Each of these individuals played an important role in making Holy Cross survey ready. The Board and Senior Leadership want to thank each of you for a job well done. Thank you for providing high quality and safe care to those we serve. Great work everyone!
Individuals who were interviewed by a surveyor and did an outstanding job:
- Trish Hendricks – Medical Staff Coordinator
- Lenora Cisneros – Admin
- Erin Kizen – Dietary
- Irene Sadler – HSC
- Ada Stevenson – HR
- Dale Cisneros – Imaging
We would like to thank the following team members for outstanding preparation regarding the survey:
Dennis Fox/ Plant – in 6 weeks organized the department and was able to provide documentation and answer many questions
Beth Hood/ CM – Updated policies, prepared documents, held UR meetings in prep for survey
Doris West/IP– developed a survey readiness tool that the surveyor requested as an example for other organizations to use
Brittany Lamendola/Nursing – updated all restraint audits for 2018 adding additional information in prep for survey
Daisy Faustino/Lab – Prepared a notebook of all lab documents making sure they were up to date and ready for review as well as an extensive reference list
Sue Romansky – Overseeing DNV survey preparation, communicating with leaders, auditing and providing guidance
DNV Survey Report
As most of you know we had a team of three DNV surveyors on site. They reviewed records, looked at the physical environment, questioned staff, checked policies, and reviewed our processes and programs. We are happy to report that we did very well! We had seven findings this year which matches what we received last year. The findings included one Conditional Level, four Level One Nonconformities and two Level Two Nonconformity. Below is a list of the findings:
Ligature Risk – Found opportunity to improve our evaluation and documentation of patients for suicidal ideation, improve our evaluation of the physical environment and increase observation of patient during their stay. Much work has already been done including education, documentation process and evaluation of rooms for risk.
Nonconformity Level 1
Anesthesia – Found we had not yet appointed a Medical Director of Anesthesia. We had already identified this need before the inspection and were working with CCI. We were able to correct the finding on the spot. Dr. Boyd is now the Medical Director of Anesthesia.
Restraints – Asked to improve documentation around face to face evaluation of patients and rationale for using restraints. Changes are being made to the EMR to included desired elements and staff training is being scheduled.
Nursing Care Plans – Would like us to include additional diagnoses found in physician notes. We are in the process of finding a way to help staff access this information easily. Education will follow.
Fire Extinguishers – Discovered a few fire extinguishers that were mounted too high and several fire doors that would not close. Corrections were made and noted in the report.
Nonconformity Level 2
Panel Boxes – Not all boxes were fully labeled showing what each switch in the box was for. Corrections are being made and will be completed as soon as possible.
Regulated Waste – One staff member lacked required Hazwoper training to handle and sign the waste manifest. Training has been scheduled.
The survey team recognized that we had made progress in several areas, closed four findings from last year and said that there were many noteworthy efforts.
Each of you played an important role in making Holy Cross survey ready. The Board and Senior Leadership want to thank each of you for a job well done. Thank you for providing high quality and safe care to those we serve. Great work everyone!