Ambulatory EOC Rounds

• Prepared by

• Date Conducted

  Date
• Location of Inspection
  Address

Clinic Name (includes visiting specialties)

• undefined

• Is the Disaster Manual available? Is the Department Specific Response Plans updated annually? Is the Department Call Back List updated quarterly? SCHS Document Library. Disaster Binder Table of Contents JC: EM.02.02.01 (EP 2) CMS Appendix Z - §482.15 & §485.625

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Are Department Disaster Plans current and readily available? (Ask caregiver a <br>question directly from their department specific disaster plan manual such as where their evacuation/muster area is located.) <br><br>JC: EM.02.02.01 (EP 2) <br> EC.03.01.01 (EP 2) <br> EC.02.03.03 (EP 5) <br>CMS Appendix Z - §482.15 & §485.625 CMS §482.41(b)(1)(i) TAG: A-0710

  Yes

  No

  N/A

• Are any drills conducted regularly at this clinic? JC: EM.01.01.01 - EM.04.01.01

  Select Mock Codes Code Grey/De-escalation Code Orange Amber Alert Active Shooter Bomb Threat External/Internal Triage Other

  • Mock Codes
  • Code Grey/De-escalation
  • Code Orange
  • Amber Alert
  • Active Shooter
  • Bomb Threat
  • External/Internal Triage
  • Other

• Is evacuation equipment necessary (i.e. stair chair or sled bed for clinics on a second or higher floor). Are evacuation devices are securely anchored and are not obstructing exits or posing a safety risk? <br> <br>JC: EM.02.02.03 (EP 9, 10) <br> LS.02.01.20 (EP 13) <br>CMS §482.15(a)(3) TAG: <br>CMS §482.41(a) TAG: A-0701

  Yes

  No

  N/A

• Are downtime materials available ("Downtime Binder")? Is there record that the Downtime Computer has been logged into once a month? <br> <br>JC: EM.01.01.01 - EM.02.02.11

  Yes

  No

  N/A

• Caregiver can verbalize how to appropriately respond during an emergency code. <br>(Ask a Caregiver how they call in and initiate a code appropriate for their <br>departments.) (Examples: Code Red, Code Orange, Active Weapon Threat) <br> <br>JC: EC.03.01.01 (EP 2) <br> EC.02.03.03 (EP 5) CMS §482.41(b)(1)(i) TAG: A-0710

  Yes

  No

  N/A

• Is the clinic using the Ambulatory Clinic Debrief Form? <br> <br> Fact Finding <br> JC: EM.04.01.01

  Yes

  No

  N/A

• Does Facilities conduct annual Fire Drills at the clinic? <br> <br>JC: EM.01.01.01 <br> LS.01.01.01 - LS.03.01.70

  Yes

  No

  N/A

• Is there documentation of caregiver participation in the Fire Drills? [should include all caregivers employed by that clinic] <br> <br> JC: EM.02.02.05 - EM.02.02.11

  Yes

  No

  N/A

• Are fire extinguishers checked monthly, mounted, handles are placed 3 ½ - 5 feet above the floor and secured, and are free from obstruction?<br> JC: EC.02.03.05 (EP 15, 16) <br>CMS §482.41(d)(2) <br>OSHA - CFR 1910.157 <br>NFPA 10-2010: 7.1.2; 7.2.2; 7.2.4; 7.3.1

  Yes

  No

  N/A

• Are full and empty oxygen or compressed gas cylinders secured and housed in a proper storage area?<br><br>JC: EC.02.02.01 (EP 9) <br>CMS §482.41(d)(4) TAG: A-0726

  Safe

  At Risk

  N/A

• Are oxygen cylinders stored securely and in an appropriately labeled rack? [Full and empty racks.]<br><br>EC.02.05.09 (EP 9 & 12) <br>CMS §482.41(d)(2) TAG: A-0724 <br>(For full text, refer to NFPA 99-2012: 5.1.3.1; 5.1.3.2.3; 5.2.3.1; 5.3.10; 11.3; 11.6.5.2.1)

  Safe

  At Risk

  N/A

• Are there are no more than 12 oxygen cylinders stored per storage area?<br><br>JC: EC.02.02.01 (EP 9) <br> EC.02.03.01 (EP1) <br> LS.02.01.30 (EP 2) <br>CMS §482.41(d)(4) TAG: A-0726; §482.41(b) TAG: A-0709; §482.41(b)(1)(ii) TAG: A-0710

