INTEGRIS Health
Executive Summary of Recent TJC Surveys (by Standard)
Program
Standard
EP
All entries in the medical record, including all orders, are timed
The hospital minimizes risks associated with selecting, 5 handling, storing, transporting, using, and disposing of hazardous chemicals
Exits, exit accesses, and exit discharges are clear of 13 obstructions or impediments to the public way, such as clutter HAP
RC.01.01.01
HAP
EC.02.02.01
HAP
LS.02.01.20
HAP
MM.03.01.01
3
HAP
EC.02.05.09
3
HAP
MS.01.01.01
3
HAP
MS.08.01.01
1
HAP
MS.08.01.03
1
HAP
PC.03.05.05
1
HAP
RC.02.01.03
7
HAP
EC.02.03.01
1
HAP
EC.02.03.05
3
HAP
EC.02.05.01
6
HAP
EC.02.05.05
4
HAP
EC.02.05.07
6
HAP
HR.01.02.05
1
HAP
HR.01.04.01
5
HAP
IC.02.02.01
2
HAP
IC.02.02.01
4
HAP
LS.02.01.10
HAP
LS.02.01.10
HAP
LS.02.01.20
HAP
LS.02.01.20
HAP
LS.02.01.30
HAP
LS.02.01.30
HAP
LS.02.01.35
HAP
MM.05.01.17
Page 1 of 5
Brief Description (please see standard and actual observation by facility)
19
Type
Edmond
10/18/2011
Indirect
Bass Pavillian
5/2/2012
IBMC
IHCV
Miami
6/12/2012
9/5/2012
10/3/2012
x
x
x
x
Doors required to be fire rated have functioning hardware, including positive latching devices and self‐closing or 5
automatic‐closing devices. Gaps between meeting edges of door pairs are no more than 1/8 inch wide, and undercuts are no larger than 3/4 inch. The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire‐rated walls 9
and floors are protected with an approved fire‐rated material
Doors in a means of egress are unlocked in the direction of 1
egress.
The hospital meets all other Life Safety Code means of 32
egress requirements
All hazardous areas are protected by walls and doors in 2
accordance with NFPA 101‐2000: 18/19.3.2.1
Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are 11 hinged so that they swing. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 1 inch
18 inches or more of open space maintained below the 6
sprinkler
The hospital implements its policy on retrieving and 2 handling medications when they are recalled or discontinued for safety reasons
Grove
Total
x
x
6
x
x
x
x
4
Indirect
x
x
x
x
4
x
x
x
x
x
Every requirement set forth in Elements of Performance 12 Indirect
through 36 is in the medical staff bylaws
A period of focused professional practice evaluation is Indirect
implemented for all initially requested privileges
Ventilation system provides appropriate pressure relationships, air‐exchange rates, and filtration efficiencies
Physical conditions potentially compromised the clean environment.
Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches
The hospital verifies staff qualifications (timeliness and primary source)
The hospital provides orientation to staff (orientation to cultural diversity)
Cleaning patient equipment according to manufacture specifications
The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies
Bass
Indirect
The hospital stores all medications and biologicals, including Indirect
controlled (scheduled) medications, in a secured area to prevent diversion, and locked when necessary
Cart was observed to be blocking the medical gas shutoff Indirect
valves
There is a clearly defined process in place that facilitates the evaluation of each practitioner’s professional practice
The hospital initiates restraint or seclusion based on an individual order
Op report must be available before patient is transferred to next level of care
The hospital minimizes the potential for harm from fire, smoke, and other products of combustion
Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors
