Title Page
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Conducted on
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Prepared by
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Location
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FMS.1: The ambulatory care organization plans and implements a program to provide a safe physical facility through inspection and planning to reduce risks.
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Leadership knows what laws, regulations, and other requirements apply to the organization’s facilities and implements the applicable requirements or approved alternatives.
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The ambulatory care organization has a program to provide a safe physical facility.
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The ambulatory care organization has a documented, current, accurate inspection of its physical facilities.
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Leadership ensures periodic inspection of the patient care facilities and that the organization meets the conditions of facility inspection reports and citations
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The ambulatory care organization has an ongoing monitoring program that provides data on incidents, injuries, and other events that support planning and further risk reduction.
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The ambulatory care organization plans and budgets for upgrading or replacing systems, buildings, or components needed for the continued operation of a safe, secure, and effective facility.
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FMS.1.1: The ambulatory care organization plans and implements a program to provide a secure environment for patients, families, staff, and visitors. (
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The ambulatory care organization has a program to provide a secure environment, including monitoring and securing areas identified as security risks.
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The program ensures that all staff, contract workers, and vendors are identified.
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All security risk areas and restricted areas are identified, documented, monitored, and kept secure.
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FMS.2: The ambulatory care organization’s facility is designed to provide accessible, efficient, and safe clinical care in a secure and supportive environment.
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The ambulatory care organization’s facility is designed to be accessible and accommodate the organization’s patient population.
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The ambulatory care organization’s facility is designed to facilitate safe and efficient clinical care.
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Features a) through i) in the intent are incorporated as appropriate into the ambulatory care organization’s mission and facilities.
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Accommodations are provided for the age and ability level of the organization’s patients.
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Office/exam rooms are designed to ensure privacy for patients during dressing and undressing and during treatments.
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Adequate seating is provided for normal patient flow and in a manner that ensures privacy of communication with reception staff in the waiting room.
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The premises, fittings, and furniture are kept clean and in good repair, meeting standards for lighting, heating, ventilation, and infection prevention and control.
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A special, separate waiting area with separate ventilation is available for patients who may have an infectious disease.
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Adequate hand-hygiene methods are located in or adjacent to the office/exam rooms.
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Safe storage and disposal is available for clinical waste and potentially infectious waste.
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Security is provided to take responsibility for the safety of the environment, the premises, and the office/exam rooms.
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A means for obtaining immediate assistance and/or emergency egress is provided in all clinics and office/exam rooms.
HAZARDOUS MATERIALS
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FMS.3: The ambulatory care organization establishes and implements a program for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and waste. (
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Hazardous materials and wastes are identified.
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Hazardous materials and wastes are safely managed through the hazardous materials and waste program.
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The program includes elements a) through h) in the intent.
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the inventory of hazardous materials and waste that includes the material, the quantity, and the location;
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handling, storage, and use of hazardous materials;
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proper protective equipment and procedures during use, spill, or exposure;
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proper labeling of hazardous materials and waste;
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making available up-to-date information related to procedures for handling or working with hazardous materials in a safe manner, including information about the physical data of the materials;
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reporting and investigation of spills, exposures, and other incidents;
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proper disposal of hazardous waste; and
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Documentation, including any permits, licenses, or other regulatory requirements.
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The program is implemented and followed.
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FMS.4: The ambulatory care organization establishes and implements a program for the prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and non-fire emergencies.
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The ambulatory care organization establishes and implements a program to ensure that all occupants of the organization’s facilities are safe from fire, smoke, or other non-fire emergencies.
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The program includes the documented assessment of fire risks, including when construction is present in or adjacent to the facility.
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The program includes the early detection of fire and smoke.
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The program includes the abatement of fire and containment of smoke.
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The program includes the safe exit from the facility when fire and non-fire emergencies occur.
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FMS.4.1: The ambulatory care organization regularly tests its fire and smoke safety program, including any devices related to early detection and suppression, and documents the results.
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All staff participate in at least one fire and smoke safety program test per year.