  Safe

  At Risk

  N/A

• All electrical power strips used with patient care devices are medical-grade? <br> <br>JC: EC.02.03.01 (EP 1) <br> LS.03.01.70 (EP 6) <br>CMS §482.41(b) TAG: A-0709; §482.41(b)(1)(ii) TAG: A-0710

  Safe

  At Risk

  N/A

• Are cords managed and organized to decrease the risk of arcing, overheating, combustion, and/or tripping? <br> <br> JC: EC.02.03.01 (EP 1) <br> LS.03.01.70 (EP 6) <br>CMS §482.41(b) TAG: A-0709; §482.41(b)(1)(ii) TAG: A-0710

  Yes

  No

  N/A

• Are 3-prong electrical prongs present on all patient care devices? <br> <br>JC: EC.02.03.01 (EP 1) <br> LS.03.01.70 (EP 6) <br>CMS §482.41(b) TAG: A-0709; §482.41(b)(1)(ii) TAG: A-0710

  Safe

  At Risk

  N/A

• Are there any portable heaters or other heat generating devices? [These are prohibited.] <br><br>JC: EC.02.03.01 (EP 1) <br> LS.03.01.70 (EP 3) <br>CMS §482.41(b) TAG: A-0709; §482.41(b)(1)(i) TAG: A-0710 <br>SCHS Document Library, Document #2048: General Electrical & Equipment Safety for Caregivers

  Safe

  At Risk

  N/A

• Is there clutter of cardboard, files, boxes or paper under desks or work areas? Are materials stored directly on the floor?<br><br>JC: EC.02.06.01 (EP 1, 20) <br> IC.01.03.01 (EP 2) <br>CMS §482.41 TAG:A-700; §482.42(a)(3) <br>SCHS Document Library, Document #5089 & #8117 <br>Rationale: CDC - Best Practices for Environmental Cleaning in Healthcare Facilities: in Resource-Limited Settings

  Safe

  At Risk

  N/A

• Are trash and recycle containers 32 gallons or smaller? Are trash and recycle containers used correctly? <br> <br>JC: EC.02.03.01 (EP 1) <br> LS.03.01.70 (EP 2) CMS §482.41(b) TAG: A-0709 NFPA 101-2012: 18/19.7.4

  Safe

  At Risk

  N/A

• Are Confidential Material and Protected Health Information physically secured and <br>protected? [All PHI discarded in Secure-Shred PHI bins.] <br> <br>45 CFR §160 §164 - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) <br>JC: EC.02.01.01 (EP 8) <br> IM.02.01.03 (EP 1,5) CMS §482.15(b)(5) <br> §482.13(d)(1) <br> §482.24(b) <br> §482.15(b)(5)

  Yes

  No

  N/A

• All soiled linen and hazardous waste containers larger than 32 gallons are<br>located in a room protected and labeled as a hazardous area? If not stored in a protected room, soiled linen and hazardous waste containers have a protective lid. <br> <br>JC: EC.02.03.01 (EP 1) CMS §482.41(b) TAG: A-0709

  Safe

  At Risk

  N/A

• Are the exits clear of obstructions or impediments to the public way, such as clutter, equipment, carts, furniture, construction material, snow, ice, etc.?<br><br>JC: LS.02.01.20 (EP 10-14) CMS §482.41(b) TAG: A-0709<br>NFPA 101 (18.2.3.4)

  Safe

  At Risk

  N/A

• Is access to alarms, electrical closets/panels, emergency shutoff valves, and fire extinguishers free of obstructions?<br><br>JC: LS.02.01.35 (EP 10) <br>CMS §482.41(b) TAG: A-0709 NFPA 101-2012: 20/21.3.5.3; 9.7.4.1 NFPA 10 section 6.1.3.1; annex D.2.3.1; annex F.7.2.2; NFPA 70, 110.32; <br>OSHA CFR 1910.303(g)(1)(i)(B)

  Safe

  At Risk

  N/A

• Are IT closets and electrical rooms free from penetrations or other fire code violations?<br><br>JC: LS.05.01.10 (EP 1-7) CMS §482.41(b)(1)(i) <br>(For full text, refer to NFPA 101-2012: 18/19.3.7.3; 8.2.3; 8.5.2; 8.5.6; 8.7)

