• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Survey Readiness Checklist/Audit/Tracer


  • Manager or delegate attended survey?

  • Debrief of findings completed at end of mock survey?

  • Staff address mock survey team, smile and are helpful?

  • Staff can state, identify, find or know about the following: * KP Learn <br>* UO Reporting: Culture of Safety and Reporting <br>* Red Rule/2 Patient Identifier <br>* Look alike-Sound alike drugs * Policies and Procedures

  • Staff know what numbers to call codes and where to find code carts and resources.

  • Staff know where the emergency manual and departmental plan is.

  • Staff know where to find information regarding chemicals, exposure and what to do if injured.

  • Staff understand the incident command structure/talk about drills and what we do an after action debrief for?

  • Staff know what to do if a patient presents with chemical contamination-Isolate patient from other/facility, call 911.

  • Able to promptly deliver requested logs and materials required for review.

  • All employees and visitors(reps, translators, students) are wearing photo/name ID.

  • Any additional comments regarding positive or suboptimal issues observed during the tracer.


  • Patients and families properly informed of their rights.<br> Patient rights and responsibilities are provided to the patient prior to admission. They are also posted in the facility waiting room in a font size legible to most. They are available in other languages for non-English speaking patients. The state health department and Medicare Ombudsmen contact information are also included in the document.

  • Please enter missing information

  • Advance directives, as required by state or federal law and regulations is provided and documented.

  • Please enter missing information

  • The patient is asked about AD and a copy is obtained if the patient has an executed AD.

  • Methods for providing feedback, including complaints is posted. The difference between a complaint and grievance is defined in the policy and procedure.There is a flow chart for the process and logs are maintained. Elements m.1-M.6 are addressed.

  • All patients are informed in the pre op call of the requirement for a responsible adult to drive them home and stay with them for the first 24 hours.


  • Confidential Patient Information:<br>Cannot be overheard or seen by unauthorized persons:<br> * Computer terminals signed off when not in use. <br> * Patient information is not discussed in public areas.<br> * Labels and PHI are obliterated before discarding in the trash. <br> * Patient conversations private

  • Please provide examples of NC(include picture if appropriate)

  • Medical Record Documentation:


  • Medication rooms are clean and uncluttered.

  • Visual inspection of medication containers: Containers are not full or overflowing. Medications are properly disposed of in correct disposal bin.

  • Controlled substances are secure/policies are followed.

  • Please provide explanation and picture

  • Area free of distractions.

  • Medication is appropriately labeled.<br> * Medication name<br> * Medication strength<br> * Initials of person drawing up medication<br> * Date and time of draw<br> * Expiration date and time(one hour from draw)<br><br>

  • All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

  • Medications stored appropriately to maintain stability.

  • No expired medications or supplies(check all treatment areas which staff stock)

  • Staff check ID band and allergies prior to administering medications.

  • Opened multi-dose vials dated and initialed. Not expired.

  • Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * Extra locks kept secured.<br> * All supplies & drugs that are on the inventory list are on the cart.<br> *. Cart is clean.<br> *. O2 tank is >1/2 full <br> *. Initials of person completing check are present.

  • Patient Bedside: <br> *. IV tubing is labeled per policy.<br> *. Medication is secured and labeled.<br> *. All solutions are labeled at the bedside. <br> *. "Scrub the hub"-vial tops wiped and hubs scrubbed prior to administration(alcohol:15 secs, CHG 30 secs)

  • Medication and anesthesia Carts: Doors and drawers are locked.

  • A list of look-alike/sound-alike medications is kept on the ADM.

  • Prescription pads are kept in a locked location. Prescriptions are submitted electronically.

  • MH Cart:


  • Point of Care testing lab controls documented and control solution labeled & dated.<br> *expiration and open dates

  • Observation and interviews confirm that space, equipment and supplies are sufficient:

  • Training for staff that are completing waived testing is available. Annual competencies are assessed and documented.

  • CLIA waiver exists for staff performed blood and urine tests.

  • The organization has a policy to ensure test results are reviewed and acknowledged in writing by the ordering physician or qualified designee.

  • Established procedures are followed in obtaining, identifying, storing and transporting specimens.

  • Specimens are handled and labeled according to departmental policies:

  • Specimen procurement is observed intraoperatively:


  • Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * No unapproved lotions<br> * No expired products

  • Isolation Precautions: <br> * Document patient/family education when patient is in isolation precautions <br> * Followed per policy and procedures <br> * Isolation cart is available and signage is visible

  • PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>

  • Food and drink only in designated areas:<br> * No evidence of it in patient areas, hazardous chemical storage area, laboratory specimen area, or any area where cross contamination may occur.

  • Patient food & drinks: No expired items.

  • Patient care supplies:<br> * Not expired, damaged, soiled.

  • Curtains, drapes or blinds clean.

  • Linen and Linen Carts: Covered and carts have solid bottoms.

  • Soiled Linen: Properly stored and not overfilled.

