Example 1
At the time of the full survey the hospital does not meet the standard for use of blood and blood products,
standard COP.3.3, because clinical guidelines and procedures are not established and implemented and do not
address a) through e) of the intent. When the surveyor(s) returns for the focused survey, the organization
presents evidence that clinical guidelines and procedures have been established and based on evidence from
literature, professional associations, and other credible sources, that include processes for a) through e) of the
intent. In addition, staff have been educated on these guidelines and interviews with staff confirm that they
are knowledgeable about the process. Documentation in the clinical records show processes are being
followed.
Based on the hospital’s actions and the evidence observed by the surveyor(s), the hospital would be in full
compliance.