Infection Control
Documentation
Safety
Ethics
Surveyor Says
100

First action taken if a resident develops a cough and fever.

What is:  Initiate appropriate precautions and notify Clinical Lead and Physician?

100

Date/Time/Signature/Credentials and objective documentation.

What are: Details that must be included in every chart entry?

100

The hazard created when supply boxes block a hallway exit.

What is: Fire and evacuation hazard?

100

The principle related to a resident refusing to take medications?

What is:  The right to choose and have autonomy?

100

Surveyor says "Do you know where to find Health and Safety information?"

What is: Surge and Health and Safety binder in the Home Center?

200

This is how long hand hygiene needs to be performed with Alcohol Based Hand Rub.

What is:  15-20 secs (until hands are dry)?

200

Missing from "Resident is comfortable".

What are:  Supporting details/assessment/evidence?

200

Interventions to implement when a resident is identified as high risk for falls.

What are: Ensure engagement of bed alarm, more frequent safety checks, ensuring bed is in the lowest position, place fall mat, non-slip footwear?

200

Your resident is in obvious pain but refusing scheduled and prn medications so you strongly share that they are making the wrong choice.

True or False

What is:  False?

200

Surveyor says "Tell me about your Care Plan".

What is: It includes all Domains and it is personalized to meet each resident's needs/goals. It is updated nightly and prn.  Family are included in circle of care and goals of care?

300

This standard has been missed when a staff member enters a room wearing gloves but without eye protection when doing a splash-risk procedure.

What is:  The appropriate PPE selection based on the point-of-care risk assessment?

300

Problem related to undocumented symptoms.

What is:  Incomplete communication and continuity of care risk?

300

The importance of the Emergency Binder during a fire drill.

What is: It contains emergency procedures and resource locations?

300

These steps can be taken when a resident practices a faith and has beliefs that are unfamiliar or even opposing to your own.

What are:  Respect/support the resident's right to their own beliefs, ask if they might like a Spiritual Care referral, ask what we can do to support their faith, educate ourselves, update the Care Plan?

300

Surveyor says "How does your hospice use quality improvement to enhance resident and family care "?

What are:  The hospice conducts audits, surveys, incident reporting/review, education, performance reviews, feedback and checking with resident/family re: hospice experience?

400

"Dirty" (used supplies) left on bedside table after care causes this.

What is: Infection Prevention and Control and environmental safety risk?

400

Documentation required after a medication error.

What are: Noting objective facts, completing incident report, and following disclosure procedures?

400

Steps you take when you discover a safety hazard or witness an incident?

What is: ensure immediate safety, report concern, document as per policy and initiate any appropriate follow-up actions?

400

This has happened if others overhear a confidential conversation about a resident that has taken place in a public space.

What is: a breach of privacy/confidentiality?

400

Surveyor says "Demonstrate your emergency preparedness for maintaining a safe environment for residents, families and staff".

What are: Taking part in Monthly drills, knowing where to find related policies in Surge / S;drive and Home Center, required review of polices assigned on Surge?

500

This is a disqualifier for hospice.

What is CDiff?

500

“How does accurate documentation support safe, high-quality hospice care?”

What is: It supports communication, continuity of care, clinical decision-making, legal accountability, resident safety, and quality improvement.

500

This is where emergency policies can be found.

What is: The Home Center in the red ER Binder and on Surge?

500

What to do when family says they do not want staff to discuss prognosis with their loved one but your resident asks you a direct question.

What is:  Answer the question truthfully?

500

Surveyor says "How do you ensure that consent is informed"?

What is:  Our consent includes a Privacy and Confidentiality Statement given to SDM/POA on admission to keep for better understanding?