Physical Setting and Safety Standards

• Facility accessible to the disabled − parking, entrance, restrooms, hallways and elevators 
• Hallways and floors clear, and there is adequate room for movement 
• Exit signs visible 
• Patient rights posted where they’re likely to be noticed by patients or surrogate 
• Visible, charged fire extinguishers (A, B, C) 
• Fire and disaster evacuation routes posted 
• Emergency carts are immediately available and log maintained 
• Separate designated area or adequate space for medication storage, prep and dispensing 
• Controlled drugs are properly handled − locked cabinet and log maintained. 
• Provisions for appropriate disposal of biohazardous materials and waste, and signs posted 
• Evidence mechanical and electrical equipment is regularly inspected and tested. 
• Evidence of safety and plant management program, such as books 

Lab on-site (yes) 

• Written policies and procedures 
• Current Clinical Laboratory Improvement Amendments certificate is displayed or certificate of waiver is available 
• Equipment maintenance log available 

Lab on-site (no) 

• Certificate of CLIA waiver available 
• Written policies and procedures 

Pharmacy on-site (yes) 

• Written policies and procedures outlining process for reconstitution, storage and dispensing of peritoneal dialysis medications 

Quality program review 

• Mission statement 
• Quality Assurance and Performance Improvement written plan, policy and procedures 
• Annual review or revision of written plan with evidence of oversight 
• QAPI committee meets regularly and minutes are signed and dated 
• Evidence of coordination of activities throughout facility; examples include infection control, safety, maintenance and pharmacy 
• Infection control policies and procedures 
• Documented monitoring of problems and trends with corrective action plan 

Complaints 

• Evidence of files maintained and investigated with results and resolution 

Safety and plant management program 

• Written policies and procedures include preparation and storage of dialysis solution 

Disaster plan 

• Written policy and procedure that specifically defines handling of emergencies such as fire, natural disaster or functional failures in equipment  
• Evidence of annual disaster drill with assessment and corrections as indicated  

Biohazard and waste management 

• Written policy and procedure related to biohazardous and waste management 

Staff review

Medical staff bylaws

• Written plan of medical staff responsibility, training and scope with annual review 

Medical staff credentialing, including temporary medical staffing 

• Written plan, policy and procedures include primary source verification 

Professional staff 

• Written plan, policy and procedures 
• Written staffing matrix or plan 
• Documented monitoring of license renewals 
• Documented monitoring of required continued education 
• Documented evidence-based training in management of adverse or unexpected outcomes in patient population, such as shock, seizure and arrest 
• Documented training of all individuals performing waived testing procedures 
• Nursing staff and ancillary staff members are CPR certified 

Nonprofessional staff oversight 

• Written plan, policy and procedures 
• Documented monitoring of certification renewals 

Employee orientation 

• Written plan, policy and procedures 
• Documentation of core competencies specific to job description 
• Training includes confidentiality and privacy training 

• Office is accessible to the disabled − parking, entrance, restrooms, hallways and elevators
• Office appearance is clean and organized
• Waiting area has adequate seating
• Exam room or consulting office design ensures privacy
• Exam rooms have adequate lighting, sink with running water or 60% alcohol-based hand solution, if applicable
• There are provisions for appropriate disposal of biohazardous materials and waste
• Exit signs visible
• Fire and disaster evacuation routes posted
• Visible, charged fire extinguisher
• Staff trained to manage emergencies. such as environmental and medical
• The clinic has a preventive maintenance program to ensure that all essential mechanical, electrical and patient-care equipment is maintained and in safe operating condition
• Controlled drugs are properly handled − locked cabinet and log maintained
• Sample drugs, prescription pads, needles and syringes only available in restricted area
• Policy and procedure for expired and discarding medications 
• Patient rights and responsibilities posted in plain sight 

Provision of services

• The clinic’s policies include a description of the services the clinic furnishes directly (scope of service) and those furnished through agreement or arrangement
• The clinic’s policies include guidelines for the medical management of health problems, which include treatment protocols

Program evaluation

• The clinic carries out or arranges for an annual evaluation of its total program
• The clinic conducts an evaluation to determine whether the utilization of services were appropriate

