Physical Setting and Safety Standards
1. Facility is accessible to the disabled, parking, entrance, restrooms, hallways, elevators
2. Department of health license is current
3. Hallways and floors clear and adequate for movement
4. Exit Signs visible
5. Patient rights posted where likely to be noticed by patients or surrogate
6. Visible, charged fire extinguishers (A,B,C)
7. Fire/disaster evacuation routes posted
8. Emergency carts/kits are up to date/log maintained; drugs, equipment, O2, etc.
9. Controlled drugs are properly handled; locked cabinet, log maintained
10. Evidence of sterilization /re-use process standards (logbooks maintained)
11. Provisions for appropriate disposal of bio-hazardous materials/waste-signs posted
12. Evidence of mechanical and electrical equipment is regularly inspected and tested.
13. Evidence of safety and plant management program (logbooks maintained)
Lab
14. Current CLIA certificate is displayed or certificate of waiver available
15. Written policies and procedures
16. Equipment maintenance log available
Pharmacy
17. Registered pharmacist oversees the pharmacy
18. If no registered pharmacist, written policy/procedure or process for oversight
Radiology
19. Current Oklahoma state radiation certificate is available.
20. Written policy and procedures
21. Safety badges visible
22. Lead protective shields available
23. Pregnancy notices posted
Quality Program Review
24. Mission Statement
25. Written plan, policy and procedures
26. Evidence of data driven monitoring of problems and/or trends with analysis and actions.
27. Evidence of coordination/monitoring of activities throughout the facility; examples include infection control, safety/maintenance and pharmacy.
28. QAQI Committee meets regularly, and contemporaneous minutes are signed/dated.
Complaint Monitoring
29. Evidence of files maintained and investigated with results and resolution.
Infection Control Plan
30. Written plan, policies and procedures.
31. Evidence of monitoring of infection trends, analysis and actions.
Disaster Plan
32. Written disaster preparedness plan to provide for emergency care of patients, staff, others in the facility in event of fire, national disaster or equipment failure.
33. Evidence of disaster drill at least annually with assessment and corrections if indicated.
Biohazard and Waste Management
34. Written plan, policy and procedures
Safety and Plant Management Program
35. Written plan, policy and procedures
Immediate Transfer Procedure (Freestanding ASC)
36. Written policy and procedure for immediate transfer/communication with receiving hospital
Employee Review
Medical Staff Bylaws
37. Written plan of medical staff responsibility, training and scope with annual review.
Medical Staff Credentialing Plan
38. Written plan, policy and procedure.
Professional Staff
39. Written plan, policy and procedures
40. Nursing service directed under leadership of RN
41. RN with specialized emergency training available whenever there is a patient in ASC.
42. Documented monitoring of license renewals
43. Documented monitoring of continued education, CPR and competency.
Nonprofessional Staff
44. Written policy for non-professional staff oversight.
45. Documented monitoring of certifications/education as required.
Orientation
46. Written orientation with includes confidentiality and privacy training