Free compliance, quality &amp; safety checklists

The Joint Commission CAMHTJC National Patient Safety Goals

The Joint Commission Hospital Accreditation & National Patient Safety Goals Readiness

Continuous-readiness checklist for a Joint Commission hospital accreditation survey, including the current National Patient Safety Goals and tracer methodology focus areas.

OSHA General Duty ClauseANA SPHM StandardsNIOSH lifting guidance

Safe Patient Handling & Mobility Audit

Audit of a safe patient handling and mobility (SPHM) program covering assessment, mechanical lift use, equipment availability, and staff training.

FDA SUD Reprocessing GuidanceCMS 42 CFR 482.42AAMI ST58

Single-Use Device Reprocessing Policy Audit

Audit of policies governing the reprocessing of single-use devices, ensuring reprocessing is performed only by FDA-cleared reprocessors and tracked.

TJC EC.02.06.01CMS QSO ligature guidanceTJC NPSG.15.01.01

Ligature-Risk Environmental Scan

Environmental scan of behavioral health and general-acute areas for ligature and self-harm risks, mitigation, and monitoring for at-risk patients.

ANSI/AAMI/ISO 23500CMS 42 CFR 494.40AAMI RD52 legacy

Dialysis Water Quality Audit (AAMI)

Audit of dialysis water treatment system monitoring, microbial and chemical testing, and endotoxin control under the AAMI water quality standards.

OSHA / NIOSH Latex AlertAORN GuidelinesTJC provision of care

Latex Allergy Program Audit

Audit of a facility latex-safe program covering patient screening, latex-safe environments, product substitution, and staff protection.

DEA 21 CFR 1301TJC LD.04.03.13CMS 42 CFR 482.25

Opioid Stewardship & Controlled-Substance Diversion Audit

Audit of controlled-substance security, reconciliation, waste, and diversion-monitoring controls alongside an opioid stewardship program.

TJC NPSG.03.01.01ISMP List of Confused Drug NamesISMP Tall Man Lettering

Look-Alike/Sound-Alike (LASA) Medication Safety Audit

Audit of controls that prevent errors from look-alike/sound-alike medication names, including tall man lettering, separation, and staff awareness.

ISMP High-Alert Medications ListTJC NPSG.03.05.01TJC MM.01.01.03

High-Alert Medication Independent Double-Check Audit

Audit of independent double-check practices and additional safeguards for high-alert medications such as insulin, anticoagulants, opioids, and concentrated electrolytes.

TJC NPSG.01.01.01CAP GEN.40490CLIA 42 CFR 493.1242

Patient Identification & Specimen Labeling Audit

Audit of two-identifier patient verification and specimen labeling at the point of collection to prevent misidentification and mislabeled specimens.

CLIA 42 CFR 493 SubpartCAP POC checklistFDA/manufacturer IFU

Blood Glucose Point-of-Care Testing (CLIA Waived) Audit

Audit of waived blood-glucose point-of-care testing including operator competency, quality control, reagent handling, and result documentation.

AHA ACLS/BLS GuidelinesTJC PC.02.01.19CMS 42 CFR 482.55

Code Blue & Rapid Response Team Audit

Audit of resuscitation readiness, rapid response activation, code documentation, and post-event debrief for a hospital code blue program.

MHAUS GuidelinesAORN GuidelinesTJC PC.03.01.01

Malignant Hyperthermia Readiness Audit

Audit of malignant hyperthermia crisis readiness in anesthetizing locations, including dantrolene stock, cooling supplies, and staff drills.

CMS 42 CFR 482.42CDC Core Elements of Hospital ASPTJC MM.09.01.01

Antimicrobial Stewardship Program (ASP) Audit

Audit of a hospital antimicrobial stewardship program against the CDC Core Elements and the CMS infection prevention and antibiotic stewardship Condition of Participation.

CDC/HICPAC Intravascular Catheter GuidelineNHSN CLABSIIHI Central Line Bundle

Central Line-Associated Bloodstream Infection (CLABSI) Bundle Audit

Observation-based audit of central line insertion and maintenance bundle compliance to prevent central line-associated bloodstream infections.

