MOCK SURVEY CHECKLIST

MOCK SURVEY CHECKLIST
Center Name:
Clinical Director:
Address:
TASK YES NO NA COMMENTS:
Contracts Completed YES NO NA
Pharmacy
Patient Transfer
Lab/Pathology (Medicare certified)
Radiology (Medicare certified)
Biomedical
Ambulance (non-emergency transfer)
Laundry
Hazardous Waste
Pest Control
Gas Lines
Cleaning Service
Maintenance
Occupational Health
Infection Prevention Nurse
Contract for anesthesia services
Be sure to get copies of his license, verify that license. Document
orientation to your facility.
ONLY if you will be doing procedures that require x-ray (except
Nevada)
Everything should be stickered prior to the survey
Be sure to have your linen in the facility prior to the survey.
Be sure to have your sharps disposable containers in place prior to
survey.
The gas lines have to be certified prior to the survey.
Document that the contractor cleaning your OR’s are competent to
clean them. Put that info behind this contract.
Be sure to have copies of their credentials. Check license if
applicable.
This can be a simple written agreement that states the anesthesia
provider is providing your anesthesia services.
Credential Files Complete YES NO NA You should use a CVO to do your credentialing.
Surgeon
Anesthesia
1

MOCK SURVEY CHECKLIST
Employee Files YES NO NA
Make sure ALL employees have had TB skin testing
within last year.
All employees should have physical within last year
Should have HEP B declination in all files that decline
HEP B for whatever reason
Background check on all employees
You should have Rubella & Rubeola (if born after
1956) titers on all staff (or immunization record)
At least 1 RN and 1 MD should be ACLS at any time
there is a patient in the facility.
All clinical staff must have current BLS
All Pre/PACU staff should be ACLS
All orientation should be completed and documented in
each employee file.
Reference: Be sure you have documented checking
the references for all employees. Document who you
talked with and comments.
Be sure you’ve verified all licenses (RN’s, LV(P)Ns,
Pharmacist consultant, Infection Preventionist RN)
TJC expects to see a copy of the RN’s education
verification (such as copy of nursing school diploma) If
the nurse can’t find it, you should call the nursing
school and try to verify education. Document
who/when you talked with to verify.
Signed job description: everyone should have signed
their job description. If they work in more than 1 area,
then they should have a signed job description for each
area worked.
Staff Education/In-Service Documentation
Make sure you have in-service documented prior to the
survey on the following:
Fire/Safety, Disaster Drill, Infection Control, HIPPA,
Abuse Identification (to include child, domestic, and
Verify that your state doesn’t require 2-step.
All employees must have OSHA training prior to treating patients.
You should use a 1” Binder and call it “In-Service”. Put Jan-Dec tabs
in it. Put all your completed in-services in this book. Use the forms in
our books to complete for each in-service indicated below. Have
employees sign each in-service they attended.
2

MOCK SURVEY CHECKLIST
adult), patient rights/grievance, OSHA
Policy Books Approval YES NO NA COMMENTS:
All policy books should have been approved by the
governing body. Each policy should have the date that
the policy was approved in the “approval date” section
of the policy (at the top).
Governing Body Meeting Minutes YES NO NA COMMENTS:
You must have a documented governing body meeting
minutes to show they have approved:
We have to prove the governing body approved all the policies and
protocols for the center.
The date should coordinate with the governing body meeting minutes
where they were approved. If you have questions about this, call me.
Each physician credential
All Contracts
All Policies
Committee Delegation YES NO NA Each committee should have an MD and an RN. Then for Pharmacy
committee, should have Rph consultant.
Make sure you define each committee
Found in Meeting minute book
Governing body, medical Advisory, Pharmacy and
Therapeutics, Medical Records, QAPI, etc.
Officers: Be sure to define officers:
Safety Officer, Infection Control Preventionist, Medical
Director, OSHA coordinator, etc.
JCAHO/AAAHC Application YES NO NA COMMENTS:
You should have completed your application to
AAAHC/JCAHO
Signage YES NO NA COMMENTS:
You should have hours of operation and information
about what to do in case of an emergency posted at
your front door so that if a patient showed up at your
door they could see to go to the emergency room or
call 911.
Grievance procedure posted in front lobby with your
state health department and Ombudsman contact
information, and accrediting body info (TJC) on it.
The clinical director is the first person the patients are
guided to when a complaint is filed. Be sure your
policy states this clearly.
Patient Rights and Responsibilities posted in front
You will only be starting the process. The accrediting bodies won’t
complete the application until you have your state license number.
3

