Volume 2025 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
Compliance tips for:
Compliance tips for:
The intent of the standard is to ensure that adequate information is provided to all patients to allow full exercise of their rights.
The intent of the standard is to minimize safety risks through proactive patient screening and regular assessment of environmental risks. When a risk is identified, the expectation is that mitigating actions will be defined and enacted. ■ Audit patient records for inclusion of results of screening for risk of harm to self or others. ٝ When an at risk patient is identified, audit for evidence of mitigation efforts, e.g., one-on-one monitoring. ■ Create a checklist for use during environmental rounding that includes a focus on ligature risk points, and unsecured medications and supplies. ■ Research and identify potential screening tools.
Nerd Newbies (understand the requirement)
Nerd Newbies (understand the requirement)
■ Audit admission packets for inclusion of patient rights information that is clear and legible. ■ Audit medical records for documentation that patient rights information was received. ■ Observe for posted signage throughout the hospital including its outpatient settings. ■ Review policies to ensure that requirements are implemented. ■ Conduct staff training for how to identify the appropriate representative in order to maintain patient rights in cases where the patient is incapacitated.
Nerd Apprentices (audit for excellence)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Nerd Trailblazers (prepare the path for others)
CHAPTER 08: SURGICAL SERVICES 08.00.06 Informed consent Frequency of the citation: 56%
06.10.08 Patient and safety: Safe setting Frequency of the citation: 44%
Overview of the requirement: The hospital has established protocols to promote a safe environment including means to minimize risk for patients identified to be at risk for harm to self or others. Comment on deficiencies: Compliance is assessed through direct observation and document review. Surveyors noted a lack of screening protocols and environmental safeguards. Examples of ACHC Surveyor findings: ■ Patients presenting to the ED were not screened for risk of harm to self or others. ■ Unsecured needles and syringes (35+) were observed in the preoperative area. ■ The hospital lacked evidence that it had policies and procedures for screening patients for risk of harm to self or others, identifying environmental safety risks, and educating staff and volunteers on these topics. ■ Four of four patients identified as high risk for self-harm were not visually monitored as required by the policy “Psychiatric/Suicide Risk Patient.”
Overview of the requirement: A patient must provide informed consent to proceed with procedural care. The consent form includes a minimum set of defined items, including explanation of the risks and consequences of the proposed treatment, probability of success, and who will perform elements of the surgical intervention. Comment on deficiencies: Compliance with this standard is assessed through medical record review. Most findings noted that the surgeon’s dated and timed signature was missing or that other participants in the procedure were not identified on the consent. Examples of ACHC Surveyor findings: ■ Consents were missing the name of the physician assistant who assisted in the surgery and performed the closing. ■ Provider signatures were missing from surgical consent forms. ■ The procedure was identified using medical terminology and not explained in simple language. ■ Consents did not identify the type of anesthesia to be used.
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