Complaint monitoring

• Evidence of files maintained and investigated with results and resolution

Lab on-site (yes)

• Current Clinical Laboratory Improvement Amendments certificate is displayed
• Written policies and procedures
• Equipment maintenance log available

Lab on-site (no)

• Certificate of CLIA waiver available
• Written policies and procedures

Pharmacy on-site (yes)

• Registered pharmacist oversees the pharmacy
• If no registered pharmacist, written policies and procedure or process for oversight 

• Office is accessible to the disabled − parking, entrance, restrooms, hallways and elevators
• Office appearance is clean and organized
• Appearance of office staff is neat and professional
• Waiting area is comfortable with adequate seating
• Exam room or consulting office design ensures privacy
• Exam rooms have adequate lighting, a sink with running water or 60% alcohol-based hand solution
• There are provisions for appropriate disposal of biohazardous materials and waste
• Controlled drugs are properly handled − locked cabinet, log maintained
• Evidence that vaccines are refrigerated and maintained as per recommendations
• Evidence of staff training to manage emergencies, such as environmental and medical
• Visible, charged fire extinguisher
• Fire and disaster evacuation routes posted
• Exit signs visible
• The clinic has a preventive maintenance program to ensure that all essential mechanical, electrical and patient-care equipment is maintained and in safe operating condition
• Emergency carts and kits are up to date with log maintained

Provision of services

• The clinic’s policies include a description of the services the clinic furnishes directly (scope of service) and those furnished through agreement or arrangement
• The clinic’s policies include guidelines for the medical management of health problems and include treatment protocols

Program evaluation

• The clinic carries out or arranges for an annual evaluation of its total program to include evaluation of appropriate utilization of services

Complaint monitoring

• Evidence of files maintained and investigated with results and resolution

Lab on-site (yes)

• Current Clinical Laboratory Improvement Amendments certificate is displayed
• Written policies and procedures
• Equipment maintenance log available

Lab on-site (no)

• Certificate of CLIA waiver available
• Written policies and procedures

Radiology on-site (yes)

• Current Oklahoma state radiation certificate
• Written policy and procedures
• Safety badges available
• Lead protective shields available
• Pregnancy notices posted

Pharmacy on-site (yes)

• Registered pharmacist oversees the pharmacy
• If no registered pharmacist, written policies and procedure or process for oversight

• Hallways and floors are clear with adequate room for movement
• Department of Health license is current
• Exit signs are visible
• Visible, charged fire extinguishers (A, B, C)
• Equipment maintenance documented and log current
• Provisions for appropriate disposal of biohazardous materials and waste
• Temperature control of stored vaccines is ensured

Lab on-site (yes)

• Current Clinical Laboratory Improvement Amendments certificate is displayed
• Written policies and procedures
• Equipment maintenance log available

Lab on-site (no)

• Current certificate of waiver available
• Written policies and procedures

Pharmacy (yes)

• Registered pharmacist oversees the pharmacy
• Controlled drugs are properly handled − locked cabinet and log maintained
• If no pharmacist, must have written policy and procedure-process for oversight

Quality program

• Mission statement
• Quality Assurance and Performance Improvement written plan, policies and procedures include improvement of health outcomes, safety and quality of care with annual review
• QAPI program measures, analyzes and tracks adverse events with corrective action plan as indicated with annual review
• Evidence of coordination and monitoring of activities throughout the facility
• QAPI meets regularly and contemporaneous minutes are signed and dated

Infection control

• Written policy, plan and procedure
• Documented monitoring of problems and trends with corrective action plan

Complaint monitoring

• Written policy and procedures to address acceptance, processing, review and resolution

Biohazard policies and procedures

• Biohazard written plan, policy and procedures to include home and travel

Disaster plan policies and procedure

• Written policy, plan and procedure for fire, tornado, bomb threat and city, state or national emergency

Medical staff bylaws

• Written plan of staff responsibilities with annual review

Medical staff credentialing plan

• Written plan, policy and procedure

Professional staff

• Written plan, policy and procedure
• Documented monitoring of license renewals
• Documented monitoring of continued education as required
• Nursing staff cardiopulmonary resuscitation certified

Nonprofessional staff oversight

• Written plan, policy and procedure to include registered nurse supervision of licensed practice nurse and certified nursing assistant
• Documented monitoring of nonprofessional staff
• Monitoring of license renewals, education and CPR training

Employee orientation

• Written plan, policies and procedures
• Documented certification or training of home health aides to include privacy and patient rights
• Documented competency evaluation of CNA and nursing

Below are standards for BlueLincs HMO^SM, health delivery organization site survey and hospital and ambulatory surgery.