CDC/HICPAC CAUTI Guideline 2009NHSN CAUTIAHRQ CUSP for CAUTI

Catheter-Associated Urinary Tract Infection (CAUTI) Bundle Audit

Audit of indwelling urinary catheter appropriateness, insertion technique, maintenance, and timely removal to reduce catheter-associated urinary tract infections.

CDC SSI Guideline 2017NHSN SSISCIP / AORN Guidelines

Surgical Site Infection (SSI) Prevention Audit

Perioperative audit of surgical site infection prevention practices including antimicrobial prophylaxis, skin antisepsis, normothermia, glycemic control, and NHSN surveillance.

WHO Five Moments for Hand HygieneCDC Hand Hygiene GuidelineTJC NPSG.07.01.01

Hand Hygiene Direct Observation Audit

Direct-observation tool for auditing hand hygiene compliance across the WHO Five Moments, including technique, product use, and glove practices.

CDC Isolation Precautions Guideline 2007OSHA 1910.132/1910.1030TJC IC.02.01.01

Isolation Precautions & PPE Competency Audit

Audit of transmission-based isolation precautions, signage, PPE availability, and staff donning/doffing competency.

USP General Chapter 797USP 1116State Board of Pharmacy

Sterile Compounding Environmental Monitoring Audit (USP 797)

Audit of viable and non-viable environmental monitoring, certification, and cleanroom controls for a sterile compounding pharmacy under USP General Chapter 797.

ACR Manual on MR SafetyTJC EC.02.01.01FDA MRI Guidance

MRI Safety Zones & Screening Audit

Audit of MRI suite safety covering the four-zone access model, ferromagnetic screening, MR safety personnel roles, implant verification, and quench/emergency procedures per the ACR Manual on MR Safety.

CMS 42 CFR 482.52ASA Practice GuidelinesTJC PC.03.01.01

Moderate Sedation & Anesthesia Services Audit

Audit of anesthesia and moderate sedation services covering pre-sedation assessment, qualified providers, physiologic monitoring, rescue capability, and post-anesthesia recovery under CMS anesthesia CoPs.

CMS 42 CFR 482.57AARC Clinical Practice GuidelinesTJC PC.01.02.03

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.

NPIAP GuidelinesCMS 42 CFR 483.25(b)TJC PC.01.02.07

Wound Care & Pressure Injury Prevention Audit

Audit of pressure injury prevention and wound care covering skin risk assessment, repositioning, support surfaces, nutrition, wound assessment, and documentation of unavoidable injuries.

CMS 42 CFR 482.43IMPACT ActTJC PC.04.01.01

Discharge Planning & Care Transitions Audit

Audit of hospital discharge planning covering timely screening, patient goals and preferences, post-acute provider choice, medication reconciliation, and transfer of information under the CMS discharge planning CoP.

Patient Self-Determination ActCMS 42 CFR 482.13(b)42 CFR 489.102

Advance Directives & Informed Consent Audit

Audit of advance directive and informed consent practices covering inquiry and documentation of directives, patient rights notice, informed consent elements, and surrogate decision-making.

OSHA 29 CFR 1910.1030Needlestick Safety and Prevention ActCDC Guidelines

Bloodborne Pathogens Exposure Control Audit

Audit of the OSHA bloodborne pathogens program covering the exposure control plan, engineering and work-practice controls, hepatitis B vaccination, PPE, and post-exposure follow-up.

CMS SEP-1 (NQF 0500)Surviving Sepsis CampaignTJC

Sepsis SEP-1 Bundle Compliance Audit

Audit of the CMS SEP-1 severe sepsis and septic shock early management bundle covering lactate measurement, blood cultures, antibiotics, fluid resuscitation, and reassessment timing.

42 CFR 418.5642 CFR 418.5442 CFR 418.22

Hospice Interdisciplinary Group (IDG) Compliance Audit

Audit of hospice interdisciplinary group composition, comprehensive assessment, plan of care, and terminal-illness certification under the Medicare Hospice Conditions of Participation.

