Class: Regulatory and Compliance Week 9 WRITTEN ASSIGNMENT: Project - Monitoring Tools for Compliance Plans It's time to describe the monitoring tools for your two compliance plans in a way that all

Previous Written Assignments

Week-2: Project - Select Two Compliance Plans

The first step of your assignment this module is to choose two compliance plans from the list of compliance violation areas below.

1. Clinical staff members are not washing their hands between patients.

2. Employee attacks patients while under the influences of narcotics.

3. Nurse charges for Diabetes Management Education as a Physician Visit.

4. Medical staff members are not aware that the application of an initial cast for a broken limb should be included in the cost of the visit. Instead, they are charging extra for the application of this initial cast.

5. Employees are not knowledgeable in the use of fire extinguishers.

6. Many employees are not able to fulfill the requirement to discuss the facilities Mission Statement and Vision Statement.

After you choose two areas (only two!), write a paragraph about each one to present to your faculty member. In each paragraph, explain why you believe the chosen area represents key issues in compliance and why you want to develop a compliance plan for this area.

Remember, your faculty member must confirm your two compliance violation areas before you begin your research and writing. Most of you should be able to write about your preferred plan areas, but in some cases, to ensure that all areas are covered by class members, you may receive a different plan to write about. As soon as your selections are approved, begin your research on the Internet and at your college's online library, which you can access through the Resources tab.

Week 2 Answer:

Select Two Compliance Plans

For Plan one, I chose the topic Clinical staff members are not washing their hands between patients. According to the article Infection prevention in hospitals: The importance of hand hygiene in Helio, in the year 2014 the CDC data show that approximately one in 25 patients acquire a healthcare-associated infection (HAI) during their hospital care. This added up to about 722,000 infections a year. And, out of the 722,000 patients 75,000 patients died of their infections. In the same article stated at this time, the CDC Director Tomas Frieden, MD MPH, said even the most advanced health care would not work if clinicians neglect basic practices such as hand hygiene. By reading this article and working in healthcare industry different types of infections and illnesses are passed on from person to person by the staff, not washing their hands between caring for patients, which this the key issue.

The reason why I want to develop a compliance plan for this topic is to make the staff aware how severe and vital staff hand hygiene is in the healthcare industry. And if poor hygienes continue, how problematic it can have on the patients that they see. As mentioned above, a patient can get sick from infections and germs and could lead to death for some patients. All of this is due to not simply taking the time to wash your hands.

For Plan two, I chose the topic Employees are not knowledgeable in the use of fire extinguishers. The federal law PORTABLE FIRE EXTINGUISHERS 29 CFR 1910.157states, “The federal portable fire extinguisher rule applies to the placement, use, maintenance, and testing of portable fire extinguishers provided for the use of employees. Employers are generally required to provide portable fire extinguishing equipment in the workplace for use in fighting incipient-stage fires. An “incipient-stage fire” means initial or beginning stage that can be controlled or extinguished by portable fire extinguishers. (BLR, n.d.)” Therefore, we need a plan to stay compliant with federal law, which is the key issue. The healthcare facility has all type of patients, visitors, and staff members that come in and out of the facilities. Every staff member needs to know how to operate the fire extinguishers to save the lives of the people documented in the previous sentence. We are here to save lives, and this is one way to protect them and stay complainant.

References

BLR. (n.d.). Fire Extinguishers laws & safety compliance analysis. Retrieved from https://www.blr.com/Workplace-Safety/Emergency-Planning-and-Response/Fire-Extinguishers

Healio: Infectious Disease. (2014, April). Infection prevention in hospitals: The importance of hand hygiene. Retrieved from https://www.healio.com/infectious-disease/nosocomial-infections/news/print/infectious-disease-news/%7Bdd1e115b-8a00-4889-9e85-8566391f2541%7D/infection-prevention-in-hospitals-the-importance-of-hand-hygiene

Week 4: Project - Overview of Compliance Plans

So, you are developing two compliance plans in a way that all employees will understand at a large medical facility where you are the Compliance Officer.

To help your employees gain an overview of compliance and its importance, write a 2-3 page Overview of Compliance Plans paper for your two compliance plans. In your overview, state the purpose of your two compliance plans for your company. Then, in terms that every employee will grasp, explain how all employees would benefit by supporting the key elements in every compliance plan - compliance standards, high-level responsibility (for each employee), education (about compliance), communication, monitoring/auditing, enforcement/discipline, and response/prevention.

