Skilled Nursing Facility

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

9. Resident medications labeled and stored properly

Biohazard and Waste Management

10. Written policies and procedures 

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

Disaster Plan

12. Written policy; fire, tornado, bomb threat, city state/national emergency

13. Written evidence of a disaster drill in the past 12 months

Resident Monitoring

14. Written policy to address abuse, neglect as well as dignity, privacy and respect

Dietary

15. Written policy regarding monitoring of food preparation and dietary staff training

Quality Program Review

16. Mission Statement

17. DOH License is current

Quality Improvement

18. Written Plan, Policies and Procedures

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

20. QI/QA Committee meets regularly, and contemporaneous minutes are signed/dated

21. Evidence of coordination/monitoring of activities throughout the facility; examples include infection control, safety/maintenance and pharmacy

Complaint Monitoring

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

Infection Control Plan

23. Written policies and procedures

24. Documented monitoring of problems/trends with correction action plans

Safety and Plant Management Program

25. Written policies and procedures

26. Documented monitoring

Lab On Site (Yes)

27. Current CLIA certificate is displayed 

28. Written policies and procedures

29. Equipment maintenance log available

Lab On Site (No)

30. Certificate of CLIA waiver available

31. Written policies and procedures

Pharmacy On Site (Yes)

32. Registered pharmacist oversees the pharmacy

33. If no registered pharmacist, written policy & procedure or process for oversight

Employee Review

Medical Staff Bylaws

34. Written plan of medical staff responsibilities with annual review

Medical Staff Credentialing Plan (Including Temporary Medical Staffing)

35. Written plan, policies and procedures

Professional Staff Licensure

36. Written policy

37. Documented monitoring of license renewals

38. Documented monitoring of continued education as required

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

Non-Professional Staff Oversight

40. Written policy

41. Documented monitoring of certification renewals

42. Documented monitoring of continued education as required

Employee Orientation

43. Written plan

44. Orientation includes confidentiality/privacy training