Mhs inspection tool (joint commission mock survey tool) checklist
Audit tool
What does this form include?
This form contains 9 sections:
ENVIRONMENT OF CARE
- No items stored under sinks?
- Equipment / Furniture: * No broken equipment or furniture stored on the patient care units. * Coverings are intact - no rips or repairs needed.
- Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.
- Laundry and trash chute accesses are locked.
- Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.
- Hazardous chemicals and flammable agents are labeled and stored properly.
- Eyewash stations: Inspection tags are present and up to date.
- Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)
- Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.
- Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.
- Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.
- No outer shipping carton boxes in patient care areas.
- No expired items.
- Preventative Maintenance: * Equipment checked with up to date bio-med sticker.
- Central Alarm Monitor: * Logs accurate and complete.
EMERGENCY PREPAREDNESS
- Can staff locate medical gas zone shutoff valves.
INFORMATION MANAGEMENT
- Confidential Patient Information:Cannot be overheard or seen by unauthorized persons: * Computer terminals signed off when not in use. * Patient information is not discussed in public areas. * Labels and PHI are obliterated before discarding in the trash.
- No clipboards displayed as sign-in sheets when multiple patient names on the list.
- If fax machine is in public area, patient information is quickly removed.
LIFE SAFETY
- Appropriate storage of boxes and pt care items: * Not directly on floor. * 18" clearance from sprinkler head. * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping. * Volume of combustible material is not stored in large quantity as to create a fire hazard.
- Oxygen or other combustible compressed gas cylinders are stored properly: * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall) * Limited to 12 E-cylinders per smoke compartment. * Greater than 12 stored in a secured room.
- Fire exits and hallways are cleared: * Egress corridors must have 8ft clearance. * Equipment in corridors must be actively accessed to be in use.
- Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.
- Fire extinguishers have been inspected monthly.
- Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)
- Fire doors are not blocked or propped and when closed there is positive latching.
- Exit signs are illuminated.
- Evacuation route posted & current.
- Everyone has ID badges and worn appropriately: * Staff and Visitors
- Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.
- Floors, ceilings, walls, and other surfaces intact and free from holes.
- Nurse call lights working.
STANDARD PERFORMANCE IMPROVEMENT
- Are units quality improvement dashboards posted on unit.
- Is unit's PI project data posted.
PROVISION OF CARE TREATMENT AND SERVICES
- Are there any alarms sounding that staff is not attending to in a timely manner.
INFECTION PREVENTION
- Food and drink in designated areas: * No evidence of it in patient rooms/area, perches, hazardous chemical storage area, laboratory specimen area.
- Hand Hygiene Products: * No empty alcohol gel bottles * No empty soap or paper towels * No unapproved lotions
- PPE: * Readily available * Clearly marked * Worn correctly
- Patient food & drinks: No expired items.
- Biohazard Waste: * Discard in Red Bags with a biohazard symbol * Not overfilled * Covered when transported
- Soiled Linen: Properly stored and not overfilled.
- Separation of clean vs. dirty supplies & equipment: * Clearly marked * Clean items if stored in soiled utility are covered & clearly marked
- Patient care supplies: * Not expired, damaged, soiled.
- Linen and Linen Carts: Covered and carts have solid bottoms.
- Sharps Waste: * Placed in puncture resistant sharps container. * Disposed of when 3/4 full or "full" indicator * Mounted appropriately
- General Cleanliness: * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms * No blood or bodily fluids
- Air vents: Clean
- All items in PT care area that are not disposable are able to be wiped down.
- Curtains, drapes or blinds clean.
- Negative and Positive air flow rooms function appropriately.
- Ice machines clean.
- Water fountains clean and functioning.
DESCRIBE THE UNITS RESPONSE TO YOUR ARRIVAL
- Greet the team with smiles and introductions.
- Any additional comments regarding positive or suboptimal issues observed during the tracer.
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