Regulatory Hot Topic: How to Prepare for Possible GACH Survey

RUHS – Medical Center is overdue for an unannounced five-day compliance survey and staff are asked to be prepared by following important rules and procedures.

The General Acute Care Hospital Relicensing Survey (GACHRLS) promotes quality hospital care by verifying hospitals are in compliance with state regulations.

Staff should follow the guidelines below:

All Staff:

• Keep RUHS badge visible.

• Know the location of nearest fire extinguishers.

• Review R.A.C.E. fire information on CODE card attached to RUHS employee badge.

• Perform hand hygiene in each of the following circumstances:

  • When entering or leaving a patient room

  • When touching patient surroundings or belongings

  • Before donning gloves

  • After removing gloves

• Close disinfection wipe containers so they don’t dry out. Check expiration dates on wipe containers and discard if expired.

• Keep personal items, food and drinks out of nursing stations and patient care areas.

• Never prop doors open and assure egress is clear in all corridors.

• Maintain 18-inch clearance from ceilings for stored items, and assure no items are stored in front of electrical panels. No corrugated cardboard.

• Prevent waste bins and sharps containers from overflowing. Always close them properly.

• Assure no patient labels are left on the label printer.

Nursing/Medical Staff:

• Complete documentation

  • Make sure care plans are up to date

  • Patients understanding of teaching is documented

  • Assessments and reassessments are documented (including pain after medication);

  • Diet matches order

  • Nozin and CHC bath are completed and documented

  • All appropriate education is documented

  • Restraints checklist up to date (if restraints were ordered)

  • Physician order is up to date.

• Keep personal items, food, and drinks out of nursing stations and patient care areas, and off Workstations on Wheels (WOWs).

• Don’t leave medications or test strips unattended.

• Assure insulin vials have patient label and expiration date visible.

• Protect patient information, including on defibrillator printouts.

• Label IV tubing per policy.

• Clean pill crushers after every use (no medication residue).

• Check units for expired supplies, including items in pantry and in Tube Feeding cart.

• Assure Crash Cart Logs and Temperature Logs are up to date (no white out).

• Clean/disinfect glucometers utilizing 2 bleach wipes: one wipe to clean, 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.

If you have questions about any of the above guidance, please contact Betty Lyons by emailing b.lyons@RUHealth.org