I recently had the pleasure of participating in an unannounced CMS Validation survey at the Hospital I work at. It served as a great wakeup call to all hospital staff of the necessity to be survey-ready at all times. It would seem simple enough to say that you should always be ready for a survey, but that usually isn’t the case. At a minimum, all Hospital Environmental Services departments should be prepared for the following inspection points:
1. Is your facility clean? Now I’m not just referring to whether it generally looks clean. Be detailed. Are the supply and return air vents clean and free of grime and dust? Are the walls clean and free of grime, smudges, smears and marks? Are all ledges clean and free of dust and dirt? Are all corners and edges clean and free of built up soil pushed in by sweeping, mopping and floor work? And, finally, are finished floors shiny and clean or dull and dirty?
2. Are all policies and procedures, training and department records up to date? Have policy and procedures been recently reviewed and revised? Do your training records reflect all aspects of the EVS Technician’s job training and function (e.g. bed-making, room cleaning, waste removal, personal protective equipment (PPE’s))? Medical waste manifests, solid waste pick-ups, linen deliveries, and pest control service are just some examples of records that you want to keep on top of.
3. Are there any cleaning or work processes your department is currently performing that are not formally documented as policies or procedures? One example from personal experience is our former method for cleaning ice machines. The previous process we used at our hospital was to apply a deliming agent to all exterior surface areas and then to rinse thoroughly with water. A surveyor disagreed with our procedure (the deliming agent wasn’t optimal for patient safety) and that our cleaning process wasn’t uniform within our facility (i.e. several of our EVS Techs had slightly varying cleaning processes). The end result was that we dropped the deliming agent for a food grade sanitizing disinfectant and, more importantly, created a documented cleaning policy for our ice machines to keep everyone on the same page.
4. Does your staff know how to respond to Environment of Care emergency codes? I know that in my facility a code “pink” means infant abduction and my staff knows exactly what their response is supposed to be. Does yours?
5. Is your staff able to respond to surveyor’s questions or are there communication or language barriers? One item I have always found helpful to staff is the small little card that is attached to the back of their ID Badge. Employees can find the usual required information such as descriptions of RACE and PASS fire safety protocol, Mission Statement, and Environment of Care codes. If all else fails, employees should let surveyors know that if they don’t have an answer to a particular question, they know to call their supervisor for help.
In my many years of experience, ensuring you have followed these five steps will guarantee your department is successful during any type of facility survey that comes your way.