EvaluatorLet’s focus on preparing for your upcoming regulatory visit (TJC, State Survey, CMS) by ensuring that you and your team are prepared to respond to the following hot topics that are frequently focused on by regulatory surveyors:

  • Be able to describe the Scope of Services in your unit/area/facility.  Ensure that you have a written Scope of Service.  Regulatory surveyors are reviewing Scopes of Services in detail.  It is recommended that your Scope of Service include organizational structure, hours of operation, age range of patients, patient population, if sedation/anesthesia used, licensed bed numbers, average daily census, number of visits, and average length of stay.
  • Be able to describe how your unit/area is/will be staffed.  Ensure that you have a written Staffing Plan.  Regulatory surveyors are reviewing unit Staffing Plans in detail.
  • Ensure that your staff personnel files are complete and up-to-date.  Regulatory surveyors are reviewing personnel files in great detail.  Everything needs to be complete and in order – for example, ensure there are no blanks, and job descriptions and competency documentation are signed and dated.
  • Be able to describe what competencies are required for staff to work in your unit/area.  For example, Operating Rooms may want to ensure that their staff are competent to handle a surgical fire if the situation arises or Cardiac Catheterization Labs may want to ensure that their staff are competent on cardiac rhythm interpretation.
  • Ensure that all licenses and certifications required to work in your unit/area are current and that primary source verification has been done.
  • Be able to describe the actions you take if a patient codes in your unit/area.  Ensure that you have a written Code Blue response and/or rapid response plan.
  • Know where your emergency equipment (Adult and/or Broselow Cart and/or emergency kits) is located.  Surveyors will ask you to show them your emergency equipment and often will want to open an emergency cart and check it thoroughly to ensure that the contents on top and inside the cart are complete and that there are no expired supplies and medications.  Surveyors will review lock changes.  They will want to verify that the emergency cart and/or emergency kit content lists have been reviewed and approved by your Pharmacy and Therapeutics Committee.
  • Be able to describe how your emergency cart and or emergency kits are being checked and who is responsible for these checks.  For example, know if your unit allows non-nurse categories (such as radiology technicians) to check emergency carts.  Regulatory surveyors will review the emergency cart check documentation.
  • Be able to describe how you test the defibrillator or AED located with the emergency cart and how often.  Be sure that you are following the manufacturer’s guidelines for testing your equipment.  Surveyors may ask you and your staff to demonstrate how you do this.  Surveyors may also ask how you know the batteries are charged (if applicable).
  • Know who has access to the Medication Room and other locations where medications are stored.  Determine if staff access is part of an employee’s Job Description. Surveyors can ask for your Policy related to Housekeeping being authorized to clean Medication Rooms or these other areas where medications are stored (like in the OR).
  • Be able to demonstrate your process for monitoring medication refrigerator temperatures and nutrition refrigerator temperatures.  Ensure that temperature settings are appropriate for the items that are stored.
  • Be able to describe your role in a fire, disaster or other emergency situation.  Surveyors will ask you and your staff for the location of fire extinguishers, pull stations, and evacuation plans and equipment.  Surveyors will ask all categories of employees who work in your unit/area, including Housekeeping, Respiratory Therapists, etc.
  • Be able to describe what products you and your staff use to clean and when and what gets cleaned.  Know the contact time for each product you have available in your unit/area.  Surveyors will look for standardized processes and answers for cleaning same types of equipment (such as, BP cuffs, computer equipment, monitors, etc.).

Have any questions related to your upcoming regulatory visit? Please visit us at www.consultHTS.com.

Contributed by Michele Rubin, Ph.D., MHSM and Debra Winter, RN, MS