  Safe

  At Risk

  N/A

• Are all fire resistant doors free of obstructions and not propped open? [Doors that do not prop open by themselves should be considered fire resistant doors.]<br> <br>CMS §482.41(b)(1)(i) <br>NFPA 101-2012: 8.3.3.2; 8.3.4.2; Table 8.3.4.2; 20/21.3.7.1 <br> 80-2010: 5.2.13.3

  Safe

  At Risk

  N/A

• Are decorations (holiday decorations) stored away from patient care or medical/patient supply areas [linen closets, medical supply areas, etc.]? <br> <br>JC: LS.03.01.30 <br> LS.03.01.70

  Safe

  At Risk

  N/A

• Are electrical and mechanical rooms free of anything combustible? Materials and supplies for the operation and maintenance of the room shall be permitted (NFPA 1 – 10.19.5.1) OSHA follows NFPA standards. <br> <br>NFPA 1 – 10.19.5.1

  Yes

  No

  N/A

• Are all spare breakers are turned off? <br> <br>JC: EC.02.01.01 (EP 3) CMS §482.13(c)(2) TAG: A-0144<br> §482.26(b) TAG: A-0535<br> §482.41(a) TAG: A-0701

  Yes

  No

  N/A

• Is there 18 inches or more of open space below sprinkler heads?<br><br>JC: LS.03.01.35 (EP 6) <br>CMS §482.41(b) TAG: A-0709<br>NFPA 101, §9.7.1.1, §9.7.1.4, and §9.7.5; <br> 13, §8.6.6; <br> 25, §2-2.1.2

  Safe

  At Risk

  N/A

• Is nothing suspended from the ceiling that could interfere with the sprinkler system?<br><br>JC: LS.03.01.35 (EP 5) <br>CMS §482.41(b)(1)(i) <br>NFPA 101-2012: 20/21.3.4.4 <br> 25-2011: 5.2.1; 5.2.2 <br> 13-2010: 6.2.6.2; 6.2.7.1

  Safe

  At Risk

  N/A

• Yes

  No

  N/A

• Are all employees, licensed independent practitioners, contractors, vendors, volunteers, and visiting dogs wearing SCHS-approved ID badges?<br> JC: EC.02.01.01 (EP 7) <br>CMS §482.13(c)(2) TAG: A-0144

  Yes

  No

  N/A

• The clinic controls access to and from areas it identifies as security sensitive (secure areas are locked and/or secured including medication rooms/preparation areas, soiled utility, etc.)? <br> <br>JC: EC.02.01.01 (EP 8) <br>CMS §482.13(c)(2) TAG: A-0144 §482.53(b) TAG: A-1035

  Yes

  No

  N/A

• Does the clinic have security cameras/video surveillance? <br> Fact Finding

  Yes

  No

  N/A

• Does the clinic have enhanced lighting in the parking lot? <br> <br> Fact Finding

  Yes

  No

  N/A

• Does the clinic have security mirrors in key locations (blind corners)? <br> <br> Fact Finding

  Yes

  No

  N/A

• Are soiled utility rooms secured from public access? <br> <br>JC: EC.02.02.01 (EP 12) <br> LS.02.01.30 (EP 2); LS.02.01.70 (EP 6) <br> IC.02.01.01 (EP 6) <br>CMS §482.41(b)(1)(i) <br>NFPA 101-2012: 18/19.7.5.7 <br> 101-2012: 18.3.2.1; 18.3.2.2; 18.3.2.3; 18.3.2.4; Table 18.3.2.1

  Yes

  No

  N/A

• Is hazardous waste (both sharps and biological waste) emptied into the correct collection containers in the soiled utility? <br>Are the collection containers routinely collected by the appropriate vendor? <br><br>JC: EC.02.02.01 (EP 5) <br>CMS §482.41(a) TAG: A-0701; §482.41(b)(4) TAG: A-0713

  Yes

  No

  N/A

• Are sharps containers securely anchored and less than 2/3 full? <br> <br>JC: EC.02.02.01 (EP 5) <br> EC.04.01.01 (EP 8) <br> IC.01.02.01 (EP 3) CMS §482.41(a) TAG: A-0701 <br> §482.41(b)(4) TAG: A-0713 <br> §482.26(b)(2) TAG: A-0537 <br> §482.42 TAG: A-0747

  Yes

  No

  N/A

• Are biological waste bins in procedure rooms properly labeled, contain the correct biohazard liner (red liner), and not overflowing? <br> <br>JC: EC.02.02.01 (EP 5) <br>CMS §482.41(a) TAG: A-0701 <br> §482.41(b)(4) TAG: A-0713

