MINIMUM STANDARDS FOR ALL HEALT
FACILITY: ADDRESS: ____
ADMINISTRATOR: TELEPHONE #
SURVEYOR/S: ___________________________________E-Mail/Web:_____
RULE GUIDELINES
37.106.313 MINIMUM STANDARDS FOR ALL RULE INTENT: To
HEALTH CARE FACILITIES: COMMUNICABLE health and human s
DISEASE CONTROL (1) All health care facilities health care setting b
shall develop and implement an infection prevention infection control pr
and control program. At a minimum, the facility must comprehensive, cur
develop, implement, and review, at least annually, implemented.
written policies and procedures regarding infection
prevention and control which must include but are not GUIDE
limited to:
(1): Review facility
(a) procedures to identify high risk procedures for Infec
individuals; and content. Do they ad
required in this rule
(b) the identification of methods used to
protect, contain, or minimize the risk to patients, Is there evidence of
residents, staff, and visitors.
Note specific requir
(2) The administrator or infection control facility infection co
officer will be responsible for the direction, provision, During the survey p
and quality of infection prevention and control observation, intervi
services. determine if the pol
implemented. Is the
37.106.314 MINIMUM STANDARDS FOR ALL evidence that the in
HEALTH CARE FACILITIES: MEDICAL by (2) is involved in
control program?
Based on 2013 rules. RULE INTENT: To
maintenance and sto
1
TH CARE FACILITIES SURVEY TOOL
___DATE/S:________
TASK/WORK ORDER #:________
_____________________________________License #:___________
YES NO COMMENTS
o protect public
safety within a
by requiring an
rogram that is
rrent, and
ELINES
y policies and
ction Control
ddress the specifics
e?
f an annual review?
rements of the
ontrol policies.
process, through
iews, etc.,
licies are
ere documented
ndividual required
n the infection
o ensure the safe
orage of medical
1
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
RECORDS (1) A health care facility must initiate records within a hea
and maintain a safe, secure, and confidential medical
record for each patient, resident, or client. GUIDE
(2) A health care facility, excluding a hospital, (1): Observe medic
shall retain a patient's, resident's, or client's medical How is the docume
records for no less than six years following the date of
the patient's, resident's, or client's discharge or death, (2): Request closed
or upon the closure of the facility. determine the lengt
maintained,
37.106.315 MINIMUM STANDARDS FOR ALL Be aware that facili
HEALTH CARE FACILITIES: EMPLOYEE FILES may have different
(1) The facility is responsible for maintaining a file on record storage. For
each employee and substitute personnel. Employee living facility rules
files may be inspected by the department at any time. record retention for
If the file is not maintained at the facility it must be following resident d
available to the department within 24 hours of request. Facility specific req
followed in case of
(2) At a minimum, the employee file must Minimum Standard
contain: RULE INTENT: To
patients / residents
(a) the employee's name; care facility by ensu
(b) a job description signed by the employee; and volunteers of a
(c) documentation of employee orientation, have documentation
signed by the employee; and identity, qualificatio
(d) a copy of current credentials, certification, / training.
GUIDE
(1): If files are not a
time of the survey,
so within 24 hours b
or by facility arrang
Based on 2013 rules. 2
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
alth care setting.
ELINES
cal records systems.
entation secured?
d records to
th of time files are
ity specific rules
requirements for
example, assisted
require resident
r three (3) years
discharge / death.
quirements are to be
conflict with
ds.
o protect the
/ clients of a health
uring that all staff
health care facility
n evidencing
ons, and orientation
ELINES
available at the
they must be made
by surveyor revisit,
gement as needed
2
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
or professional licenses required to perform the duties (e-mail, fax, in-pers
described in the job description. Ensure that the man
files are provided m
(3) Volunteers may be utilized at a health care confidentiality, in s
facility, but may not be included in the facility staffing unauthorized indivi
plan in lieu of employees. All volunteers who are able to gain access
performing duties which are commonly performed by
facility staff must have a file which is maintained at (2) and (3): Reques
the facility and documents the following: volunteer files from
positions, i.e. nursin
(a) orientation to the facility and its residents; physician, dietary, s
and Does each contain t
required?
(b) orientation to and training of the duties to
be performed.