ISMC
10/9/2012 10/15/2012 10/23/2012
Indirect
x
4
x
3
x
3
x
x
x
x
x
3
x
x
x
3
Indirect
x
Direct
x
Direct
x
x
x
x
x
3
3
x
2
Indirect
x
x
2
Direct
x
x
2
Direct
x
x
Direct
x
Indirect
x
Indirect
x
Direct
x
Indirect
Indirect
Indirect
x
x
x
x
x
2
x
2
x
2
x
2
x
2
2
x
Indirect
x
2
x
Direct
Indirect
x
2
x
2
x
2
x
2
Indirect
x
x
2
Indirect
x
x
2
x
2
Direct
x
Standards highlighted in Yellow = Top Standards Compliance Issues Nationwide as Idendified by TJC for First Half of 2012 INTEGRIS Health
Executive Summary of Recent TJC Surveys (by Standard)
Program
Standard
EP
Type
Edmond
10/18/2011
Bass Pavillian
5/2/2012
IBMC
IHCV
Miami
6/12/2012
9/5/2012
10/3/2012
The medical staff bylaws include the following requirements for the medical executive committee’s function, size, and composition, as determined by the organized medical staff Indirect
20
and approved by the governing body; the authority delegated to the medical executive committee by the organized medical staff to act on the medical staff’s behalf; and how such authority is delegated or removed. HAP
MS.01.01.01
HAP
MS.08.01.03
3
HAP
PC.01.02.01
1
HAP
PC.01.02.03
5
HAP
PC.01.02.07
1
HAP
PC.01.02.07
3
HAP
PC.01.02.08
1
HAP
PC.03.01.03
1
HAP
PC.03.01.07
7
HAP
PC.03.05.03
2
HAP
PC.03.05.15
1
HAP
RC.02.01.07
2
HAP
TS.03.02.01
2
HAP
TS.03.02.01
5
HAP
UP.01.03.01
4
HAP
APR.01.03.01
1
HAP
EC.02.01.01
9
HAP
EC.02.02.01
HAP
EC.02.03.01
HAP
EC.02.03.03
HAP
EC.02.03.03
HAP
EC.02.03.05
HAP
EC.02.03.05
HAP
EC.02.03.05
HAP
EC.02.03.05
Page 2 of 5
Brief Description (please see standard and actual observation by facility)
The process for the OPPE of Allied Health Practitioners
The hospital defines in writing the scope and content of assessment
For a H&P that was completed w/in 30 days prior to registration or IP admission, an update documenting any changes in the patient's condition is completed within 24 hrs after registration or IP admission, but prior to anesthesia services.
The hospital assesses and manages the patient's pain
The hospital reassesses and responds to the patient’s pain, based on its reassessment criteria
The hospital assesses and manages the patient's risks for falls
The hospital conducts a presedation or preanesthesia patient assessment
A postanesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services
The use of restraint and seclusion is in accordance with a written modification to the patient's plan of care
The hospital documents the use of restraint or seclusion
Ambulatory services ‐ medical record contains a summary list for each patient
x
Indirect
x
x
x
Direct
x
Direct
x
x
2
x
2
x
2
x
2
x
x
2
x
Indirect
x
Indirect
x
Indirect
x
2
2
x
x
2
x
2
x
x
Hospital notifies TJC w/in 30 days of a change in ownership, Indirect
control, location, capacity, or services offered
The hospital has written procedures to follow in the event of a security incident, including an infant or pediatric Indirect
abduction
2
x
x
2
2
x
Direct
Total
2
x
x
Direct
Grove
x
Indirect
The hospital traces all tissues bi‐directionally. The hospital Indirect
identifies, in writing, the materials and related instructions used to prepare or process tissues
The hospital traces all tissues bi‐directionally. The hospital retains tissue records on storage temperatures, outdated Indirect
procedures, manuals, and publications for a minimum of 10 years
A time‐out is performed before the procedure (suspend all Direct
activities)
For managing hazardous materials and waste, the hospital has the permits, licenses, manifests, and material safety data sheets required by law and regulation.