  Yes

  No

  N/A

• Is the Ambulatory Clinical Waste Classification sign posted in an area easily visible to caregivers? <br> <br>Fact Finding <br>JC: EC.01.01.01 <br> EC.02.06.01 <br> EC.03.01.01 <br> EC.04.01.05

  Yes

  No

  N/A

• What chemicals are currently used in the clinic? Are all chemicals known to the Ambulatory Clinical Support Team and an SDS for the chemical is available in Sphera? <br> JC: EC.02.02.01 (EP 5) <br> EC.04.01.05 <br>CMS §482.26(b)(1) TAG: A-0536<br> §482.41(a) TAG: A-0701<br> §482.53(b) TAG: A-1035<br> §482.53(b)(2) TAG: A-1035

  Yes

  No

  N/A

• If chemicals are moved to a secondary container (e.g., diluting a chemical, Oxivir large wipe containers), is the secondary container labeled with appropriate OSHA hazard label? <br> <br>JC: EC.02.02.01 (EP 5) <br>CMS §482.26(b)(1) TAG: A-0536<br> §482.41(a) TAG: A-0701<br> §482.53(b) TAG: A-1035<br> §482.53(b)(2) TAG: A-1035

  Yes

  No

  N/A

• Is there a spill kit readily accessible to caregivers? <br> <br>JC: EC.02.02.01 (EP 5) OSHA 1910

  Yes

  No

  N/A

• How do you dispose of used batteries and light bulbs? <br> <br>EPA Used Battery Recommendations JC: EC.04.01.01 - EC.04.01.05

  Yes

  No

  N/A

• How do you dispose of aerosolized containers (e.g. aerosol hand sanitizer)? <br> EPA: 40 CFR 273 <br>JC: EC.04.01.01 - EC.04.01.05

  Yes

  No

  N/A

• Ask at least 2 caregivers what PPE to use when handling hazardous materials. Responses correct? Comment in notes on feedback given. <br> <br>JC: EC.02.02.01 (EP 3, 5) <br> IC.02.01.01 (EP 2) <br>CMS §482.42 TAG: A-0747<br> §482.42(a) TAG: A-0748<br> §482.51 TAG: A-0940<br> §482.51(b) TAG: A-0951 <br> §482.26(b) TAG: A-0535<br> §482.26(b)(1) TAG: A-0536<br> §482.26(b)(3) TAG: A-0538<br> §482.41(a) TAG: A-0701<br> §482.53(b) TAG: A-1035

  Yes

  No

  N/A

• Are areas under sinks free of supplies, equipment, and other items except cleaning supplies and vases? <br> <br>EC.02.06.01 (EP 26) <br>IC.01.03.01 (EP 2) <br>IC.02.01.01 (EP 1) <br>CMS §482.41 TAG: A-0700<br> §482.41(a) TAG: A-0701 <br> §482.13(c)(2) TAG: A-0144<br> §482.42 TAG: A-0747<br> §482.42(a) TAG: A-0748<br> §482.51 TAG: A-0940<br> §482.51(b) TAG: A-0951

  Safe

  At Risk

  N/A

• Is there visible evidence of food consumption in patient care areas and all drinks are covered? <br> <br>EC.02.06.01 (EP 20) <br>IC.02.01.01 (EP 1) <br>CMS §482.41 TAG: A-0700<br> §482.41(a) TAG: A-0701 <br> §482.13(c)(2) TAG: A-0144<br> §482.42 TAG: A-0747<br> §482.42(a) TAG: A-0748<br> §482.51 TAG: A-0940<br> §482.51(b) TAG: A-0951

  Safe

  At Risk

  N/A

• Are supplies and equipment not stored directly on the floor (including oxygen tanks unless on wheels or in a rack)? <br>Are supplies and equipment stored on shelves at least 6 inches off the floor? Does the bottom shelf have a shelf liner and the liner is intact? <br> <br>IC.01.03.01 (EP 2) <br>EC.02.06.01 (EP 20 & 26) <br>SCHS policies #5089 & #8117 CMS §482.42 TAG: A-0747 <br> §482.41 - TAG: A-0700 & §482.41(a) TAG: A-0701 <br> <br>Rationale: CDC - Best Practices for Environmental Cleaning in Healthcare Facilities: in Resource-Limited Settings

