Physical Setting and Safety Standards

1. Facility accessible to the disabled-parking, entrance, restrooms, hallways, elevators.

2. Hallways and floors clear and there is adequate room for movement.

3. Exit signs visible

4. Patient rights posted where likely to be noticed by patients or surrogate

5. Visible, charged fire extinguishers (A,B,C)

6. Fire/disaster evacuation routes posted

7. Emergency carts are immediately available/log maintained.

8. Separate designated area/adequate space for medication storage, prep/dispensing.

9. Controlled drugs are properly handled-locked cabinet, log maintained.

10. Provisions for appropriate disposal of bio-hazardous materials/waste-signs posted.

11. Evidence of mechanical/electrical equipment is regularly inspected and tested.

12. Evidence of Safety and plant management program. i.e. books

Lab On Site: (yes)

13. Written policies and procedures

14. Current CLIA certificate is displayed or certificate of waiver available.

15. Equipment maintenance log available

Lab On Site: (no)

16. Certificate of CLIA waiver available

17. Written policies and procedures

Pharmacy On Site: (yes)

18. Written policies/procedures outlining process for reconstitution, storage, and dispensing of peri-dialysis medications.

Quality Program Review

19. Mission statement

20. QAPI Written plan, policy and procedures

21. Annual review/revision of written plan with evidence of oversight

22. QAPI committee meets regularly/minutes signed and dated.

23. Evidence of coordination of activities throughout facility, examples include: infection control, safety/maintenance and pharmacy.

24. Infection control policies and procedures.

25. Documented monitoring of problems/trends with corrective action plan.

Complaints

26. Evidence of files maintained and investigated with results and resolution.

Safety and Plant Management Program:

27. Written policies and procedures include preparation/storage of dialysis solution.

Disaster Plan:

28. Written policy/procedure that specifically defines handling of emergencies such as fire, natural disaster or functional failures in equipment. 

29. Evidence of annual disaster drill with assessment and corrections as indicated. 

Biohazard and Waste Management

30. Written policy/procedure related to biohazardous/waste management.

Staff Review

Medical Staff Bylaws

31. Written plan of medical staff responsibility, training and scope with annual review.

Medical Staff Credentialing (includes Temp Medical staffing)

32. Written plan, policy, and procedures include primary source verification. 

Professional Staff

33. Written plan, policy and procedures.

34. Written staffing matrix/plan

35. Documented monitoring of license renewals.

36. Documented monitoring of required continued education

37. Documented evidence-based training in management of adverse or unexpected outcome(s) in patient population; shock, seizure, arrest, etc.

38. Documented training of all individuals performing waived testing procedures

39. Nursing staff and/or ancillary staff members are CPR certified

Non-professional staff oversight

40. Written plan, policy and procedures

41. Documented monitoring of certification renewals.

Employee Orientation

42. Written plan, policy and procedures

43. Documentation of core competencies specific to job description

44. Training includes confidentiality and privacy training