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Notes From Anne's Desk - 2023

July 24, 2024

So sorry for the long delay! So busy…….Stay in Touch!!!

I am not getting any Incident Reports... What gives? Crank up the old scanning machines and get those documented and sent in!

Are you all set with your survey vendor? I had so hoped it wouldn’t happen, as the regulation had been postponed, I believe, twice before, but it goes into effect January, ’25.

Someone told me you no longer have to wash the OR walls for terminal cleaning, but I sure had not been able to find where it says that has been deleted, so keep it up until told otherwise!

Watch for new policies on temperature taking and Care of the Transgender Patient. I am researching formaldehyde dispensing, and high level disinfection.

OSHA says that wherever the staff person is exposed to blood or other potentially infectious body fluid, scrubs must be managed though a licensed laundry.

Hot here… some days stifling. We are busy doing a lot of home maintenance and repairs…..painting, painting, painting, but don’t be a stranger!

April 22, 2024

It’s a beautiful cool morning here in the Sunshine state…sitting on the front porch sipping my decaf! ….and thinking about the measles epidemic. I urge you to conduct the Infection Control study in which you are documenting your staff’s childhood immunzations. This should be part of their Employee Health documentation.

And, if you haven’t already, this inquiry should also be a routine question on the pre-op assessment. The new policy will be up soon.

April 17, 2024

Watch for some new policies regarding transgender patients, and revisions to the employee health program and age based assessments.

Do your staff members belong to their professional organizations? How is certification for the techs and the sterile processing technician going? Let me know.

April 5, 2024

Did you see that TB has broken out in some Chicago migrant centers following the measles? Get those tests done! Also, add to preop assessment. Watch out for signs and symptoms!

April 4, 2024

Joint Commission Accreditation Survey Results

I am listing some of the findings from a recent survey. While this is a Joint survey, since CMS is very standardized, therefore, you should read these and take any action needed.

Male sure you know what is to be cleaned with a high level disinfectant vs low.

Follow those physicians delivering patient care to determine that they are washing hands between patients.

Know and follow your policies to include your employee health requirement. Inspect your ceiling tile. …no spaces or stains.

Have your annual door inspection reports done and make sure any issues are corrected.

Make sure all circuit breakers are identified on the circuit directory.

Check to determine that your air pressures are accurate for positive and negative.

Extension cords cannot be used as permanent wiring.

Follow the ADA “Medical Staff File Preparation and Order” …also for Allied Health staff and employees.

Unless you have a compounding license you cannot mix drugs in a syringe. If you need to do this get an agreement with a local pharmacist to provide this.

Get those panic alarms for the generator in place. They cannot be installed on the generator itself, but need to be within 25-26 ft. from the generator.

It is important that when one of ADA’s consultants advise you what needs done, either in the Report of Visit or even on those Post-ems or the Periodic Performance Assessment Tools that I leave with you……this is not an invitation, but is required if you are going to do well.

Good luck and Do Well!

April 2, 2024

Hope you all had a fabulous Easter holiday. The weather here was fabulous. We had the traditional Easter Egg Hunt with plastic eggs scattered around the yard, but rather than filled with candy (two toddlers present), the eggs were filled with cute little toys like plastic dump trucks, etc. The wee ones were a little skeptical about all the excitement, but had a great time. Summer outdid herself with the ham dinner.

SURVEY FINDINGS

One of our clients had a truly challenging survey last week. I will provide a more detailed report before the week is out, but let me warn you that the surveyors are all over those IFUs. You better have them all together and the staff had better check them out thoroughly to make certain they are following the instructions to the letter.

Caio’

March 29, 2024

Wow! How time flies!!!! Please forgive the lateness of this communication. Many things have been happening in forms and policy changes as well as client staffing changes that have kept us hopping. Watch for changes.

Anne will be contacting you regarding the new format for all the policies that will make finding your policies on line a BREEZE!!!! We are so excited to be able to offer this innovative approach to policy accessibility to those clients who qualify. This is Stephanie’s baby and we are quite proud of it. The clients who have already qualified are totally in love with it and are thrilled with the difference it is making in efficiency.

