Facility and physical premises

Standard 1

Handicapped Entrance (D)
1-A

An existing public facility, or facility used by the public, undergoing an alteration other than ordinary maintenance, after July 20, 1975, shall meet the barrier-free design requirements contained in the state construction code.

Facility is clean, orderly and with adequate lighting (D)
1-B

Proper lighting can prevent accidental injury and is conducive to proper practice. For example, a medication room with low or no light could lead to improper dosing. Entrances, exam rooms and waiting rooms should be cleaned regularly, including floors and other horizontal surfaces.

Handicapped Restroom with Rails (D)
1-C

It is recommended that at least one public restroom have handicapped accessibility, with handrails, to allow for barrier free accessibility in a safe and convenient manner for all patients. An existing public facility or facility used by the public undergoing an alteration other than ordinary maintenance after July 20, 1975, shall meet the barrier free design requirements contained in the state construction code.

Hallways Clear (D)
1-D Exits Clear (at least two) (D)
1-E

All exits must be free from obstruction AT ALL TIMES. The Fire Marshal requires that corridors, hallways and doorways are free from obstruction so that a stretcher can be moved down the hallway in case of an emergency. In case of fire, exits and hallways must be clear so that time is not lost in evacuating the building. NOTHING can be left in hallways that may obstruct the emergency exit path.

Fire extinguisher available and checked annually
1-F

The Fire Marshall and MI building code require public facilities to be adequately equipped to extinguish or control fire hazards. A fire extinguisher should be available with an affixed tag indicating annual inspection.

Adequate Seating (N)
1-G

The general waiting area for patients and in exam rooms should be adequate to meet the number of scheduled and open access appointments. Patients should not have to stand in the general waiting area or exam room while waiting to be seen.

Exam and procedure rooms

Standard 2

Soap dispensers (D)
2-A

Soap dispensers should be used to prevent cross-contamination between those who use the sink. If bar soap is used, it must NEVER be left to lie in water. The soapy gel formed when bar soap lies in water is an excellent medium for bacterial growth. To prevent cross contamination, it is recommended that disinfectant hand-wipes be placed in the patient exam rooms so that staff can clean their hands prior to exiting the room. Staff should wash their hands with soap and water after exiting the room.

Paper Towel Dispensers (D)
2-B

Disposable paper towels are required. Towels should be in a dispenser or on a dispenser roll. Paper towels laid on the edge of the sink can become contaminated through dripping water from hand washing at the sink. Cloth towels must not be used in order to prevent cross contamination.

Acceptable use of under sink storage (D)
2-C

Patient care items and paper products may not be stored under sinks due to the risk of water contamination through leakage or other plumbing problems.

Syringes Disposed of in Puncture-Proof Containers (D)

Syringes, once used, must be disposed of in their entirety in the proper manner. Do not bend, break or remove the needle to prevent accidental needle puncture with contaminated needles. Place the entire syringe in a container that complies with the Michigan Medical Waste Regulatory Act.

Biomedical Waste Container Covered, Opaque, Impervious Liners (D)
2-E

Biomedical waste containers must be covered and lined with opaque, impervious liners. Containers in patient care areas are to be lined with a leak resistant bag and covered to protect patients from contaminated materials.

Patient care areas decontaminated daily after contact with blood/OPIM. Exam table paper changed after each use. (D)
2-F

Patient care areas are to be decontaminated daily and after each patient use when contamination is apparent. The exam table paper must be changed between each patient use. This is to prevent cross-contamination among patients and promote cleanliness and safety.

Equipment storage, maintenance, cleaning, and sterilizing

Standard 3

All patient care supplies stored off the floor (D)
3-A

To prevent both contamination of patient supplies and injury due to accidents, patient care supplies are to be stored off the floor.

Proper storage of toxic/hazardous/combustible materials (D)
3-B

Cleaning agents are potentially hazardous and should not be stored in exam rooms. They may leak and contaminate other items stored nearby and also pose a threat to small children. Cleaning supplies may be stored under sinks only in work areas or utility rooms.

Combustible items must NEVER be stored on or near the furnace, water heater or any other source of heat.

