Page 532 - eBook Version 8 Book 1 of 2 JUL 2022

STANDARD OPERATING PROCEDURE Research Administration SOP No: R-Adm-001 SOP Title: Joint Commission Readiness
5.1.4.2.1 5.1.4.2.2
5.1.4.2.3
Send your findings to the TLs, Director, and Senior Director highlighting any findings for review and resolution.
The TL will review, develop a plan to implement the resolution issues within the next 24 hours, include a snippet of the Block and Block (or Joint commission Notes/findings during a survey visit) on the Clean Sweep Inventory.
TL will review monthly findings in the unit huddles along.
5.2 During Joint Commission Surveys: Culture of Safety & Compliance
5.2.1 Know your policies and procedures
5.2.1.1 Review applicable policies in “Policy Tracker” which can be found on our ChildNet
site under Quick Links
5.2.2 Prepare beforehand...and when surveyors arrive
5.2.2.1 If you are approached by a surveyor, please escalate Surveyor engagements to Senior Director, Director, and TL promptly Complete Sections 5.1 on a daily basis and incorporate them with the Joint commissions Notes or findings from the daily employee communications
5.2.2.2 Review the Surveyor Arrival of the Survey Readiness Guide
5.2.2.3 Review the checklists of the Survey Readiness Guide
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