Are you watching your forms changes? I know everyone is concerned about policy changes, but don’t forget that forms changes that you don’t identify can come back to bite you hard.

Watch all those inspection schedules making sure that you are having all the required inspections and maintenance activities done on schedule. Also make sure you stay current on keeping all your logs current.

You know your contract allows us to review your incident reports----trouble is we aren’t getting any?????? What’s happening? This goes for those clients whose contracts qualify for this service.

We have also been working on streamlining all the Officers’ Workbooks, so keep watching for these changes.

How many of you did the Diabetic Medication benchmark? It’s a good one, and one we would hope you capture, as there are parties that are gravely concerned about this issue…..very concerned!

Did you all find the 2024 Goals? Look at and evaluate the 2023 goals. Which were met? Which were not met? If not, you must say “Why not?”. Did you all get all the management plan evaluations done? How about those risk assessments?

Don’t forget those flu shots and the Annual Health History forms

Did you catch that your Medical Director must be ACLS certified? Did you put in the revised job descriptions for the Medical Director, OR Supervisor/Director and Administrative Director?

There is a new accreditation agency: The Accreditation Commission for Health Care. No, we haven’t worked with them yet.

When was the last time you did a MOLD CHECK? It is probably overdue! Check out your Resource Link on the Home Page for more Clinical Practice Guidelines. Are you using the ISMP (Institute for Safe Medication Practices)?

See you soon!

December 6, 2023

Greetings! Hope all of you had a great Thanksgiving Day with friends and family. Ours was fabulous. Summer and Stephanie out did themselves on the food…..the white chocolate cheesecake was my favorite!

It’s that time of year with the gathering of all information to complete all the “annual” reports, audits, studies, etc. Go to the workbooks and the schedules and complete all these to include evaluations. Check out the various schedules to make sure all are current.

Don’t forget that the Equipment Assessment Tools now must be complete on all equipment and supplies in the ORs. Check out the IFUs for the normal humidity and temperature ranges for the item. If you can’t find the info, check with the manufacturer.

Have all reports, etc. done in December to present to the Annual Meeting of the Governing Body in January!

More later…….

October 4, 2023

Beautiful day in Florida…and all week, actually…mid 80s with low humidity. You can’t beat it. House all festooned with autumn decorations…wonderful time of the year.

Changes:

We are working on Master Changes, so watch for these. Changes will be in both forms and documents but also in policies. Fire Alarm Log, Smoke Alarm Log, Time Out Competency form. We had previously changed the generator log to include the amperage and cool down.

If you don’t have the 24-7 refrigerator temperature gauge, this is a REQUIREMENT not an invitation! You have to be able to see the temperature over weekend and holidays.

When the Life Safety engineer performs the annual fire alarm system inspection and the sprinkler system, he must include the correct NFPA code on his report. Add this to your Fire Alarm log.

When you are checking the generator, also inspect for rust and note under comments...you can’t have that rust!

October 2, 2023

October already!!! This year has sped past me, or so it seems! Geeze!

Lots of memos coming from CMS. Some clarification regarding validation surveys includes that you might expect a medicare validation surveyor to accompany an accreditation surveyor. There will be no more black out dates and neither will there be a 7:30 am survey alert coming from the surveyors.

All these changes are to standardize the state, cms and accreditation surveys. If you have any questions, let us know.

September 18, 2023

Just a quick note to make sure all of you “deemed status” accredited centers got the information from CMS regarding validation surveys. No surprise to us, as we know CMS is far behind in conducting surveys, and have no $ to hire more staff to help them catch up. They have been ordered to do so, and, as such, are leaning on the accreditation organizations to do the “deemed status” surveys to take the pressure off. The recent announcement states that validation surveys will be conducted not by CMS anymore but by the accrediting organizations through direct observation conducted during the triennial surveys.

We have several surveys coming up, so will keep you posted.

