Stroke survey review september 2012 findings reminders observations
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Stroke Survey Review September 2012 Findings Reminders Observations PowerPoint PPT Presentation


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Stroke Survey Review September 2012 Findings Reminders Observations. Stroke Survey Review. THANK YOU for your assistance with the personnel files during the Comprehensive Stroke Survey!. Nutrition ; Care Coordination; Speech Pathology; Radiology; Emergency Dept.; Rehab; Nursing;

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Stroke Survey Review September 2012 Findings Reminders Observations

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Stroke Survey ReviewSeptember 2012FindingsRemindersObservations


Stroke Survey Review

THANK YOU for your assistance with the personnel files during the Comprehensive Stroke Survey!

  • Nutrition;

  • Care Coordination;

  • Speech Pathology;

  • Radiology;

  • Emergency Dept.;

  • Rehab;

  • Nursing;

  • Patient Access Services;

  • Quality Mgmt;

  • Neurosurgery;

  • Stroke Team


Docs Reviewed During HR/Competency Interview

  • License Verification Printouts

  • Other Certifications, such as BLS, ACLS,

  • PALS, MICN

  • Job Description

  • Performance Evaluations for last two years

  • Annual Education

  • Annual Competencies

  • Specific Stroke Education


Observations For Licenses/Certifications When Prepping Personnel Files

  • Please make sure every required license and certification for a position is listed on the employee profile in the HR Competency Tracking System so it can be tracked and expiration dates can be met.

  • 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.


Observations for Licenses/Certifications

  • 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!

  • 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.

  • Education degrees – Documented on JDs


Going Forward ...

Upcoming Surveys:

  • Transplant Survey

  • Patient Safety Licensing Survey

  • WW TJC Survey

  • Same preparation process for all licensing visits:

  • Keep HR tracking up to date

  • Be aware of due dates and expiration dates

  • Review documents for completeness before entry and filing


Department-wide Responsibilities for Licenses

  • The HR Chapter of the licensing standards is not the Human Resource Department Chapter.

  • It’s a chapter about the qualifications of the people in our organization; the “human” resources of every dept.

  • Every dept./clinic is responsible for the requirements of their staff (the “human” resources), so their areas remain successful, productive and in compliance.

  • There are over 5,000 licensed staff members. Many with multiple credentials.

  • Therefore, license verifications are completed in the department by a designated person or people and must be a priority when it comes to meeting the expiration deadlines.

  • Your HR team and the HR Tracking System are your support network.


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