MOCK SURVEY CHECKLIST
MOCK SURVEY CHECKLIST
MOCK SURVEY CHECKLIST
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<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
Center Name:<br />
Clinical Director:<br />
Address:<br />
TASK YES NO NA COMMENTS:<br />
Contracts Completed YES NO NA<br />
Pharmacy<br />
Patient Transfer<br />
Lab/Pathology (Medicare certified)<br />
Radiology (Medicare certified)<br />
Biomedical<br />
Ambulance (non-emergency transfer)<br />
Laundry<br />
Hazardous Waste<br />
Pest Control<br />
Gas Lines<br />
Cleaning Service<br />
Maintenance<br />
Occupational Health<br />
Infection Prevention Nurse<br />
Contract for anesthesia services<br />
Be sure to get copies of his license, verify that license. Document<br />
orientation to your facility.<br />
ONLY if you will be doing procedures that require x-ray (except<br />
Nevada)<br />
Everything should be stickered prior to the survey<br />
Be sure to have your linen in the facility prior to the survey.<br />
Be sure to have your sharps disposable containers in place prior to<br />
survey.<br />
The gas lines have to be certified prior to the survey.<br />
Document that the contractor cleaning your OR’s are competent to<br />
clean them. Put that info behind this contract.<br />
Be sure to have copies of their credentials. Check license if<br />
applicable.<br />
This can be a simple written agreement that states the anesthesia<br />
provider is providing your anesthesia services.<br />
Credential Files Complete YES NO NA You should use a CVO to do your credentialing.<br />
Surgeon<br />
Anesthesia<br />
1
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
Employee Files YES NO NA<br />
Make sure ALL employees have had TB skin testing<br />
within last year.<br />
All employees should have physical within last year<br />
Should have HEP B declination in all files that decline<br />
HEP B for whatever reason<br />
Background check on all employees<br />
You should have Rubella & Rubeola (if born after<br />
1956) titers on all staff (or immunization record)<br />
At least 1 RN and 1 MD should be ACLS at any time<br />
there is a patient in the facility.<br />
All clinical staff must have current BLS<br />
All Pre/PACU staff should be ACLS<br />
All orientation should be completed and documented in<br />
each employee file.<br />
Reference: Be sure you have documented checking<br />
the references for all employees. Document who you<br />
talked with and comments.<br />
Be sure you’ve verified all licenses (RN’s, LV(P)Ns,<br />
Pharmacist consultant, Infection Preventionist RN)<br />
TJC expects to see a copy of the RN’s education<br />
verification (such as copy of nursing school diploma) If<br />
the nurse can’t find it, you should call the nursing<br />
school and try to verify education. Document<br />
who/when you talked with to verify.<br />
Signed job description: everyone should have signed<br />
their job description. If they work in more than 1 area,<br />
then they should have a signed job description for each<br />
area worked.<br />
Staff Education/In-Service Documentation<br />
Make sure you have in-service documented prior to the<br />
survey on the following:<br />
Fire/Safety, Disaster Drill, Infection Control, HIPPA,<br />
Abuse Identification (to include child, domestic, and<br />
Verify that your state doesn’t require 2-step.<br />
All employees must have OSHA training prior to treating patients.<br />
You should use a 1” Binder and call it “In-Service”. Put Jan-Dec tabs<br />
in it. Put all your completed in-services in this book. Use the forms in<br />
our books to complete for each in-service indicated below. Have<br />
employees sign each in-service they attended.<br />
2
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
adult), patient rights/grievance, OSHA<br />
Policy Books Approval YES NO NA COMMENTS:<br />
All policy books should have been approved by the<br />
governing body. Each policy should have the date that<br />
the policy was approved in the “approval date” section<br />
of the policy (at the top).<br />
Governing Body Meeting Minutes YES NO NA COMMENTS:<br />
You must have a documented governing body meeting<br />
minutes to show they have approved:<br />