MOCK SURVEY CHECKLIST
lobby.
Hand washing posters should be posted in all
bathrooms
Language Barrier sign
Do not enter without proper attire should be posted in
all areas going into the sterile corridor.
Should be posted at front desk.
Advance Directive Brochures YES NO NA COMMENTS:
CMS requires that you have copies of your state
This is a CMS requirement and must be in place.
mandated advance directive brochures. Keep them at
the front desk
Advance notice Brochure YES NO NA COMMENTS:
Have you made sure that all your patients have
received the advanced notice brochure and signed the
attestation when they admit?
The surveyor will be looking for this process. Even though CMS
changed the advance notice part, you still have to meet this
regulation.
CLIA Waiver
Make sure you have your CLIA waiver posted
In the state of Nevada, there is a separate CLIA survey.
Infection Control YES NO NA COMMENTS:
This is an addition to the Infection Prevention Nurse.
Have you completed infection vulnerability
assessment (found in IC book in IC plan policy)
CS person has documentation of some education in
processing instruments. Courses can be found online.
Pharmacy Area
Are drugs stored properly
Be sure to complete your vulnerability found in section 1 of your IC
book.
You must have your RpH set up your pharmacy area to ensure drugs
are stored properly.
Drug labeling
TJC requires that all drugs are stored/labeled to prevent look alike
sound alike mistakes. Review the pharmacy policies to see how to
identify hazardous drugs, look alike sound alike, tall man/little man,
etc. Be sure to identify these things on all your drugs to include the
ones in the crash cart.
Hazardous drugs
Be sure to identify any hazardous drugs you might have (mitomycin
would be classified as one)
Crash Cart YES NO NA COMMENTS:
Be sure to include:
Your crash cart should be complete prior to the survey.
The list of what’s in each drawer
4

MOCK SURVEY CHECKLIST
Testing log for the defibrillator
Trach set
For NY state you must have a Thoracotomy Set avail
Disposable Ventilator
ACLS meds
Intubation tools for your patient population
Defibrillator on top (checked each patient day)
Working gomco or Suction device on top
Break off lock
Reference Library YES NO NA COMMENTS:
AORN Standards
ASPAN Standards
AAMI Standards
State/Federal ASC regulations
Facts & Comparisons (pharmacy)
JCAHO/AAAHC Standards
NFPA life safety references
Community References (meals on wheels, etc.)
Drills Required before Survey YES NO NA COMMENTS:
Fire Drill with critique x You have to pull the station to be sure it’s operational.
Mock Code with critique
x
MH Drill (if you have any MH inducing drugs or doing x
general anesthesia)
Disaster Education Drill with critique x You should have a tabletop disaster drill prior to the first survey.
Staff Orientation YES NO NA COMMENTS:
The orientation should be completed on all the
employees that will be doing the 3 test cases and the
case the day of the survey.
Employees YES NO NA COMMENTS:
Everyone has on name tags
No outside clothes
No cloth hat
Safety YES NO NA COMMENTS:
Identify Safety Officer
Evacuation plan is posted
Know how to manage the generator
How to report a fire
5

MOCK SURVEY CHECKLIST
Where is the nearest extinguisher
Items 18” from ceiling
Items at least 5 feet from furnace or hot water system
Fire Plan
Smoke Compartment drawings
You must use your building plans to identify your smoke
compartments. You need to post those so that people can see where
to move patients to the smoke compartment opposite of the fire. If
you have less than 10,000 sq feet, you may not have compartments.
Fire Extinguishers YES NO NA COMMENTS:
Tag inspected within last year, checked monthly and
documented on the back of the tag.
Fire extinguishers seal intact
Fire extinguishers labeled as to type and class of fire.
CLIA Waived Testing YES NO NA COMMENTS: You should have the information on the tests, at the
test location (usually the nurse’s station).
Glucometer
Be sure you have a copy of the manufacturer’s
recommendation for cleaning, testing, and controls on
each of the CLIA waived testing you do.
The glucometer must be for multiple patients, not one
for single patient use.
You should have a log to document the high/low
controls and the patient’s tests results. You can use
patient ID number instead of name to ensure
confidentiality.
HCG/pregnancy testing
CLIA Waiver: Make sure you have your CLIA waiver
posted
In the state of Nevada, there is a separate CLIA
survey.
Have copies at the testing site so the staff can clearly understand the
manufacturer’s recommendation on cleaning between patients, doing
controls, documentation, what to do if values are out of normal
parameters (report to physician).
Be sure you have the test that has an internal control as well as an
external control.
The state of Nevada has a separate survey from CLIA.
Disaster Plan
Completed Hazard vulnerability Analysis
Letter from local authorities that they don’t want you to
This is a CMS requirement, you must have this. You should have
6

