General Acute Care Hospital (GACH) Relicensing Survey
Things To Do Now to Be Ready for the Unannounced Survey
All Staff:
Keep RUHS badge visible.
Know the location of the nearest fire extinguishers.
Review R.A.C.E. fire information on CODE Badge Buddy.
Perform Hand Hygiene when entering or leaving a patient room, touching patient surroundings or belongings, or before donning gloves and after removing gloves.
Close disinfection wipe containers so they don’t dry out. Check expiration dates on wipe containers. If expired, discard.
Keep personal items, food, and drinks out of nursing stations and patient care areas.
Never prop doors open and ensure egress is clear in all corridors.
Maintain 18” clearance from ceilings for stored items, and ensure no items are stored in front of electrical panels. No corrugated cardboard.
Prevent waste bins and sharps containers from overflowing; always close properly.
Assure no patient labels are left on the label printer.
Nursing/Medical Staff:
Complete documentation: Care Plans up to date, patient’s understanding of teaching documented, assessments/re-assessments documented (including pain after medications), diet matches order, ordered medications given and documented, Nozin and CHG bath completed and documented. Restraints, if ordered, checklist up to date and physician order up to date.
Keep personal items, food, and drinks out of nursing stations, patient care areas, and off WOWs.
Don’t leave medications or test strips unattended.
Assure insulin vials have the patient label and the expiration date is visible.
Protect patient information, including defibrillator printouts.
Label IV tubing per policy.
Clean pill crushers after every use (no medication residue).
Check units for expired supplies, including items in the pantry and the Tube Feeding cart.
Assure Crash Cart Logs and Temperature Logs are up to date (no whiteout).
Clean/disinfect glucometers utilizing 2 bleach wipes: one wipe to clean and, the second wipe to disinfect.
Unsure how to answer a question asked by a Surveyor?
Inform the Surveyor you don’t have the answer, but you will acquire the information and get back to them. Contact your manager for additional instructions