Physical Setting and Safety

1. Hallways and floors are clear with adequate room for movement.

2. Department of Health license is current.

3. Exit signs are visible.

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

5. Equipment maintenance documented and log current.

6. Provisions for appropriate disposal of bio-hazardous materials and waste.

7. Temperature control of stored vaccines is ensured. 

Lab On Site: (yes)

8. Current CLIA certificate is displayed

9. Written policies and procedures.

10. Equipment maintenance log available.

Lab On Site: (no)

11. Current certificate of waiver available.

12. Written policies and procedures.

Pharmacy: (yes)

13. Registered pharmacist oversees the pharmacy

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

15. If no pharmacist, must have written policy/procedure-process for oversight

Quality Program

16. Mission statement

17. QAPI written plan, policies and procedures include improvement of health outcomes, safety and quality of care with annual review.

18. QAPI program measures, analyze and tracks adverse events with corrective action plan as indicated with annual review.

19. Evidence of coordination and monitoring of activities throughout the facility.

20. QAPI meets regularly and contemporaneous minutes are signed/dated

Infection Control

21. Written policy, plan and procedure

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

Complaint Monitoring

23. Written policy, procedures to address acceptance, processing, review and resolution.

Biohazard Policies and Procedures

24. Biohazard written plan, policy, and procedures to include home and travel.

Disaster Plan Policies and Procedure

25. Written policy, plan and procedure for fire, tornado, bomb threat, city/state/national emergency.

Medical Staff Bylaws

26. Written plan of staff responsibilities with annual review

Medical Staff Credentialing Plan

27. Written plan, policy and procedure.

Professional Staff

28. Written plan, policy and procedure

29. Documented monitoring of license renewals

30. Documented monitoring of continued education as required

31. Nursing staff CPR certified

Non-Professional Staff Oversight

32. Written plan, policy, procedure to include RN supervision of LPN and CNA.

33. Documented monitoring of non-professional staff

34. Monitoring of license renewals, education, CPR training.  

Employee Orientation

35. Written plan, policies and procedures.

36. Documented certification or training of home health aides to include privacy and patient rights.

37. Documented competency evaluation of CNA and nursing.