Environment of Care
Infection Prevention
Surveyor Interaction
Procedural Areas
Medical Records
100

Clean items can be stored in Dirty Utility rooms

What is FALSE

100

These should never be worn in the hall unless actively providing patient care

What are: gloves

100
When the surveyors ask what QI/PI projects are in progress...

What is: take them to the QI/PI boards 

100
Standing still, attention on the person speaking/white board with patient information

What is: how to participate in a Time Out

100

30 days or less

What is: How long an H&P is valid for

200

This type of dusting should be done at the beginning of each day 

What is: High Level Dusting

200

Personal drinks should be stored here

What is: the designated hydration station

200

If the surveyors ask about Sentinel Events...

What is: state "Our Risk Mangement department handles Sentinel Events"

200

Where the Time Out is read from

What is the Informed Consent for the procedure

200

Good only for the current procedure, others are good for current admission

What are: procedure and moderate sedation consents

300

These areas must never be blocked by stretchers, wheelchairs, beds, carts, etc.

What are egresses, fire extinguishers, fire alarm pulls, gas shutoff valves, and electrical panels

300

This is where PPE worn in isolation rooms should be removed

What is: before exiting the room

300

How to answer surveyor's questions

What is: directly and concisely

300

BEFORE the patient is taken to the procedure room

When is: Sedation Assessment/H&P update completed

300

Screening performed on EVERY patient at admission

What is: suicide and abuse 

400

This is how glucometers are cleaned

What is: using bleach only, squeeze out excess fluid and wipe front and back of meter, dry, then using new wipe with excess fluid squeezed out, 3 vertical/3 horizontal swipes on front, then same process for the back, allow to air dry

400

1 minute for Hydrogen Peroxide, 3 minutes for Bleach

What is: WET time for disinfectant wipes

400

Phrases to avoid when talking to surveyors

What are: "I usually", "I almost always", "What we try to do is", etc. 

400

Immediately after being added to the field and/or after drawing up whole dose, but only administering a partial dose

When is: medication labeled

400

Must be included if an interpreter is used for consent

What is: Interpreter name and ID number, whether in person or iPad

500

What is FRESHA, and what does each letter stand for?

What is: Fire, Respiratory, Engineering, Security, House Coordinator, Anesthesia - authority to turn off medical gases

500

This is done before instruments are taken to SPD for processing

What is: Pre clean instruments and saturate with Pre-Klenz

500

Joint Commission surveyors expect you to know all the answers 

What is: False - know your resources

500

3 minutes

What is: dry time for Chlorprep

500

Proper completion of Patient Transfer to Outside Facility form

What is: Part I completed and signed by MD, Part III completed and signed by RN and EMS. Part II signed by patient if able to sign

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