August 30, 2023

HAPPY DAYS!
Happy September to you all! This is my favorite time of the year…..of course, it is my Birthday month. I love the fall colors and the cooler weather. Actually lovely here this weekend and today.

RETIRING? NOT ME!
Don’t be concerned about my retirement. After some really big soul searching we have decided to postpone such conversations. I love what I do. I am very healthy. I enjoy working with all of you and I still haven’t been able to find the benefits I don’t already have.

BENCHMARKING
Collaborating with Mary Sierra at Advanced Eye & Laser in Poland, Ohio. She wants to know what other centers are doing with the patients they have coming in who are taking the diabetic medications TRLICITY OR OZEMTIC? AS you know these drugs work by slowing down the emptying of the stomach in the digestive process. Patients have the sensation of “being full” because they are! The situation is that it is taking longer than our usual 8 Hours NPO for the stomach to empty. Consequently patients are vomiting and are aspirating in the preop and the operating rooms. The ASA is calling for the patient to NOT TAKE FOR ONE WHOLE WEEK PRIOR TO THEIR PROCEDURE.

How are you handling these patients? If you want to participate in this study, please send me a copy of your protocol. In the meantime I will be calling you!

August 30, 2023

Hurricanes Idalia and Franklin!!!

Pity the poor people who have moved to Florida this last year and have never been through one of these storms! We old die hards have a lot on our hands in separating all the hype from reality while the transplants just tale the news casters to heart. …long lines at the gas station, ATMs, ….grocery shelves empty or near empty. Now, don’t get me wrong.. We diehards remain prepared with canned food, water jugs full, gasoline cans also full….batteries on hand…..we just kinda live that way, but not in panic. Tampa and up to the Big Bend area are looking pretty bad…..pretty sure the “hype” has a high degree of reality there. The devastation from one of these storms can be incredible….send prayers.

August 28, 2023

Hello, all! It has been quite some time since last I posted. While I may not have posted, or been out on the road so much this last two months, it has been busy here at ADA working to make things more efficient. Exciting news on the horizon has to do with making changes in the program that will make you very happy if you are technologically inclined. Several clients already have this in place with more to be done. QUESTIONS? Call Stephanie @ 386-956-6649 or email her stephanielaradean@gmail.com.

Did you know that most of the ADA forms can be completed electronically?

Other:

Hope you are all staying cool. Hot, hot, hot here!!! Still cleaning up the yard from Spring….still purging everything…..still lots of home maintenance!!! Savanna off to her senior year at Highpoint University in No. Ca. Triston is now a senior in high school…Catherine still on Maui until April, but fires were on the other side of the mountain from her and Tyler’s place. Tyler is at Scripps in Jupitor researching antibiotic resistant TB.

Still looking for some more benchmarking ideas.

Caio

July 13, 2023

So, I got really excited reading a report from a recent survey ‘cause it sounded like we were no longer going to have to pull an alarm with each drill. But alas! No…according to NFPA-61 drills still have to be pulled with the possible exeption from 9pm to 6am when a “coded announcement” may be acceptable….so keep at it!

July 12, 2023

Hello to all!!! Zizzling hot here in the deep south of Florida tho’ some mornings there is a nice breeze.

If you are Joint Commission accredited pay heed that the Joint wants you to use a specific format for the annual evaluation of each of the plans. I have revised the form that was on the Online Center ---forms/notices and logs to the Environment of Care forms to the Management Plans. You will see the newly revised form called the annual Environment of Care Plan Review. Complete one for each of the plans: Hazardous Materials, Safety and Security, Life Safety, Utilities and Equipment. These correspond to the policies and will be due 12/23

Don’t forget to check for revised forms periodically. Working on policies.

Have a great day!

June 29, 2023

So hot here in Florida with heat indices over 105 degrees. It literally takes your breath away when you open the door to go outside! Hopefully, it will break this weekend.