  Safe

  At Risk

  N/A

• Are supply and storage areas clean and organized? Is there no evidence of ANY corrugated cardboard in exam rooms? <br>Is there no evidence of external shipping containers (corrugated cardboard with shipping labels) in patient care/medical supply storage areas? <br> <br>IC.01.03.01 (EP 2) <br>EC.02.06.01 (EP 20 & 26) <br>NPSG.07.03.01 (EP 1) <br>SCHS policies #5089 & #8117 CMS §482.13(c)(2) TAG: A-0144<br> §482.42 TAG: A-0747<br> §482.42(a) TAG: A-0748<br> §482.51 TAG: A-0940<br> §482.51(b) TAG: A-0951 <br> <br>Rationale: CDC - Best Practices for Environmental Cleaning in Healthcare Facilities: in Resource-Limited Settings

  Safe

  At Risk

  N/A

• Are supplies stored in exam and procedure rooms stored in containers that keep dust and moisture from contaminating the supplies? <br>Are supplies clean and free of dust? <br> <br>IC.01.03.01 IC.01.04.01 IC.02.02.01

  Yes

  No

  N/A

• Are clean and soiled/dirty items are separated? <br> <br> IC.02.02.01 (EP 1-5)

  Yes

  No

  N/A

• Clean linen is covered. <br> <br>IC.02.02.01.4 <br>CMS §482.42 TAG: A-0747<br> §482.42(a) TAG: A-0748<br> §482.51 TAG: A-0940<br> §482.51(b) TAG: A-0951

  Safe

  At Risk

  N/A

• Soiled linen hampers are covered. <br> <br>IC.02.02.01.4 <br>CMS §482.42 TAG: A-0747<br> §482.42(a) TAG: A-0748<br> §482.51 TAG: A-0940<br> §482.51(b) TAG: A-0951

  Yes

  No

  N/A

• Are ice machines visibly cleaned and has a sticker indicating it has been cleaned by facilities annually? <br> <br>IC.01.04.01 IC.02.02.01

  Yes

  No

  N/A

• Are ice machine trays clean and free from mineral build up?

  Yes

  No

  N/A

• Ask at least 2 caregivers how to properly clean equipment and rooms for standard precaution patients?

  Yes

  No

  N/A

• Ask at least 2 caregivers what the appropriate contact time is for disinfecting products. (2 minutes for Super Sani, 1 minute for Oxivir)

  Yes

  No

  N/A

• Ask at least 2 caregivers what PPE they would use and how to properly clean equipment and rooms for patients in isolation? Does the caregiver know the correct amount of time rooms should remain closed after aerosol generating procedures in patients with suspected and confirmed COVID-19 [2 hours]?

  Yes

  No

  N/A

• Patient equipment, supply, and procedure carts/totes are clean and dust free.

  Yes

  No

  N/A

• Reusable patient equipment disinfected in between patient use. Appropriate contact time is observed.

  Yes

  No

  N/A

• Is there documentation that specimen collection areas (window pass throughs, containers, etc.) are disinfected daily?

  Yes

  No

  N/A

• Sterile supplies are stored correctly (with enough room and in clean supply areas) and not stored beyond the storage use date per the sterile packaging Instructions for Use.

  Yes

  No

  N/A

• There are sufficient hand sanitizer dispensers and/or clean sinks to allow for proper hand hygiene (i.e. before and after patient care, in and out of exam rooms, after touching an item in a dirty area). IC.01.01.01 NPSG.07.01.01, EP 1

  Yes

  No

  N/A

• Refrigerators are appropriately labeled and contain the appropriate items dependent on the type of refrigerator. Medication fridge labeled for medications only and only contains medications, lab fridge labeled with biohazard label and contains only lab specimens.

  Yes

  No

  N/A

• Other Infection Control Issues Found

  Safe

  At Risk

  N/A

• Other Infection Control Issues Found

  Safe

  At Risk

  N/A

• Other Infection Control Issues Found

  Safe

  At Risk

  N/A

• Multi-use containers of liquids, gels, or lotions for use in direct patient care labeled with a 28 day expiration date. (per policy 30 days but for simplicity with multi-dose vials, 28 days). <br>SCHS #4183

  Yes

  No

  N/A

• Does the clinic have the appropriate CLIA license for the POC tests performed at that clinic?

  Yes

  No

  N/A

• Do you have providers preforming microscopy procedures (PPMP)? Who is training providers? Is this documented?

