Title Page
-
Document No.
-
Audit Title
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
Medication
-
Are controlled substances counted and administered by licensed staff only?
-
Are controlled substances kept under double lock system and all medications secured in cabinet/closets with locking doors?
-
Are there any expired medications? Samples and/or stock meds?<br>
-
Is the temperature for the refrigerator in compliance? Is the refrigerator maintained at 35°F to 46°F (2°C to 8°C) Is the freezer maintained at 5°F or below (-15°C)<br>
-
Are temperature logs complete with all required documentation? <br>
-
Multi dose vials stored with expiration date reflecting 28 days.<br>
-
High alert medications are labeled in medication area.<br>
-
Is NIZ sign posted in medication areas with protocol properly followed?<br>
-
Staff are utilizing two identifiers during medication administration and/or drawing blood.<br>
-
Check emergency box and all logs. Are there any expired medications? Any items missing?<br>
Emergency Management
-
Are evacuation maps accurate and posted in appropriate areas?<br>
-
Is the utilities shut down map posted? (If applicable)<br>
-
Are emergency doorbells, lights, and exit lights in working order? Check the bathroom doorbell!<br>
-
The disaster notification list is available. IMG lists on SharePoint and clinic specific list should be in clinic.<br>
Hazard Materials
-
Lids are on the biohazard bins and doors secured.<br>
-
There are chemical, mercury and mess spill kits available.<br>
-
Flammable liquids are stored in a proper cabinet.<br>
-
Are hazard materials and waste properly labeled?<br>
Infection Control
-
Are all parts of the clinic clean and well-maintained? Check trash, ceiling tiles, floor/carpet stains, bugs or dust behind equipment.<br>
-
Are sharps containers mounted and less than 2/3 full? (Check all exam rooms as well as med prep areas)<br>
-
Are only approved standardized safety devices stocked? (PPE Kits, Spill Kits, approved needles, etc)<br>
-
Are clean, dirty and sterile areas marked in autoclave area?<br>
-
Are autoclave logs complete (spore testing, monthly maintenance with weekly water changes, instrument logs, etc)<br>
-
Are instrument packages properly stored to avoid puncture or contamination? <br>
-
Are PPE kits available?<br>
Lab Safety
-
Is CLIA certificate posted and current?<br>
-
Are lab signs posted? Analytical area (any version)?<br>
-
Does in-house testing reports contain date, time, name of Provider,patients name, initials of tech performing test, test selection and results?<br>
-
Are chemical and/or biohazard material disposed of properly? Is urine discarded down toilet? Are chemicals disposed according to the guidelines provided in the SDS? (Urine cannot be poured down the sink unless the sink is designated as a biohazard sink)<br>
-
Is an eye wash available in lab? Is it checked weekly with documentation?<br>
-
Are temperature monitors in place and in range in the refrigerator? Documented?<br>
-
Are clean supplies not stored with patient specimens? (Including personal items)<br>
-
Are test logs maintained for all tests performed or sent out?<br>
-
Is there a mechanism to track all lab, pathology, and tissue specimens?<br>
-
Are centrifuge RPM's checked yearly with documentation? (Two RPM speeds-one for urine and one for blood.)<br>
-
Are manufacturer maintenance and instrument manuals maintained in the lab?<br>
-
Are test kits stored according to manufacturer's guidelines? ( Temperature and humidity monitors in place and in range? Documented?)<br>
-
Are test kits standardized according to kits approved by quality committee?<br>
-
Are two levels of controls performed on each day of patient testing for glucometers?<br>
-
Has most current package insert for each test performed. (This is the folded insert with test details)<br>
-
All lab policies are signed off by Lab Director.<br>
-
The waived test logs reflect quality controls were conducted each day of patient testing and quality assurance logs are up to date and reviewed by the Lab Director?<br>
-
Is there an action plan initiated for each problematic area with documentation?<br>
-
Are there competency checklists with documented training for each person eligible to perform patient testing in the lab?<br>
-
Quick test procedure cards are posted by all kits?<br>
-
If a PPMP site is accuracy of PPMP test results verified at least twice a year and is the proficiency testing rotated between all staff performing patient testing?<br>
-
Are the fire extinguisher's located every 75ft and have they been checked appropriately?<br>
Radiology Safety
-
Is current certificate for x-ray posted?<br>
-
Are radiation badges available for personnel involved in radiology?<br>
-
Are pregnancy signs posted in English and Spanish in radiology room?<br>
-
Is there a private area for patients to change in gowns in the radiology room?<br>
-
Is the approved color-coded radiation sign in the radiology room? <br>
-
Is the techniques chart posted as well as is it neat and typed in the radiology room.<br>
-
Is there an electrical panel in room labeled "Radiology Room"?<br>
-
Are the lead aprons and gloves hung and in good condition?<br>
-
Is the x-ray equipment serviced regularly with documentation?<br>
-
Is the x-ray equipment inspected annually by physicist? Are problems identified and corrected with documentation?<br>
-
Does the imprint include tech's initial?<br>
Safety
-
Are items stored no closer than 18" from the ceiling? (if building is sprinkled)<br>
-
Are child proof locks or dangerous objects out of the reach of children?<br>
-
Are there expired supplies?<br>
-
Are cabinets and drawers containing syringes and needles locked?<br>
-
Battery powered lights required for egress have functional test performed every 30 days for a minimum of 30 seconds.<br>
-
Oxygen tanks are secured in cylinder caddy or bolted to wall and are full and operational.<br>
-
Front door has emergency number and nearest hospital posted.<br>
-
Handicap parking is clearly identified.<br>
-
Severe weather protected area marked.<br>
Rights
-
Patient Rights and Responsibilities are posted.<br>
Security
-
Is the staff wearing name tags? (check all staff)<br>
-
Is confidentiality maintained throughout. Fax machine, computer screen, counter tops. <br>
Utility Mangement
-
Are power outage labels properly placed on electrical box and medication refrigerator?<br>
Medical Equipment Management
-
Equipment has PM stickers current within the last 12 months and appropriately calibrated.
