Critical Access Hospital Audit
**The following checklist will be presented to each Department Head upon arrival at facility.
- Incident Reports for the past year
- List of grievances/complaints
- List of Current Patients (include name, diagnosis, admit date, physician, Note(**acute care or **swing bed)
- List of Discharged patients for the last 3 months-Please include name, diagnosis, admit date, discharge date, physician, **acute care or **swing bed
- List of ALL staff (clinical, non-clinical, agency, contractors, physician, allied health)
- Emergency Room – Log Book for last 6 months, and Policies, transfer and consultation agreements with other hospitals.
- Surgery & Procedure Log for last 6 months
- Organizational Chart with names and titles
- List of Contracted Services and Agreements
- Anesthesia and Surgery: Policies and Procedures Table of Contents
- Governing Body: Bylaws, meeting minutes for the past year
- Medical Staff: Bylaws, Rules and Regulations, meeting minutes for the past year.
- Nursing: Policies and Procedures Table of Contents
- Dietary: Policies and Procedures, consultant dietitian report, copy of nutritional screening from, Dietary Manual
- Quality Improvement: plan & meeting minutes for the past year-include yearly evaluation for the entire program.
- Laboratory: list of services provided and CLIA certificate
- Infection Control: Policies and Procedures; infection control log; current plan; all surveillance/monitoring activities & meeting minutes for the past 12 months, Infection Control Practitioners name & personnel file with education.
- Organ Procurement: list of all (ER & Inpt) Deaths for the past year; contract with Life Share (organ procurement agency) & Activity Reports from Life Share for the same time period; policies/protocols concerning reporting to Life Share
- Swing Bed: Policies and Procedures; activities person (name & credentials); Social services person; Abuse policies (allegations against employees)
- Health screening policy for employees and other workers
- Radiology: list of qualified personnel; current permit; radiation badge reports; physicists report, policies and procedures, competencies for staff; Name of Chief Radiologist and credentialing file
- Pharmacy: Policies and Procedures, Consultant pharmacist reports for last 12 months, Pharmacy & therapeutics committee meeting minutes for past 12 months, & Drug Formulary
- Physical Therapy: Policies and Procedures
- Respiratory Therapy: Policies and Procedures, nurse competency training
- Emergency Disaster Plan: Drills for past year