  Yes

  No

  N/A

• What POC testing is performed in the clinic?

• Who maintains the POC equipment? Is this documented?

  Yes

  No

  N/A

• Are Quality Control (QC) checks performed routinely? Are these documented? Documentation kept for 3 years?

  Yes

  No

  N/A

• Is there POC training for new caregivers by appropriate preceptors (i.e. appropriate certification/licensure teaching the correct caregivers, RN training RN, RN or MA training MA)? Are records kept of this training?

  Yes

  No

  N/A

• What medical equipment is used in this clinic?

• Is rechargeable medical equipment charged when not in use?

  Yes

  No

  N/A

• Is there evidence of biomedical inspection of medical equipment annually (annual biomed sticker)?

  Yes

  No

  N/A

• Is there any new medical equipment being used in the clinic? Has this been evaluated for use, competency, and inspected by biomed?

  Yes

  No

  N/A

• What procedures are performed?

  Yes

  No

  N/A

• Who is performing these procedures?

  Yes

  No

  N/A

• Is there a medication room/storage area that is locked and not patient accessible?

  Yes

  No

  N/A

• Do you have chemotherapy medications in this clinic? Fact Finding

  Yes

  No

  N/A

• Do you have controlled substances in clinic? Are these stored correctly? Are they documented properly?

  Yes

  No

  N/A

• No medications found stored outside of secured, approved medication storage areas (medication room)?

  Yes

  No

  N/A

• Are there expired medications or vaccines? <br> <br>SCHS. Document Library. Ambulatory Care Medication Administration. Document #: 9921.

  Yes

  No

  N/A

• Mutli-dose medication vials labeled with open date and expiration date (28 days from open date)? <br> SCHS. Document Library. Ambulatory Care Medication Administration. Document #: 9921.

  Yes

  No

  N/A

• Is there excess materials or other stored items in the medication room? Fact Finding

  Yes

  No

  N/A

• Are there pharmaceutical waste bins? Are the bins marked with the accumulation start date?

  Yes

  No

  N/A

• Is there evidence of routine medication counts? Is this documented? Fact Finding

  Yes

  No

  N/A

• Are the medications stored with pharmacy safety standards (look alike sound alike medications labeled, tall man lettering, par level indicated, etc.). <br> FDA Tall Man Lettering Recommendation.

  Yes

  No

  N/A

• Are orders placed for medications administered? (Lidocaine, triamcinolone, silver nitrate sticks, etc.) <br> <br> SCHS. Document Library. Ambulatory Care Medication Administration. Document #: 9921.

  Yes

  No

  N/A

• Are medications/vaccines either administered from the original container, drawn up in the exam room, or properly labeled if drawn up in the medication preparation area and transported to the exam room? <br> <br>FDA: Federal Drug Administration. Drug Safety and Availability.

  Yes

  No

  N/A

• Are samples (if applicable) in secured, approved medication storage areas? Is it documented when samples are received and dispensed? Are samples dispensed documented in the patient's EMR? <br> <br> SCHS. Document Library. Sample Medication. Document #: 1611.

  Yes

  No

  N/A

• Do you store patient assistance medications? If so, how long do you store them? <br>Fact Finding

  Yes

  No

  N/A

• Ask at least 2 caregivers what the 10 rights of medication administration? <br> <br>SCHS. Document Library. Ambulatory Care Medication Administration. Document #: 9921.

  Yes

  No

  N/A

• Do you have Isensix monitoring? Do you have a backup temperature monitoring system? Example-data logger. Is this uploaded to the SCMG SharePoint site under Data Loggers? <br> <br>SCMG SharePoint: https://stcharleshealthsystem.sharepoint.com/StCharlesMedicalGroup/DataLoggers/Forms/AllItems.aspx

  Yes

  No

  N/A

• Do you have vaccines in your clinic? Do you have Vaccines for Children (VFC) and private vaccines?

  Yes

  No

  N/A

• How often are vaccine counts being done for VFC and private?

  Yes

  No

  N/A

• Do you reconcile vaccines in the state Alert Immunization Information System (ALERT IIS)? If yes, how often?

