Non-Subscription Audit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Name and position of person responsible for the hospital non-subscription program.

• When did the facility begin the non-subscription program (opted out of Workers Compensation insurance?

Required Data

• Is the DWC Form-005 filed each year between February 1 and April 30 each year?

  Yes

  No

  N/A

• Is the DWC Form-005 filed electronically each year?

  Yes

  No

  N/A

• Is the DWC Form-005 filed by a hard copy (not electronically)?

  Yes

  No

  N/A

• Is the DWC Form-007 completed and sent to the TDI Division of Workers Compensation EACH Month?

  Yes

  No

  N/A

• Does the DWC For-007 include the following:

  Select A work related or on-the-job death An employee absent from work more than1 day as the result of on-the-job injury Knowledge of occupational disease

  • A work related or on-the-job death
  • An employee absent from work more than1 day as the result of on-the-job injury
  • Knowledge of occupational disease

• When filing the DWC Form-007, is an injury data sheet completed on EACH employee injured during the reporting period?

  Yes

  No

  N/A

• Does the DWC Form-007 include all Full time, Part time and Temporary employees?

  Yes

  No

  N/A

• Is there a posted notice that the facility has no workers compensation coverage where the employee can see it regularly?

  Yes

  No

  N/A

• Is the posted notice of non-coverage provided in Spanish or other appropriate language?

  Yes

  No

  N/A

• Is the written notice of non-coverage provided to each new employee?

  Yes

  No

  N/A

• Is a copy of non-coverage signed and dated by the new employee and a facility representative and filed in the new employee's personnel file?

  Yes

  No

  N/A

• For each employee accident or illness, is there an internal report completed?

  Yes

  No

  N/A

• When there is an accident or illness, where is the report sent within the hospital?

• What is the established time frame that the accident/illness report must be completed?

• Name of department and position that reviews each injury report.

• If the accident or illness reported is reviewed and questioned regarding on-the-job event is work related, what are the procedures taken?

• Is there current information available regarding who to contact when there is a potential for denial of the claim?

  Yes

  No

  N/A

• Is there an IMMEDIATE follow up by a supervisor following an accident or illness specifically in regard to causes.

  Yes

  No

  N/A

• Is there a third party administrator available to the hospital when there is a question regarding the validity of the accident/illness report?

  Yes

  No

  N/A

• Is there a corporate contact person that is available to discuss accident/illness issues?

  Yes

  No

  N/A

• Yes

  No

  N/A

Training/education

• Are all new hires provided safety training with specifics of the non-subscription program PRIOR to beginning their position?

  Yes

  No

  N/A

• Is ALL training for new hires documented and filed for future references?

  Yes

  No

  N/A

• Is safety training provided to ALL employees and documentation regarding the type of training for all employees maintained for future references and includes dates of training?

  Yes

  No

  N/A

• Is annually safety training to ALL employees based on accident trends?

  Yes

  No

  N/A

• Is there a safety or hazard reporting system available to all employees with follow up?

  Yes

  No

  N/A

• Does the equipment management program include documented training on the safe use of all equipment and includes patient and non-patient equipment for EACH employee?

  Yes

  No

  N/A

• Is there a committee (EOC) or subcommittee that meets monthly and safety issues or safety hazards addressed?

  Yes

  No

  N/A

• Is there any outside assistance used to enhance the facility employee safety program?

  Yes

  No

  N/A

• Is the Texas Department of Insurance (TDI) used for safety training?

  Yes

  No

  N/A

• undefined