The written fire response plan describes the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin, including when and how to 10
sound fire alarms, how to contain smoke and fire, how to use a fire extinguisher, and how to evacuate to areas of refuge
When quarterly fire drills are required, at least 50% are 3
unannounced
Staff who work in buildings where patients are housed or 4 treated participate in drills according to the hospital’s fire response plan
For automatic sprinkler systems: Every week, the hospital 6
tests fire pumps under no‐flow conditions
For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all 9
system risers. The completion date of the tests is documented
11
Bass
x
Indirect
Direct
ISMC
10/9/2012 10/15/2012 10/23/2012
x
x
2
2
x
1
x
1
Indirect
x
1
Indirect
x
1
Indirect
x
1
Indirect
x
1
Indirect
x
1
Indirect
Every 12 months, the hospital tests automatic smoke‐
Direct
detection shutdown devices for air‐handling equipment. The completion date of the tests is documented
Documentation of maintenance, testing, and inspection 25 activities for fire alarm and water‐based fire protection Indirect
systems x
1
19
x
x
1
1
Standards highlighted in Yellow = Top Standards Compliance Issues Nationwide as Idendified by TJC for First Half of 2012 INTEGRIS Health
Executive Summary of Recent TJC Surveys (by Standard)
Program
Standard
EP
HAP
EC.02.04.01
2
HAP
EC.02.05.01
2
HAP
EC.02.05.01
3
HAP
EC.02.05.01
4
HAP
EC.02.05.07
1
The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life‐support equipment) and equipment incident history
The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life‐support systems)
The hospital identifies, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory
EC.02.05.07
HAP
EC.02.05.07
HAP
EC.02.06.01
HAP
EC.02.06.01
HAP
EC.04.01.01
HAP
IC.02.02.01
HAP
IM.02.02.01
3
HAP
IM.04.01.01
1
HAP
LD.04.01.05
4
HAP
LS.01.01.01
2
HAP
LS.02.01.10
4
HAP
LS.02.01.20
12
HAP
LS.02.01.20
28
HAP
LS.02.01.20
Type
Edmond
10/18/2011
Bass Pavillian
5/2/2012
IBMC
IHCV
Miami
6/12/2012
9/5/2012
10/3/2012
The corridor width is not obstructed by wall projections.
Illumination in the means of egress, including exit discharges, is arranged so that failure of any single light fixture or bulb will not leave the area in darkness
Signs reading "No Exit" are posted on any door, passage, or 30 stairway that is neither an exit nor an access to an exit but may be mistaken for an exit
Doors in smoke barriers are self‐closing or automatic‐
closing, constructed of 1 3/4‐inch or thicker solid bonded wood core or equivalent, and fitted to resist the passage of 23
smoke. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 3/4 inch. Doors do not have nonrated protective plates more than 48 inches above the bottom of the door
HAP
LS.02.01.30
HAP
LS.02.01.35
HAP
MM.03.01.01
8
HAP
MM.04.01.01
13
HAP
MM.05.01.01
1
14 The hospital meets all other Life Safety Code automatic extinguishing requirements related to NFPA 101‐2000
Grove
Total
1
Direct
x
1
Direct
1
x
x
1
Direct
Direct
x
1
x
1
x
1
Indirect
x
Indirect
x
x
x
Direct
x
Indirect
Direct
1
1
x
Indirect
1
1
1
1
x
1
x
1
Indirect
x
1
Direct
x
1
Direct
x
1
Indirect
Indirect
x
x
Indirect
x
x
Direct
A pharmacist reviews the appropriateness of all medication Indirect
orders for medications to be dispensed in the hospital
1
1
The hospital removes all expired, damaged, and/or Indirect
contaminated medications and stores them separately from medications available for administration
The hospital implements its policies for medication orders
Bass
x
The hospital conducts environmental tours every six months Indirect
12 in patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risks
Cleaning and performing low‐level disinfection of medical Direct
1
equipment, devices, and supplies
The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations
Hospital has processes to check the accuracy of health information
The hospital effectively manages its programs, services, sites, or departments. Staff are held accountable for their responsibilities
The hospital maintains a current electronic Statement of Conditions Openings in 2‐hour fire‐rated walls are fire rated for 1 1/2 hours. ISMC
10/9/2012 10/15/2012 10/23/2012
Indirect
Indirect
keeping logs documenting dish machine temperatures
At 30‐day intervals, the hospital performs a functional test of battery‐powered lights required for egress for a minimum Direct
duration of 30 seconds
Every 12 months, the hospital either performs a functional test of battery‐powered lights required for egress for a 2
duration of 1 1/2 hours; or the hospital replaces all batteries every 12 months and, during replacement, performs a random test of 10% of all batteries for 1 1/2 hours
Generator load test did not meet the minimum load testing 8
requirement
Interior spaces meet the needs of the patient population 1 and are safe and suitable to the care, treatment, and services provided
The hospital maintains ventilation, temperature, and 13 humidity levels suitable for the care, treatment, and services provided
HAP
Page 3 of 5
Brief Description (please see standard and actual observation by facility)
1
x
x
1
1
1
Standards highlighted in Yellow = Top Standards Compliance Issues Nationwide as Idendified by TJC for First Half of 2012 INTEGRIS Health
Executive Summary of Recent TJC Surveys (by Standard)
Program
Standard
EP
Brief Description (please see standard and actual observation by facility)
Type
Edmond
10/18/2011
IBMC
IHCV
Miami
6/12/2012
9/5/2012
10/3/2012
The hospital dispenses medications and maintains records in accordance with law and regulation, licensure, and Indirect
professional standards of practice
The medical staff bylaws include requirements for 16 completing and documenting medical histories and physical Indirect
examinations.
