Commonly missed survey criteria

Everything but the kitchen sink

Just what areas do agencies fail to prepare for adequately prior to a Joint Commission survey? Just about all of them, says Martha George, owner of Healthcare Accreditation Consultants, a consulting firm in Spring Hill, TN. (See related story on preparing for an accreditation survey, p. 170.)

Here’s her top 10 list:

1. Infection control. Staff remember hand washing, but agencies often forget infection surveillance and tracking.

2. Safety. Agencies forget to consider fire safety plans and evacuation routes. Staff security also is often overlooked.

3. Human resources. Mistakes here are legion, says George. You might have a personnel record, but do you know you have to have health files that contain results of TB skin tests and hepatitis B Waivers? Do you know the health file has to be separated from the personnel record?

And don’t forget about staff education and competency, says George. "Think of every type of procedure your staff does and write it on a list or create a form," she says. "Check each one off as they do an inservice or skill lab. This is much easier than trying to get it done in a week."

Then trend and analyze the results, she says. "Agencies don’t do this because they sometimes don’t know how. The terminology to aggregate the results’ makes it sound more complex than it is. It can be intimidating, but all you have to do is have written tests after an inservice. Grade the tests, see how they score, and note what questions are missed. This is identifying a learning need through aggregating and trending data. Simple."

4. Contracting. "There are certain things outlined by the Joint Commission that you should have in your contract, but legalese is hard to read. Agencies forget to compare their contracts with the commission list and they are cited for it."

5. Ethics. While she has never seen a Type 1 issued for ethics mistakes, George says there are a couple areas that people often miss. "One thing that is easy to correct is marking on your brochures which services you provide and which ones are contracted to others. People always miss that, but all you have to do is put an asterisk after that service and a small footnote that this is handled through contract."

6. Leadership. Agencies overlook financial questions. (For a list of some of those questions, see box on p. 170.)

7. Physician licensing. You have to come up with a method to verify each physician’s license, she says. George suggests using the State Board of Medical Examiners or the Joint Commission-accredited hospital you are near or associated with.

8. Orders. Many companies get caught for not being specific or missing something on their orders. One client had a caregiver for an Alzheimer’s patient use a bed sheet to restrain the patient while using a lift. The company received a Type 1 with one month report because there was no order for restraint.

9. Medication Profiles. Be sure, says George, that your medication profiles include everything. Don’t forget over-the-counter, herbal, and home remedies. Make sure your medication profile matches the 485 exactly.

10. Consistency. Your notes should match your order (485s or supplementals) and should also match your medication profiles.

George says she is seeing a lot of problems with physician orders these days. "These seem simple, but they can be very tricky," she says. "Pay special attention to them, because with new standards, they can be more bothersome than they have been in the past, and if you get a recommendation on these, you may trigger recommendations in other areas. Do lots and lots of chart and document reviews."