PREPAREDNESS CHECKLIST



PREPAREDNESS CHECKLISTThis checklist serves to provide assistance in preparedness for unannounced regulatory surveys. These hot-button items can be checked off quickly in each area to prepare for the unannounced regulatory surveyors’ review. It is important to be aware of and follow your hospital policy when considering certain checklist items, such as appropriate items at workstations.I. GENERAL CONSIDERATIONSAll associate ID badges are above the waist and clearly visible. Mandatory signage is visible and in place in public areas: license, interpreter assistance, financial assistance, patient rights, etc.II. PATIENT IDENTIFICATIONEmployees can clearly state primary patient identifiers.III. CULTURAL COMPETENCIESEmployees can clearly state practices related to patient self-reporting on preferred language, race, and ethnicity.IV. PATIENT PRIVACYCopies of the HIPAA Notice of Privacy Practice are available for distribution.Associates are aware of and follow HIPAA guidelines for appropriate use.Associate is never away from screen while computer is logged into patient record.Associate is aware when people are walking or standing in view of the computer screen.Associates use good practice concerning the creation and security of computer puter screen visibility is capable of being minimized or hidden when necessary.Check open access areas: There are no unsecured patient records in open access areas (including patient profiles, physician orders, patient insurance information, etc.) or left unattended.Check printers: There are no unsecured patient records in open access areas (including patient profiles, physician orders, patient insurance information, etc.) or left unattended.Check copiers: There are no unsecured patient records in open access areas (including patient profiles, physician orders, patient insurance information, etc.) or left unattendedV. INFECTION, PREVENTION & CONTROLEmployees can clearly state infection control practices. Employees know where infection control materials and personal protective equipment (PPE) are kept (hand sanitizer, masks, tissue, gloves, etc.).Employees can access infection control materials and personal protective equipment (PPE).Infection control materials and personal protective equipment (PPE) is readily available for public utilization (hand sanitizer, masks, tissue, gloves, etc.).Refrigerator logs have been updated.Refrigerators are clean.Items inside refrigerators are appropriate.No staff lunches are inside patient refrigerators.Subject to hospital policy, there are no food items or drinks at work stations.Subject to hospital policy, there are no unapproved items, such as hand lotions, at work stations.Only cleaning supplies are under sinks and/or in cabinets.VI. ENVIRONMENT OF CAREEnvironment of care resources are readily visible and accessible.All fire safety resources are readily visible and accessible.All surrounding halls are passable (eight feet in patient access hallways).All unused COWs (computers on wheels) and other wheeled items are stored out of the hallways. Check all fire doors: No fire door is blocked.NOTES & REFERENCESI. GENERAL CONSIDERATIONSSee Standards FAQ Details (“Identification Badge Requirements”) at - FAQ. Are evacuation maps required to be posted in health care organizations? If so, where and how many are needed? . PATIENT IDENTIFICATIONSee NPSG.01.01.01 (Identify patients correctly) - Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.See Standards FAQ Detail for multiple questions and answers regarding patient identifiers – Q. What is the intent of the requirement for using two identifiers? A. The intent here is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Therefore, the two patient/client/resident-specific identifiers must be directly associated with the individual and the same two identifiers must be directly associated with the medications, blood products, specimen containers (such as on an attached label), other treatments or procedures.?III. CULTURAL COMPETENCIESIV. PATIENT PRIVACYV. INFECTION, PREVENTION & CONTROLSee NPSG.07.01.01 (prevent infection) – Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.See also The Joint Commission’s Hand Hygiene Project: Standards FAQ Details on Hand Hygiene: See Standards FAQ Details on Monitoring of Hand Hygiene: FAQ: Is there a Joint Commission standard which requires us to maintain temperature logs for staff only refrigerators? FAQ:? Are food and drinks for staff members allowed in patient care areas? FAQ: Do the Joint Commission standards prohibit use of under sink cabinets for storage? . ENVIRONMENT OF CARESee FAQ: How long can computers on wheels be in corridors? Are they allowed to charge in the corridors? ................
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