Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
CHAPTER 04: ORGANIZATIONAL STRUCTURE 04.01.02 Oversight of patient care supplies Frequency of the citation: 44%
Overview of the requirement: Supplies intended for care of patients are maintained in usable condition. A process is in place to remove expired products and effectively manage recalls. Comment on deficiencies: Compliance is evaluated through document review. Most deficiencies noted that a recall process was not fully documented. Examples of ACHC Surveyor findings: ■ The hospital did not have a log to verify that all elements of the recall process were completed. ■ An electronic log and tracking system is being implemented but was not operational during the survey and an existing recall log was not available for review. ■ The medical-surgical crash cart included expired supplies. Safety needles and the IV tubing for a pain pump in the intensive care unit clean utility room were four- to six-months expired.
CRITICAL ACCESS HOSPITAL ACCREDITATION
FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN CRITICAL ACCESS HOSPITALS
Compliance tips for:
The intent of the standard is to ensure accountability for the presence of adequate supplies to support the services provided. There must be a defined process for managing recalled products and for removing expired and/or contaminated supplies from inventory. ■ Audit supply areas regularly and rotate stock to minimize the risk of expired supplies being the only items available for patient care. ■ Audit crash carts and less frequently used storage locations. ■ Review the recall policy and logged documentation to ensure that it addresses: ٝ Receipt and distribution of recall notices. ٝ Verification of products within the hospital. ٝ Verification of recall removal of relevant items. (When? By whom?)
Nerd Newbies (understand the requirement)
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
04.01.02
06.03.08
06.03.09
06.10.01
06.10.08
08.00.06
08.03.06
16.00.17
18.02.01
Patient Rights
Restraints Infection Prevention & Control and Antibiotic Stewardship
Organizational Structure
Nutritional Services
Surgical Services
achc.org | (855) 937-2242 | 53
52
Made with FlippingBook - PDF hosting