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