Surveyor Says
Safety First
Medication Station
Chart Smart
What Would You Do?
100

A surveyor asks you a question and you genuinely don't know the answer. What should you do?

Say you aren't sure and explain how you would find out—such as checking the policy or asking the appropriate person. Do not guess.

100

At Via, this depression screening is completed at intake, discharge, when clinically indicated, and monthly throughout the stay.

What is the PHQ-9?

100

True or False: Via staff administer medications to residential clients.

False. Clients self-administer medications while staff monitor/supervise the process. 

100

Exym access is tied directly to this account/login.

Your Microsoft account through Single Sign-On (SSO). Bonus: Didi Hirsch also uses MFA to access the system environment.

100

During intake, a client reports physical pain and says she doesn't have a primary care provider. What should happen?

Staff should encourage medical follow-up and begin exploring/coordinating linkage to a PCP. 

200

A surveyor asks you about a process. Should you explain what is supposed to happen, or what you actually do in your day-to-day work?

What we actually do.

200

Where are client medications stored at Via?

Locked in the medication storage room, in appropriate locked/client-specific storage, with access restricted to authorized staff.

200

You receive a suspicious email that looks like phishing. How do you report it?

Report the phishing/suspicious email to IT through Outlook.

200

You become aware of a critical incident involving a client. How long do employees have to submit the electronic CIR?

Within one business day of discovering the incident. 

300

True or False: If a surveyor asks about something outside your role, “That's not my job” is an acceptable answer.

False. Explain that another role/department handles it and offer to connect the surveyor with the appropriate person.

300

A client tells you she has started having suicidal thoughts. You remember that her risk assessment (C-SSRS) was already completed earlier. What should you do? 

Address immediate safety, notify/consult appropriate clinical staff or supervisor, reassess the risk as clinically indicated, follow the suicide-risk process, and document appropriately.

300

A client says, "I'm not taking that medication tonight." Name two things staff should do.

  • Do not force or coerce the client.  
  • Attempt to determine the reason/intervene if possible.  
  • Document the refused/missed medication.  
  • Follow the process for prescriber/psychiatry reassessment as indicated. 
300

Exym isn't working. What's the first thing staff should do to report the outage?

Submit an internal ticket through Fresh Service to the EHR team.

300

Someone is behaving violently and there is an actual or potential workplace-violence emergency. What is your first action?

Call 911 immediately. Once reasonably safe, follow the reporting/notification process. 

400

A surveyor asks a confusing question and you're not sure what they're asking. What's your first move?

Ask them to clarify the question.

400

True or False: Harm to Others (HTO) screening is only completed when a client has a known history of violence. 

False. For applicable clients, HTO is completed at opening and discharge and again when clinically indicated.

400

A client's medication has been changed, but the new medication hasn't arrived yet. Should staff update the medication process based on the new order anyway?

No. If the change requires medication that has not yet arrived, staff do not implement that medication change until the medication is received. Once received, staff verify that the medication name, strength, and dosage instructions match the new order before making the change.

400

True or False: If Exym is down, staff can wait until it comes back online before documenting services. 

False. Staff use approved downtime documentation/printable forms or other approved alternate processes and continue meeting urgent care needs. 

400

A client needs continued care from an outside provider after Via. Name two things you can do to support continuity.

Provide appropriate referrals/resources, coordinate with outside providers when appropriate/authorized, help address barriers to linkage, communicate relevant information to the treatment team, and give the client appropriate discharge instructions.

500

You realize that something you just told the surveyor was incorrect. What should you do?

Correct the information and explain the actual process. Don't panic or try to cover up the mistake.

500

A client is determined to be at high risk for suicide and may require psychiatric hospitalization. Name three things staff should do while the client is awaiting evaluation/transport.

  • Ensure immediate safety.
  • Notify appropriate clinical/LPS-designated support.
  • Keep the client in the presence of staff.
  • Remove/access-control objects that could be used for self-harm.
  • Engage additional staff support as needed.
  • Stay with the client until transport.
  • Document risk/interventions.
  • Update the treatment team as appropriate. 
500

A client asks you whether a new side effect means she should stop taking her medication. You're not qualified to make that decision. What should you do?

Do not give medical advice outside your role. Help connect/escalate the question to the appropriate medical/prescribing provider and follow the medication process.

500

Exym is back online after an outage. What happens to the clinical documentation completed during downtime?

It must be reconciled/uploaded into Exym within 48 hours of system restoration. Paper documentation containing PHI is then shredded appropriately. 

500

During your shift, a client tells you she has started having suicidal thoughts. She also refuses her scheduled medication because she thinks it is making her feel worse. While you're addressing this, Exym goes down. What do you do?

  • Address immediate client safety first.
  • Notify/consult appropriate clinical staff and follow the suicide-risk/reassessment process.
  • Do not force or coerce the client to take medication.
  • Explore the reason for refusal and follow the medication-refusal/medical consultation process.
  • Document the refusal appropriately.
  • Report the Exym outage through Fresh Service.
  • Use the approved downtime documentation process.
  • Reconcile the documentation into Exym after restoration. 
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