The Basics
To bring the healing, help, and hope of Jesus Christ to those in need with a compassionate, caring presence.
What is our mission?
These key components help prevent the spread of infection: hand hygiene, personal protective equipment (PPE) safe injection practices, environmental cleaning, etc.
What are standard precautions?
This is the co-worker at each ministry who serves as the designated official responsible for privacy and HIPAA compliance functions
Who is the Privacy Officer?
All clients age 10 and older must be screened for suicide risk using this tool.
What is the Columbia Suicide Severity Rating Scale (C-SSRS)?
This is what co-workers should do if they notice unsafe working conditions.
What is report the situation to their immediate supervisor?
During the Site Survey, these documents are reviewed to verify compliance with TJC Standards.
What are policies and procedures?
Before giving a medication, staff must use at least these two checks to confirm the correct client.
What are two patient identifiers (such as name and date of birth)?
This is the document that outlines both the individual’s and the organization’s rights and responsibilities during care, treatment, and services, including the form to file a complaint.
What is the “Your Rights & Responsibilities” brochure?
This is the type of event that results in death, permanent harm, or severe temporary harm to a patient and must be reported immediately to leadership and investigated.
What is a sentinel event?
Except for Marygrove which has stricter standards, all residential sites need to have at least this many fire drills per year
What is at least 6 per year? (bi-monthly, at least 2 occurring at night when clients are sleeping)
This method is used by surveyors to follow a client’s care experience through different departments, co-workers, and documentation.
What is a Tracer?
These building features, such as doors and walls, are designed to slow the spread of smoke and fire.
What are fire barriers or fire doors?
This is a document allowing a person to give directions about future health care, or to designate another person(s) to make health care decisions if the individual loses decision-making capacity.
What is an Advance Directive?
In behavioral health settings, rooms must be designed to reduce this type of risk, which includes hazards like exposed pipes or anchor points.
What is ligature risk?
These four steps form an acronym that describe how to properly use a fire extinguisher.
What is PASS (Pull, Aim, Squeeze, and Sweep)
These annual reviews ensure co-workers (particularly direct care) are competent in their roles and meet behavioral health standards set by the Joint Commission.
What are competency assessments?
This assessment should be completed annually to determine the organization’s risk of infection and contamination.
What is the Infection Control Risk Assessment?
The list of organizational, legal, and regulatory timeframes for maintaining case records.
What is the “Record Retention Schedule”?
A formalized process in an organization through which the need for a program or services of continuing and follow up care, treatment, or services is ascertained and, if warranted, initiated for each individual served.
What is Discharge Planning?
Behavioral health organizations must have a plan for continuing care during natural disasters or power outages.
What is a continuity of operations plan?
This standardized approach helps organizations identify, measure, and improve patient safety, quality, and care outcomes.
What is performance improvement (PI) or quality improvement (QI)?
When surveyors conduct building tours, they often look for these three key life safety features to be in working order and unobstructed.
What are fire doors, sprinklers, and alarm systems?
This is the mechanism a co-worker uses when they want to protect an individual’s information as it is transmitted or accessed electronically.
What is encryption?
This evidence-based tool is recommended for creating individualized safety plans with clients at risk for suicide.
What is the Stanley-Brown Safety Plan?
This required assessment helps organizations identify, prioritize, and plan for potential risks such as natural disasters, utility failures, or violence.
What is a Hazard Vulnerability Analysis (HVA)?