HAP
MM.05.01.11
HAP
MS.01.01.01
HAP
MS.01.01.01
HAP
MS.05.01.01
HAP
MS.06.01.05
HAP
MS.08.01.01
HAP
NPSG.02.03.01
HAP
NPSG.03.04.01
HAP
PC.01.02.01
HAP
PC.01.02.03
HAP
PC.01.03.01
1
HAP
PC.01.03.01
5
HAP
PC.02.01.03
7
HAP
PC.02.03.01
1
HAP
PC.03.05.03
HAP
RC.01.01.01
HAP
RC.01.01.01
HAP
RC.02.03.07
HAP
RI.01.03.01
HAP
TS.03.01.01
HAP
TS.03.01.01
3
HAP
TS.03.01.01
5
HAP
TS.03.01.01
7
HAP
TS.03.02.01
3
HAP
UP.01.02.01
4
2
The hospital, based on recommendations by the organized medical staff and approval by the governing body, establishes criteria that determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested
The organized medical staff develops criteria to be used for evaluating the performance of practitioners when issues 2
affecting the provision of safe, high quality patient care are identified
3 Evaluate the timeliness of reporting critical results
In perioperative and other procedural settings both on and 1 off the sterile field, label medications and solutions that are not immediately administered
During patient assessments and reassessments, the hospital 23
gathers the data and information it requires
H&P no more than 30 days prior to, or within 24 hours after, 4 registration or inpatient admission, but prior to anesthesia services.
The hospital plans the patient’s care, treatment, and services based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing
The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals.
The hospital provides care, treatment, and services using the most recent patient order(s)
The hospital provides patient education
The hospital implements restraint or seclusion using safe techniques identified by the hospital’s policies and procedures in accordance with law and regulation
The medical record contains the information needed to 5
support the patient’s diagnosis and condition
Post Anesthesia Evaluation form not completed by Dr who 7
had signed it
Verbal orders are authenticated within the time frame 4
specified by law and regulation
Dr to discuss risks, benefits, side effects or alternatives of 11
proposed treatment
Written procedures for acquisition, receipt, storage, and 2
issuance of tissues
1
OME
EC.02.02.01
4
OME
NPSG.15.02.01
1
OME
PC.02.01.03
7
Bass
1
x
1
x
Indirect
1
x
Indirect
1
x
1
Indirect
x
1
Direct
x
Direct
x
Indirect
1
Direct
x
Indirect
x
Direct
1
x
1
x
1
Indirect
x
Indirect
x
Indirect
1
1
x
Direct
1
1
x
Indirect
Total
1
1
1
x
1
Direct
x
1
Indirect
x
1
The hospital confirms that tissue suppliers are registered Direct
with the U.S. Food and Drug Administration (FDA) as a tissue establishment and maintain a state license when required
The hospital follows the tissue suppliers’ or manufacturers’ written directions for transporting, handling, storing, and Direct
using tissue
The hospital verifies at the time of receipt that package integrity is met and transport temperature range was Direct
controlled and acceptable for tissues requiring a controlled environment
The hospital traces all tissues bi‐directionally. The hospital Indirect
documents the dates, times, and staff involved when tissue is accepted, prepared, and issued
The method of marking the site and the type of mark is unambiguous and is used consistently throughout the Direct
hospital
The organization implements its procedures in response to hazardous material and waste spills or exposures
Conduct a home oxygen safety risk assessment The organization provides care, treatment, or services using the most recent patient order(s). Grove
x
The medical staff bylaws include the process, as determined Indirect
21 by the organized medical staff and approved by the governing body, for selecting and/or electing and removing the medical executive committee members
8 Med staff is involved w/ departures from established Indirect
2
ISMC
10/9/2012 10/15/2012 10/23/2012
x
Direct
x
1
x
1
x
1
x
1
x
2
Page 4 of 5
Bass Pavillian
