Medical Facility Audit V6 - use with Poisons Audit 2022 - duplicate

• Site conducted

  Select

• Prepared by

• Date Conducted

• Client & Site Name

• Location

Have previous audits been conducted at the facility?

• Have previous audits been conducted at the facility?

  Yes

  No

  N/A

• Are there any outstanding actions? If so please carry forward to this audit and mark as urgent.

  Yes

  No

  N/A

• What positions are held at the facility?

  Select Nurse Paramedic OHN HSEC ICP

  • Nurse
  • Paramedic
  • OHN
  • HSEC
  • ICP

• How many casual staff are inducted at this facility?

• Is the amount of casual coverage sufficient for this facility?

  Good

  Fair

  Poor

  N/A

On Call Medical Staff

• Does the facility use the CPAG 24/7 on-call doctor service?

  Yes

  No

  N/A

• Do after hours staff have access to the on call doctor in case of an emergency?

  Yes

  No

  N/A

• Does the facility meet best practice hygiene and cleanliness standards?

  Yes

  No

  N/A

• Are the bench tops clear of dust and dirt?

  Yes

  No

  N/A

• Is there good lighting for clinical examination?

  Yes

  No

  N/A

• Is there adequate temperature control and ventilation?

  Yes

  No

  N/A

• Are air conditioning systems regularly maintained?

  Yes

  No

  N/A

• Is there adequate work space for staff?

  Yes

  No

  N/A

• Is there adequate environmental protection such as insect control, dust screens etc?

  Yes

  No

  N/A

• Are there adequate consumables and equipment for WHO compliant hand washing - Clean running water, hand soap dispenser, paper towel dispenser, hand sanitiser?

  Yes

  No

  N/A

• Are floor surfaces clean and uncluttered?

  Yes

  No

  N/A

• Are all entries and walkways clear?

  Yes

  No

  N/A

• Is emergency lighting in place and operable?

  Yes

  No

  N/A

• Is there a cleaning service, are they effective and regular?

  Yes

  No

  N/A

• Is linen clean and are there adequate supplies at hand?

  Yes

  No

  N/A

• Are rubbish bins located at suitable points throughout the clinic?

  Yes

  No

  N/A

• Are they emptied regularly?

  Yes

  No

  N/A

• Are Biohazard bins pedal operated for hygiene reasons

  Yes

  No

  N/A

• Is there a mop, cleaning bucket and cleaning agents close by for spills management?

  Yes

  No

  N/A

• Are there adequate supplies of biohazard bags and disinfectant to clean up bodily fluid spills?

  Yes

  No

  N/A

• Is there a yellow spill kit for major bodily fluid spills as per CPAG Infection Control Procedure?

  Yes

  No

  N/A

• Is there suitable biological waste management and disposal in place that follows site procedure?

  Yes

  No

  N/A

• Is there adequate PPE for all CPA staff?

  Yes

  No

  N/A

• Is there adequate wet weather gear available for staff?

  Yes

  No

  N/A

• Is the furniture in the facility in good condition? Check for safety hazards such as sharp edges, broken wheels etc.

  Yes

  No

  N/A

• Are there toilets, hand washing facilities and clear running water?

  Yes

  No

  N/A

• Is there a shower for burns casualties and does the water run cool?

  Yes

  No

  N/A

• Is there a shower chair available?

  Yes

  No

  N/A

Electrical

• Are electrical sockets, cables and appliances in good condition and working order and away from any water or other potential hazards?

  Yes

  No

  N/A

• Are all cables tagged?

  Yes

  No

  N/A

• Is there a reliable telephone system?

  Yes

  No

  N/A

• Is there a reliable radio system?

  Yes

  No

  N/A

• Is there a satellite phone?

  Yes

  No

  N/A

• Is there adequate and appropriate IT software and hardware?

  Yes

  No

  N/A

• Ask staff to show proficiency of use of common systems. Note any competency concerns.

• Is there a telemedicine facility such as webcam or ability to take photos and email/text to doctor?

  Yes

  No

  N/A

• Do staff have access to a mobile phone with decent camera?

  Yes

  No

  N/A

• Is all electrical medical equipment in working order?

