Healthcare Facility Compliance 11 items
Respiratory Therapy Services Compliance Audit
Audit of respiratory care services covering medical direction, practitioner qualifications, physician orders, ventilator management, and oxygen therapy safety under the CMS respiratory care CoP.
CMS 42 CFR 482.57AARC Clinical Practice GuidelinesTJC PC.01.02.0342 CFR 482.23
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Direction & Staffing
- Is respiratory care under the medical direction of a qualified doctor of medicine or osteopathy? *
- Are respiratory services delivered by qualified respiratory therapists or technicians with appropriate credentials? *
- Are the scope, complexity, and staffing of services adequate to meet patient needs? *
Orders & Delivery of Care
- Are respiratory services provided only on the order of a physician or qualified practitioner responsible for the patient? *
- Do orders specify the type, frequency, and duration of therapy, plus oxygen concentration and delivery method? *
- Are treatments and patient responses documented in the medical record? *
Ventilator & Oxygen Safety
- Are mechanical ventilators checked at defined intervals with settings verified against orders and alarms functional? *
- Is oxygen stored, labeled, and handled safely as a hazardous/oxidizing compressed gas? *
- Is a ventilator-associated event/pneumonia prevention bundle implemented and monitored? *
Blood Gas & Equipment Control
- Are arterial blood gas sampling and point-of-care testing performed by competency-verified staff with QC? *
- Is reusable respiratory equipment cleaned, disinfected, and stored to prevent cross-contamination? *
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