Community Hospital Self Assessment

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Community Hospital
Self Assessment

Instructions	Licensure and Insurance	HIPAA	Employee Training	Lab	Anesthesia	Emergency Room	Risk Management
Quality Improvement	Environment of Care	Restraint Use	Infection Control	Falls Management	Patient Management	Documentation	Pharmaceutical Management

CRITERIA MEASURE	Met	Not Met	Comments	Refer to Department
Most recent regulatory survey completed and corrected
All corrections documented and filed with administration
Corrections implemented are currently in place and continue to be in compliance
Fire Marshal report current; corrections completed and currently in compliance
Health Department report current; corrections completed and currently in compliance
CPR Licensure is current and documented in Personnel files
Employee licensures are current and documented in Personnel files
Granting privilege processes are clearly defined and there is evidence all requirements are met
Physician licensure is current and accurate:
Liability Insurance
DEA Licensure
State Medical License
Annual background check
Specialized designations current
Hospital privileging is current
Medical Staff By-Laws are current and signed by the Medical Director and Administrator
Medical staff participates in Quality Improvement initiatives
Medical Staff By-Laws address governance and accountability to the governing body
Vendors provide proof of liability insurance:
Oxygen supplier
Ambulance
Pharmaceutical
Labor Pool
Food suppliers
Durable Medical Equipment
Medical Equipment
Medical Supplies
Toxic Waste Removal
Medical Record Storage
Records Destruction Service
Pest Control
Vendor contracts are evaluated for compliance
Methods are in place for granting privileges in emergency situations
Staff who provide deep anesthesia are properly credentialed
Laboratory staff meet CLIA criteria and licensure
Governing By-Laws are updated at least annually
Each employee receives a job description and company handbook
Drug testing is conducted for all employees
Staff evaluations are written at least annually