Transcript THANK YOU! - Health human resources

TJC Survey Review
December 2012
Findings
Reminders
Observations
Jan. 2013
HR File Review
THANK YOU for your assistance with the
personnel files during the
Joint Commission PPR Survey!
 Nutrition;
NRRU
 Care Coordination;
Bio Engineering
 Speech Pathology;
Pharmacy
 Radiology;
GI
 Emergency Dept.;
CT
 Rehab;
Respiratory
 Medical Procedures Unit
 Nursing;
 Dialysis;
 Jules Stein
(Four Specific Employee Names / Seven Specific Positions)
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Docs Reviewed During
HR/Competency Interview
 License Verification Printouts
 Other Certifications, such as BLS, ACLS, PALS, MICN
 Job Description
 Performance Evaluations
 Annual Education
 Annual Competencies
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Observations
When Prepping Personnel Files
o Needed some departments to complete performance evaluations
and annual competencies the week of survey (or on interview
morning) because not in file when we did the review.
o While many files did contain the required license verification printout,
the printout date was NOT ALWAYS completed prior to the last
expiration of the license.
o The only acceptable license verification is the timely printout from
the Board website.
 Copies of licenses cannot replace the verification printout from
the Board website. They can be tampered with easily.
 Late printouts that are past the license expiration date will not
pass a surveyor’s inspection. It tells them we let someone work
without verifying if a license is valid.
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Observations
when Prepping Personnel Files
o Some staff have multiple licenses listed on the Board website, such as
RN, NP, and Public Health Nurse. Please print them all for the files!
o It’s important the education requirements are accurate on JD.
Required vs. Preferred.
o While HR did review files during the week as surveyor spoke to staff,
official list from surveyor did not come until morning of HR interview. Had
only two hours to prepare all the files. So, very important keep up with
due dates and get papers into files timely.
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Going Forward ...
Upcoming Surveys:
 Transplant Survey - open
 Patient Safety Licensing Survey - open
 WW TJC Survey – Summer 2013; Week of Aug. 16th is Week 36.
Same preparation process for all licensing visits:
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Keep HR tracking up to date
Be aware of due dates and expiration dates
Complete forms timely
Review documents for completeness before entry and filing
Use HR Staff as a resource for forms, entry, and compliance
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