42 CFR 412.62242 CFR 412.29CARF Medical Rehabilitation Standards

Inpatient Rehabilitation Facility (IRF) & CARF Readiness Audit

Readiness audit for inpatient rehabilitation facilities covering the intensity-of-therapy standard, interdisciplinary team, IRF-PAI documentation, and CARF program requirements.

The Joint Commission EC.02.06.01CMS 42 CFR 482.13(e)NPSG.15.01.01

Behavioral Health Unit Ligature Risk & Safety Audit

Environmental and clinical safety audit of psychiatric and behavioral health units focused on ligature-resistant design, self-harm risk mitigation, and suicide screening.

CMS 42 CFR 482.60AWHONN StandardsACOG Guidelines

Obstetrics & Labor and Delivery Safety Audit

Maternal safety audit covering obstetric hemorrhage readiness, hypertension/preeclampsia management, high-alert medications, and fetal monitoring on labor and delivery units.

AAP Guidelines for Perinatal CareFGI GuidelinesTJC NPSG.01.01.01

NICU Neonatal Safety & Care Audit

Safety audit for neonatal intensive care units covering patient identification of newborns, human milk management, thermoregulation, alarm and equipment safety, and NICU level of care designation.

ANSI/AAMI ST91SGNA StandardsFDA Reprocessing Guidance

Flexible Endoscope Reprocessing Compliance Audit

Multi-society compliance audit of flexible endoscope reprocessing covering precleaning, leak testing, manual cleaning, high-level disinfection, drying, storage, and traceability.

10 CFR Part 3510 CFR Part 20NRC Materials License

Radiation Safety & Nuclear Medicine Compliance Audit

Compliance audit for nuclear medicine and radioactive materials programs covering the radiation safety officer, ALARA, dose measurement, medical events, and radioactive waste under NRC 10 CFR Part 35.

CMS 42 CFR 484SOM Appendix BOASIS

Home Health Agency Conditions of Participation Audit

Survey-readiness checklist for home health agencies covering patient rights, comprehensive assessment, plan of care, and QAPI under 42 CFR 484.

USP <797>USP <800>CMS 42 CFR 482.25

Pharmacy Sterile Compounding USP <797>/<800> Audit

Audit of pharmacy sterile and hazardous drug compounding operations against USP <797> and <800> for facilities, engineering controls, and personnel practices.

CLIA 42 CFR 493CAP Laboratory AccreditationCMS

Clinical Laboratory CLIA / CAP Inspection Readiness

Inspection-readiness checklist for clinical laboratories covering CLIA personnel, quality control, proficiency testing, and specimen management.

AABB StandardsFDA 21 CFR 606CMS 42 CFR 482.27

Blood Transfusion Service AABB Compliance Audit

Audit of hospital transfusion services covering patient identification, compatibility testing, blood storage, and transfusion reaction management under AABB standards.

EMTALA 42 CFR 489.24CMS 42 CFR 482.55SOM Appendix V

Emergency Department & EMTALA Compliance Audit

Audit checklist for hospital emergency departments to verify compliance with EMTALA medical screening, stabilization, transfer, and on-call obligations.

CMS 42 CFR 482.51AORN GuidelinesThe Joint Commission Universal Protocol

Surgical Services & Operating Room Compliance Audit

Perioperative audit covering surgical services organization, informed consent, the Universal Protocol time-out, and OR environment controls.

ANSI/AAMI ST79CMS 42 CFR 482.42AORN Guidelines

Sterile Processing Department (SPD) AAMI ST79 Audit

Audit of the sterile processing department covering decontamination, cleaning, sterilization monitoring, and sterile storage in line with AAMI ST79.

CMS 42 CFR 494AAMI Water StandardsSOM Appendix H

Dialysis / ESRD Facility Conditions for Coverage Audit

Survey-readiness checklist for end-stage renal disease facilities covering infection control, water treatment, patient assessment, and reuse under the ESRD Conditions for Coverage.

CMS 42 CFR 416SOM Appendix LThe Joint Commission

Ambulatory Surgery Center (ASC) Conditions for Coverage Audit

Survey-readiness checklist for ambulatory surgery centers covering governing body, patient rights, surgical services, and infection control under the ASC Conditions for Coverage.