• Facility is accessible to the disabled − parking, entrance, restrooms, hallways and elevators
• Department of health license is current
• Hallways and floors clear and adequate for movement
• Exit signs visible
• Patient rights posted where likely to be noticed by patients or surrogate
• Visible, charged fire extinguishers (A, B, C)
• Fire and disaster evacuation routes posted
• Emergency carts and kits are up to date and log maintained, such as for drugs, equipment and oxygen
• Controlled drugs are properly handled − locked cabinet and log maintained
• Evidence of sterilization and reuse process standards, such as logbooks maintained
• Provisions for appropriate disposal of biohazardous materials and waste-signs posted
• Evidence mechanical and electrical equipment is regularly inspected and tested
• Evidence of safety and plant management program, such as logbooks maintained

Lab

• Current Clinical Laboratory Improvement Amendments certificate is displayed or certificate of waiver available
• Written policies and procedures
• Equipment maintenance log available

Pharmacy

• Registered pharmacist oversees the pharmacy
• If no registered pharmacist, written policy and procedure or process for oversight

Radiology

• Current Oklahoma state radiation certificate is available
• Written policy and procedures
• Safety badges visible
• Lead protective shields available
• Pregnancy notices posted

Quality program review

• Mission statement
• Written plan, policy and procedures
• Evidence of data driven monitoring of problems and trends with analysis and actions
• Evidence of coordination and monitoring of activities throughout the facility; examples include infection control, safety and maintenance and pharmacy
• Quality assurance and quality improvement committee meets regularly and contemporaneous minutes are signed and dated

Complaint monitoring

• Evidence of files maintained and investigated with results and resolution

Infection control plan

• Written plan, policies and procedures
• Evidence of monitoring of infection trends, analysis and actions

Disaster plan

• Written disaster preparedness plan to provide for emergency care of patients, staff, others in the facility in event of fire, national disaster or equipment failure
• Evidence of disaster drill at least annually with assessment and corrections if indicated

Biohazard and waste management

• Written plan, policy and procedures

Safety and plant management program

• Written plan, policy and procedures

Immediate transfer procedure (freestanding ambulatory surgery center)

• Written policy and procedure for immediate transfer and communication with receiving hospital

Employee review

Medical staff bylaws

• Written plan of medical staff responsibility, training and scope with annual review

Medical staff credentialing plan

• Written plan, policy and procedure

Professional staff

• Written plan, policy and procedures
• Nursing service directed under leadership of registered nurse
• RN with specialized emergency training available whenever there is a patient in the ambulatory surgery center
• Documented monitoring of license renewals
• Documented monitoring of continued education, cardiopulmonary resuscitation and competency

Nonprofessional staff

• Written policy for nonprofessional staff oversight
• Documented monitoring of certifications and education as required

Orientation

• Written orientation that includes confidentiality and privacy training

• Facility is accessible to the disabled − parking, entrance, restrooms, hallways and elevators
• Hallways and floors clear and adequate for movement
• Exit signs visible
• Visible, charged fire extinguishers (A,B,C)
• Fire and disaster evacuation routes posted
• Equipment maintenance current and documented
• Emergency carts and kits are up to date and log maintained, such as for drugs, equipment and oxygen
• Controlled drugs are properly handled − locked cabinet and log maintained

Biohazard and waste management

• Written policies and procedures
• Provisions for appropriate disposal of biohazardous materials and waste, and signs posted

Disaster plan

• Written emergency procedures
• Written evidence of unannounced test and analysis

Quality program review

• Scope and mission of facility is documented
• Department of Health license is current