  Yes

  No

  N/A

• Are they meeting the VFC and CDC requirements below: <br>-Oregon VFC Management Guide completed (VFC) <br>-Annual Trainings for standard users and Primary/Backup VFC Coordinator <br>-Calibration certificates for Isensix and Backup data loggers (VFC and Private) - Borrow log (VFC) <br>-Alert inventory being tracked (VFC and Private) -VIS sheets current (VFC and Private) -Isensix "Check Points" marked on days when clinic is open (VFC and Private) -Temp logs maintained daily when open and records kept for 3 years (VFC) Refrigerator and Freezers: (VFC and Private) <br>-Isensix batteries changed yearly -Fridge and freezers cleaned- vents, vacuuming the tops of refrigerators/freezers <br>-Probe wires secured <br>-Probe bottles filled <br>-"Do Not Unplug" stickers on outlets and breakers -Good air flow around vaccines -Packing material for transport <br>-Backup data logger info uploaded to sharepoint-Cold Storage Checklist) <br>-Vaccine packaging is correct <br> <br>VFC: Section 1 - 6 CDC: Vaccine Storage and Handling Toolkit

  Yes

  No

  N/A

• Are VFC vaccines labeled with CDC labels? <br> <br>CDC: Vaccine Label Examples https://www.cdc.gov/vaccines/hcp/admin/storage/guide/vaccine-storage-labels.pdf

  Yes

  No

  N/A

• Are excursions tracked and documented? <br> <br>VFC: Section 1 - 6 CDC: Vaccine Storage and Handling Toolkit

  Yes

  No

  N/A

• Is there evidence of use of Power BI medication and immunization BCMA compliance? Is feedback given to staff with low BCMA compliance? Fact Finding

  Yes

  No

  N/A

• Do you have an emergency kit (or crash cart) and an AED?

  Yes

  No

  N/A

• What items are included in your emergency kit?

  Yes

  No

  N/A

• Who checks your emergency kit and how often? How is this documented? <br> SCHS Document Library. Daily Code Cart and AED Inspection and Testing. Document #: 4285

  Yes

  No

  N/A

• Where is your AED located?

  Yes

  No

  N/A

• Who checks your AED and how often? How is this documented? <br>SCHS Document Library. Daily Code Cart and AED Inspection and Testing. Document #: 4285

  Yes

  No

  N/A

• Who orders the supplies for your emergency kit and AED?

  Yes

  No

  N/A

• Is the clinic checking for expired supplies regularly? Fact Finding

  Yes

  No

  N/A

• Does your team use SMART Checks? Are these assigned to caregivers? SMART Checks include-EKG Cart, Stocking Med Room, hand sanitizer expirations, Emergency kit/AED, Eye wash stations, Linens, Procedure Room supply PAR levels and expirations, Oxygen tanks, Vaccine Information Sheets (VIS), End of day closing tasks, Instrument processing, POC Quality checks, etc. Fact Finding

  Yes

  No

  N/A

• Do you have descriptions of your SMART Checks and what is expected? Where do store SMART check documents? Fact Finding

  Yes

  No

  N/A

• Do you follow up with caregivers if they have not completed their assigned SMART Checks?

  Yes

  No

  N/A

• Do you follow the standard rooming process? Are audits conducted? Where is this documented?

  Yes

  No

  N/A

• Is medical supply waste tracked and documented?

  Yes

  No

  N/A

• Is typical supply waste tracked and documented?

  Yes

  No

  N/A

• Is medication and vaccine waste tracked and documented?

  Yes

  No

  N/A

• Who monitors supplies and cleanliness in exam rooms and storage areas for visiting specialties?

  Yes

  No

  N/A

• Is Personal Protective Equipment (PPE) available and in working condition? <br> <br>EC.02.02.01 (EP 3, 5) <br>IC.02.01.01 (EP 2) <br>CMS §482.42 TAG: A-0747<br> §482.42(a) TAG: A-0748<br> §482.51 TAG: A-0940<br> §482.51(b) TAG: A-0951 <br> §482.26(b) TAG: A-0535<br> §482.26(b)(1) TAG: A-0536<br> §482.26(b)(3) TAG: A-0538<br> §482.41(a) TAG: A-0701<br> §482.53(b) TAG: A-1035

  Yes

  No

  N/A

• Do you have a caregiver trained to complete N95 FIT testing in the clinic? Is this documented and uploaded to the appropriate database (Vader)? Is fit testing and/or evaluation occurring annually? If applicable, does the clinic have Powered Air-Purifying Respirators (PAPRs)? Are the PAPRs in good working order and batteries charged?

