Department Representative Meeting
Survey Preparation
To Meet
TJC Standards
March 2013
1
Standard HR.01.02.05
The Hospital Verifies Staff Qualifications
Elements of Performance:
EP 1: When law or regulation (or hospital EP 2)
requires care providers to be currently licensed,
certified, or registered to practice their
professions, the hospital both verifies these
credentials with the primary source and
documents this verification when a provider is
hired and when his or her credentials are
renewed.
2
Standard HR.01.02.05
The Hospital Verifies Staff Qualifications
Supportive Finding / Explanation:
•
It is the responsibility of the department mgr/designee (or Nursing
Admin for RN and LVNs) to ensure that all individuals employed in a
position requiring a license, CPR certificate, certification and/or
degree, assure that primary source verification requirements are met
and are current.
•It is the responsibility of the employees in such positions to maintain
appropriate licensure, CPR card, certification, and to renew their
license and/or certification prior to the expiration date.
•Staff cannot work with an expired license, not even with a cancelled
check and copy of renewal paperwork.
•Current Primary Source Verification Printouts must be in all
applicable personnel files.
3
BOARD OF REGISTERED NURSING
Licensee Name:
JANE BRUIN
License Type:
Registered Nurse
License Number:
123456
License Status:
ACTIVE Definition
Expiration Date:
February 28, 2015
Issue Date:
January 01, 1983
County:
LOS ANGELES
Actions:
No
(2/28/13 was last day to verify on time)
Related Licenses/Registrations/Permits
No records returned
Disciplinary Actions
No information available from this agency
This information is updated Monday through Friday - Last updated: MAR-14-2013
(late primary source verification by 2 weeks)
Disclaimer
All information provided by the Department of Consumer Affairs on this web page, and on its other web pages and internet sites, is made available to provide immediate access for the convenience of interested persons. While the Department believes the
information to be reliable, human or mechanical error remains a possibility, as does delay in the posting or updating of information. Therefore, the Department makes no guarantee as to the accuracy, completeness, timeliness, currency, or correct sequencing of the
information. Neither the Department, nor any of the sources of the information, shall be responsible for any errors or omissions, or for the use or results obtained from the use of this information. Other specific cautionary notices may be included on other web pages
maintained by the Department. All access to and use of this web page and any other web page or internet site of the Department is governed by the Disclaimers and Conditions for Access and Use as set forth at California Department of Consumer Affairs'
Disclaimer Information and Use Information.
BOARD OF REGISTERED NURSING
Licensee Name:
JOE BRUIN
License Type:
Registered Nurse
License Number:
987654
License Status:
ACTIVE Definition
Expiration Date:
March 31, 2015
Issue Date:
March 12, 2003
County:
LOS ANGELES
Actions:
No
Related Licenses/Registrations/Permits
No records returned
Disciplinary Actions
No information available from this agency
This information is updated Monday through Friday - Last updated: MAR-14-2013
(Verified ON TIME!)
Disclaimer
All information provided by the Department of Consumer Affairs on this web page, and on its other web pages and internet sites, is made available to provide immediate access for the convenience of interested persons. While the Department believes the
information to be reliable, human or mechanical error remains a possibility, as does delay in the posting or updating of information. Therefore, the Department makes no guarantee as to the accuracy, completeness, timeliness, currency, or correct sequencing of the
information. Neither the Department, nor any of the sources of the information, shall be responsible for any errors or omissions, or for the use or results obtained from the use of this information. Other specific cautionary notices may be included on other web pages
maintained by the Department. All access to and use of this web page and any other web page or internet site of the Department is governed by the Disclaimers and Conditions for Access and Use as set forth at California Department of Consumer Affairs'
Disclaimer Information and Use Information.
CPR Card Update
•As of 2/1/13, the American Heart Association (AHA) revised the format
of the CPR cards.
•The AHA requires the appropriate course completion cards be
stamped, typed, or computer printed to reduce the risk of course
completion cards being altered.
•A valid AHA card is the original card with all the information printed
(handwritten is not acceptable except for the card holder’s signature).
Standard HR.01.02.05
The Hospital Verifies Staff Qualifications
Elements of Performance:
:EP 3: The hospital verifies and documents that the applicant
has the education and experience required by the job
responsibilities.
Supportive Finding/Explanation
•In the case that a degree/education is a prerequisite in order
to receive a license, it is not required that a copy of the degree
be kept in the file. Advanced degrees require proof in the file
if required on JD, but no licensure is required for the position.
•Staffing Office has a clearinghouse to verify degree and a
vendor to check references.
Standards related to Cultural Diversity
HR.01.04.01
The Hospital Provides Orientation to Staff.
EP5: The hospital orients staff on the following :
Sensitivity to cultural diversity based on their job
duties and responsibilities
Standard HR.01.05.03
Staff Participate In Ongoing Education and Training.
EP 5: Staff participate in education and training that is
specific to the needs of the patient population
served by the hospital.
LGBT Education
•A new video available for all UCLA Health staff called “Anyone Can Be An Ally, Speaking
Up for an LGBT Inclusive Workplace.
•This video demonstrates how anyone can be an “ally” in helping to create a respectful
workplace that is inclusive of gay, lesbian, bisexual and transgender co-workers.
•It can help employees and managers build bridges of mutual respect and provide skills
to become allies who speak up on behalf of others. It is not about changing the beliefs
of others, but about changing behaviors and putting a face on the issues confronting
LGBT workers.
• You can find it on the UCLA Health System Human Resources website under Training
and the e-Learning Library. Click on the Anyone Can Be An Ally link to watch.
•It is not a specific requirement yet, but it is an important issue to address and this video
is a valuable tool to open up the discussion in a department staff meeting or huddle.
