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Survey preparedness goes beyond compliance, resonating deeply in the dynamic healthcare landscape. Even the most meticulous organizations can be caught off-guard by unforeseen interpretations and requirements. This underscores the need for sustained survey readiness among entities like hospitals, behavioral health care organizations, ambulatory clinics, home care companies, and others. Our distinct approach, rooted in extensive Joint Commission & CMS experience, propels your readiness beyond compliance, driving perpetual organizational excellence.

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We exhibit adaptability and responsiveness by customizing surveys to your precise needs, whether tailored for your accreditation body or solely focused on CMS CoPs compliance. Acknowledging the varied requirements of healthcare facilities—hospitals, home health & hospice services, ambulatory surgery centers, psychiatric hospitals, and critical access hospitals—we deliver a verbal exit report and a comprehensive written report post mock survey. These reports are strategically designed for immediate, impactful action in upcoming surveys and ongoing regulatory readiness.

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Safety University's accreditation and compliance consultants are seasoned Environment of Care (EOC) and Life Safety surveyors, chosen for their technical expertise and coaching proficiency. They transcend mere mock surveyors, sharing your compliance goals. Our emphasis extends beyond survey execution, encompassing consultative guidance to implement and sustain compliance seamlessly.

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Safety University is dedicated to delivering actionable outcomes, enabling our healthcare clients to promptly address deficiencies and drive improvements.

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Sample Agenda 

Our accomplished team of mock survey consultants collaborates closely with you to meticulously plan a comprehensive review. With a clear agenda in place, you'll be well-prepared, fully aware of what to anticipate, and informed about the on-site activities. This agenda encompasses the following essential components and is customizable:

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Document Review Session:

• Thorough Building Assessment(s)

• Examination of Life Safety Drawings

• Assessment of Interim Life Safety Measures

• Review of Fire Response Plan

• Scrutiny of Fire Drills

• Evaluation of Fire Protection/Suppression Testing, Inspection, and Maintenance

• Analysis of Medical Equipment Inspection, Testing, and Maintenance

• Risk Management for Utilities Systems & Water Management

• Maintenance and Testing of Emergency Power Systems

• Maintenance and Testing of Medical Gas and Vacuum Systems

• Monitoring of Environmental Conditions Data

• Assessment of Emergency Management & Business Continuity Programs

• Evaluation of Environment of Care Management Plans

• Review of Ligature Risk Assessment, optional

 

All the elements integrated into our service are meticulously designed to fortify your
organization's readiness for your upcoming accreditation survey.

 

Building Tour: 

We undertake a comprehensive building tour in collaboration with your Facilities Management, Safety, and Environmental Services teams, assessing key areas:

• Fire and Smoke Separations

• Hazardous Areas (Soiled Linen Rooms, Trash Collection Rooms, Oxygen Storage Rooms)

• "Above the Ceiling" Survey: Identification of Penetrations and Discontinuities

• Identified Security Sensitive Areas

• Verification of Fire Exits and Continuous Pathways

• Examination of Kitchen Cooking Devices

• Comprehensive Assessment of Infection Control Practices & Equipment

• Condition Evaluation of Emergency Power Systems and Equipment

 

Environment of Care/Emergency Management Session: 

Upon request, we simulate the evaluation process employed by surveyors for your Environment of Care (EOC) program. This involves a comprehensive review and discussion of your EOC Plans, Safety Committee minutes, and your methods for identifying and managing environmental risks. Your organization’s representatives will have the opportunity to practice presenting their EOC and Emergency Management programs and addressing surveyor inquiries.

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