Support your overview with at least three research sources outside of your required reading. Citations in APA format should be listed in a References Page at the end. Guidelines for APA are included under your Resources tab.

Save your assignment as a Microsoft Word document.

Week 4 Answer:

Clinical Staff Hand Hygiene between Patients Plan

As an overview, the following compliance plan touches on the compliance issues associated with activities that relate to hygiene at our medical facility center. The program will explain hygiene activities in terms of patient handling cleanliness, monitoring, and responsibility based on our policy.

The medical facility's aim, propose, or standard for the hygiene plan is the commitment to institutional values, ethical principles, and laws, and regulatory compliance and fare as patient care are concerned. We profoundly recognize the responsibilities and privileges that come with patient care provision. Additionally, we aim at providing the highest quality of services ever.

In our healthcare facility, every staff is required to portray high levels of responsibilities of cleanliness. Every employee is expected to consider all patient handling precautions to avoid the risks of contracting and spreading diseases. Each medical officer must monitor and take responsibility for their patients and them as far as hygiene is concerned. They are expected to observe the following;

• Hand washing while attending to another patient

• Sanitizing or cleaning instruments used as well as safely disposing of those that can't be re-used.

• Use sufficient agents for cleaning hands such as detergents and water.

For the discipline and enforcement, any medical officer who does not comply with the healthcare regulations, laws, Compliance Program, or requirements is liable to disciplinary measures and may even cause termination (Steiner, 2016). They are subject to loss of the privileges that they enjoy as clinical officers.

Educating members of staff will impart the necessary knowledge on the importance of observing cleanliness as well as the risks involved if they don't maintain high levels of hygiene. Additionally, education will help members understand the penalties and disciplinary action in case they are on; they don't observe cleanliness.

Communication will ensure that there is continuous engagement between the staff members and the policymaker. This will allow for correction and clarification in case of misunderstanding. Monitoring is essential for any policy compliance as it helps keep check of any deviation from the set target and correct them early. Finally, prevention is always better than cure. It helps minimize risks and hazards associated with handling patients with dirty hands.

Fire Extinguisher Laws and Safety Compliance Analysis Plan

For the overview of this plan, it is the responsibility of the medical facility to provide fire extinguishers for their members of staff. This duty should be delivered by offering education on how to use fire extinguishers and on other precautions that ensure that the members of the team are on the right side in case of a fire outbreak within the facility premises. Proper education can help prevent hazards such as destruction of properties, injuries, and death.

The purpose of the compliance plan is to ensure that all medical officers and other facility workers have the appropriate training on the use of fire extinguishers. As recent statistics indicate, about 200 people die and more than 5, 000 suffer injuries from fire every year. Damages worth $2 billion have been reported in recent years caused by not less than 75,000 workplaces fire incidences. There have been more cases of fire extinguisher standards violations in our medical facility. Therefore, employees must get training on how to use fire extinguishers and the hazards associated.

The education of this plan is critical to the staff members. Even though the facility has professionals who have fire handling skills, every staff must get trained to minimize hazards and save time during firefighting. The word PASS is used as the code for the steps to be taken in case of a fire outbreak.

• Pull the extinguisher pin to release the locking mechanism, which allows the user to discharge the extinguisher.

• Aim at the fire's base and not the flame. One should focus on the fuel, not the fire to put it out (Educational resources, 2011).

• Slowly squeeze the lever to release the extinguishing agent. A release on the lever stops the discharge.

• Sweep from one side of the firebase to another until the flame goes off.

Also, the Fire Extinguisher’s Laws and regulations state the following:

• All employers should provide, mount, identify, and locate fire extinguishers at places that are easily accessible to all employees without putting them in danger.

• Testing, inspection, and maintenance should be performed regularly.

• Regular selection and destruction.

• Employers should have an emergency action plan that is in line with the 1910.38 requirements. The action plan should be clear on the employees who are allowed to handle the available fire extinguishers. It should also give valuable information on the assembling of employees as soon as the fire alarm sounds (Bosco et al., 2015).