We have to prove the governing body approved all the policies and<br />
protocols for the center.<br />
The date should coordinate with the governing body meeting minutes<br />
where they were approved. If you have questions about this, call me.<br />
Each physician credential<br />
All Contracts<br />
All Policies<br />
Committee Delegation YES NO NA Each committee should have an MD and an RN. Then for Pharmacy<br />
committee, should have Rph consultant.<br />
Make sure you define each committee<br />
Found in Meeting minute book<br />
Governing body, medical Advisory, Pharmacy and<br />
Therapeutics, Medical Records, QAPI, etc.<br />
Officers: Be sure to define officers:<br />
Safety Officer, Infection Control Preventionist, Medical<br />
Director, OSHA coordinator, etc.<br />
JCAHO/AAAHC Application YES NO NA COMMENTS:<br />
You should have completed your application to<br />
AAAHC/JCAHO<br />
Signage YES NO NA COMMENTS:<br />
You should have hours of operation and information<br />
about what to do in case of an emergency posted at<br />
your front door so that if a patient showed up at your<br />
door they could see to go to the emergency room or<br />
call 911.<br />
Grievance procedure posted in front lobby with your<br />
state health department and Ombudsman contact<br />
information, and accrediting body info (TJC) on it.<br />
The clinical director is the first person the patients are<br />
guided to when a complaint is filed. Be sure your<br />
policy states this clearly.<br />
Patient Rights and Responsibilities posted in front<br />
You will only be starting the process. The accrediting bodies won’t<br />
complete the application until you have your state license number.<br />
3
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
lobby.<br />
Hand washing posters should be posted in all<br />
bathrooms<br />
Language Barrier sign<br />
Do not enter without proper attire should be posted in<br />
all areas going into the sterile corridor.<br />
Should be posted at front desk.<br />
Advance Directive Brochures YES NO NA COMMENTS:<br />
CMS requires that you have copies of your state<br />
This is a CMS requirement and must be in place.<br />
mandated advance directive brochures. Keep them at<br />
the front desk<br />
Advance notice Brochure YES NO NA COMMENTS:<br />
Have you made sure that all your patients have<br />
received the advanced notice brochure and signed the<br />
attestation when they admit?<br />
The surveyor will be looking for this process. Even though CMS<br />
changed the advance notice part, you still have to meet this<br />
regulation.<br />
CLIA Waiver<br />
Make sure you have your CLIA waiver posted<br />
In the state of Nevada, there is a separate CLIA survey.<br />
Infection Control YES NO NA COMMENTS:<br />
This is an addition to the Infection Prevention Nurse.<br />
Have you completed infection vulnerability<br />
assessment (found in IC book in IC plan policy)<br />
CS person has documentation of some education in<br />
processing instruments. Courses can be found online.<br />
Pharmacy Area<br />
Are drugs stored properly<br />
Be sure to complete your vulnerability found in section 1 of your IC<br />
book.<br />
You must have your RpH set up your pharmacy area to ensure drugs<br />
are stored properly.<br />
Drug labeling<br />
TJC requires that all drugs are stored/labeled to prevent look alike<br />
sound alike mistakes. Review the pharmacy policies to see how to<br />
identify hazardous drugs, look alike sound alike, tall man/little man,<br />
etc. Be sure to identify these things on all your drugs to include the<br />
ones in the crash cart.<br />
Hazardous drugs<br />
Be sure to identify any hazardous drugs you might have (mitomycin<br />
would be classified as one)<br />
Crash Cart YES NO NA COMMENTS:<br />
Be sure to include:<br />
Your crash cart should be complete prior to the survey.<br />
The list of what’s in each drawer<br />
4
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
Testing log for the defibrillator<br />
Trach set<br />
For NY state you must have a Thoracotomy Set avail<br />
Disposable Ventilator<br />
ACLS meds<br />
Intubation tools for your patient population<br />
Defibrillator on top (checked each patient day)<br />
