AAAHC/CMS Tracer Survey Tool

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

DESCRIBE THE UNITS RESPONSE TO YOUR AUDIT

• Manager or delegate attended survey?

  Yes

  No

  N/A

• Debrief of findings completed at end of mock survey?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

• 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.

  Yes

  No

  N/A

• Please enter missing information

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

  Yes

  No

  N/A

• Please enter missing information

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

PATIENT INFORMATION MANAGEMENT(HIPAA)

• 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

  Yes

  No

  N/A

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

• Medical Record Documentation:

  Yes

  No

  N/A

MEDICATION MANAGEMENT

• Medication rooms are clean and uncluttered.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Controlled substances are secure/policies are followed.

  Yes

  No

  N/A

• Please provide explanation and picture

• Area free of distractions.

  Yes

  No

  N/A

• 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>

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Medications stored appropriately to maintain stability.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• MH Cart:

  Yes

  No

  N/A

PATHOLOGY and MEDICAL LABORATORY/POINT OF CARE/WAIVED TESTING

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Specimens are handled and labeled according to departmental policies:

  Yes

  No

  N/A

• Specimen procurement is observed intraoperatively:

  Yes

  No

  N/A

INFECTION PREVENTION

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Patient food & drinks: No expired items.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Curtains, drapes or blinds clean.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Soiled Linen: Properly stored and not overfilled.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• Air vents: Clean

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Items are disinfected after use<br>

  Yes

  No

  N/A

• Negative and Positive air flow rooms function appropriately.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

CS Department:

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Logs are available and up to date:

  Yes

  No

  N/A

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

  Yes

  No

  N/A

ENVIRONMENT OF CARE

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

  Yes

  No

  N/A

• Waiting room is separated from other patient care areas.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• No items stored under sinks? Cabinets are locked.

  Yes

  No

  N/A

• No outer shipping carton boxes in patient care areas.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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:

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is MRI done in this area.

  Yes

  No

  N/A

• Warning signs in place:

LIFE SAFETY

• 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>

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Exit signs are illuminated.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

EMERGENCY PREPAREDNESS

• Can staff locate medical gas zone shutoff valves.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

STANDARD PERFORMANCE IMPROVEMENT

• Are units quality improvement dashboards posted on unit.

  Yes

  No

  N/A

• Is unit's PI project data posted and current

  Yes

  No

  N/A

• Staff can speak to current PI projects and goals

  Yes

  No

  N/A

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

• RCA:

  Yes

  No

  N/A

• Survey Findings:

  Yes

  No

  N/A

• Quality Projects:

  Yes

  No

  N/A

• UO Trends:

  Yes

  No

  N/A

Follow up findings from previous audits:

• Finding:

• Finding:

• Finding:

• Finding:

Opportunities for Improvement/NPSG:

• 2 Patient Identifiers

  Yes

  No

  N/A

• Specimen Labeling

  Yes

  No

  N/A

• Read Back

  Yes

  No

  N/A

• Procedure Checklist

  Yes

  No

  N/A

• Hand Hygiene

  Yes

  No

  N/A

• Fall Prevention

  Yes

  No

  N/A

• Critical Result Reporting

  Yes

  No

  N/A

• Label meds on/off sterile field

  Yes

  No

  N/A

• High Alert Meds with independent double check

  Yes

  No

  N/A

• Verification of Employee desk files?

  Yes

  No

  N/A

• 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.