1. EOC: Semi-Annual Review of DOH Survey Citations, The Top 10!
Randy Benson
Executive Director
Rural Healthcare Quality Network
September, 2013

2. Survey Citations, The Top 10!
Learning Objectives:
1. List the top 10 DOH/Fire Marshal survey citations during the past six months
2. Discuss reasons why these citations were in the top ten
3. Identify what to do to avoid receiving a citation from the top ten list

3. Survey Citations, The Top 10!
#10 Disaster Plan Issues
Why: 1. Requirement for up-to-date disaster/ emergency response policies is in the RCWs
2. Disaster Plans are constantly changing and evolving.
3. Hospitals fail to review/revise annually
4. Hospitals fail to exercise the disaster plan a minimum of twice yearly

4. Survey Citations, The Top 10!
#10 Disaster Plan Issues
Why: (cont.)
5. Safety Committee did not approve the policies or they were not signed off on by the CEO, Chief of the Medical Staff and Board representative
6. Disaster/Emergency Response plan was not comprehensive or facility specific

5. Survey Citations, The Top 10!
#10 Disaster Plan Issues
What to do:
1. Review/revise the plan annual and document
2. Exercise the plan at least twice a year and do a thorough evaluation of the drills
3. If you use a plan that someone else wrote, be sure to customize it to your needs and facility

6. Survey Citations, The Top 10!
#9 Safety Committee Issues
Why: 1. Committee not properly organized
2. Committee does not meet often enough
3. Committee does not have a set of goals and objectives
4. Committee does not annually report to the Board or Administration

7. Survey Citations, The Top 10!
#9 Safety Committee Issues
What to do:
1. Assure that the committee has both staff and management representatives
2. The committee must have an annual set of goals and objectives which are covered in the annual report to Administration and/or the Board
3. The committee must meet at least quarterly and detailed minutes kept of all meetings

8. Survey Citations, The Top 10!
#8 EOC Management Plan Issues
Why: 1. Engineering/Physical Plant failed to develop a written EOC management plan (WAC )
2. Engineering/Physical Plant failed to produce an annual report based on their EOC Management Plan
3. The EOC management plan was not share with Administration or the Board

9. Survey Citations, The Top 10!
#8 EOC Management Plan Issues
What to do:
1. Develop an annual comprehensive EOC management plan that covers all 7/8 areas of the EOC.
2. Write an annual report that covers all 7/8 areas of the EOC plan and make sure that it is seen and approved by the Safety Committee, Administration and the Board

10. Survey Citations, The Top 10!
#7 Equipment Preventive Maintenance (PM) Issues
Why: 1. Engineering/Physical Plant does not do an annual PM of all equipment (e.g. wheelchairs)
2. Engineering/Physical Plant did not keep adequate records of all PMs
3. PMs were not done according to hospital policy

11. Survey Citations, The Top 10!
#7 Equipment Preventive Maintenance (PM) Issues
What to do:
1. Assure that the equipment PM policy covers everything related to patient care (refrigerators)
2. Assure that all equipment is PM’d according to policy and proper documentation is kept
3. Keep competency records on outside vendors

12. Survey Citations, The Top 10!
#6 Fire Drills
Why:
The requisite number of fire drills were not conducted.
Fire drills were not fully evaluated
Fire Drills were not held for all shifts and weekends

13. Survey Citations, The Top 10!
#6 Fire Drills
What to do:
1. Conduct fire drills according to hospital and fire marshal policy.
2. Assure that everyone (all departments) are evaluated at the end of a fire drill
3. Training is conducted in all departments annually

14. Survey Citations, The Top 10!
#5 Food Service Issues
Why:
1. Refrigerator temperatures not taken daily
2. Lack of proper sanitation (e.g. hair cover, gloves, shipping containers)
3. Failure to maintain proper food temperatures

15. Survey Citations, The Top 10!
#5 Food Service Issues
What to do:
1. Keep daily refrigerator/freezer temperatures
2. Assure that staff are always wearing hair nets/caps
3. Staff wear gloves appropriately
4. Hand hygiene
Vegetable and meat preparation sites

16. Survey Citations, The Top 10!
#4 Clutter in hallways
Why:
1. Blocks evacuation of patients and staff via identified evacuation route.
2. Creates a trip or fall hazard
3. Potential access to HIPAA protected patient information (laptops on stands)

17. Survey Citations, The Top 10!
#4 Clutter in hallways
What to do:
Remove all equipment, carts, wheelchairs, etc. from fire evacuation hallways
Assure that laptops on stands do not allow unauthorized access to protected health information
Only code carts and isolation carts may be parked in hallways

18. Survey Citations, The Top 10!
#3 Infection Prevention Issues
Why:
1. Dust
2. Failure to include IP in remodeling supervision
3. Policies
4. Infection preventionist competency

19. Survey Citations, The Top 10!
#3 Infection Prevention Issues
What to do:
Be ever vigilant for dust (e.g. high dust, dirty floors, light fixtures, equipment, etc.
IP rounds of remodeling projects (prevent dust penetration)
Keep extensive documentation of compliance with IP standards and practitioner competency (e.g. education, experience, policy reviews/revisions

20. Survey Citations, The Top 10!
#2 Staff Competency
Why:
1. WAC (3) mandates that all staffs are competent to do work for which they were hired
2. The issue is most often a lack of documentation, not a lack of competency
3. Lack of documentation for non-clinical departments

21. Survey Citations, The Top 10!
#2 Staff Competency
What to do:
1. Develop a full list all competencies for each job description
2. Complete a review of competency annually (in association with the employee’s evaluation)
3. Submit the competency assessments and evaluations to HR

22. Survey Citations, The Top 10!
#1 Air Flow Issues
Why: 1. Impacts infection prevention, EOC management plan, Patient Safety, Fire Plan
2. Failure to check air flow regularly
3. Failure to provide a safe environment for patient care

23. Survey Citations, The Top 10!
#1 Air Flow Issues
What to do:
1. Check all air flow requirements on a regular basis (e.g. dirty utility rooms, clean utility rooms, procedure rooms, O.R.s)
2. Be aware of and comply with all patient isolation requirement for air flow
3. Report all air flow checks (especially problems ) to the Safety Committee routinely

24. Survey Citations, The Top 10!
Questions?

25. Survey Citations, The Top 10!
Randy Benson
RHQN Executive Director