Working gomco or Suction device on top<br />
Break off lock<br />
Reference Library YES NO NA COMMENTS:<br />
AORN Standards<br />
ASPAN Standards<br />
AAMI Standards<br />
State/Federal ASC regulations<br />
Facts & Comparisons (pharmacy)<br />
JCAHO/AAAHC Standards<br />
NFPA life safety references<br />
Community References (meals on wheels, etc.)<br />
Drills Required before Survey YES NO NA COMMENTS:<br />
Fire Drill with critique x You have to pull the station to be sure it’s operational.<br />
Mock Code with critique<br />
x<br />
MH Drill (if you have any MH inducing drugs or doing x<br />
general anesthesia)<br />
Disaster Education Drill with critique x You should have a tabletop disaster drill prior to the first survey.<br />
Staff Orientation YES NO NA COMMENTS:<br />
The orientation should be completed on all the<br />
employees that will be doing the 3 test cases and the<br />
case the day of the survey.<br />
Employees YES NO NA COMMENTS:<br />
Everyone has on name tags<br />
No outside clothes<br />
No cloth hat<br />
Safety YES NO NA COMMENTS:<br />
Identify Safety Officer<br />
Evacuation plan is posted<br />
Know how to manage the generator<br />
How to report a fire<br />
5
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
Where is the nearest extinguisher<br />
Items 18” from ceiling<br />
Items at least 5 feet from furnace or hot water system<br />
Fire Plan<br />
Smoke Compartment drawings<br />
You must use your building plans to identify your smoke<br />
compartments. You need to post those so that people can see where<br />
to move patients to the smoke compartment opposite of the fire. If<br />
you have less than 10,000 sq feet, you may not have compartments.<br />
Fire Extinguishers YES NO NA COMMENTS:<br />
Tag inspected within last year, checked monthly and<br />
documented on the back of the tag.<br />
Fire extinguishers seal intact<br />
Fire extinguishers labeled as to type and class of fire.<br />
CLIA Waived Testing YES NO NA COMMENTS: You should have the information on the tests, at the<br />
test location (usually the nurse’s station).<br />
Glucometer<br />
Be sure you have a copy of the manufacturer’s<br />
recommendation for cleaning, testing, and controls on<br />
each of the CLIA waived testing you do.<br />
The glucometer must be for multiple patients, not one<br />
for single patient use.<br />
You should have a log to document the high/low<br />
controls and the patient’s tests results. You can use<br />
patient ID number instead of name to ensure<br />
confidentiality.<br />
HCG/pregnancy testing<br />
CLIA Waiver: Make sure you have your CLIA waiver<br />
posted<br />
In the state of Nevada, there is a separate CLIA<br />
survey.<br />
Have copies at the testing site so the staff can clearly understand the<br />
manufacturer’s recommendation on cleaning between patients, doing<br />
controls, documentation, what to do if values are out of normal<br />
parameters (report to physician).<br />
Be sure you have the test that has an internal control as well as an<br />
external control.<br />
The state of Nevada has a separate survey from CLIA.<br />
Disaster Plan<br />
Completed Hazard vulnerability Analysis<br />
Letter from local authorities that they don’t want you to<br />
This is a CMS requirement, you must have this. You should have<br />
6
e a part of their disaster plan<br />
Space identified for evacuation of patients<br />
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
Fire Exits YES NO NA COMMENTS:<br />
Fire exit lights not burned out.<br />
All emergency lighting, including the illumination of exit<br />
signs, must be tested every 30 days for 30 seconds,<br />
and once per year for at least 90 minutes.<br />
Exits free and unobstructed.<br />
Egress corridors free from equipment.<br />
Exit doors: Open outward and operate freely, not<br />
locked or have panic bars.<br />
something from state and local disaster planning committee.<br />
This should be a specific place. It could be a place in the parking lot,<br />
or a business neighbor (Ask a neighbor if you could house your<br />
patients there during an emergency evacuation. Get a letter from your<br />
neighbor saying you can house them there. If you don’t have<br />
