concerns about pt safety & quality of care)
100
When is it necessary to use soap and water vs. hand sanitizer?
When hands are visibly dirty or greasy.
200
What are the 2 Compass goals in place to help fulfill mission?
1.) Provide short-term mental health stabilization for patients with serious emotional disturbances. 2.) Recruit and retain outstanding clinicians to provide effective and efficacious treatment.
200
Where are fire extinguishers (closest to adolescent program) & pull stations located? What is the acronym we use for fire extinguisher use?
1.) Suite 100 lobby (pull station) 2.) Conference room hallway (extinguisher) 3.) adol wing on the wall (extinguisher) PASS: Pull pin, aim at base of fire, squeeze handle, sweep side to side **all of this info is on the common drive under Staff Resources/Safety & Emergency Northbrook
200
Where do we document any referrals given to patients?
In the "clinical note, referrals" section.
200
What do you do if a pt has a concern or complaint?
Refer to Director; they should try to field independently. If pt wants to issue a formal complaint, bring them to front desk and they will be given a form to log complaint. They can also call JCAHO to report concern about pt safety or quality of care.
200
What are some key things we do to ensure we are HIPAA compliant? Please list at least 3
1.) We do not leave our computers open w/ info if not present or pt is present 2.) We do not use pt's last names in discussion 3.) Turn papers over on desk if they contain any confidential info 4.) Lock computer screen when walk away 5.) Shred papers that have pt info 6.) Straighten copy room when you see items that need to be put in mailboxes or turned over 7.) All conversations about patients happen in confidential locations.
300
What are 4 of the many things that are reviewed during new employee orientation?
1.) Staff have a 90 day "trial period" and an annual review 2.) Job description is provided during orientation & can be found on the Common Drive under Compass Staff Resources 3.) Background checks are run 4.) We are given employee handbooks & HIPAA & Compass Policies are reviewed 5.) You know who your direct supervisor is 6.) You are informed of emergency procedures & infection control
300
How do you spread the word in the event of an emergency?
Use panic button- 1 push= help/staff assistance; 2 push= emergency requiring 9-1-1 response Use intercom/PA system to communicate w/ entire facility
300
What are 2 of the things does Compass do to minimize the spread of illness?
1.) Encourage flu shots 2.) Instructed to stay home (or go home) if ill 3.) Hand sanitizers in offices 4.) Specific hand washing guidelines (before/after eating; before/after patient care; after pet therapy; "visibly soiled")
300
What steps are taken after pt logs a complaint?
Written complaint goes to David (CEO), Claudia (Med Director) and is investigated w/in 24-48 hours. Pt will receive a written response.
300
How does our CEMR system set-up protect confidential info?
1.) We have a unique password for CEMR that isn't shared w/ anyone 2.) Our CEMR locks and a passcode is needed to reopen
400
How are staff at Compass assessed or evaluated?
- A competency assessment is completed at Orientation and a 2nd assessment is completed at 90 days. - 90 day review and yearly review - Ongoing feedback
400
Define the following & what to do: 1.) Lockdown 2.) Shelter-in-Place 3.) Bomb Threat
1.) Lockdown = stay in office/work area, away from windows; exterior doors and offices are locked. 2.) Shelter-in-Place = staff & pts proceed to assigned/nearest secured room 3.) Bomb Threat= keep caller on phone, use checklist, notify another staff to call 9-1-1 & initiate a lockdown
400
Can patients at Compass administer their own medication?
No, patients @ Compass are not allowed to self administer meds. They must be monitored by one of our nurses & meds must be brought in original prescription bottle. Parents must have signed proper forms.
400
What is a Sentinal event?
An unanticipated event that results in death or other serious injury. At Compass that would be elopement of a minor or suicide on site.
400
How do we know who wrote a note and when?
Our medical record notes are authenticated when we sign them and contain our credentials and date.
500
CEMR notes must be signed within how many hours?
24 hours
500
1.) Where are Compass AED's located? 2.) How do you know it's functioning? 3.) What do you do if it isn't working?
1.) Located in 100 and 202 2.) Blinking light indicates it is functioning 3.) Audible beep indicates equipment malfunction; notify emergency response team member
500
What should you NOT say if asked a question that you do not know by JCAHO?
Do not say "I don't know." Say "I am not confident in my answer, but I know several ways I could get the answer. My Director is always available; I could review the employee handbook or Clinical Staff Procedure Manual (kept on Common drive under Compass Staff Resources); Emergency procedure handbook are on Common drive & in Front offices
500
Can patients have access to their medical records? If no, why? If yes, how?
Yes, any patient can have access to their medical records with a properly executed Medical Records ROI.
500
How does Compass manage patient privacy?
- HIPAA compliant - Pt files and records are maintained electronically in our secure EMR system - Encourage pt communication to occur in person or via phone rather than via email -Minimum necessary info sharing to maintain confidentiality
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