37.106.320 MINIMUM STANDARDS FOR ALL RULE INTENT: To
HEALTH CARE FACILITIES: PHYSICAL PLANT safety by requiring
AND EQUIPMENT MAINTENANCE (1) Each safety within a heal
facility must have a written maintenance program
describing the procedures to keep the building, GUIDE
grounds, and equipment in good repair and free from
hazards. (1): Review mainte
survey to ensure the
(2) A health care facility must provide followed.
housekeeping services on a daily basis.
Observe building &
(3) All electrical, mechanical, plumbing, fire repair or hazards.
protection, heating, and sewage disposal systems must
be kept in operational condition. Observe facility thr
(4) through (6).
(4) Floors must be kept clean and in good
repair at all times. (7): Measure the ha
bathing facility wat
(5) Walls and ceilings must be kept in good multiple hot water h
repair and be of a finish that can be easily cleaned. used, test the hot w
(6) Every facility must be kept clean and free
of odors. Deodorants may not be used for odor
control in lieu of proper ventilation.
(7) The temperature of hot water supplied to
Based on 2013 rules. 3
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
son delivery, etc.).
nner in which the
maintains
such a manner that
iduals would not be
to the files.
st employee /
m a variety of staff
ng, housekeeping,
support staff, etc.
the information
o protect human
environmental
lth care facility.
ELINES
enance P & Ps, and
e P&Ps are
& equipment for any
roughout survey for
and washing &
ter temperatures. If
heaters / boilers are
water supplied by
3
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
hand washing and bathing facilities must not exceed each hot water heat
120°F.
Step One –
glass with e
water and ic
ice slush mi
instant read
centre of the
sure not to t
bottom of th
thermomete
degrees cels
fahrenheit) m
two. Otherw
probe and p
Step Two –
the thermom
face is away
underside of
look for the
the probe to
holds the fac
adjustable w
nut gently. R
temperature
nut until you
appropriate
Many mode
built right in
that keeps th
protected!
Based on 2013 rules. Be aware that stand
4
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
ter / boiler.
Testing: Fill a
equal parts cold
ce cubes to make an
ixture. Insert the
probe into the
e mixture being
touch the sides or
he glass. If the
er does not read 0
sius (or 32 degrees
move on to step
wise, clean the
put it away.
– Calibrating: Turn
meter so that the
y from you. On the
f the thermometer,
nut that attaches
o the casing that
ce. Use a small
wrench to turn this
Retest the
e and readjust the
u get the
reading. Note:
els have a wrench
nto the same holder
he probe clean and
dard tank hot water
4
RULE MINIMUM STANDARDS FOR ALL HEALT
GUIDELINES
heaters (not boilers)
ability to accurately
specific water temp
variance of 5F deg
acceptable. Anythin
is potentially dange
considered complia
37.106.321 MINIMUM STANDARDS FOR ALL RULE INTENT: To
HEALTH CARE FACILITIES: ENVIRONMENTAL safety by requiring
CONTROL (1) A health care facility must be safety within a heal
constructed and maintained so as to prevent entrance
and harborage of rats, mice, insects, flies, or other GUIDE
vermin.
During the survey, o
(2) Hand cleansing soap or detergent and construction / main
individual towels must be available at each lavatory in disrepair.
the facility. A waste receptacle must be located near
each lavatory. (2): Observe all lav
supplies.
(3) Cleaners used to clean bathtubs, showers,
lavatories, urinals, toilet bowls, toilet seats, and floors (3): Observe housek
must contain fungicides or germicides with current closets. Interview st
EPA registration for that purpose. products are being u
and / or germicides.
(4) Cleaning devices used for lavatories, toilet products to verify a
bowls, showers, or bathtubs may not be used for other EPA registration is
purposes. Those tools used to clean toilets or urinals EPA registration nu
must not be allowed to contact other cleaning devices. found on the produc
(5) A minimum of 10 foot-candles of light (4): Interview staff
must be available in all rooms and hallways, with the cleaning devices are
following exceptions: areas of the facility.
(a) all reading lamps must have a capacity to
provide a minimum of 30 foot-candles of light;
(b) all toilet and bathing areas must be
provided with a minimum of 30 foot-candles of light;
Based on 2013 rules. 5
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
) do not have the
y set and maintain a
perature. As such, a
grees over 120F is
ng beyond this level
erous and not
ant.
o protect human
environmental
lth care facility.
