Joint Commission Survey Checklist
Healthcare
The Joint Commission will evaluate your effectiveness and practices regarding emergency carts, medication security, multi-dose vials, refrigeration, and sampled medications. Preventing medical errors. The workflow, policies, and procedures that you implement directly impact your patients and their fair treatment.
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Joint Commission Survey Mock Audit

ENVIRONMENT OF CARE

No items stored under sinks?
Yes
No
N/A
Equipment / Furniture: * No broken equipment or furniture stored on the patient care units. * Coverings are intact - no rips or repairs needed.
Yes
No
N/A
Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.
Yes
No
N/A
Laundry and trash chute accesses are locked.
Yes
No
N/A
Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.
Yes
No
N/A
Hazardous chemicals and flammable agents are labeled and stored properly.
Yes
No
N/A
Eyewash stations: Inspection tags are present and up to date.
Yes
No
N/A
Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)
Yes
No
N/A
Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.
Yes
No
N/A
Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.
Yes
No
N/A
Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.
Yes
No
N/A
No outer shipping carton boxes in patient care areas.
Yes
No
N/A
No expired items.
Yes
No
N/A
Preventative Maintenance: * Equipment checked with up to date bio-med sticker.
Yes
No
N/A
Central Alarm Monitor: * Logs accurate and complete.
Yes
No
N/A

EMERGENCY PREPAREDNESS

Can staff locate medical gas zone shutoff valves.
Yes
No
N/A

INFORMATION MANAGEMENT

Confidential Patient Information:Cannot be overheard or seen by unauthorized persons: * Computer terminals signed off when not in use. * Patient information is not discussed in public areas. * Labels and PHI are obliterated before discarding in the trash.
Yes
No
N/A
No clipboards displayed as sign-in sheets when multiple patient names on the list.
Yes
No
N/A
If fax machine is in public area, patient information is quickly removed.
Yes
No
N/A

LIFE SAFETY

Appropriate storage of boxes and pt care items: * Not directly on floor. * 18" clearance from sprinkler head. * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping. * Volume of combustible material is not stored in large quantity as to create a fire hazard.
Yes
No
N/A
Oxygen or other combustible compressed gas cylinders are stored properly: * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall) * Limited to 12 E-cylinders per smoke compartment. * Greater than 12 stored in a secured room.
Yes
No
N/A
Fire exits and hallways are cleared: * Egress corridors must have 8ft clearance. * Equipment in corridors must be actively accessed to be in use.
Yes
No
N/A
Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.
Yes
No
N/A
Fire extinguishers have been inspected monthly.
Yes
No
N/A
Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)
Yes
No
N/A
Fire doors are not blocked or propped and when closed there is positive latching.
Yes
No
N/A
Exit signs are illuminated.
Yes
No
N/A
Evacuation route posted & current.
Yes
No
N/A
Everyone has ID badges and worn appropriately: * Staff and Visitors
Yes
No
N/A
Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.
Yes
No
N/A
Floors, ceilings, walls, and other surfaces intact and free from holes.
Yes
No
N/A
Nurse call lights working.
Yes
No
N/A

PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS

Are PSG posted on unit.
Yes
No
N/A

STANDARD PERFORMANCE IMPROVEMENT

Are units quality improvement dashboards posted on unit.
Yes
No
N/A
Is unit's PI project data posted.
Yes
No
N/A

PROVISION OF CARE TREATMENT AND SERVICES

Are there any alarms sounding that staff is not attending to in a timely manner.
Yes
No
N/A

INFECTION PREVENTION

Food and drink in designated areas: * No evidence of it in patient rooms/area, perches, hazardous chemical storage area, laboratory specimen area.
Yes
No
N/A
Hand Hygiene Products: * No empty alcohol gel bottles * No empty soap or paper towels * No unapproved lotions
Yes
No
N/A
PPE: * Readily available * Clearly marked * Worn correctly
Yes
No
N/A
Patient food & drinks: No expired items.
Yes
No
N/A
Biohazard Waste: * Discard in Red Bags with a biohazard symbol * Not overfilled * Covered when transported
Yes
No
N/A
Soiled Linen: Properly stored and not overfilled.
Yes
No
N/A
Separation of clean vs. dirty supplies & equipment: * Clearly marked * Clean items if stored in soiled utility are covered & clearly marked
Yes
No
N/A
Patient care supplies: * Not expired, damaged, soiled.
Yes
No
N/A
Linen and Linen Carts: Covered and carts have solid bottoms.
Yes
No
N/A
Sharps Waste: * Placed in puncture resistant sharps container. * Disposed of when 3/4 full or "full" indicator * Mounted appropriately
Yes
No
N/A
General Cleanliness: * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms * No blood or bodily fluids
Yes
No
N/A
Air vents: Clean
Yes
No
N/A
All items in PT care area that are not disposable are able to be wiped down.
Yes
No
N/A
Curtains, drapes or blinds clean.
Yes
No
N/A
Negative and Positive air flow rooms function appropriately.
Yes
No
N/A
Ice machines clean.
Yes
No
N/A
Water fountains clean and functioning.
Yes
No
N/A

MEDICATION MANAGEMENT

Medication rooms are clean and uncluttered.
Yes
No
N/A
Laminar flow hood is used for IV admixture when appropriate.
Yes
No
N/A
Visual inspection of medication containers: No Issues.
Yes
No
N/A
Area free of distractions.
Yes
No
N/A
Medication is appropriately labeled. * Expiration dates, directions, etc..
Yes
No
N/A
All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.
Yes
No
N/A
Controlled substances stored to prevent diversion.
Yes
No
N/A
Medications stored appropriately to maintain stability.
Yes
No
N/A
Medications, formula, & solutions not expired beyond expiration date.
Yes
No
N/A
Opened multi-dose vials dated and initialed. Not expired.
Yes
No
N/A
Code Carts: * Locked and marked with then first drug to expire. * Checked per policy. * Include defibrillator check. * Extra locks kept secured. * All supplies & drugs that are on the inventory list are on the cart. *. Cart is clean. *. O2 tank is >1/2 full
Yes
No
N/A
Syringes are labeled when in use.
Yes
No
N/A
Medication refrigerator: Only contain medications for current patients.
Yes
No
N/A
Breast Milk Refrigerators: Only contain milk for current patients.
Yes
No
N/A
Patient Bedside: *. IV tubing is labeled per policy. *. Medication is secured and labeled. *. All solutions are labeled at the bedside.
Yes
No
N/A
Medication Carts: Doors and drawers are locked.
Yes
No
N/A

RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

Patients and families properly informed of their rights. *. Rights and Responsibilities statement
Yes
No
N/A
Family guides provided to all families on admissions.
Yes
No
N/A

WAIVED TESTING / POINT OF CARE TESTING

Point of Care testing lab controls documented and control solution labeled & dated. *. Reagents, i Stat analyzes, glucometers, GEMS
Yes
No
N/A
Point of Care Testing Quality Control: *. Consistently and correctly documented *. Dates missing initials *. Performed by qualified person *. Out of range is followed *. Logged numbers match bottle ID numbers
Yes
No
N/A

DESCRIBE THE UNITS RESPONSE TO YOUR ARRIVAL

Greet the team with smiles and introductions.
Yes
No
N/A
Have a space designated for the team to conduct interviews and file reviews.
Yes
No
N/A
Promptly deliver materials required for review to the tracer team.
Yes
No
N/A
Any additional comments regarding positive or suboptimal issues observed during the tracer.
Yes
No
N/A
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