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
* UO Reporting: Culture of Safety and Reporting
* Red Rule/2 Patient Identifier
* 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.
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:
Cannot be overheard or seen by unauthorized persons:
* Computer terminals signed off when not in use.
* Patient information is not discussed in public areas.
* Labels and PHI are obliterated before discarding in the trash.
* 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.
* Medication name
* Medication strength
* Initials of person drawing up medication
* Date and time of draw
* Expiration date and time(one hour from draw)
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.
* Locked and marked with then first drug to expire.
* Checked per policy.
* Include defibrillator check.
* Extra locks kept secured.
* All supplies & drugs that are on the inventory list are on the cart.
*. Cart is clean.
*. O2 tank is >1/2 full
*. Initials of person completing check are present.
*. IV tubing is labeled per policy.
*. Medication is secured and labeled.
*. All solutions are labeled at the bedside.
*. "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.
Point of Care testing lab controls documented and control solution labeled & dated.
*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:
* No empty alcohol gel bottles
* No empty soap or paper towels
* No unapproved lotions
* No expired products
* Document patient/family education when patient is in isolation precautions
* Followed per policy and procedures
* Isolation cart is available and signage is visible
* Readily available
* Clearly marked
* Worn correctly
Food and drink only in designated areas:
* 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:
* 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:
* Clearly marked
* Clean items if stored in soiled utility are covered & clearly marked
* Discard in Red Bags with a biohazard symbol
* Not overfilled
* Covered when transported
* Chemo is handled and disposed of in proper collection bin
*Staff can speak to proper drying times of various wipes and use correct wipes on surfaces
*Proper drying time between case turnover and patients is witnessed
* Placed in appropriate puncture resistant sharps container.
* Disposed of when 2/3 full or "full" indicator
* Mounted appropriately
* Recycling used instrument storage bin does not have items sticking out of bin
* Sharps waste has proper items in correct bin
* Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms
* 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
Negative and Positive air flow rooms function appropriately.
Ice machines clean.
*log available and up to date
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:
* No broken equipment or furniture stored on the patient care units.
* 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.
* 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.
* 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:
* Egress corridors must have 8ft clearance.
* Equipment in corridors must be actively accessed to be "in use".
Appropriate storage of boxes and pt care items:
* Not directly on floor.
* 18" clearance from sprinkler head.
* Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.
* 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.
* 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:
* 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
*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
2 Patient Identifiers
Critical Result Reporting
Label meds on/off sterile field
High Alert Meds with independent double check
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.