MMH TJC - EC/EM -Mock Survey

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

ENVIRONMENT OF CARE

• No items stored under sinks?

  Yes

  No

  N/A

• Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.

  Yes

  No

  N/A

• Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.

  Yes

  No

  N/A

• Laundry and trash chute accesses are locked.

  Yes

  No

  N/A

• Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.

  Yes

  No

  N/A

• Hazardous chemicals and flammable agents are labeled and stored properly.

  Yes

  No

  N/A

• Eyewash stations: Inspection tags are present and up to date.

  Yes

  No

  N/A

• Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)

  Yes

  No

  N/A

• Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.

  Yes

  No

  N/A

• Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.

  Yes

  No

  N/A

• Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.

  Yes

  No

  N/A

• No outer shipping carton boxes in patient care areas.

  Yes

  No

  N/A

• No expired items.

  Yes

  No

  N/A

• Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker.

  Yes

  No

  N/A

• Central Alarm Monitor:<br> * Logs accurate and complete.

  Yes

  No

  N/A

EMERGENCY PREPAREDNESS

• Can staff locate medical gas zone shutoff valves.

  Yes

  No

  N/A

• Can Team Members code definitions.<br> * Red<br> * Yellow<br> * Orange <br> * Green<br> * Black<br> * Pink<br> * Silver<br> * Blue

  Yes

  No

  N/A

• Define PASS

  Yes

  No

  N/A

• Define RACE<br>

  Yes

  No

  N/A

• Do Team Members know where nearest Extinguishers are?

  Yes

  No

  N/A

• Do Team Members know evacuation routes?

  Yes

  No

  N/A

• Do Team Members know where nearest pull stations are?

  Yes

  No

  N/A

DESCRIBE THE DEPARTMENTS RESPONSE TO ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

• Have a space designated for the team to conduct interviews and file reviews.

  Yes

  No

  N/A

• Promptly deliver materials required for review to the tracer team.

  Yes

  No

  N/A

• Any additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A

• Surveyors Signature

  Sign