We have been working on the recredentialing issue off and on for several weeks now. Online inquiries aren’t working, as mostly we don’t find any references to time frames for the recredentialing process. Now we have resorted to calling each state where we have clients. Not only is this tedious but a lot of the states have message centers now, so you don’t get a “live” body….

I am working on all the pandemic policies still and will alert you about any changes there.

Happy, happy 4th. We have the house fully festooned across the front porch and plan to leave Old Glory up all summer.

Caio’

June 23, 2023

Hello from rainy Florida! Love the storms as long as they aren’t hurricanes!

I hope you have read the results of the various surveys, especially as they impact your generator and HVAC systems.

Have you still got all your notices either run or in the binder in the waiting room?

How are your fire drills? Are you indicating which extinguisher was tested during your drill?

How are your competency assessments going? You only can be assessed by someone who has been assessed!!!

We are working on the master changes especially regarding credentialing and BMI…..Don’t forget the Time Out changes.

ADA made a lot of changes on forms this year so far with more to come, so when you need a form, make sure you are getting it from the ADA website and not some file somewhere.

Stay in touch!

Let’s have a moment of prayer for the adventurers on the Titan!

May 31, 2023

Hope your Memorial Day celebrations were awesome and that you all were able to remember loved ones who made the ultimate sacrifice.

Make sure all competency assessments include a demonstration as well as a test. I will take on revising the forms this month.

All waived testing should have controls and these need to be dated just like the test control.

Checking of the AED must include on and off of power. Same with the suction apparatus….remember that this must have back up battery back up. Are your anesthesia providers auscultating the heart and lungs “clear to auscultation”?

I had a physician tell me it was ridiculous to ban nail polishing and artificial nails from the OR and other patient care areas. Have you ever looked at what is lodged under those nails? Have you read the reports of what is growing there?

Caio’

May 24, 2023

MUY IMPORTANTE!

You have a policy in the Environment of Care policies discussing humidity levels in the operating room and the impact these may have on equipment and supplies stored and used in those rooms. It says for you to check with the manufacturers of these items to determine humidity levels that are best for those items to function ideally and safely! You MUST do this from a risk point of view, but also for patient safety. Surveyors are surveying to this.

You have a form called EQUIPMENT ASSESSMENT TOOL in forms: Environment of Care. We have had you completing this tool on at least two pieces of equipment used in the OR yearly. That has sufficed to meet the requirements so far, BUT NOT ANYMORE! You need to fill this tool out annually now on all equipment used in the OR. I am adding a space for you to add the humidity range best for the piece of equipment on which you are performing a risk assessment. Keep these in the EOC Workbook.

We are working on how to manage the supplies stored in the OR, so keep watching!

May 11, 2023

Greetings! Well, Summer and her little family have gone back to Wisconsin for the summer. They are going to try the “snow bird” lifestyle. Still running all over the place while trying to get the house and yard in order.

It has been crazy, still, with surveys, but now only have two in the que ‘til August. In the meantime, as all of you know, after each survey there is a mountain of work left for us to do.

Just a reminder that you can move physician and allied health credentialing to three years rather than two. HOWEVER…check with your facility licensing agency to make sure this will meet those regulations. If there is nothing preventing your making this change, show acceptance of the change in Board minutes and alert all physicians likewise. If you are on the ADA ongoing contract, advise us that you need the policy and bylaw changes done.

If your thermometer does not document the refrigerator temperature for all days to include days when the center is closed, you need to upgrade it to one that has this feature.

Work with your staff to make sure the staff working with refrigerator temperatures know what to do should it go “out of range”.The thermometer should provide you with an alert….but then, does your staff know what to do should it go out of range? You can’t have your log just showing out of range temperatures day after day after day!!!

Note that we will be officially changing the Dangerous Drug Notice to Hazardous Drugs. Make certain you change yours. Also, review your list. You should only have those drugs that you have in your inventory.

Watch your TIME OUT process. ALL ACTIVITY IN THE ROOM MUST STOP!!! It looks like staff in the ORs are getting a little too cavalier about this process…like familiarity breeds laziness in not initiating rigidity where this activity is being performed.

