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
Pest and Rodent Control systems in place and managed
Kitchen is clean
No evidence of damaged serving utensils, dishes, glasses etc.
No evidence of damaged cans or food containers
Meat stored below fresh produce
Temperature logs are accurate, and documents appropriate temps
Dishwashing PH testing done at least weekly
Environmental services check distribution solution for dishwasher
Hood is ventilated and clean
Serving line equipment is tested and temperature logs are current
Temperature of food is tested prior to serving
Staff wear appropriate gloves and hairnets
Footwear is appropriate for kitchen areas
Preventive Maintenance Program exists
Logs reflect active preventive maintenance
Tag Out/ Lock Out procedures in place
Medical Equipment Testing can be verified
Call light system tested at least weekly
Safe water temperature logs current and documented
Infection Control precautions are utilized for all housekeeping staff
Spills are cleaned using universal precautions
Wet floor hazard signs are utilized by staff
Cleaning supplies on carts are stored and locked appropriately
Disinfectant is used on all contact surfaces
Oxygen delivery system maintenance is checked at least weekly
Product recalls are addressed and managed promptly
Grounds are maintained: parking lot, sidewalks, automatic doors, etc
Environmental safety tours are conducted at least monthly
Mechanical systems are assessed according to manufacturer's recommendations
Smoking is prohibited inside the building
Patients who are deemed unsafe to smoke are monitored while smoking in outdoor designated areas
Compressed gasses are stored properly and away from patient care areas
All staff wear appropriate identification when on hospital grounds
One staff member is designated as media contact; staff are instructed not to speak to media
Hazardous materials are disposed properly:
Bio-waste
Chemicals
Radioactive materials
Infectious medical waste; including sharps disposal
Hazardous gases
MSDS sheets are available for all staff who access hazardous materials
Hazardous environmental risks are evaluated at least annually
The hospital participates in the community emergency response plan
Fire management plan is current and updated at least annually
Fire drills are conducted according to local and state requirements and at least quarterly on all shifts
Fire suppression system is maintained and inspected according to local and state requirements
Fire drills are assessed for participation, accurate and prompt response
Kitchen fire suppression system is tested at least every six months
Carbon dioxide and other gaseous systems tested at least annually
Provisions for emergency management of medical equipment is tested at least every six months
Emergency electrical power is tested at least monthly