e a part of their disaster plan
Space identified for evacuation of patients
MOCK SURVEY CHECKLIST
Fire Exits YES NO NA COMMENTS:
Fire exit lights not burned out.
All emergency lighting, including the illumination of exit
signs, must be tested every 30 days for 30 seconds,
and once per year for at least 90 minutes.
Exits free and unobstructed.
Egress corridors free from equipment.
Exit doors: Open outward and operate freely, not
locked or have panic bars.
something from state and local disaster planning committee.
This should be a specific place. It could be a place in the parking lot,
or a business neighbor (Ask a neighbor if you could house your
patients there during an emergency evacuation. Get a letter from your
neighbor saying you can house them there. If you don’t have
neighbors and need to evacuate to the parking lot, then identify the
area/space in the parking lot for everyone to evacuate to.
7

MOCK SURVEY CHECKLIST
Radiation Safety (if you have x-ray at center) YES NO NA COMMENTS:
Caution radiation sign posted in area
X-ray aprons and shields free from cracks.
Badge readily available
Badge reports previous 3 months are posted
Radiation equipment inspected within 12 month
Electrical: YES NO NA COMMENTS:
Biomed stickers on all equipment
Cords are 3 pronged
Free of frayed edges
No cords in traffic areas
Autoclave: YES NO NA COMMENTS:
Clean
Log books started (biological done on each autoclave)
Someone available that knows the sterilization process
of your autoclaves.
Posted on Wall by autoclave: Clearly defined
directions on how to operate, clean, manage each
different type autoclave you have.
CS person has documentation of some education in
processing instruments. Courses can be found online.
Oxygen Tanks: YES NO NA COMMENTS:
Proper signage on outside of gas tank room (NFPA)
All tanks either in carts or chained to walls, none
without support.
OSHA: YES NO NA COMMENTS:
PPE available
Where is MSDS?
Eyewash Station Location
Regulated waste storage area clean
Needles, syringes secure from patients and visitors
Sharps containers not more than ¾ full
OSHA employee Poster’s
Chart YES NO NA COMMENTS:
Review the charts of the test cases to be sure
everything is complete to include:
Someone in the facility should have complete knowledge of each
autoclave, how to start, run different types of loads, how to manage
biological, how to troubleshoot, how to clean, etc…everything….
It’s important to have information from the manufacturer on how to
clean and sterilize your instruments.
8

MOCK SURVEY CHECKLIST
H&P (even for YAG procedures) within 30 days of case
Consent
Safe Surgery Checklist (new form required by CMS)
Pre-op instructions/Pre-op call
Signed Orders
MD assessed patient immediately prior to procedure
Operative Record
PACU record (if not YAG)
Discharge assessment by an MD
Discharge instructions
Post-op dictation from MD
Allergies listed with what their response to those
allergies are (i.e., do they get a rash, stop breathing?)
Patient for test case day of survey (new centers) YES NO NA COMMENTS:
ID Band on
Allergies on Chart/with reaction to allergy (i.e., rash,
death, etc.)
Marking done by surgeon
H&P on chart within 30 days
Time out done
Pain assessment done
Outdates YES NO NA COMMENTS:
No expired dates on medications
No expired dates on supplies
No expired dates of solutions
Supplies YES NO NA COMMENTS:
No Outdates Found
Supplies covered
Heavy supplies on lower shelves
Supplies are put away
You have to have sufficient supplies in the center
To include everything needed from admission to discharge.
needed to care for your patient population
Nothing on shelves closer than 18” from the ceiling
Refrigerator YES NO NA COMMENTS:
Cleaned monthly with logs
Temperature monitored with logs
You must have 24/7 monitoring of medication refrigerator.
No food is in any medication refrigerator
Sign that says “Medication Only” should be on medication fridge.
9

MOCK SURVEY CHECKLIST
Specimen fridge has biohazard sticker on it
Cidex (if doing GI) YES NO NA COMMENTS:
Date/Initial and expiration on
Clean YES NO NA COMMENTS:
Floors clean and uncluttered
All linen and supplies are stored with covers
Drawers and shelves are clean
No cardboard containers are sitting on floor
No outside boxes behind red line
Laundry hamper not overflowing
Walls clean
Ice machine is clean, scoop not in it.
Beds made
10