JC Basics
How are patients informed of their rights?
Brochures are available in the waiting room/check in area in all practices. Also, patients sign consent to treat at intake.
Patients receive a copy patient rights at Intake
Name two of the 2025 National Patient Safety Goals.
What is
Where are the Fire Extinguishers and Pull Stations located?
What are all hallways (4 total).
What are areas of Egress- the front and rear exits have pull stations so that you can alarm as you evacuate.
When you document a session with a patient, what three elements must always be present?
What are:
1) Name of the person(s) seen
2) Modality (in person/phone/telehealth)
3) Time Spent
What compliance, quality, and performance data is collected? How are you involved?
What is Quarterly Chart Audits - If there are any deficiencies than a plan is developed on how to improve that outcome.
Survey data collected at discharge.
PHQ-9 and GAD-7 scores taken at intake, follow-up, and discharge.
What is "tracer methodology"?
Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.
Name the most important way to reduce the risk of health-care associated infections in your department.
What is Handwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 15 seconds. Alcohol-based hand rubs may be used if there is no visible soiling.
What do you do if you are concerned about a perceived threat or acts of hostility?
What is seek safety (run)
Hide (in a locked room- preferably without door window)
Fight (as a last resort)
Call 911.
When is the EOC opened, and the Treatment Plan due for completion?
What is EOC opened on day of scheduled admission, and Treatment Plan completed by the end of the 3rd treatment day?
Maggie is starting her shift. She walks down the hall, Starbucks in hand, and waves "hi" to the front desk staff. She rounds the corner, going through the propped open side door to the main office. She takes out her breakfast sandwich and dumps her empty coffee cup in the trash. Where's the TJC violation?
What is doors may not be propped open.
What is HIPAA? Name one way protected health information is kept private at APHP.
HIPAA: Health Insurance Portability and Accountability ACT. HIPAA States, PHI may only be used for purposes of treatment, payment, healthcare operations. Other ways to protect PHI (1) Dispose of PHI per policy (2) don't discuss patient information in the hallway, (3) keep office doors closed, (4) lock computer screens.
How do we manage Environmental/Ligature Risk at APHP?
1. Annual review and update of the assessment of environment.
2. Per policy, staff monitor clinical acuity and suicide risk.
3. Patient will not be left alone in room if acutely suicidal.
4. If patient leaves a session in distress, clinician will follow patient for 1:1 assessment and triage to appropriate intervention.
What do RACE and PASS mnemonics stand for when there is a fire?
What is R - Rescue patients and others, A- Alarm, C- Contain the fire (close doors), E- Extinguish the fire when it is safe to do so or E - Evacuate
P- Pull the pin, A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle from side to side
True or False- You can use Google Translate for Interpreting a letter sent to the patient.
False: Interpreter Services will Translate letters for you. Please provide some lead time and alert them to your timeline.
JC and OMH Require that we utilize standardized measures to guide our treatment. Name 1 of the standardized measures that we use.
What is:
PHQ9-(Patient Health Questionnaire-9) is a widely used tool for screening, diagnosing, and monitoring depression.
GAD-7 (The Generalized Anxiety Disorder 7-item) is a easy to perform initial screening tool for generalized anxiety disorder.
How can you respond if you do not know the answer to a surveyor's question
I would be happy to get that answer for you right away.
Name 3 times when we are required to complete a CSSRS and review/update the safety plan?
1) During the intake assessment
2) When the clinical presentation changes
3) There are new/increasing psychosocial stressors
4) During crisis sessions/safety assessment sessions
5) Clinical judgment indicates increased risk
6) When patients unexpectedly request to leave early
In a patient emergency who must be alerted -right away
Who is:
1) an administrator who can take charge (help coordinate a response)
2) additional staff to assist in maintaining safety
3) call public safety
True or false Can a family member translate if they are clearly fluent in both languages and the patient consents to using them as the interpreter?
What is False! You need qualified Interpreter.
What is Live Interpretation Can be requested via Interpreter Services. Ask Brenda for assistance in initiating this, or when necessary use Cyracom or Language Line.
Where is our Emergency Equipment located and what do we have?
Main office: Defibrillator with pads, Narcan kits, Red emergency box that includes Ambu bags (both child and adult), bleeding control kit
Anne’s office: Medication box that includes syringes, epinephrine, Benadryl PO and IM.
How often are fire drills conducted?
What are fire drills 2x per year.
What tool is used to assess Suicide Risk? When is this conducted.
Columbia Suicide Severity Risk Scale - CSSRS
At the time of Intake and anytime that a change in risk is suspected/reported.
When patients leave without telling anyone, what steps do we take to assure their safety?
1) Send an inbasket to the team whenever we don't know where a patient is.
2) Call the patient (multiple times in a row if there is no answer).
3) Call collateral with ROI (if it is an emergency, call any/all #'s in the chart).
4) MCT referral.
If a patient becomes dysregulated and bolts out of the group room, what does the group therapist do?
Excuse yourself from the group and follow the patient to help them find their way to a therapist, RN, or NP for further assessment and assistance.
Option to press their distress button for further assistance if needed.
I have no idea how to answer that question, please don't bother me I am busy and that is a stupid policy anyway.
What is something you would never say to a surveyor!