  Yes

  No

  N/A

• Request evidence of last biomedical maintenance and check report for any outstanding actions.

• When was the last Biomedical Maintenance completed (must be within last 12 months)?

  Date

• Have all issues been resolved?

  Yes

  No

  N/A

• What issues remain outstanding?

• Question: Are there any concerns with medical equipment, batteries, cables or chargers?

• Spot check: Check 3 items of electrical medical equipment - have they been calibrated/serviced in the past 12 months?

  Yes

  No

  N/A

• All items should be documented on an asset/equipment register and align with recent maintenance report. Add action item to update register if non-compliant.

Accessibility

• Is there adequate wheelchair and stretcher access?

  Yes

  No

  N/A

• Is the facility easily accessible in general?

  Yes

  No

  N/A

• Are staff, contractors and visitors made aware of the facility during induction?

  Yes

  No

  N/A

• Are there relevant contact details on the external door of the facility and instructions explaining how to contact staff on duty if they are out of office?

  Yes

  No

  N/A

• Are they legible? ie. not faded, correct details.

  Yes

  No

  N/A

Displays

• Is the CP Medical Advisor contact information up to date and displayed prominently in the facility?

  Yes

  No

  N/A

• Are CP EAP service flyer and copy of current Poisons Approval displayed in the facility?

  Yes

  No

  N/A

• Is the current 2016 ARC ALS algorithm displayed prominently in the emergency treatment area of the facility?

  Yes

  No

  N/A

• Are the local/responding hospital emergency department and ambulance numbers known and displayed or stored in clinic mobile phone?

  Yes

  No

  N/A

• Is there an ambulance on site?

  Yes

  No

  N/A

• Is the ambulance within its service requirements?

  Yes

  No

  N/A

• Is a daily vehicle inspection performed using a checklist?

  Yes

  No

  N/A

• Is the vehicle equipped to deal with terrain safely?

  Yes

  No

  N/A

• Is the vehicle fully site compliant?

  Yes

  No

  N/A

• Is the vehicle clean and tidy?

  Yes

  No

  N/A

• Is there radio communication installed in the vehicle? Is it operational?

  Yes

  No

  N/A

• Is the stretcher operational?

  Yes

  No

  N/A

• Is there easy access for the stretcher in and out of the ambulance?

  Yes

  No

  N/A

• Are there adequate oxygen supplies?

  Yes

  No

  N/A

• Is oxygen stored correctly, with flowmeters biomedically checked in last 12 months?

  Yes

  No

  N/A

• Oxygen cylinders over half full?

  Yes

  No

  N/A

• Oxygen resus kit including airway kit (NGA,OPA,iGels) available and fully stocked, within expiry dates

  Yes

  No

  N/A

• Suction available? Portable unit acceptable

  Yes

  No

  N/A

• Are perishable items stored in the ambulance?

  Yes

  No

  N/A

• Confirm that no medications ever stored in ambulance?

  Yes

  No

  N/A

• Adequate ventilation and temperature control?

  Yes

  No

  N/A

• Ask staff to explain the procedure involved in responding to an emergency in the Ambulance.

• Are directions and contact details for the receiving facility kept inside the ambulance?

  Yes

  No

  N/A

• Traction splint (CT-6 preferred)

  Yes

  No

  N/A

• Spinal board

  Yes

  No

  N/A

• Scoop Stretcher

  Yes

  No

  N/A

• Straps for stretchers

  Yes

  No

  N/A

• Soft collars/head blocks

  Yes

  No

  N/A

• KED

  Yes

  No

  N/A

• Pelvic Splint (Prometheus) or Sam pelvic splints in 2 sizes

  Yes

  No

  N/A

Emergency Management - Airway kit is assessed in Ambulance Section

• Is the emergency/treatment room set up to handle a minimum of 1 emergency/critical patient?

  Yes

  No

  N/A

• Is all emergency equipment online and connected to power or otherwise?

  Yes

  No

  N/A

• Is the response bag equipped to CPAG equipment levels?

  Yes

  No

  N/A

• Is a laminated copy of response bag contents list kept in the bag?

  Yes

  No

  N/A

• All equipment in date and evidence of regular checks performed (daily/weekly)?

