Stroke Survey Review September 2012 Findings Reminders Observations

2 THANK YOU for your assistance with the personnel files during the Comprehensive Stroke Survey! Nutrition; Care Coordination; Speech Pathology; Radiology; Emergency Dept.; Rehab; Nursing; Patient Access Services; Quality Mgmt; Neurosurgery; Stroke Team

3 Docs Reviewed During HR/Competency Interview  License Verification Printouts  Other Certifications, such as BLS, ACLS, PALS, MICN  Job Description  Performance Evaluations for last two years  Annual Education  Annual Competencies  Specific Stroke Education

4 Observations For Licenses/Certifications When Prepping Personnel Files o Please make sure every required license and certification for a position is listed on the employee profile in the HR Competency Tracking System so it can be tracked and expiration dates can be met. o While many files did contain the required license verification printout, the printout date was NOT ALWAYS completed prior to the last expiration of the license.

5 Observations for Licenses/Certifications o Some staff have multiple licenses listed on the Board website, such as RN, NP, and Public Health Nurse. Please print them all for the files! o The only acceptable license verification is the timely printout from the Board website.  Copies of licenses cannot replace the verification printout from the Board website. They can be tampered with easily.  Late printouts that are past the license expiration date will not pass a surveyor’s inspection. It tells them we let someone work without verifying if a license is valid. o Education degrees – Documented on JDs

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10 Going Forward... Upcoming Surveys:  Transplant Survey  Patient Safety Licensing Survey  WW TJC Survey Same preparation process for all licensing visits:  Keep HR tracking up to date  Be aware of due dates and expiration dates  Review documents for completeness before entry and filing

11 Department-wide Responsibilities for Licenses  The HR Chapter of the licensing standards is not the Human Resource Department Chapter.  It’s a chapter about the qualifications of the people in our organization; the “human” resources of every dept.  Every dept./clinic is responsible for the requirements of their staff (the ‘human” resources), so their areas remain successful, productive and in compliance.  There are over 5,000 licensed staff members. Many with multiple credentials.  Therefore, license verifications are completed in the department by a designated person or people and must be a priority when it comes to meeting the expiration deadlines.  Your HR team and the HR Tracking System are your support network.