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Chapter 4 Human Resources
Chapter 7 Infection Control
Chapter 16
Nursing
Chapter 13
Life Safety
Chapter 12
QAPI
100
This includes certification, minimum qualifications, training and education requirements, and permits (such as food handlers permits).
What is Licensure.
100
This person has been designated as Infection Control Officer (ICO) or officers to develop and implement policies governing control of infections and communicable diseases
What is Robin Young
100
This Person must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the
What is Jeri Shaffer (CNO)
100
Exits shall be marked by an approved sign readily visible from any direction of exit access and be illuminated. Illuminated signs must be legible in both the normal and emergency lighting mode.
What is Signage
100
The hospital must use the data collected to identify opportunities for improvement and changes that will lead to improvement.
What is Quality Improvement Program Activities.
200
Some of these may result in external or internal mechanisms for certification. Maintenance of such competence is considered in the design of these policies and procedures.
What is Competency.
200
Effective means are in place for preventing / controlling the transmission of infection among pa-tients and personnel.
What is Infection Control Precautions.
200
The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse,
What is 24-Hour Provision of Services
200
This system shall transmit an appropriate signal to an offsite monitoring station, or directly to the emergency response force.
What is Fire alarm system
200
The hospital has a process to documentation each performance project, including: 1. Reason for selecting the performance improvement project 2. Initial baseline data to support the performance improvement project 3. Ongoing data that demonstrates progress with improving healthcare for each project 4. Timelines for each phase of the performance improvement project 5. Data to support sustained improvement
What is Performance Improvement Projects
300
Fair Labor practices, Equal Employment Opportunity standards, and etc. Employee handbooks, human resource manuals, and other documents outline facility standards regarding nondiscrimination practices with concomitant personnel expectations.
What is Federal Employment Regulations.
300
There is a mechanism for investigating infections, particularly those occurring in clusters.
What is Infection Clusters.
300
1. Are initiated as soon as possible after admission for each patient. 2. Describe patient goals and address, as appropriate, the physiological and psychosocial factors as well as discharge planning.
What is Plan of Care
300
In case of a fire all employees must remember these acronyms
What is RACE and PASS
300
The hospital has an approved methodology for performance improvement projects
What is PDCA
400
The period of orientation is docu-mented and may vary according to the classification of the professional, support staff, agency or contractual, volunteer, student, etc., including prior experience(s).
What is New Employee Orientation.
400
Prevention of person-to-person transmission of infections. Explicit organizational policies and procedures are in place regarding hand decontamination and the prevention of nosocomial infections which include: A. Use of alcohol-based hand rubs. B. Surgical hand antisepsis. C. Elimination of the use of artificial nails for ALL staff working in intensive care units and operating
What is Hand-Washing Guidelines.
400
All orders for drugs and biologicals, with the exception of influenza and pneumococcal vaccines, must be documented and signed by a practitioner who is responsible for the care of the patient, as specified under §482.12(c), or who is another practitioner who is authorized by hospital policy and medical staff bylaws, rules and regulations, and who is acting in accordance with State law, including scope of practice
What is Medication Orders
400
During this phase of a fire all doors must be closed
What is C (contain)
400
The participants in the committee / function shall include individuals within the organization who have the expertise necessary to review and improve the processes that affect outcomes.
What is the quality committee
500
Hospital policy defines the information to be provided on the identification badge. Minimally, the badge should include:  First name  Job title
What is Employee Identification System.
500
Influenza vaccinations will be made available to all healthcare workers. The vaccination status of all employees will be maintained; employees refusing vaccination shall have such refusal noted. These guidelines take place in which department
What is Employee Health
500
These orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter it into a computer (in the case of a hospital with an electronic prescribing system) without delaying treatment.
What is a verbal order
500
In case of fire a Code Red must be called to this number
What is 3333
500
The quality manager has received formal training in principles of quality improvement to prepare the individual for the required duties.
What is Leslie Thomas-Muldrow