  Yes

  No

  N/A

• If crash trolley is present, is it equipped for emergency airway, trauma and cannulation?

  Yes

  No

  N/A

• Chest Decompression Kit (Pneumodart or equivalent)

  Yes

  No

  N/A

• IO access equipment with instructions?

  Yes

  No

  N/A

• Adequate oxygen supplies for the facility?

  Yes

  No

  N/A

• Is oxygen stored in accordance with CP Operating Procedures?

  Yes

  No

  N/A

• Are all cylinders over half full?

  Yes

  No

  N/A

• Are regulators and flow meters within their biomedical maintenance schedule?

  Yes

  No

  N/A

• Is there portable suction available? (manual suction should be back up only)

  Yes

  No

  N/A

• Is there access to an additional AED/manual /semi?

  Yes

  No

  N/A

• Are there 3 sizes of iGEL (LMA's acceptable) present? (plus lube, tape, laryngoscope with batteries)

  Yes

  No

  N/A

• Is there mass casualty equipment available and stored in an organised fashion?

  Yes

  No

  N/A

• Triage cards or system?

  Yes

  No

  N/A

• Is all medical equipment within it's biomedical maintenance schedule?

  Yes

  No

  N/A

• Are treatment beds in good working condition?

  Good

  Fair

  Poor

  N/A

• Is there a maintenance schedule for the beds in the facility?

  Yes

  No

  N/A

• 360 degree access available to allow for airway management?

  Yes

  No

  N/A

• Slide board/sheets available?

  Yes

  No

  N/A

• Question: What is your process for evacuation with regard to equipment and drugs in the event of an emergency?

Locate item and check for maintenance, working condition, spare batteries present, adequate consumables, calibration date etc.

• Thermometer

  Yes

  No

  N/A

• Sphygmomanometer

  Yes

  No

  N/A

• Pulse Oximeter

  Yes

  No

  N/A

• Stethoscope

  Yes

  No

  N/A

• Opthalmoscope (not essential)

  Yes

  No

  N/A

• Otoscope

  Yes

  No

  N/A

• BeBird ear camera

  Yes

  No

  N/A

• UV black light and fluorets or fluorescein

  Yes

  No

  N/A

• Eye Chart

  Yes

  No

  N/A

• Laryngoscope (operational with spare batteries)

  Yes

  No

  N/A

• Scales and height measure

  Yes

  No

  N/A

• Urinalysis dip sticks capable of detecting blood

  Yes

  No

  N/A

• Pregnancy test kits

  Yes

  No

  N/A

• 12 Lead ECG/Defib with ETCO2/NIBP/SaO2/pacing

  Yes

  No

  N/A

• Spirometer/Peak Flow (not essential)

  Yes

  No

  N/A

• Audiometer/booth (check ear muffs are in good condition)

  Yes

  No

  N/A

• Glucometer

  Yes

  No

  N/A

• Refractometer or other method for measuring urine SG

  Yes

  No

  N/A

• Pneumodart decompression needle or equivalent

  Yes

  No

  N/A

• Is a daily check performed on all emergency equipment to ensure all medical equipment is located and in working order?

  Yes

  No

  N/A

• Is a weekly check performed on all non-emergency equipment to ensure all medical equipment is located and in working order?

  Yes

  No

  N/A

• Request evidence of last daily and weekly check and note any outstanding actions here.

• Are there any suggestions from staff that could improve equipment on site?

Locate each item and check expiry/condition

• Syringes, needles and sterile swabs

  Yes

  No

  N/A

• Adequate supply of IV fluids (5L of N/saline minimum)

  Yes

  No

  N/A

• Splints (Sam and/or cardboard)

  Yes

  No

  N/A

• Are NWR amd WR records separated for confidentiality purposes?

  Yes

  No

  N/A

• Is the client denied access to all NWR information, unless with express worker consent?

  Yes

  No

  N/A

• Are electronic medical records kept on site?

  Yes

  No

  N/A

• Are paper records kept in secure locked cabinet with access only by medical staff?

  Yes

  No

  N/A

• Do non-medical personnel have access to these records?

  Yes

  No

  N/A

• Are medical records non-editable after consultation notes are saved?