ELINES
observe for any
ntenance areas of
vatories for required
keeping carts /
taff as to which
used as fungicides
. Inspect these
an EPA registration.
confirmed by an
umber, which is
ct label.
as to which
e used for what
. Ensure that
5
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
(c) general lighting in food preparation areas findings comply wi
must be a minimum of 50 foot-candles of light; and
(5): Observe quality
(d) hallways must be illuminated at all times lighting throughout
by at least a minimum of five foot-candles of light at candles are the stan
the floor. is measured. A gene
seems too dark, it is
37.106.322 MINIMUM STANDARDS FOR ALL dark, measure the li
HEALTH CARE FACILITIES: DISASTER PLAN candle meter. Foot-
(1) All health care facilities must develop a written available through th
disaster plan as follows: RULE INTENT: To
life within a variety
(a) skilled nursing facilities (long-term care), settings by establish
outpatient centers for primary care, outpatient centers specific standards r
for surgical services, critical access hospitals, and fire.
hospitals, residential hospice facilities, inpatient
hospice facilities, and infirmaries must develop a GUIDE
written disaster plan in conjunction with other
emergency services in the community; Rules (1)(a) and (1)
requirements for sp
(b) these procedures must be developed such health care facilities
that they can be followed in the event of a natural or rule section utilized
man-caused disaster. facility type surveye
(2) The health care facilities identified in (1) Review facility disa
must conduct a review or physical exercise of such contain, at a minim
procedures at least once a year. After a review or required?
exercise a health care facility shall prepare and retain
on file for a minimum of three years a written report (1)(a): For facility t
including but not limited to the following: (1)(a), does the ann
have all the required
(a) date and time of the review or exercise; documented? If the
(b) the names of staff involved in the review policy/ plan has ele
or exercise; those required by th
(c) the names of other health care facilities, if
Based on 2013 rules. 6
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
ith (4).
y/amount of
t facility. Foot-
ndard by how light
eral rule is; If it
s. It if seems too
ight with a foot-
-candle meters are
he Department.
o protect human
y of healthcare
hing facility-
related to disasters
ELINES
)(3) describe
pecific types of
s. Ensure that the
d is specific to the
ed.
aster plan. Does it
mum, the elements
types covered in
nual review / drill
d elements
e facility disaster
ements beyond
hese minimum
6
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
any, which were involved in the review or exercise; standards, are those
(d) the names of other persons involved in the documented as well
review or exercise; (1)(3): For facility t
(e) a description of all phases of the procedure (1)(3), does the ann
have all the required
and suggestions for improvement; and documented? If the
(f) the signature of the person conducting the drill policy/plan has
those required by th
review or exercise. standards, are those
(3) Adult day care facilities, adult foster care documented as well
homes, assisted living facilities, chemical dependency (4) Review docume
treatment centers, end-stage renal dialysis facilities, ensure that drills are
intermediate care facilities for the developmentally as required. Be awa
disabled, mental health centers, outdoor behavioral specific rules may h
facilities, residential treatment facilities, retirement requirements for fir
homes, and specialty mental health facilities must example, assisted li
develop a written disaster plan for their facility, and require two, as oppo
conduct a documented review of the disaster plan with drills per year, no c
all facility staff annually. This documentation must be months apart. Facili
maintained at the facility for a minimum of three requirements are to
years. The disaster plan must include: case of conflict with
Standards.
(a) plans for remaining at the facility during
and subsequent to the disaster. Plans must include 7
such elements as acquisition of additional blankets,
water, food, etc.; and
(b) plans for resident evacuation and
identification of at least one off-site evacuation point.
A written agreement must be maintained in the facility
record and updated annually.
(4) Fire drills must be conducted at all health
care facilities.
(a) health care facilities that house patients or
residents must conduct at least four fire drills
annually, no closer than two months apart, with at
least one drill occurring on each shift. Drill
observations must be documented and maintained at
the facility for at least two years. The documentation
Based on 2013 rules.
