CMS-Emergency Management Survey Rounds

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

• What purpose does the Hospitals Command Center serve?

  Yes

  No

  N/A

• Where is the Command Center Located at SMC?

  Yes

  No

  N/A

• Where are the Emergency operations and management plans located?

  Yes

  No

  N/A

• What is the Emergency Phone number at SMC?

  Yes

  No

  N/A

• What is a Code Pink?

  Yes

  No

  N/A

• What is a Code Gamma?

  Yes

  No

  N/A

• What is a Tornado Warning and how should you respond?

  Yes

  No

  N/A

• What is a Phase 1 evacuation?

  Yes

  No

  N/A

• What is a Phase 2 evacuation?

  Yes

  No

  N/A

• Staff can verbalized evacuations routes?

  Yes

  No

  N/A

• Staff knows what a Code Silver is and how to respond?

  Yes

  No

  N/A

• Give three methods of communications that are available to you in the event the landline phone system failed ?

  Yes

  No

  N/A

Comments and additional findings.

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