Inpatient Premises

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Environmental Protocol

  Date

Emergency Room: 9.39; 527.5(b)

• Separate area for MH, Privacy, Safety, Immediate or on-call access to appropriate mental health staff, Arrangements for appropriate referral

  Yes

  No

  N/A

Storage: 77.7, 580.6(a)(3), 580.6(a)(8), 580.8(b), 582.6(a)(3), 582.6(a)(6), 582.8(b)

• Records (access, confidentiality), Medication (access), Personal items (secured area), Food storage (tempature)

  Yes

  No

  N/A

Furnishings/Décor/Milieu: Part 27.4(b), 77.3, 77.7, 77.8

• Community space, personal space, wall décor, furnishings, beds (hospital beds/rails only by clinical exceptions/no electrical beds, no cranks, individual clinical assessment to determine, safe occupancy), air quality/ventilation, Heating/AC, Lighting, Smoking areas

  Yes

  No

  N/A

Infection Control: 77.4

• Storage/cleaning of restraints, Dirty linen covered/clean linen storage, Hazardous waste disposal, Cleanliness of space

  Yes

  No

  N/A

Space: 77.7

• Consistency between licensed capacity, number of beds, and number of patients, Overcrowded bedrooms, Appropriate examination room, Adequate dining space, Available lounge space, Adequate program space, Adequate recreational space, If the facility serves children, education space is available

  Yes

  No

  N/A

Seclusion Rooms

• How many, suitable location, vestibule with bathroom access, smoth and secure environment (monolithic celing, continous sheet vinyl flooring, impact resistant gypsum board walls, no blind spots, protected glass in window/vision panel, steel door, opens out, flush door pull on inside, recessed light fixtures, flush type sprinkler heads, and tamper resistant HVAC grilles, no electrical outlets, switches, or controls, no hazardous furniture)

  Yes

  No

  N/A

Restraint Area

• Which areas are used for restrining patients (bedrooms, seclusion rooms), Types of restraints utilized, where are restraints stored, Is equipment maintained in sanitary fashion, no key-locked restraints

  Yes

  No

  N/A

ECT Space and Equipment

• Functionality of ECT and recovery areas, Presence of supplies, equipment and meds, ECT device is constant and current waveform type, Maintenance of machine matches policies and procedures and is current, Medical records are accessible during treatment sessions, Appropriate medication storage

  Yes

  No

  N/A

Patient Rights: Part 27, 527, Part 21

• Rights/Advocacy Agencies Posted-CQC, OMH, County, MHLS, PAMI, Confidentiality of names, logs, records, Visiting hours posted, Phones available, Privacy (use of intercoms)

  Yes

  No

  N/A

Population: 580.6(b)(2), 582.6(b)(2)

• Census (certified vs occupied), Location (in bed, dressed in street clothes, participating in activities), # of beds (count)

  Yes

  No

  N/A

Program Activity: 580.6(a)(4), 582.6(a)(4)

• As scheduled, posted, choice, patients engaged

  Yes

  No

  N/A

Access to Unit: Part 21

• Locked areas/unlocked (rationale), visiting

  Yes

  No

  N/A