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
e elements
l?
types covered in
nual review / drill
d elements
e facility disaster
s elements beyond
hese minimum
e elements
l?
ented fire drills to
e being conducted
are that facility
have different
re drills. For
iving facility rules
osed to four, fire
closer than four
ity specific
o be followed in
h Minimum
7
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
must include: RULE INTENT: To
(i) location of the drill; and continuity of pa
(ii) documentation that identifies participating comprehensive, cur
implemented polici
staff;
(iii) problems identified during the drill; Guideline:
(iv) steps taken to correct such problems; and (1): Observe the loc
(v) signature of the individual responsible for Ps. The format (i.e.
internet, etc.) of the
the day-to-day operation of the health care facility. regulatory issue as l
available to all parti
37.106.330 MINIMUM STANDARDS FOR ALL regulation.
HEALTH CARE FACILITIES: WRITTEN POLICY Have the P&P been
AND PROCEDURE (1) A current written policy and the last 12 months?
procedure manual that describes all services provided documented? Does
in the health care facility must be developed, include the approva
implemented, and maintained at the facility. The administrator and /
manual must be available to staff, residents, resident director?
family members, resident legal representatives, and
the department and must be complied with by all
facility personnel and its agents. Policies and
procedures must be reviewed at least annually by
either the administrator or the medical director with
written documentation of the review.
37.106.331 MINIMUM STANDARDS FOR ALL RULE INTENT: To
HEALTH CARE FACILITIES: LAUNDRY AND laundered items util
BEDDING (1) If a health care facility processes its care facility are clea
laundry on the facility site, it must: condition.
(a) use rooms solely for laundry purposes; Guideline:
(b) equip the laundry room with at least one (1)(a): The intent of
mechanical washer and hot air tumble dryer, hand
Based on 2013 rules. 8
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
o promote quality
atient care by
rrent, and
ies and procedures.
cation of the P &
. binder, CD,
e P & Ps is not a
long as they are
ies listed in this
n reviewed within
? How is the review
the documentation
al of the facility
or medical
o ensure that
lized by a health
an and in good
f this rule is to
8
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
washing facilities, mechanical ventilation to the prevent laundry pro
outside, a fresh air supply, and a hot water supply taking place in a kit
system which supplies the washer with water of at bedroom, or in an a
least 160˚F (71˚C) during each use. If the laundry processing would p
water temperature is less than 160˚F, chemicals and inconvenience, etc.
detergent suitable to the water temperature and the
manufacturer's recommended product time of (1)(b): Is there adeq
exposure must be utilized. facilities? Is the me
ventilation to the ou
(c) sort and store soiled laundry in an area fresh air supply?
separate from that used to sort and store clean laundry;
Be aware that a stan
(d) provide well maintained carts or other water heater does n
containers impervious to moisture to transport to heat water to 160
laundry, keeping those used for soiled laundry separate can attain this temp
from those used for clean laundry;
(1)(d): What is bein
(e) dry all bed linen, towels, and washcloths in transporting laundry
a manner that protects against contamination; containers separate
clean?
(f) protect clean laundry from contamination;
and (1)(g): How is the c
protected from cont
(g) ensure that facility staff handling laundry
cover their clothes while working with soiled laundry, Interview staff that
use separate clean covering for their clothes while ensure that separate
handling clean laundry, and wash their hands both worn while handlin
after working with soiled laundry and before they laundry. The use of
handle clean laundry. is acceptable, as lon
reused.
(2) If laundry is cleaned off-site, the health
care facility must utilize a commercial laundry which (2): IF: Name of La
satisfies the requirements stated in (1)(a) through (g). service__________
(3) A health care facility with beds must:
(a) keep each resident bed dressed in clean
bed linen in good condition;
(b) keep a supply of clean bed linen on hand
sufficient to change beds often enough to keep them
clean, dry, and free from odors;
(c) supply each resident at all times with clean
Based on 2013 rules. 9
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
ocessing from
tchen, a resident
area in which the
present an
quate hand washing
echanical
utside? Is there a
ndard tank hot
not have the ability
0F (only boilers
perature).
ng used for
y? Are these
for dirty and
clean laundry
tamination?
handles laundry to
e gowns are being
ng clean and soiled
f disposable gowns
ng as they are not
aundry
__________
9
MINIMUM STANDARDS FOR ALL HEALT
RULE GUIDELINES
towels and washcloths; Location:________
(d) provide each resident bed with a moisture-
Conduct on-site sur
proof mattress or a moisture-proof mattress cover and compliance with (a)
mattress pad; and
(3): Examine unuse
(e) provide each resident with enough blankets moisture-proofing &
to maintain warmth while sleeping. bedding.
Examine storage fo
of bed linen, towel,
Interview residents/
any complaints of b
time of day while at
Based on 2013 rules. 10
TH CARE FACILITIES SURVEY TOOL
YES NO COMMENTS
___________
rvey of service for
) through (g).
ed facility bed for
& condition of
or available supply
, and blankets.
/patients and note
being cold at any
t bed rest.
0