The time out has to be done BEFORE any treatment, so if your surgery has two phases, then there must be TWOOUTS!

You must document the date opened on waived testing control solution.

Don’t forget that you have to document your “range values” on your preop flow sheet. Show that the physicians know what the range values are in your minutes and document the point at which the physicians want to be alerted if the test shows out of range.

Do you know if the container and the urine specimen to conduct the pregnancy test are compatible? They aren’t if you are using Styrofoam. Switch to paper cups.

Are you doing everything you can do to provide visual and auditory privacy to the extent you can? PULL THOSE PRIVACY CURTAINS BETWEEN PATIENTS.

One of the hazards we face when we work at the same place for many years is that our storage areas start looking like our cupboards and storage spaces at work start looking cluttered like some of those areas in our homes……like our garages? You face getting a deficiency if this is the case. Clutter hides those DUST BALLS, EXPIRED DRUGS AND SUPPLIES and slow us down at critical times, as we try to wade through our messy spaces hunting for critical drugs and supplies. Cupboards, drawers….the tops of carts like the anesthesia and crash carts…..all need to be organized and clean.

Have you updated your crash cart recently? ADA made changes to this form to reflect the AHA recommendations, BUT your cart should also reflect drugs and supplies commiserate with the kinds of patients and procedures in your center.

DISCUSS THINGS LIKE STOCKING MAG SULFATE AND SUCCINYLCHOLINE. THESE ARE BOTH HAZARDOUS DRUGS, SO TAKE THE TIME FOR THE CONVERSATION ABOUT THEIR BEING IN YOUR FORMULARY.

When checking the anesthesia and crash carts, make sure you are checking the laryngoscope bulbs and handles.

For a point of clarification..You cannot take your crash cart and defibrillator out of your center to attend a crises in the clinic or elsewhere in the building as long as you have patients still in your ASC. I recommend that you have the clinic, or the building get a Banyan kit for emergencies.

Are you checking the AED and the SUCTION on and off power?

Watch the dates on your credentialing packages. You CANNOT send your letter granting privileges and appointing the physician or allied health person UNTIL all documents are present and signed.

This sounds silly, but when checking off on all the various forms for “yeses or nos” use only one type…like all xs or all checks not a mixture of the two on the form.

On credentialing don’t forget to validate/verify certifications like “certified scrub tech” or Certified Sterilization Processing Tech.

In regards to competencies, remember that the person assessing the competency must have been deemed competent in order to conduct a competency assessment AND the assessment must be within the scope of practice of the person conducting the competency assessment.

If you aren’t using the paper Rx pads, get rid of them! Check with the docs, first, of course.

We will be adding “no stud earrings” to OR dress code along with false eyelashes as some of those are being pulled off when anesthesia takes off the tape on the eyes at the end of the procedure.

How do you account for insulin your center? Think about it, ‘cause you don’t really know what is in that vial if they are bringing the insulin in from home. I think they could “self administer” but I wouldn’t recommend you give it. We will be studying this process, so watch for info about this.

Make sure you are keeping the Infection Survey Tool in that workbook. This is a CMS tool that the accreditation surveyor, in the presence of a deemed status survey, has to complete on their tool and submit it to CMS. You should review it annually and submit it to your surveyor during your survey.

Get your manufacturer’s rep to in service the techs on the sterilizers.

Send your Infection Preventionist to the APIC annual meeting!!!

Administrators should go to State and National ASC meetings!

The PUBLIC HEALTH EMERGENCY is over. Find out what your State is doing and follow those protocols. However, watch now for mini-epidemicsof childhood diseases from the vast entry of unvaccinated persons coming through our borders. This is happening now!

Please feel free to call for clarifications!

March 29, 2023

CREDENTIALING:

So the Joint has changed its credentialing of physicians standard. You now have the option of extending physician credentialing from every two years to every three years. now…..What about medicare? You have to check your State Law to see if it conflicts with this new standard. If your State Law does not address it, you can change it to 3 years. You have to adopt whichever is the most stringent.

