Volume 2024 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
CHAPTER 05: STAFFING 05.05.03 Evaluation of competence Overview of the requirement:
An objective process for competency assessment is defined and occurs at least annually. Compliance is evaluated through document review. Deficiencies noted a failure to follow hospital policy regarding competency assessment.
Comment on deficiencies:
Frequency of citation:
38%
Examples of surveyor findings:
n Seven of fourteen files reviewed lacked evidence of a 60-day evaluation as required by hospital policy. n Contract employees are provided training on compliance, computer security, and other administrative items, as well as avoidance of risk (falls, universal precautions, etc.) and emergency management, but the hospital failed to evidence hospital- specific training and competency requirements for these employees. n The sterile processing department could not provide initial competencies for sterile processing techs. n Establish competencies for all roles. Assess at onboarding, at least annually, and if job responsibilities change. n Assess competencies for contracted staff as well as employed staff. n Review your policies. If you have defined time frames for evaluation, ensure that they are followed, with results documented.
CRITICAL ACCESS HOSPITAL ACCREDITATION
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 05.05.03 06.03.08 06.08.09 06.08.12 06.10.02 07.01.00 08.00.06 16.00.07 16.00.08 16.00.17 17.01.06 17.01.11 18.02.01 18.05.04 FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN CRITICAL ACCESS HOSPITALS
Tips for complianc e:
CHAPTER 06: PROVISION OF SERVICES 06.03 | Nutritional Services
06.03.08 Policy requirements: Food preparation and storage 06.03.09 Lighting, ventilation, and temperature control
Overview of the requirement:
Policies and procedures define refrigeration/storage and preparation of food across all patient care areas to maintain quality and safety. Compliance is assessed through direct observation, interview, and review of policies and procedures. The standard is designed to address a consistent approach to managing food safety. Most deficiencies were cited for deviation from written policies and procedures, or failure to take action when temperature readings fell out of range.
Comment on deficiencies:
Frequency of citation:
06.03.08: 46%; 06.03.09: 38%
Surgical Services
Infection Prevention & Control and Antibiotic Stewardship
Staffing
Provision of Services
Medical Records
Restraints
Emergency Management
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