Communication will help keep the members of staff updated on any changes on matters relating to firefighting in the facility as well as a means for exchanging feedback with the policymaker. Monitoring help ensures that all staff members are acting in accordance with the set rules and regulations, and if they are not, action to be taken. Discipline and enforcement are usually provided to make employees comply. The thought of going off either losing work privileges or getting laid of keeps them alert and aware of the rules to follow. Finally, prevention measures help minimizes any likely future occurrence of fire outbreak or inability to contain such an incidence.

In conclusion, with these two plans will can move forward with a better healthcare environment. We have focused on the overview, the compliance standards, high-level responsibility (for each employee), and education (about compliance). Also, we covered communication, monitoring/auditing, enforcement/discipline, and response/prevention. Our staff members will benefit so much from these two plans.

References

Bosco, A., Wentz, W., Dawson, D., & MARCOM Group, L. (2015.). Using fire extinguishers. Marcom: [Wilmington, Del.?].

Educational Resources, (2011.) Fire extinguishers: how and when to use them. Lexington: Lexington, SC: ERI Safety Videos, Inc.

Steiner, J. (2016). Clinical research law and compliance handbook. Sudbury, Mass.: Jones and Bartlett Publishers.

Week 6: Project - Policies for Compliance Plans

Are you ready to present the policies for your two compliance plans in a way that all employees will understand at a large medical facility where you are the Compliance Officer?

Your assignment is to write two 1-2 page sections in a Word document describing the policies for each of two compliance plans. Remember to support your policies for the two plans with a total of three research sources, cited at the end in APA format. (That's 1-2 research sources per plan.)

Polices you should consider covering for each plan come under the key compliance elements: Compliance Standards, High-Level (personal) Responsibility, Education, Communication, Monitoring/Auditing (for Safety), Enforcement/Discipline, and Response/Prevention.

Look these over in your research and then select just two of these key elements and write your policies under them for each of your two compliance plans. (Your policies for each plan can zero in on different key elements.)

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document.

Week 6 Answer:

Polices for Compliance Plans

We have two policies that our facility will focus on for this month. This is a description of the two policies for each of the two compliance plans. The Policy for Clinical Staff Hand Hygiene between Patients will focus on the High-Level (personal) Responsibility and Response/Prevention. And the Policy for Fire Extinguisher Laws and Safety will cover the Compliance Standards and Education. Both of these policies are very important to our employees and should have excellent knowledge or understanding of each one of them.

Policy for Clinical Staff Hand Hygiene between Patients

Taking into consideration the guidance implemented by the Department of Health, the hospital has selected to adopt a ‘Nothing below the Elbows’ policy for all staff members working in the clinical environment. This set of regulations encourages effectual hand hygiene by making sure that the wrists and hands are completely exposed to the product used; it also outlines that any items or products that can become contaminated during patient activities (for instance jewelry, long sleeves) or have the capacity to assimilate micro-organisms are removed (Karaaslan, et al., 2014).

• The regulation of ‘Nothing below the Elbows’ must be followed by all staff members involved in any form of direct medical care. This includes all the hospital employees who work mainly in a clinical environment (ward secretaries or ward clerks). The policy also applies to staff members who visit the hospital for a specific duration of time and are in direct connection with the patients and their associated treatment/bed areas (such as operational managers, consultants, pharmacists, and dieticians).

• As an employee arrives at the clinical environment, he/she must remove coats/jackets/cardigans and hang them on the designated areas for the department and ward they are responsible for. Items such as bracelets, wristwatches, bands, and rings (except a plain wedding band) must be taken off as well. Long sleeves must be kept above the elbow, and hands must be disinfected with alcohol gel/hand rub or soap and water following poster guidelines on display in different clinical wards.

• Selecting the method of hand disinfection will depend on the evaluation of what is suitable for the care procedures, the availability of resources in the proximity of care, the practical possibilities, and, to an extent, individual preferences depending on the acceptance of materials or provisions.

• Routine hand washing will involve foam/liquid soap and water. Proper and washing techniques will be carried out in three phases: preparation, washing, and drying.

  1. Preparation: soaking hands with running water before the application of the suggested amount of foam/liquid soap

  2. Washing: the solution must be present on all surfaces of the hands. Vigorously rubbing the palms and upper areas of the hands, a minimum amount of 10-15 seconds should be taken, paying close attention to the fingertips, the thumbs, and spaces between the fingers.