TIME OUT

Have you included the Fire Risk as part of your Time Out? Also include whether there was any pooling of liquid and whether there were saturated drapes and, if yes, that these were removed from the room.

OTHER

I should have the policy changes done by the end of next week to include the TB testing for HealthCare Workers.

Caio’

March 15, 2023

Joint Report

Been in surveys again. Know that whether it is AAAHC or the Joint Commission, surveyors are being very thorough and are conducting very comprehensive surveys. This is from a recent survey. Check yourself against these.

1. Make sure the  generator is secure…locked, and if an enclosure, that the enclosure is also locked.
2. Add “lock in place and secure “ to the Generator Log.
3. Inservice that staff are waiting 3” before draping after the prep.  ADA will do a study for this for you.
4. Expand the Time Out to include type of prep, pooling or no, solution soaked drape removed from room, the presence of pooling or not and that the surgical site is dry before applying the surgical drape. 
5. Fire Drills need to be held at varying times e.g., not at 3:30 pm each time you have them.
6. The automatic smoke detection shut down device for air handling equipment has to be checked every 12 months.
7. Develop a log to document the testing of the smoke detector shutdown devices.
8. There is a log present to document that   the NFPA standards referenced are identified on the fire alarm testing documentation.
9. Monthly testing of the generator includes  thespecific gravity using such a gauge . Results are documented on the generator log.
10. The generator log must include the cool down period.  This should not be part of the cool down period. Add amperage to the generator log.
11. Medication storage rooms must be kept locked.
12. Log the air balance reports at least annually.
13. Make sure the fire door inspections are filed in the EOC workbook for surveyors to review.
14. Find a place for storage of the entire set of blueprints and keep them there.

OTHER THINGS later!

February 5, 2023

Welcome to February, Everyone!!! Don’t forget this is Valentine month, so start getting ready for that day, and make it a BIG ONE!!!!

The big survey crunch is about done. Waiting for Holiday Surgery Center in Holiday, Florida to go through this month, then it slows down.

Lots of new things happening, so keep watching Master Policy Changes, as we will be adding these to your policies. Make sure you implement them, too!

1. Adding to Smoke Alarm Log---“smoke detector shut down device tested.”
2. List the NFPA standard on the Fire Alarm Testing Log”
3. Add “amperge” to the GENERATOR LOG.
4. Go to Grainger and find a TEMPERATURE AND HUMIDITY gauge, as you must record these parameters over the weekend.
5. Add “COOL DOWN TIME” to the Generator Log.
6. Add AUTOMATIC TRANSFER SWITCH to the Generator Log.

WE will be making these changes within a week to the various forms/logs, etc., so, again, watch for these.

Other:

We are so over the cold, and we live in Florida! Thinking of you Northerners. Got some bad cold heading your way.

Caio’

January 5, 2023

Website:

We continue working on the website in order to make it more current, more user friendly and more supportive. Please take the time to review all the various pages and let us know what you think, but also, what you would like to see that would make navigating it easier.

Note that all the 2023 forms, etc. are posted. Note the new 2023 Management Goals. I have made these separate also. These are posted on forms/notices and logs for you to print out for your workbooks…..You will see management plans but also look under infection prevention, exposure, EOC, medication safety, patient safety, emergency response and Exposure Control.

Also, review the Monthly Drill and the Monthly Inservice Schedules.

BIG NEWS:

Stephanie has been working on making more and more documents such that you will be able to type right on the document. The Annual Meeting of the Governing Board and the Board Self Appraisal are ready among others. We will send out directions to access these forms, since it is time for that documentation now. Call in if you have any questions.

Anne: Transitioning to retirement will take time, and the intention is that Stephanie will pick up the reins along with our new nurse, so service will not change for you.

We are working on the Visit Schedule, so if you have any preferences for those on-sight visits, or if you want to add visits, please let us know asap, so we can accommodate your needs. Thanks.

Caio’