5/2/2012
12
29
28
8
20
31
x
Direct
x
Direct
x
x
1
29
159
x
2
x
2
2
Standards highlighted in Yellow = Top Standards Compliance Issues Nationwide as Idendified by TJC for First Half of 2012 INTEGRIS Health
Executive Summary of Recent TJC Surveys (by Standard)
Program
Standard
EP
Brief Description (please see standard and actual observation by facility)
Based on the patient’s condition and assessed needs, the 10 education and training provided to the patient by the organization include the following: …
Every 6 months, inspects any automatic fire‐extinguishing 13
systems in a kitchen
the organization had not documented dishwasher 4
temperatures
The Emergency Operations Plan describes the following: The organization's arrangements with other organizations in the 8
event that it cannot serve its own customers as the result of an emergency
The Emergency Operations Plan describes how the 1 organization will manage activities related to care, treatment, or services during an emergency
The organization implements the components of its 11 Emergency Operations Plan that require advance preparation to manage patients during an emergency
OME
PC.02.03.01
OME
EC.02.03.05
OME
EC.02.05.01
OME
EM.02.02.03
OME
EM.02.02.11
OME
EM.02.02.11
OME
HR.01.06.01
1
OME
IC.02.02.01
1
OME
NPSG.03.06.01
1
OME
NPSG.09.02.01
1
OME
NPSG.09.02.01
2
OME
NPSG.15.02.01
2
OME
PC.01.02.01
5
OME
PC.01.02.07
3
OME
PC.02.01.03
1
OME
RC.01.02.01
3
OME
RC.02.01.01
2
OME
RC.02.01.01
4
OME
RI.01.04.01
2
BHC
CTS.03.01.03
2
BHC
EC.02.06.01
BHC
LS.02.01.30
Type
Edmond
10/18/2011
IBMC
IHCV
Miami
6/12/2012
9/5/2012
10/3/2012
Indirect
ISMC
Bass
x
Inform the patient and family/caregiver of the findings of the safety risk assessment and educate the patient and family/caregiver about the causes of fire, precautions that can prevent fire‐related injuries, and recommendations to address the specific identified risk
Based on the patient’s condition and the care, treatment, or services it provides, the organization defines, in writing, which …
The organization reassesses and responds to the patient’s pain, based on its reassessment criteria
Prior to providing care, the organization obtains or renews orders (verbal or written) from a licensed independent practitioner The author of each patient record entry is identified in the patient record
The patient record contains the following clinical information: …
When applicable to the patient’s care, treatment, or services, the organization documents the following additional information: …
The home health agency advises the patient, in advance, of the disciplines involved in providing care and how often the patient will be visited.
The plan for care, treatment, or services contains goals…
The organization establishes and maintains a safe, 20
functional environment
25 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
Total
2
Indirect
x
1
Indirect
x
1
Indirect
x
1
Indirect
x
1
Indirect
x
The organization defines the competencies it requires of its Indirect
staff who provide patient care, treatment, or services
The organization implements infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. Obtain and/or update information on the medications the patient is currently taking. This information is documented in a list or other format that is useful to those who manage medications
Assess the patient’s risk for falls
Implement interventions to reduce falls based on the patient’s assessed risk
Grove
10/9/2012 10/15/2012 10/23/2012
x
1
x
Direct
x
x
Direct
1
1
Direct
1
x
1
Direct
x
1
Direct
x
1
Indirect
x
1
Direct
x
Direct
1
x
1
Indirect
x
1
Direct
x
1
Direct
x
1
Indirect
x
0
0
4
0
7
1
0
4
11
26
Indirect
x
1
Direct
x
1
Indirect
x
1
0
2
Page 5 of 5
Bass Pavillian
5/2/2012
0
12
3
36
0
28
0
15
0
20
0
35
0
40
3
188
Standards highlighted in Yellow = Top Standards Compliance Issues Nationwide as Idendified by TJC for First Half of 2012