neighbors and need to evacuate to the parking lot, then identify the<br />
area/space in the parking lot for everyone to evacuate to.<br />
7
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
Radiation Safety (if you have x-ray at center) YES NO NA COMMENTS:<br />
Caution radiation sign posted in area<br />
X-ray aprons and shields free from cracks.<br />
Badge readily available<br />
Badge reports previous 3 months are posted<br />
Radiation equipment inspected within 12 month<br />
Electrical: YES NO NA COMMENTS:<br />
Biomed stickers on all equipment<br />
Cords are 3 pronged<br />
Free of frayed edges<br />
No cords in traffic areas<br />
Autoclave: YES NO NA COMMENTS:<br />
Clean<br />
Log books started (biological done on each autoclave)<br />
Someone available that knows the sterilization process<br />
of your autoclaves.<br />
Posted on Wall by autoclave: Clearly defined<br />
directions on how to operate, clean, manage each<br />
different type autoclave you have.<br />
CS person has documentation of some education in<br />
processing instruments. Courses can be found online.<br />
Oxygen Tanks: YES NO NA COMMENTS:<br />
Proper signage on outside of gas tank room (NFPA)<br />
All tanks either in carts or chained to walls, none<br />
without support.<br />
OSHA: YES NO NA COMMENTS:<br />
PPE available<br />
Where is MSDS?<br />
Eyewash Station Location<br />
Regulated waste storage area clean<br />
Needles, syringes secure from patients and visitors<br />
Sharps containers not more than ¾ full<br />
OSHA employee Poster’s<br />
Chart YES NO NA COMMENTS:<br />
Review the charts of the test cases to be sure<br />
everything is complete to include:<br />
Someone in the facility should have complete knowledge of each<br />
autoclave, how to start, run different types of loads, how to manage<br />
biological, how to troubleshoot, how to clean, etc…everything….<br />
It’s important to have information from the manufacturer on how to<br />
clean and sterilize your instruments.<br />
8
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
H&P (even for YAG procedures) within 30 days of case<br />
Consent<br />
Safe Surgery Checklist (new form required by CMS)<br />
Pre-op instructions/Pre-op call<br />
Signed Orders<br />
MD assessed patient immediately prior to procedure<br />
Operative Record<br />
PACU record (if not YAG)<br />
Discharge assessment by an MD<br />
Discharge instructions<br />
Post-op dictation from MD<br />
Allergies listed with what their response to those<br />
allergies are (i.e., do they get a rash, stop breathing?)<br />
Patient for test case day of survey (new centers) YES NO NA COMMENTS:<br />
ID Band on<br />
Allergies on Chart/with reaction to allergy (i.e., rash,<br />
death, etc.)<br />
Marking done by surgeon<br />
H&P on chart within 30 days<br />
Time out done<br />
Pain assessment done<br />
Outdates YES NO NA COMMENTS:<br />
No expired dates on medications<br />
No expired dates on supplies<br />
No expired dates of solutions<br />
Supplies YES NO NA COMMENTS:<br />
No Outdates Found<br />
Supplies covered<br />
Heavy supplies on lower shelves<br />
Supplies are put away<br />
You have to have sufficient supplies in the center<br />
To include everything needed from admission to discharge.<br />
needed to care for your patient population<br />
Nothing on shelves closer than 18” from the ceiling<br />
Refrigerator YES NO NA COMMENTS:<br />
Cleaned monthly with logs<br />
Temperature monitored with logs<br />
You must have 24/7 monitoring of medication refrigerator.<br />
No food is in any medication refrigerator<br />
Sign that says “Medication Only” should be on medication fridge.<br />
9
<strong>MOCK</strong> <strong>SURVEY</strong> <strong>CHECKLIST</strong><br />
Specimen fridge has biohazard sticker on it<br />
Cidex (if doing GI) YES NO NA COMMENTS:<br />
Date/Initial and expiration on<br />
Clean YES NO NA COMMENTS:<br />
Floors clean and uncluttered<br />
All linen and supplies are stored with covers<br />
Drawers and shelves are clean<br />
No cardboard containers are sitting on floor<br />
No outside boxes behind red line<br />
Laundry hamper not overflowing<br />
Walls clean<br />
Ice machine is clean, scoop not in it.<br />
Beds made<br />
10