Regulatory Body Fun Facts
This government organization allows TJC to conduct surveys in lieu of their own
What is CMS?
This must be done upon entering and exiting patient rooms.
What is hand hygiene?
This must be completed by providers involved to confirm the correct patient, procedure, and site.
What is time out?
Physicians should document this note within 24 hours of admission.
What is H&P?
Non-violent restraints orders must be renewed at this frequency (if still clinically appropriate).
What is every 24 hours?
The frequency The Joint Commission Hospital Accreditation Program surveys occur
What is every three years?
Soiled PPE should be disposed here.
What are biohazardous waste bins?
This must be completed and verified prior to a procedure.
What is informed consent?
This must be done prior to PO intake.
What is swallow screen?
These must be tried prior to the use of restraints/seclusion.
What are alternative/less restrictive interventions?
Alongside TJC, this organization plays a key role in regulating California healthcare facilities
What is the California Department of Public Health (CDPH)?
Note: CDPH also works often with CMS.
This is done by patients as best practice every day to reduce hospital-acquired infections (HAIs).
What is CHG bathing?
What are name and role?
AOTA, APTA, ASHA
What are organizations that set recommendations and practice guidelines for rehab professionals?
Violent restraints must be renewed at this frequency.
What is every 4 hours? (for patients over the age of 18)
Accredited organizations are encouraged to report these types of events to TJC.
What are sentinel events*?
*Sentinel events: patient safety event that reaches a patient and results in death, severe harm, or permanent harm.
This team is responsible for the surveillance, prevention, and control of healthcare-associated infections (HAIs) and other infectious diseases.
What is IPCD (Infection Prevention and Control Department?)
This should be used to mark the procedural site.
What is a marker?
Falls slowly from spoon and can be sipped through a straw or from a cup.
What is mildly thick liquids?
These two government agencies are notified if we suspect restraints hastened a patient's death
What is CDPH and CMS?
You receive an email
What is how you know TJC is onsite?
Green Curos caps should NOT be used on these types of lines.
What are dialysis catheters?
Per current policy, surgical marking includes this.
What are the initials of the LIP/APP performing the procedure?
Bobby pins, temperature probes, metal shrapnel from a GSW
What are things that are not MRI compatible?
These 7 elements must be assessed and documented every 2 hours when patients are in non-violent restraints.
What are:
1) Safe positioning
2) Skin & circulation
3) Mental status/level of agitation
4) Reposition & range of motion
5) Fluids & food
6) Elimination
7) Alternative interventions?