  3. Drying: using an adequate quality of disposable paper towels, dry up the hands meticulously.

• Considerable facilities must be supported to allow staff members to wash and dry their hands in an appropriate manner, to use hand gel of nay form, and to secure their skin with moisturizer.

Policy for Fire Extinguisher Laws and Safety

According to the overview of the compliance plan relating fire extinguisher laws and safety, the hospital staff should be diligent and proficient in inconsistently using the equipment. Individuals should know how to appropriately use fire extinguishers, the proper procedures to follow in a possible fire accident, as well as the maintenance and care of the extinguishing equipment (Sierra, Rubio-Romero, & Gámez, 2012). Also, the federal law PORTABLE FIRE EXTINGUISHERS 29 CFR 1910.157states, “The federal portable fire extinguisher rule applies to the placement, use, maintenance, and testing of portable fire extinguishers provided for the use of employees. Employers are generally required to provide portable fire extinguishing equipment in the workplace for use in fighting incipient-stage fires. An “incipient-stage fire” means initial or beginning stage that can be controlled or extinguished by portable fire extinguishers. (BLR, n.d.)” The employees should follow these policies to implement training and information processing.

• Designing a fire extinguisher program is necessary for all departments and employees around the hospital. The organization maintains that everyone gains and insight into the emergency procedures and how different functionalities have to be mediated.

• Every program should combine hands-on instructional and classroom constituents. Multiple essential elements can and should be highlighted before asking the employees to assemble their theoretical information with practical implementation.

• Employees must know about the five classes of fire, depending on the clinical area they work in. According to the fire event, they should be taught how to select the correct fire extinguisher with the help of visual posters or additional materials.

• Many fire extinguishers are designated to be used on specific fire types. The most common types are:

  1. Class ABC: dry chemical powder

  2. Class BC: CO2

  3. Class A: water

• Staff members must realize that the operational purpose of a fire extinguisher is to control and limit the damage. Using an extinguisher that does not relate with the class of fire can enhance the hazard and threatens the user and people present nearby. Talking about the best options for every condition is critical.

• The training staff should take into consideration stimulating multiple fire situations, including different forms of accidents or fire challenges.

• Employees must know how to maintain a suitable distance from fires depending on the size of fire extinguishers that are used and the form of an accident. A representation of how to appropriately moving away from the accident space is also necessary.

• All employees must be enrolled in in-classroom training for the conduction of appropriate information. Training is difficult when the clinical environment is linked with multiple professionals, but a proper arrangement of programs is suitable enough.

• Employees should sign up for the fire extinguishing training program every month to avoid any consequences or delays in the acknowledgment and teaching.

As you can see, these policies can improve the quality of health and make our facility a safer environment for our employees, patients, and guests. We have discussed the High-Level (personal) Responsibility and the Response/Prevention of the Policy for Clinical Staff Hand Hygiene between Patients. And we have described the Compliance Standards and Education for the policy on Fire Extinguisher Laws and Safety. If you have any additional questions or concerns please contact the Compliance & Ethics Department at 601-555-2323.

References

BLR. (n.d.). Fire Extinguishers laws & safety compliance analysis. Retrieved from https://www.blr.com/Workplace-Safety/Emergency-Planning-and-Response/Fire-Extinguishers

Karaaslan, A., Kadayifci, E. K., Atıcı, S., Sili, U., Soysal, A., Çulha, G., … Bakır, M. (2014). Compliance of Healthcare Workers with Hand Hygiene Practices in Neonatal and Pediatric Intensive Care Units: Overt Observation. Interdisciplinary Perspectives on Infectious Diseases, 2014, 1–5. DOI: 10.1155/2014/306478

Sierra, F. J. M., Rubio-Romero, J. C., & Gámez, M. C. R. (2012). Status of facilities for fire safety in hotels. Safety Science, 50(7), 1490–1494. DOI: 10.1016/j.ssci.2012.01.006

Week 8: Project -Procedures for Compliance Plans

Your assignment is to write two 1-2 page sections in a Word document describing the procedures for each compliance plan. Remember to support your procedures for each of two plans with a total of three research sources (1-2 per procedure), cited at the end in APA format. Write your procedures in a way that all employees will understand at a large medical facility where you are the Compliance Officer.

