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Methodist Hospital

Physician Serv. Joint Commission Survey Form

For the Associated Event:
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Associated Event   
  Location Surveyed
  Surveyor
  Date
  Staff Surveyed
  Correct signage on office with Physician & hrs of operation? YES     NO     N/A    
  Employees wearing ID badges above the waist? YES     NO     N/A    
  Patient/Rights Responsibilities posted in waiting room or exam rooms? YES     NO     N/A    
  Two identifiers used to check patient in & pull chart (Name & SS#)? YES     NO     N/A    
  HIPAA Compliance observed in handling of files and verbal/phone discussion at desk? YES     NO     N/A    
  Patient charts are protected from unauthorized access? (Under staff supervision during hrs & protected from access by contracted housekeeping staff if access area after hours)? YES     NO     N/A    
  Staff able to provide information on Advance Directive upon request? (forms print from Medforms) YES     NO     N/A    
  Staff able to verbalize how to communicate with non-English speaking patients? YES     NO     N/A    
  Soap dispenser/towels or hand sanitizer is in or in close proximity to each exam room? YES     NO     N/A    
  Staff perform hand hygiene before/ entering & leaving each exam room? YES     NO     N/A    
  Personal protective (gloves) are available to staff in each exam room? YES     NO     N/A    
  Staff can verbalize what other PPE is available and location? (masks, gowns, goggles) YES     NO     N/A    
  Exam rooms tables cleaned between & after last patient? (n/a in between pts if use paper & pillow under paper) YES     NO     N/A    
  Staff can verbalize "wet time" for surface disinfectant agent. (just standardized to Oxvir TB = 1 minute) YES     NO     N/A    
  Needles disposed of in puncture resistant container, not overfilled, out of reach of children? YES     NO     N/A    
  Staff verbalize how separate clean/dirty equipment? YES     NO     N/A    
  Staff verbalize how instruments used are sterilized? (Returned to hospital for autoclave? ) YES     NO     N/A    
  Staff verbalize how to prep instruments for return? (spray with instra-clean, redbag, & in ridged biohazard container) YES     NO     N/A    
  Cold sterilization solution dated, labeled, solution changed per manufacture direction & CQ logs done? (MWS only) YES     NO     N/A    
  No medications, syringes & RX pads are accessible to patients in exam rooms? YES     NO     N/A    
  Biohazardous waste is "red bagged" for disposal? YES     NO     N/A    
  Clean linen stored in manner to prevent contamination? (soiled stored separately: dirty not on floor, sep from clean) YES     NO     N/A    
  Waiting room is clean, free of debris and exits/halls are unobstructed? YES     NO     N/A    
  No food & drink in patient care areas or where there is potential for occupational exposure to blood born pathogens, body fluids YES     NO     N/A    
  Sample Meds stored in a supervised/locked area that patients do not access & contract HK can not access p hrs YES     NO     N/A    
  All medications are within expiration date range? No oints/creams without exp date? YES     NO     N/A    
  Multi dose vials are dated with expiration date ( 28 days after opening) & disposed of once expired? YES     NO     N/A    
  All medications/solutions are properly labeled/stored in compliance with manf. guidelines? YES     NO     N/A    
  A patient sample log is maintained for use in event of manf. recall? YES     NO     N/A    
  Medications requiring refrigeration are stored in a separate refrig from specimens/emp use? YES     NO     N/A    
  A thermometer is present in refig and temps are logged daily? Method in place to identify if temps fall below recommend storage? (i.e. electronic thermometer, penny on frozen cup of H2O) YES     NO     N/A    
  Staff explain what to do with drugs if temp falls below safe level? (to Pharm to dispose) YES     NO     N/A    
  If narcotics/controlled substances present they are stored in a YES     NO     N/A    
  Staff able to explain how prescription pads are protected from patient access? YES     NO     N/A    
  Needles & syringes are not accessible to patients & visitors. YES     NO     N/A    
  Clean & Dirty areas designated? YES     NO     N/A    
  Clean supplies are stored separately from dirty supplies? YES     NO     N/A    
  Utility & storage room doors are kept closed & passageway is clear? YES     NO     N/A    
  Supplies removed from cardboard shipping cartons, package integrity is maintained? YES     NO     N/A    
  Supplies with expiration dates are with in their date range? YES     NO     N/A    
  Supplies stored at least 3" inches from floor (bottom rack must be solid )& 18 in from sprinkler system if present? YES     NO     N/A    
  There are NO supplies on the floor. (this include clerical supplies like zerox paper) YES     NO     N/A    