Home
Benefits
Compensation
Training & Development / E-Learning Library
Department Specific Required Training
Training & Development
.
Cultural Diversity & LGBT
Resources
E-Learning Library
Employee Required Training
HIPAA Privacy and Information
Security Training for New
Workforce Members
Management Development
Calendar
New Employee Orientation
New Hire Processing Calendar
Other Training Resources
UC Compliance Training
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All Can Prevent A Fall
Annual EKG Competency
Annual Nursing Department Test
Annual Stroke Training
Annual Chemotherapy Training (Chemo Verified RNs Only)
Anyone Can Be An Ally
Call Bell Training for Med/Surg
Call Bell - ICU Training
Call Bell - Response Training - Video Only Training
Call Bell - ICU Do-Over Video
Call Bell - Response Training Video
Capnography Learning Module for Procedural Sedation
Central Venous Catheter Care Training (RN's Only)
Clinical Care Partners - Role In Safety
HBS - Time and Attendance System
HIPAA Privacy and Information Security Training for New Workforce Members
Improving Patient Experience Through Communication About Medication
MedSled Training
Safe Patient Handling Training
Sepsis Training
UCLA Bariatric Inservices
Standard HR.01.07.01
The Hospital Evaluates Staff Performance
Elements of Performance:
EP 1: The hospital evaluates staff based on performance
expectations that reflect their job responsibilities.
EP 2: The hospital evaluates staff performance once every
3 years, or more frequently as required by hospital
policy or in accordance with law and regulation.
•UCLA Health System policy requires every employee to
receive a performance evaluation once every 12 months.
11
Standard HR.01.07.01
The Hospital Evaluates Staff Performance
Supportive Finding / Explanation:
•Performance Evaluations shall be completed for all
employees, at every level in the organization, at least every
twelve (12) months by the employee's immediate supervisor
or designee.
•A grace period of 60 days is in place to allow for completion,
meeting with the employee and signature gathering.
Employees are evaluated on all duties described on their Job
Description. The job description and the performance
evaluation are a combined tool to insure all elements of the
job description are reviewed and evaluated annually.
12
Must check one or both boxes
Must fill in eval period dates
Must check applicable
age groups
This content is
the most current
New PE Content Soon To Come…
•INSTITUTIONAL AND/OR PROFESSIONAL STANDARDS
•Comply with HIPAA and Confidentiality Policies and Procedures as they apply to the job
•Comply with Department of Public Health (DPH), The Joint Commission and other
accreditation and regulatory agencies standards
•Adhere to all Hospital Policies and Procedures
•Knowledge and adherence to Infection Control and Environment of Care Guidelines
and Procedures as described in the annual education module
•Demonstrate adherence to the requirements for using the electronic medical record
•Demonstrates understanding of institutional and department specific emergency
management procedures/responsibilities to maintain personal, patient, and co-worker
safety, maintains competencies in these areas, and participates in disaster/emergency
related exercises and education.
•Demonstrates understanding of institutional and department specific safe patient
handling procedures/responsibilities and maintain a level of competency on the
proper use of departmental lift equipment to ensure personal, co-worker and patient
safety
Must check
required
boxes!
Specify
Required or
Preferred.
SKA section must be completed if form
being used as a JD
Evaluator needs to complete this section for final comments
Evaluator needs to complete this section so employee knows what
goals are for next year
Employee needs to identify any
education changes here
1. Date signed MUST be within
60 days of period of
evaluation identified on first
page of form
Tracking Entry:
2. HR
**date signed on eval is
entered as “date completed”
in PE field
** “date expiring” is based
on end date of period of
evaluation identified on first
page (month and day) and
one year later
Human Resources File Review
Employee Name: When a file is requested for survey, prior to sending it to HR,
complete this form with all dates and make note of anything missing and what
your dept. is doing about it. Sticky notes are very helpful to adhere to docs.
Hire Date:
Appropriate
Documentation
Documents
Yes / No
Title:
File Review Date:
Dept.
Comments
Follow Up:
JOINT COMMISSION & DPH REQUIRED ELEMENTS
Age Specific Trng (if app.)/Module & Post Test
Put completion dates Add any noteworthy
Anything missing?
Annual/Age Spec. Comp. Assessment: Year 1
In these columns for
explanations in this
Let HR know what
Annual/Age Spec. Comp. Assessment: Year 2
all requirements
column
your dept. is doing
Annual/Age Spec. Comp. Assessment: Year 3 (survey year)
Performance Evaluation: Year 1
to revise/complete
a req. document
Performance Evaluation: Year 2
Performance Evaluation: Year 3 (survey year)
Department /Job Specific Orientation
CPR
Licenses/Certifications/Source Verification
Write in exp. date
Write in exp. date
DPH and UCLA REQUIRED ELEMENTS
Abuse, Child
Abuse, Adult
Abuse, Domestic
Confidentiality Agreement
Annual Education Post Test (Cert.)
HR will reprint
CICARE Module and Post Test (Cert.)
all online certs.
Corporate Compliance Post Test (Cert.)
Cultural Competency Post Test (Cert.)
Form can be found
on HR website under HR
Requirements & Forms
HIPAA Privacy & Info Security Training Post Test (Cert.)
Hospital Orientation & Post Test
Initial Competency Assessment
Job Description
Employee Physical
TB Test
HR will contact
OHF Office of Records
OHF for health forms
OHF Office of Records
HR File Review Form
Upcoming Surveys
CMS Transplant Survey
Patient Safety Licensing Survey
TJC Hospital Licensing Survey (by August 2013)
•All surveys in open window for a visit
•No announced dates
•File Review Session will be part of all surveys
Please call HR if you have any
Questions