Stroke Survey Review September 2012 Findings Reminders Observations

1. Stroke Survey ReviewSeptember 2012FindingsRemindersObservations

2. 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

3. 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

4. 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.

5. 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

10. 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

11. 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.