  • Separation of clean vs. dirty supplies & equipment:<br> * Clearly marked<br> * Clean items if stored in soiled utility are covered & clearly marked

  • Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol<br> * Not overfilled<br> * Covered when transported<br> * Chemo is handled and disposed of in proper collection bin

  • Wipes: <br> *Staff can speak to proper drying times of various wipes and use correct wipes on surfaces <br> *Proper drying time between case turnover and patients is witnessed

  • Sharps Waste:<br> * Placed in appropriate puncture resistant sharps container.<br> * Disposed of when 2/3 full or "full" indicator<br> * Mounted appropriately <br> * Recycling used instrument storage bin does not have items sticking out of bin <br> * Sharps waste has proper items in correct bin

  • General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids

  • Air vents: Clean

  • All items in PT care area that are not disposable are able to be wiped down.

  • Items are disinfected after use<br>

  • Negative and Positive air flow rooms function appropriately.

  • Ice machines clean. <br>*log available and up to date

CS Department:

  • Pre treatment of instruments is observed prior to delivery to CS:

  • Instruments are in good working order and not bent or broken:

  • Instruments requested for surgery are present prior to patient entry to OR:

  • Instruments have all paramenters met and are confirmed by OR staff prior to patient entry to OR:

  • Steris recycle bins and Biohazard instrument disposal bins are not overflowing:

  • CS staff are wearing proper attire to transport dirty instruments:

  • CS department equipment is in proper working order and/or work orders in progress:

  • Logs are available and up to date:

  • Vendors are adhering to policies and procedures with regard to requests:


  • AAAHC accreditation is current and posted for viewing in a public area.

  • Waiting room is separated from other patient care areas.

  • Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.

  • No items stored under sinks? Cabinets are locked.

  • No outer shipping carton boxes in patient care areas.

  • Operable equipment, to include implants and vendor/rep supplies, not left unattended in public areas.

  • Gas cylinders secured(empty and full stored separately); no more than 12 stored in one place.

  • Gas cylinders on stretchers show more than 1/4 full.

  • No expired items.<br>* Random sampling of supplies and equipment checked.

  • Eyewash stations: Inspection logs are present and up to date.

  • Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)

  • Refrigerators: Temp-track accessible. Documentation is present for actions taken to correct out of range temps.

  • Blanket, item warmers: Set to maintain temp of 130. Temp-track accessible or log available.

  • Temperature and humidity are monitored and maintained within accepted standards of practice; and if monitoring determined temperature or humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels.<br>20%-60% humidity <br>temperature

  • Preventative Maintenance:<br> * Random sampling of equipment checked with up to date bio-med sticker.

  • Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition. No extension cords are being used. If being used are being tested for leakage of currents.

  • Overcurrent protective devices(circuit breaker panels or boxes) are not located in public access spaces, and are accessible to authorized personnel only. No equipment or shelving is blocking access to panels.

  • Lead Aprons: Not torn, Clean, hung properly, have proper labeling for current year, have been checked by a radiation physicist annually, report can be provided:

  • There is a process for cleaning of aprons between cases utilizing a product that will not harm the integrity of the aprons.

  • There is a process for cleaning of equipment for diagnostic imaging that will not harm the integrity of the imaging equipment. Including C-arms and U/S.

  • Warning signs for radiation exposure are in place throughout the facility.

  • Dosimetry badges are worn, testing has been completed quarterly and results are maintained.

  • Physicians utilizing equipment have been trained and been granted privileges to use the radiology equipment. C-arms and U/S.

  • Policies and procedures have been developed, approved and implemented for imaging services.

  • Staff using equipment are trained and checked annually for competency.

  • Is MRI done in this area.

  • Warning signs in place:


  • Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be actively accessed to be "in use".<br>

  • Appropriate storage of boxes and pt care items:<br> * Not directly on floor.<br> * 18" clearance from sprinkler head.<br> * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.

  • Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.

  • Fire extinguishers have been inspected monthly.<br> * Random sampling extinguisher tags checked.

  • Fire doors are not blocked or propped and when closed there is positive latching.

  • Exit signs are illuminated.

  • Everyone has ID badges and worn appropriately:<br> * Staff and Visitors

  • Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

  • Floors, ceilings, walls, and other surfaces intact and free from holes.


  • Can staff locate medical gas zone shutoff valves.

  • Quarterly fire drill are documented and conducted at varying times of the date<br> *three years of drills are readily available


  • Are units quality improvement dashboards posted on unit.

  • Is unit's PI project data posted and current

  • Staff can speak to current PI projects and goals

Action Items: RCA/Survey Findings/Projects/Activities/UO Trends

  • RCA:

  • Survey Findings:

  • Quality Projects:

  • UO Trends:

Follow up findings from previous audits:

  • Finding:

  • Finding:

  • Finding:

  • Finding:

Opportunities for Improvement/NPSG:

  • 2 Patient Identifiers

  • Specimen Labeling

  • Read Back

  • Procedure Checklist

  • Hand Hygiene

  • Fall Prevention

  • Critical Result Reporting

  • Label meds on/off sterile field

  • High Alert Meds with independent double check

Chart Audit

  • undefined

Personnel Files

  • Verification of Employee desk files?

  • Please enter number of files reviewed, missing items and due date.

  • Staff Competencies/Education Complete?

  • Please indicate number of files reviewed, missing items and due date.

Other Findings

  • undefined

  • undefined

  • undefined

  • undefined

  • undefined

  • undefined

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