  Yes

  No

  N/A

First Aid Kits

• Do CPAG staff perform first aid kit checks at the facility?

  Yes

  No

  N/A

• Is the first aid kit register up to date?

  Yes

  No

  N/A

• Spot check: Request to view the first aid register, is it accurate?

• Check one first aid kit, are contents in line with best practice model?

  Yes

  No

  N/A

• Are all contents in date?

  Yes

  No

  N/A

• If contents are not in date, are they on order? Request evidence of stock order.

  Yes

  No

  N/A

• Is first aid signage adequate and visible from a distance?

  Yes

  No

  N/A

• When is the next first aid kit check due?

  Date

First Aid Training

• Do CPAG staff provide first aid or other training on site?

  Yes

  No

  N/A

• Are CPAG trainers registered with Baseline Training?

  Yes

  No

  N/A

• Are there any improvements staff would like to see made to the Provide First Aid training program?

  Yes

  No

  N/A

• Is First Aid training equipment in good condition? Is there enough equipment?

  Yes

  No

  N/A

• Is RTW co-ordination conducted by CPAG staff?

  Yes

  No

  N/A

• Provide evidence of Injury Management certification for each staff member at the facility

• In the past year have all RTW cases been managed without adverse incident?

  Yes

  No

  N/A

• Give an example of how current RTW cases are being managed in accordance with best practice.

• Does the client have any concerns with the current injury management process in relation to CPA group staff involvement?

  Yes

  No

  N/A

Client Related Competencies

• Have all staff completed the full client induction?

  Yes

  No

  N/A

• Please detail any outstanding internal competencies that are overdue:

• Are client related competencies detailed within a training matrix of some kind?

  Yes

  No

  N/A

• Is the training matrix current and accessible?

  Yes

  No

  N/A

Qualification Requirements

• Are all staff registered with AHPRA (Nurses and Paramedics)?

  Yes

  No

  N/A

• Do all medical staff hold current ACLS or ALS certification

  Yes

  No

  N/A

• Do all staff hold current CPA Authority to Practice certificate

  Yes

  No

  N/A

• Please detail any outstanding qualifications which do not meet contract requirements:

• Are all qualifications documented accurately and up to date on training matrix?

  Yes

  No

  N/A

• Review the training matrix or electronic competency system to ensure all staff qualifications are current.

• Question for staff: Please list any training you have completed in the past 6 months contributing to your continuous professional development.

• Is the staff member compliant with legislative CPD requirements?

  Compliant

  Non-Compliant

  N/A

• Question for staff: Is there any additional training you can think of that would benefit you in this role?

Vaccines

• Is there a vaccine/medication fridge at the facility?

  Yes

  No

  N/A

• Make and model of fridge:

  Media

• Who is responsible for the management of the fridge? Who is the back up person responsible?

• Is there a temperature log/chart showing min/max temperatures?

  Yes

  No

  N/A

• Has this chart been completed daily?

  Yes

  No

  N/A

• Have all temperature discrepancies been reported and documented as per the Cold Chain Breach Procedure?

  Yes

  No

  N/A

• Is the medication fridge free of any malfunction (eg. poor seals, missing foot)?

  Yes

  No

  N/A

• Is there an appropriate gap between each medication/vaccine and the walls of the refrigerator?

  Yes

  No

  N/A

• Can the fridge continue to safely store the volume of vaccines/medication according to the guidelines? If no, what action has been taken? (This includes times of increased demand such as the influenza program)

  Yes

  No

  N/A

• If the fridge has a solid door is there a map/guide to where vaccines and medications are stored within it located on the door?

  Yes

  No

  N/A

• Does the power supply have a "do not disconnect" sign?

  Yes

  No

  N/A

• Is there a power supply contingency plan or generator?

  Yes

  No

  N/A

• If alternative storage is required in the event of a power failure, is it readily available with ice bricks and insulation?

  Yes

  No

  N/A

• Is the thermometer probe correctly placed within the fridge

  Yes

  No

  N/A

• If drug & alcohol testing is performed on site, is this policy accessible by staff?

  Yes

  No

  N/A

• Is the CPAG Infection Control Procedure accessible to staff?

  Yes

  No

  N/A