  Yes

  No

  N/A

• Are eyewash stations and/or emergency shower stations inspected weekly and inspections documented on an inspection card attached to the station? Are eyewash stations and/or emergency shower station easily accessible (not behind a locked door)? OSHA

  Yes

  No

  N/A

• The physical environment (ceiling tiles, walls, floors, sinks, stairwells, etc.) is free of potential safety risks and damage, water, mold, etc. <br> <br>EC.02.06.01 (EP 1, 20, 26) <br>CMS §482.41 TAG: A-0700 <br> §482.41(a) - TAG: A-0701

  Yes

  No

  N/A

• The area is clean and free of offensive odors, and all furnishings and equipment are in good repair. <br><br>EC.02.06.01 (EP 20 & 26) <br>CMS §482.41 - TAG: A-0700 & §482.41(a) TAG: A-0701 <br>Rationale: CDC - Best Practices for Environmental Cleaning in Healthcare Facilities: in Resource-Limited Settings

  Yes

  No

  N/A

• The physical environment of any area providing patient care, treatment, or services provides enough lighting and the interior spaces accommodates the use of equipment, such as wheelchairs, necessary to the flow of daily activities. <br> <br>EC.02.06.01 (EP 20 & 26) CMS §482.41 TAG: A-0700 <br> §482.41(a) TAG: A-0701

  Yes

  No

  N/A

• Clinics are tobacco and smoke free. There is signage that indicates the clinic is tobacco and smoke free. Outside areas are free of any evidence of smoking. <br> <br>EC.02.01.03 (EP 6) <br>SCHS Tobacco Policy #3781 <br>ORS 433.835 – 433.990, The Oregon Indoor Clean Air Act (ICAA)<br>OAR 333 -015 – 0025 – 333 – 015 - 0990

  Yes

  No

  N/A

• Are there bathroom pull cords in patient bathrooms? If so, are they free hanging within 12 inches from the ground and are not tied to a grab bar. <br> <br>OAR 333-535-0015 2018 Facility Guidelines Institute (FGI), Guidelines for Design and Construction of Hospitals/Outpatient Facilities <br>EC.02.06.01 (EP 1) CMS §482.41 TAG: A-0700<br> §482.41(a) TAG: A-0701

  Yes

  No

  N/A

• Are grab bars and hand rails installed and secured to walls. <br> <br>OAR 333-535-0015 2018 Facility Guidelines Institute (FGI), Guidelines for Design and Construction of Hospitals/Outpatient Facilities <br>EC.02.01.01 (EP 5) <br>CMS §482.41(a) TAG: A-0701

  Yes

  No

  N/A

• Area is free of possible trip, slip, and fall hazards. <br> <br>OSHA CFR 1910.22; 1910.28 <br>EC.02.01.01 (EP 3, 5) <br>CMS §482.13(c)(2) TAG: A-0144<br> §482.26(b) TAG: A-0535<br> §482.41(a) TAG: A-0701

  Yes

  No

  N/A

• All electrical, phone, and computer cords are secured and properly placed to reduce trip hazard.<br> <br>OSHA CFR 1910.22; 1910.28 <br>EC.02.01.01 (EP 3, 5) <br>CMS §482.13(c)(2) TAG: A-0144<br> §482.26(b) TAG: A-0535<br> §482.41(a) TAG: A-0701

  Yes

  No

  N/A

• Patient Handling powered equipment is plugged in when not in use. (Patient electric lift) <br> <br>EC.02.04.03 (EP 2) <br>CMS §482.41(d)(2) TAG: A-0724

  Yes

  No

  N/A

• Any findings from the last EOC not yet adressed? Barriers?

  Yes

  No

  N/A

• Describe in Notes

  Safe

  At Risk

  N/A

• Describe in Notes

  Safe

  At Risk

  N/A

• Describe in Notes

  Safe

  At Risk

  N/A

• Describe in Notes

  Safe

  At Risk

  N/A

• Describe in Notes

  Safe

  At Risk

  N/A

• CMS: Centers for Medicare and Medicaid Services. Life Safety Code & Health Care Facilities Code Requirements.

• FDA: Federal Drug Administration. Drug Safety and Availability.

  Yes

  No

  N/A

• JC: The Joint Commission. Ambulatory Accreditation Requirements.

• OSHA: Occupational Safety and Health Administration.

• NFPA: National Fire Protection Association. List of Codes and Standards.

• St. Charles Health System. Document Library.

• VFC: Vaccines for Children. Oregon Vaccine Managment Guide.

  Yes

  No

  N/A