  Supplies not stored in areas not intended for storage (nothing under sinks ex. cleaning items) YES     NO     N/A    
  CLIA Certification is posted and current in lab area if waived testing done? YES     NO     N/A    
  PMM Certification is posted if microscopic procedures are done by MD/ARNP YES     NO     N/A    
  Testing reagents, controls, strips & supplies are dated with expiration dates, are within expiration date & stored appropriately per label? YES     NO     N/A    
  Lab specimens are labeled in presence of the patient with 2 identifiers (Name & DOB) (Pts may label own urine) YES     NO     N/A    
  Specimen refrigerator is labeled as biohazard & contains only specimens? YES     NO     N/A    
  Specimens are labeled as biohazard & properly packaged for transport? (sealed plastic bag, rigid container) YES     NO     N/A    
  Control logs are present when applicable (UA, BGM) YES     NO     N/A    
  Evidence that staff have been competency tested on UA, BGM, etc if applicable YES     NO     N/A    
  Staff follow confidentiality guidelines: documents w PHI, chart contents are protected from public view, computer screens are turned away from public view. YES     NO     N/A    
  Records are stored away from or protected from public access & afterhours contracted cleaning staff. YES     NO     N/A    
  Medical Record entries are timed, dated, & authenticated by signature or initials YES     NO     N/A    
  A master signature authentication log containing full name & initials is maintained & up to date YES     NO     N/A    
  "Summary Sheet" is present & on top of other documents & is updated prn. YES     NO     N/A    
  Summary sheet lists: current meds, OTC, herbals & allergies if applicable YES     NO     N/A    
  Summary sheet contains significant procedures & disease states YES     NO     N/A    
  In office performed waived tests results are documented in chart noting normal range. YES     NO     N/A    
  Emergency Exit signs are present and operational YES     NO     N/A    
  Exits paths are unobstructed? YES     NO     N/A    
  Staff verbalize appropriate action for patient emergency (emg drugs if available, licensed clinics have emergency carts/drug boxes, AED's, CPR & call 911) YES     NO     N/A    
  Staff verbalize process to report critical test results (panic values) to MD with in 30 m of receipt (lab & x-rays) YES     NO     N/A    
  Medical electrical equipment has current year inspection label. If not contact Biomed. YES     NO     N/A    
  Medical equipment is well maintained. Staff verbalize what to do if malfunctions. YES     NO     N/A    
  Two identifiers are used when medications/invasive procedures are done (name/DOB to chart.) ie joint injections, minor lesion removal, xrays, ERSH YES     NO     N/A    
  Staff verbalize how to report unsafe patient conditions, (chain of command, TJC if unresolved) YES     NO     N/A    
  Oxygen or other flammable gases are secured in stand or other device and identifiable YES     NO     N/A    
  Staff verbalize/demonstrate location fire extinguishers YES     NO     N/A    
  Fire extinguishers are checked monthly. (Ck tag for initials after each month) YES     NO     N/A    
  Staff demonstrate accessing MSDS sheet. YES     NO     N/A    
  Fire drills conducted semiannually and evaluation completed. YES     NO     N/A    
  Activation of emergency procedures conducted and evaluated. YES     NO     N/A    
  Staff verbalize access to care afterhours & when office closed (doc on-call, other open MH clinic, Mom, ER). YES     NO     N/A    
  Office has answering service or answering machine with appropriate message/instructions. YES     NO     N/A    
  If applicable: Radiology equipment is currently licensed and maintained. (MWS, MOS, WCFM, MFP: Morganfield) YES     NO     N/A    
  Staff can identify a PI project the office participated in (summary sheet PI, emp. vaccination rates, Pain FMEA, PQRS) YES     NO     N/A    
  Staff can locate posted PI report or graphs YES     NO     N/A    
  What have they done to improve quality/safety of patient care? (Standardized summary sheets, standard conditions of admission & registration using SS#, increased compliance with staff flu vaccination, standardized CLIA competencies) YES     NO     N/A    
  Staff can identify how they are competent to perform their duties (licensed or certified if app, performance) evaluation, orientation, competencies & education programs YES     NO     N/A    
  Staff can identify what they would do if a surveyor came on site without hospital escort. ( ask to see surveyor ID, name badge, possibly a letter from state licensure or JC YES     NO     N/A    
  Staff can verbalize how patient hand off communication occurs between hospital & office, (ie patient reports/faxes for direct admits, hospitalist reports, labs printed to office, critical test results [panic values] phoned, Rad reports on PACS) YES     NO     N/A    
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