For your two compliance policy plans, please refer to Module 06 Course Project - Polices for Compliance Plans. Remember, you chose two compliance policy plans under the key compliance areas of Compliance Standards, High-Level Responsibility, Education, Communication, Monitoring/Auditing (for Safety), Enforcement/Discipline, and Response/Prevention. (Check them out if you forget! Remember, you may have written about different policies for the two different compliance plans.)

Save your assignment as a Microsoft Word document.

Week 8 Answer:

Procedures for Compliance Plans

The Clinical Staff Hand Hygiene between Patients and the Fire Extinguisher Laws and Safety are all safety precautions that are established to ensure the safety of the patients by safeguarding them from any form of harm they might encounter while receiving treatment at a healthcare facility. These compliance requirements are intended to form the foundation of excellent patient care and a better strategy to achieve quality care for patients. However, for this to be successful, there has to be a carefully defined procedure to be followed.

Policy for Clinical Staff Hand Hygiene between Patients

The Policy for Clinical Staff Hand Hygiene between Patients focused on the High-Level (personal) Responsibility and Response/Prevention. This policy requires all employees to observe high levels of cleanliness while attending to patients. The plan will help in the prevention of risks like contracting or spreading diseases among the people at the healthcare facility. Besides, the healthcare facility will avoid extra costs incurred for expensive treatments after an infection has occurred. Hand hygiene should take place before and after caring for the patient, before and after handling any dirt or contaminated things, before and after handling food. Hand hygiene should take 30-40 seconds (Wałaszek et al., 2017). The procedure for proper hand hygiene is outlined below and should be accompanied by well-labeled diagrams.

Procedure:

1. Removal of watches, jewelry, rings, nail polish, and ensure the nails are short as dirt and bacteria can sit under long nails, under the rings, on watches, and on jewelry (Wałaszek et al., 2017).

2. Covering scratches and wounds as they can get infected or harbor infections.

3. Applying the antiseptic or hand sanitizer and rubbing palm to palm.

4. Rubbing the back of the right hand over the left palm and vice versa.

5. Rubbing palm to palm with interfaced fingers.

6. Rubbing the back of fingers on opposing palms with the fingers interlocked.

7. Rubbing around the left thumb with the right palm and vice versa.

8. Rubbing the palm of the right hand with fingers of the left hand and vice versa.

9. Drying hands using a clean disposable paper before doing the net task.

Any of the employees that will fail to adhere to the requirements or procedures outlined are liable to face disciplinary action taken against them or even termination (Steiner, 2016). This implies that the privileges they enjoy as clinical officers might be lost as well.

The Policy for Fire Extinguisher Laws and Safety will address the Compliance Standards and Education regarding the use of fire extinguishers. All employees should know all the locations of the fire extinguishers and know the emergency action plan and how to handle the fire extinguishers. The emergency plan helps them understand what to do the fire alarm sounds immediately. The management should test, inspect, and maintain the fire extinguishers regularly to ensure compliance to standards (Harris, 2016). The procedure all employees should be aware of in putting off the fire includes teaching the employees how to extinguish the fire and should be accompanied by well-labeled diagrams.

Procedure:

1. Pulling the fire extinguisher pin to discharge the extinguisher from the locking mechanism (Harris, 2016).

2. Aiming for the base of the flame instead of the fire.

3. Slowly squeezing the lever releasing the extinguishing agent.

4. Sweeping from side to side until the flame goes off

In conclusion, the compliance plans require the employees and employers to know how to handle while fire and proper hand hygiene for the safety of patients and keeping away from harm. The employees should, therefore, adhere to the procedures outlined, the employers should ensure the standards are followed for safety and quality care for the patients.

References

Harris, J. D. (2016). Fire Extinguisher Designated Worker and Fire Watch: Self-Study Course 15672 (No. LA-UR-16-24745). Los Alamos National Lab. (LANL), Los Alamos, NM (United States).

Steiner, J. (2016). Clinical research law and compliance handbook. Sudbury, Mass.: Jones and Bartlett Publishers.

Wałaszek, M., Kołpa, M., Wolak, Z., Różańska, A., & Wójkowska-Mach, J. (2017). Poor Hand Hygiene Procedure Compliance among Polish Medical Students and Physicians—The Result of an Ineffective Education Basis or the Impact of Organizational Culture?. International journal of environmental research and public health, 14(9), 1026.