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Staff can demonstrate how to bring patients to
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Fire detection and abatement equipment and systems are inspected, tested, and maintained according to manufacturers’ recommendations.
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Inspection, testing, and maintenance of equipment and systems are documented.
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FMS.4.1.1: The fire safety program includes limiting smoking by staff and patients to designated non–patient care areas of the facility. (
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The fire safety program addresses eliminating or limiting smoking within the ambulatory care organization facility.
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The program applies to patients, families, visitors, and staff.
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The program identifies who may grant patient exceptions for smoking and when those exceptions apply.
MEDICAL TECHNOLOGY
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FMS.5: The ambulatory care organization establishes and implements a program for inspecting, testing, and maintaining medical technology and documenting the results. (
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The ambulatory care organization establishes and implements a medical technology program that includes the performance and documentation of at least a) through d) in the intent.
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an inventory of medical technology;
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regular inspections of medical technology;
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testing of medical technology according to its age, use, and manufacturers’ recommendations; and
Preventive
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Staff conducting the inspections, testing, and maintenance of medical technology are qualified and trained for the services being provided.
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The ambulatory care organization has a system in place for monitoring and acting on medical technology hazard notices, recalls, reportable incidents, problems, and failures.
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When laws and regulations require, the ambulatory care organization reports any deaths, serious injuries, or illness that are a result of medical technology.
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The medical technology program addresses the use of any medical technology with a reported problem or failure, or that is the subject of a hazard notice, or is under recall.
UTILITY SYSTEM
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FMS.6: The ambulatory care organization establishes and implements a program to ensure that all utility systems are inspected, tested, maintained, and improved.
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Utility systems and components are inspected based on organization-developed criteria.
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Utility systems and components are tested based on organization-developed criteria.
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Utility systems and components are maintained based on organization-developed criteria.
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Utility systems and components are improved when necessary.
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Utility systems and components are inventoried and labeled.
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FMS.6.1: The ambulatory care organization has emergency processes to protect facility occupants in the event of water, power, and other utility system disruption, contamination, or failure.
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Potable water is available during all hours that the ambulatory care organization is operating.
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Electrical power is available during all hours that the ambulatory care organization is operating.
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The organization identifies the areas and services at greatest risk when water, power, and other utilities fail, are contaminated, or are interrupted.
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The organization seeks to reduce the risks of such events.
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The organization plans for and tests alternative sources of water, power, and other utilities in emergencies.
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The organization develops, implements, and annually tests an emergency management program to respond to emergencies, epidemics, and natural or other disasters that have the potential of occurring within the community.
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FMS.6.2: Designated individuals or authorities monitor water quality regularly.
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Water quality is monitored at least annually or more frequently based on local laws and regulations, conditions of the sources for water, and previous experience with water quality problems. The monitoring is documented.
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Water used in renal dialysis is tested according to industry standards at least quarterly or more frequently based on local laws and regulations, conditions of the sources for water, and previous experience with water quality problems. The testing is documented.
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Actions are taken and documented when water quality is found to be
STAFF EDUCATION
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FMS.7: The ambulatory care organization educates, trains, and tests all staff about their roles in providing a safe and effective patient care facility.
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Education is provided on an annual basis for each aspect of the ambulatory care organization’s facility management and safety program to ensure that all staff on all shifts can effectively carry out their responsibilities.
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Staff knowledge is tested regarding their roles in each aspect of the facility management and safety program.
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Training, testing, and the results of testing are documented for each staff member.
Site Findings:
Figures
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Audit Criteria: As per JCI-FMS standards and measurable elements for Ambulatory Care 3rd Edition, other applicable EHS requirements.
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Total Criteria/requirements
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Site and other records review findings
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Total observations
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Recommendations:
Audit Team
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EHS Department Audit Members
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Designation/Role
Facility Representatives:
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Signature
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Designation
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Date
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Name
Entity Top Management
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Please sign the audit report and submit the corrective action plan within 3 weeks from the report receiving date.
2nd set audit
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