Performance Manager
PACE - Environment of Care - Starting FY'07 Monthly Self Survey Only
  Service:
  Building/Floor:
  Department/Division:
  Name:
  Date:
  If your survey shows that you are challenge free in an area, you need to answer only the bolded question for that section (there are 3 sections to the PACE EoC). Please write all comments at the end of the survey.  
  1. Infection Control- Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
IC1 Hand hygiene supplies are available (CalStat, soap, paper towels, hand lotion)
IC2 Patient supplies or equipment are not stored above, around or under sinks
IC3 All supplies are stored off the floor in the Clean Supply/Equipment Room
IC4 The Clean Supply/Equipment Room is free of soiled equipment and supplies
IC5 The Soiled Utility Room free of clean equipment and supplies
IC6 A regular waste receptacle is in the Soiled Utility Room
IC7 A Biohazard waste receptable is in the Soiled Utility Room
IC8 Fluid/puncture resistant receptacles are present for the storage and transport of soiled intruments
IC9 The needle box container not too high to reach (No higher than 52 inches from floor to top of insert)
IC10 The needle box is changed when full
IC11 Needle safety products and supplies are available for unit specific precedure: e.g. safety syringes, safety butterfly, safety needle holder, blood transfer set, blood gas line draw and direct draw kits, safety angiocath
IC12 Needles/syringes are stored in a secured location
IC13 Clean linen stored off the floor
IC14 Soiled linen is placed directly into labeled/covered SOILED LINEN hampers
IC15 Staff have been fit tested to wear an N95 (TB) Mask Respirators (not applicable in all areas e.g. ambulatory unless specified)
IC16 Employees perform hand hygiene: Before and after patient contact, after removal of gloves or other personal protective equipment, following any contact with blood and body fluids
IC17 The unit is in compliance with Artifical Nail Policy
IC18 Eating/drinking occurs ONLY in designated areas (e.g. louge conference room), and PROHIBITED at nurses station/specimen handling areas/medication carts/soiled and clean utility areas
IC19 Infection Control issued signage used for isolation/precautions in place (no Xeroxed signs)
IC20 Unit is complaint with isolation/precautions
IC21 Appropriate Personal Protective Equipment worn (e.g. face protection when suctioning)
IC22 All sizes of 3M & Tecnol N95 (TB) Respirator Masks available (selected unites e.g. not all amublatory)
IC23 Fluid resistant masks with visors are available
IC24 Appropriate sized gloves are available
  Cleaning and Disinfection on (Steris, Autoclave, High Level Disinfection areas only)  
IC25 There are written policies for the sterilization/disinfection of equipment including procedures for cleaning/prackaging/storage
IC26 There is a training program for personnel responsible for cleaning/sterilization/disinfection
IC27 There are autoclave policies/procedures for cleaning/maintenance
IC28 There are policies/procedures in place for autoclave failure
IC29 There are autoclave/steris records for compliance with biological monitoring
IC30 There are daily test strip monitoring records for high level disinfection
IC31 Solutions/daily test strips for high level disinfection are marked with date opened and expiration date
  Comments:
  2. Fire and Life Safety- Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
S1 Employees are wearing ID badges
S2 All flooring and carpeting is in top condition and slip resistant (no tears, fraying slippery areas)
S3 Linen chute is closed and latched (if applicable), any door to a room leading to a linen chute must also be closed and locked
S4 Excessive storage/unsafe storage of equipment, supplies, etc. stored overhead or blocking exits/egress ways
S5 Grab bars/ Emergency Pull Cords in bathrooms and shower rooms are easily accessible to patients, at least 4" from floor, and not tied to anything
S6 Proper restraint present on tub lifting devices/chairs (if applicable)
S7 Gas cylinders are secured in a rack/stand and those with regulators are secured individually
S8 704 Diamonds in place to identify hazardous materials in storage areas (i.e.) oxygen storage
S9 All chemical containers, especially those employed by Environmental Services, are labeled per the HAZCOM program (product name, manufacturer and health of physical hazards)
S10 The staff is aware of the reporting and/or cleaning up hazardous spills - Chemical, Radioactive, Chemotherapy and Blood/Body Fluids
S11 Corridor fire doors are free to close & latch properly
S12 Exits are clearly marked & illuminated
S13 A clearance of 18 inches from sprinker heads is maintained
S14 Emergency egresses, corridors and stairwells are clear and unobstructed
S15 Access to emergency equipment (alarm pull/extinguisher) is clear, visable & unobstructed
S16 Door(s) (smoke, fire, med room, clean/dirty utility room doors) are not held open wedged or tied
S17 Unit has been notified of construction in your work area, or an adjacent area, which may effect your egress way or cause dust, noise or odor
S18 Patient care equipment is tagged with a white/black bar code label, enrolled in a PM program, and inspected by Clinical Engineering
S19 Medical/patient care equipment is in top mechanical condition
S20 The use of electical cords & equipment are in compliance with internal policies (checked by Maintenance Dept.) and in good working condition
PR19 Outdated supplies are removed from inventory and properly disposed of - Clean Supply Storage Area
PR19a Outdated supplies are removed from inventory and properly disposed of - Floor/Clinic Care Area
PR23 There is a standard emergency cart with oxygen
PR24 A defibrillator is present
PR25 The defibrillator is checked regularly
PR26 Defibrillator testing intructions visable/available
PR27 Portable suction is available
PR28 A stretcher is available
PR11 Waive Testing- Quality control checks have been performed (i.e. glucometer controls run within the past 24 hours)
PR12 Waived tests current procedures, instructions are available for test
PR13 Waive Testing -Patients are correctly identified in the glucometer and on test logsheets
  Comments:
  3. Medication Management and Pharmacy- Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
MM1 Medications are locked in medication room, cabinet cart, tackle box
MM2 Stock medications properly labeled. Medications not stored in Pyxis should be organized and in anarea labeled with the drug name, strength or concentration and/or tablet or vial size
MM3 Medications stored in all areas within expiration date (Pyxis, med rooms, carts, cabinets, tackle boxes, etc.)
MM4 Prescription pads are in a secure location when not in use
MM5 Logs are maintained for each emergency (code) cart
MM6 Each cart is locked with a plastic tab
MM7 Plastic tags are kept in cart or other secure location
MM8 Medication Refrigerator temperature is between 36 and 48 degrees F (2-8 C).
MM9 Thermometer or temperature alarm is present in Medication Refrigerator
MM10 If a thermometer is present, a temperature log is maintained
MM11 If a thermometer alarm is present, it is functioning properly
MM12 Only medications are stored in the Medication Refrigerator.
MM13 Metric conversion chart is available for reference.
MM14 Patient's personal medications are not in use without written physician and pharmacy approval. Physician order in chart stating "patient may use own medication".
MM15 Patient's personal medications are not in use without written physician and pharmacy approval. A pharmacist must have identified and approved the patient's medication supply. See pharmacy policy # 03-01-03
MM16 Multi-dose vials are dated when opened and discarded 28 days after opening.
MM17 Single-dose vials are discarded immediately after use.
MM18 Pharmacy been notified and approved all samples (if applicable).
MM19 A log is maintained for each strength and lot # of each sample drug. (See pharmacy policy # 05-03-01 and 05-03-02)
  Comments:
          



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