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?
PASS
What is how you use the fire extinguisher? AND What is:
1. Pull the pin
2. Aim at the base of the fire
3. Squeeze the handle
4. Sweep from side to side
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.
After review of its geographic location, community, and population served; the care, treatment, and services it provides; and analysis of infection control data, the hospital puts together this plan for surveillance, prevention, and control activities.
What is its infection prevention and control program?
What are name and role?
AOTA, APTA, ASHA
What are organizations that set recommendations and practice guidelines for rehab professionals?
Used to communicate with patients in their preferred language
What is interpreters?
patient rights and education, infection control, medication management, and preventing medical errors
What are topics evaluated during the TJC survey?
Using the Urine Culture Collection Algorithm, the most common answer to this question is no.
What is, should I collect urine?
or Should I collect urine?
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?
Worn visibly and never left alone
What is your ID badge?
You receive an email
What is how you know TJC is onsite?
According to TJC, this group is accountable for the implementation, performance, and sustainability of the infection prevention and control program
What is the hospital's governing body?
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?
Safe positioning, Skin & circulation, Mental status/level of agitation, Reposition & range of motion, Fluids & food, Elimination, Alternative interventions, and appropriateness
What is the required assessment and documentation every 2 hours when a patient is in non-violent restraints?