Quality improvement

• Written plan, policies and procedures
• Annual review or revision of written plan with evidence of oversight
• Quality assurance and quality improvement committee meets regularly and contemporaneous minutes are signed and dated
• Evidence of coordination and monitoring of activities throughout the facility
• Regular analysis of services provided that address quality and appropriateness of service
• Regular analysis of critical incidents reported and action taken

Infection control plan

• Written policies and procedures
• Documented monitoring of problems or trends with correction action plans

Safety and plant management program

• Written policies and procedures
• Inspections are completed at least annually with documented results and corrective action plan if indicated

Lab

• Current Clinical Laboratory Improvement Amendments certificate is displayed or certificate of waiver available
• Written policies and procedures
• Equipment maintenance log available

Pharmacy

• Registered pharmacist oversees the pharmacy
• If no registered pharmacist, written policy and procedure or process for oversight

Radiology

• Current Oklahoma State radiation certificate is available
• Written policy and procedures
• Safety badges visible
• Lead protective shields available
• Pregnancy notices posted

Employee review

Medical staff bylaws

• Written plan of medical staff qualifications and responsibilities

Medical staff credentialing plan

• Written plan, policies and procedures for credentialing include criminal background checks, licensure and liability insurance with ongoing monitoring

Professional staff licensure

• Written plan, policies and procedures for license verification and criminal background checks with ongoing monitoring

Nonprofessional staff oversight

• Written plan, policy and procedure for certifications with criminal background checks

Employee orientation

• Written plan for orientation with documentation of job description with competency-based training with annual review
• Written plan for orientation to include identification of critical incidents and management with annual review
• Written plan for orientation to include orientation policy with a system of patient rights including confidentiality, privacy, freedom from abuse or neglect with annual review

Complaint monitoring

• Evidence of files maintained and investigated with results and resolution

• Facility is accessible to the disabled − parking, entrance, restrooms, hallways and elevators
• Hallways and floors clear and adequate for movement
• Exit signs visible
• Visible, charged fire extinguishers (A, B, C)
• Fire and disaster evacuation routes posted
• Equipment maintenance current and documented
• Emergency carts and kits are up to date and log maintained, such as for drugs, equipment and oxygen
• Controlled drugs are properly handled − locked cabinet and log maintained
• Resident medications labeled and stored properly

Biohazard and waste management

• Written policies and procedures
• Provisions for appropriate disposal of biohazardous materials and waste with signs posted

Disaster plan

• Written policy, including fire, tornado, bomb threat and city, state or national emergency
• Written evidence of a disaster drill in the past 12 months

Resident monitoring

• Written policy to address abuse and neglect, as well as dignity, privacy and respect

Dietary

• Written policy regarding monitoring of food preparation and dietary staff training

Quality program review

• Mission statement
• Department of Health license is current

Quality improvement

• Written plan, policies and procedures
• Annual review or revision of written plan with evidence of oversight
• Quality assurance and quality improvement committee meets regularly, and contemporaneous minutes are signed and dated
• Evidence of coordination and monitoring of activities throughout the facility; examples include infection control, safety, maintenance and pharmacy

Complaint monitoring

• Evidence of files maintained and investigated with results and resolution

Infection control plan

• Written policies and procedures
• Documented monitoring of problems or trends with correction action plans

Safety and plant management program

• Written policies and procedures
• Documented monitoring

Lab on-site (yes)

• Current Clinical Laboratory Improvement Amendments certificate is displayed
• Written policies and procedures
• Equipment maintenance log available

Lab on-site (no)

• Certificate of CLIA waiver available
• Written policies and procedures

Pharmacy on-site (yes)

• Registered pharmacist oversees the pharmacy
• If no registered pharmacist, written policy and procedure or process for oversight

Employee review

Medical staff bylaws

• Written plan of medical staff responsibilities with annual review

Medical staff credentialing plan, including temporary medical staffing

• Written plan, policies and procedures

Professional staff licensure

• Written policy
• Documented monitoring of license renewals
• Documented monitoring of continued education as required
• Nursing staff and/ ancillary staff members are cardiopulmonary resuscitation certified

Nonprofessional staff oversight

• Written policy
• Documented monitoring of certification renewals
• Documented monitoring of continued education as required

Employee orientation

• Written plan
• Orientation includes confidentiality and privacy training