CMS RAI Manual42 CFR 483.20MDS 3.0

MDS / RAI Accuracy & Coding Audit (LTC)

Audit of the resident assessment instrument process in long-term care to verify MDS accuracy, timeliness, CAA linkage, and care-plan coordination.

FDA Food CodeCMS 42 CFR 482.2842 CFR 483.60

Healthcare Dietary & Food Service Safety Audit

Food safety and nutrition audit for healthcare dietary services covering food temperatures, sanitation, therapeutic diets, and staffing.

NFPA 99CMS 42 CFR 482.41The Joint Commission EC

Medical Gas & Vacuum Systems NFPA 99 Audit

Audit of piped medical gas and vacuum systems covering source equipment, alarms, zone valves, and outlet testing under NFPA 99.

NFPA 110NFPA 99CMS 42 CFR 482.15

Emergency Generator & EPSS NFPA 110 Audit

Audit of the emergency power supply system covering generator testing, load transfer, fuel management, and maintenance under NFPA 110.

CMS 42 CFR 482.13(e)-(f)CMS 42 CFR 483.12 / 483.10(e)TJC PC.03.05 / PC.03.03

Restraint & Seclusion Compliance Audit

Compliance audit of restraint and seclusion practices covering orders, assessment, monitoring, staff training, and death reporting under the CMS patient rights CoP.

CMS 42 CFR 482.21CMS 42 CFR 483.75TJC Performance Improvement (PI)

Quality Assurance & Performance Improvement (QAPI) Program Audit

Audit of a facility's QAPI program covering the five elements, data-driven improvement, adverse event analysis, and governing body accountability.

CMS 42 CFR 482.12(a) / 482.22TJC Medical Staff (MS)NCQA Credentialing

Medical Staff Credentialing & Privileging Audit

Audit of the medical staff credentialing and privileging process covering primary source verification, privilege delineation, peer review, and ongoing professional practice evaluation.

CMS 42 CFR 483.25(b)-(d)TJC National Patient Safety GoalsNPUAP/EPUAP Guidelines

Fall Prevention & Pressure Injury Prevention Audit

Bedside audit of fall-prevention and pressure-injury-prevention practices covering risk assessment, individualized interventions, repositioning, and monitoring.

TJC Environment of Care (EC)CMS 42 CFR 482.41OSHA 29 CFR 1910

Environment of Care Safety Rounds

Environment of Care rounding checklist covering safety, security, hazardous materials, utilities, and medical equipment for hospitals and healthcare facilities.

CMS 42 CFR 482.15CMS 42 CFR 483.73CMS Emergency Preparedness Final Rule

CMS Emergency Preparedness Rule Compliance Audit

Audit of a healthcare facility's emergency preparedness program against the four core elements of the CMS Emergency Preparedness Rule.

HIPAA Privacy Rule 45 CFR 164 Subpart EHIPAA Security Rule 45 CFR 164 Subpart CHITECH Breach Notification

HIPAA Privacy & Security Rule Compliance Audit

Compliance audit of protected health information (PHI) privacy and security safeguards for a covered entity under the HIPAA Privacy, Security, and Breach Notification Rules.

CMS 42 CFR 482.13TJC Rights & Responsibilities (RI)CMS 42 CFR 483.10

Patient Rights & Informed Consent Audit

Audit of patient and resident rights covering notification of rights, informed consent, advance directives, grievances, and privacy across acute and long-term care.

Healthcare Facility Compliance 19

NFPA 101 Life Safety Code Survey for Healthcare Occupancies

Life Safety Code building and fire-protection survey checklist for hospitals and nursing facilities based on the CMS-adopted 2012 edition of NFPA 101.

NFPA 101 (2012 ed.)CMS 42 CFR 482.41 / 483.90NFPA 99

CMS 42 CFR 482.42CMS 42 CFR 483.80CDC Guidelines

Infection Prevention & Control Program Audit

Audit of a facility infection prevention and control program covering surveillance, hand hygiene, isolation precautions, and reprocessing across acute and long-term care.