Physical Setting and Safety Standards
1. Facility is accessible to the disabled; parking, entrance, restrooms, hallways, elevators
2. Hallways and floors clear and adequate for movement
3. Exit Signs visible
4. Visible, charged fire extinguishers (A,B,C)
5. Fire/disaster evacuation routes posted
6. Equipment maintenance current and documented
7. Emergency carts/kits are up to date/log maintained; drugs, equipment, O2, etc.
8. Controlled drugs are properly handled; locked cabinet, log maintained
Biohazard and Waste Management
9. Written policies and procedures
10. Provisions for appropriate disposal of bio-hazardous materials/waste; signs posted
Disaster Plan
11. Written emergency procedures
12. Written evidence of unannounced test and analysis
Quality Program Review
13. Scope and Mission of facility is documented
14. DOH License is current
Quality Improvement
15. Written Plan, Policies and Procedures
16. Annual review/revision of written plan with evidence of oversight
17. QA/QI Committee meets regularly and contemporaneous minutes are signed/dated
18. Evidence of coordination/monitoring of activities throughout the facility
19. Regular analysis of services provided that address quality and appropriateness of service.
20. Regular analysis of critical incidents reported and action taken.
Infection Control Plan
21. Written Policies and Procedures
22. Documented monitoring of problems/trends with correction action plans
Safety and Plant Management Program
23. Written policies and procedures
24. Inspections are completed at least annually with documented results and corrective action plan if indicated.
Lab
25. Current CLIA certificate is displayed or certificate of waiver available
26. Written policies and procedures
27. Equipment maintenance log available
Pharmacy
28. Registered pharmacist oversees the pharmacy
29. If no registered pharmacist, written policy/procedure or process for oversight
Radiology
30. Current Oklahoma State radiation certificate is available
31. Written policy and procedures
32. Safety badges visible
33. Lead protective shields available
34. Pregnancy notices posted
Employee Review
Medical Staff Bylaws
35. Written plan of medical staff qualifications and responsibilities
Medical Staff Credentialing Plan
36. Written plan, policies and procedures for credentialing include criminal background checks, licensure and liability insurance with ongoing monitoring.
Professional Staff Licensure
37. Written plan, policies and procedures for license verification and criminal background checks with ongoing monitoring.
Non-Professional Staff Oversight
38. Written plan, policy and procedure for certifications with criminal background checks.
Employee Orientation
39. Written plan for orientation with documentation of job description with competency-based training with annual review.
40. Written plan for orientation to include identification of critical incidents and management with annual review.
41. Written plan for orientation to include orientation policy to include a system of patient rights to include confidentiality, privacy, freedom from abuse or neglect with annual review.
Complaint Monitoring
42. Evidence of files maintained and investigated with results and resolution.