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In my July 22 column, I promised to share with you the findings of the Joint Commission once we received the official report. Since we now have their report, I have summarized the key findings below:
- A recurring theme was their dissatisfaction with our range orders for medications. Surveyors felt a number of medication orders allowed for too much discretion in terms of dose and frequency and recommended changes to our policy that would narrow this discretion or eliminate range orders altogether.
- Surveyors noted dissatisfaction with our monitoring of good hand washing/hand hygiene in some of the off-site facilities.
- Some of our off campus facilities had not completed emergency management exercises, which is a requirement.
- Surveyors found some unapproved abbreviations in our documentation, such a U,u, IU, lack of a leading zero before a decimal (.X mg), and others.
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- Parts of the Medical Staff Bylaws were found to be noncompliant with certain Joint Commission standards.
- In a couple areas of Allen, surveyors found expired medications.
- During their tracer methodology, surveyors found a couple immediate postoperative progress notes that contained only cursory information.
- Surveyors felt that the current organization chart does not meet the Center for Medicare and Medicaid requirements for reporting relationships relative to outpatient services.
- A couple of primary source verification issues with licensed staff were noted.
- Some building issues were also noted. We have decided to contest some of these, while others are being addressed.
- Surveyors observed inconsistency of Pharmacy oversight for analysis of data and process for use of non-formulary medications at some off-site facilities.
- During a tracer, surveyors noted dissatisfaction with interruptions during cleaning/disinfecting equipment, and transportation of equipment through clean/dirty areas.
- Use of a standardized process for recording fluid temperatures and thawing time of tissue.
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Our laboratory was separately reviewed by Joint Commission with only two findings. One related to waived testing and use of commercial controls. The other related to documentation of procedural controls for pregnancy testing.
Management is preparing a response to these issues, and changes are being implemented where indicated. Your help with these changes will be greatly appreciated. As noted before, Allen did well during this survey. There is nothing in this list that cannot be corrected, and Allen associates displayed very good knowledge of the standards when responding to surveyor questions. Thank you for your preparation and participation.
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Time Is Ticking Away
NetLearning modules need to be completed by October 1.
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13th Annual Golf Tournament Raffle
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Watch for us in the cafeteria over the lunch hour to purchase your raffle tickets for the 13th Annual Allen Hospital Golf Tournament.
Enter for your chance to win some great prizes and help us reach our goal for the new building at Allen College!
Tickets may also be purchased in the Foundation office, from Dina Dowden in Barrett Forum or Katie Dulin in Gerard Hall.
Please call Erin at 3960 with any questions.
Click here to see full poster.
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Flying Saucer?
Jumbo Pizza Pan?
Nope – it’s a reflector, being used to shoot a video on 3 Heart for the Allen Open Forums coming August 30.
Click here to sign up for the forum session you prefer. Schedule listed below.
SEE YOU THERE!
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Allen Gift Shop News
50% off select summer items is still running! Stop by and see us.
Upcoming Events
August 30 - Auxiliary Sponsored Senior Event at Electric Park Ballroom
September 26 and 27 - Books are Fun
October 27 and 28 - Scrubs Sale
November 22 - Masquerade Jewelry Sale
December 12 and 13 - South Bend Chocolate Sale
Fall River Excursion - Wednesday, October 12
7:30 am – Board Bus parking Lot 7a
9:30 am – Arrive in Dubuque
10:00 am – 2:00 pm – Fall Foliage Lunch Cruise
Hot buffet lunch served on boat
Musical entertainment while on boat
4:30 pm – Arrive home
$85.00 per person (pricing might change)
Space is limited, reserve your spot today. Paid reservations required by September 9.
For questions, please contact Linda Lott at Volunteer Services Office 319-235-3692.
Help Us Meet Our Bonus Budget Goal!
When we make good purchasing decisions, it helps us reach our goals in the Share Our Success incentive plan. Below is a tip to help us keep costs down and put us on track to help reach our incentive plan.
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Call Before You Repair!
If you have a stand-alone fax unit that needs to be repaired, call Purchasing to see if we have a working unit you could replace it with first. The average cost of a repair is $253 and we usually have 2-3 units available at a time. If you have any questions you can contact Amber Crooks in Purchasing at x3785.
Thanks for your help in keeping supply costs down!
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Another Try
I have had enough employees show interest in Weight Watchers to have an Informational Meeting on Thursday the 25th from 3:15 to 3:30. As long as we have 15 employees the sessions will continue. If there are enough members then the first weigh-in will be September 1st at 3 pm.
Please let others know that maybe interested in case they were not on my email list. Please RSVP to me at combsmm@ihs.org so I know if we will have enough employees to continue the sessions.
Green Team Garden Projects For August
The rain garden is in and growing. Some of the plants look a little thirsty, but as they become established with deeper roots, they will look better hydrated. Also, the irrigation system turns on at night in that area. To the left is a picture of the four scouts that planted the garden last week. We didn't have all their names last week and wanted to recognize them for their hard work. Left to right, Jack Buck, Kyle Kramer, Michael Delagardelle and Karl Kramer, the scout who is earning his Eagle Merit Badge by planning and building this rain garden. They did a great job. Another thank you goes to Phil Schuppert, water conservation specialist, and Becky Stansbery, Iowa State Horticulturist, for their guidance and hands-on help.
Becky is preparing a rock garden by the rain garden (both at Entrance 6) and it will be completed by this fall, with the help of the George Washington Carver students. This will be a beautiful garden with a stone bench and large rocks.
And now . . . on to landscaping Allen signs. Steve Buckles and I began planting around the Allen sign on the corner of Dale and Columbia Streets. Here is a picture of Steve manhandling the rototiller. Steve planted winebark, russian sage and daylilies and will be adding a few more plants. Steve is retired, but that has not slowed him down! He is a master gardener, works at another job, volunteers for Hospice, the heart support group and the Cedar Valley Aboretum and Botanic Gardens! Thanks, Steve, for offering your help at Allen!
More updates to come. Allen Green Team volunteer, Trish Pedersen
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Tulip Ordering Deadline is TODAY!
Help support breast cancer services in the Cedar Valley! Click here for more information. Click here for order form. -Sponsored by the Beyond Pink Team.
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