All gasses/oxygen are properly stored (D)
3-C

Compressed gasses, such as oxygen or nitrous, must be stored in stands built for that purpose or fastened to a strong wall or cabinet. Oxygen may be kept in a case made for that purpose. Compressed gasses are very volatile and may explode if tipped or if the "neck" of the tank is bent or broken.

Resuscitation and monitoring equipment
3-D

• Airways & bag mask respirator
• Suitable resuscitative drugs
• Blood pressure apparatus
• Oxygen source
• Suction equipment (A, S, J)

To provide treatment/monitoring during the perioperative period as well as in the event of medical emergency.

Any equipment used for patient care to be in working order. Medical offices should be prepared to show evidence of equipment maintenance according to manufacturer's recommendation.

Equipment periodically calibrated and/or preventive maintenance completed (D)
3-E

To ensure accurate results of monitoring, all equipment used for patient care is to be in working order. Medical offices should be prepared to show evidence of equipment maintenance according to manufacturer's recommendation.

Cleaning method and storage acceptable for thermometers, vaginal speculums, and otoscopes (D)
3-F

Glass thermometers, both oral and rectal, should be cleaned in soap and water and soaked in an approved sterilizing solution for longer than 30 minutes before being rinsed, dried and placed in the examination rooms for use.

ORAL AND RECTAL THERMOMETERS SHOULD NEVER BE CLEANED OR STORED TOGETHER.

Digital thermometers covered with a soft plastic sheath should be wiped with alcohol between uses.

If a digital thermometer is covered with a hard plastic sheath, it is not necessary to wipe with alcohol between uses.

Cleaning methods must prevent cross contamination between patients.

Disposable vaginal speculums must not be re-used. Metal vaginal speculums must be autoclaved or effectively cold sterilized using a 2% glutaraldehyde solution.

Otoscope tips that are not disposable should be cleaned with soap and water and soaked in alcohol for at least 60 minutes prior to re-use.

Separate clean/dirty work areas (D)
3-G

A distinction must be made between clean and dirty work areas to prevent cross contamination.

Autoclave (D)
3-H, I & J

• Supplies/instruments have date on package
• Heat-sensitive indicators used
• Spore check must be documented at least monthly

Autoclaved supplies/instruments can be marked with either the date of sterilization OR the date of expiration, for time frames specified by individual office policy. Sterility is maintained unless the integrity of the pack has been compromised by contact with moisture, dust accumulation or other pack integrity infractions. The Center for Disease Control recommends reprocessing the instruments at one year, even if the pack integrity has been maintained. Autoclaved supplies must be checked regularly for expiration of sterility. Periodicity dependent on use of equipment and need for sterilization within a practice.

Heat sensitive indicators must be used every time the autoclave is used. Results of the heat strip indicators should be documented. A record is maintained for a period of time which adequately demonstrates that spore checks are being performed in the time frame required.

Spore checks are conducted at least monthly and immediately after servicing. Priority Health requires spore checks to ensure consistent sterilization. A record of spore tests must be maintained for a period of time which adequately demonstrates that spores checks are being performed in the time frame required. Periodicity dependent on use of equipment and need for sterilization within a practice.

Instrument disinfectant (D)
3-K Labeled with:

• Type of solution
• Date solution last changed/needs to be changed

All boats or pans of disinfectant or sterilizing solution must be labeled with the name of the solution each contains and the date that each was last changed, or needs to be changed. This prevents the use of improper or outdated solutions. A 2% glutaraldehyde solution is recommended.

Medication storage

Standard 4

Medications stored away from patient care areas (except local anesthetics) (D)
4-A

All medications (except for injectable local anesthetic agents) must be stored away from patient care areas to ensure patient safety.

All medications/emergency medications are current and expiration dates checked monthly (D)
4-B

Medications that have passed the manufacturer's known expiration date are not considered safe for use in the treatment of patients. Medications should be checked for expiration dates. It is recommended that a medication review log be used to ensure that this activity is performed to identify and appropriately discard expired medications.

Narcotics double locked, use of sign-out sheet and restricted access to keys (D)
4-C

Double locking of narcotics (Class II - V medications) is a Federal regulation and must be adhered to by providers who maintain narcotics on site. Restricted access to keys is important to the doctor whose name is on the DEA license for (s)he is the one who may be audited. A log documenting narcotic administration is required and must include date, patient name, drug name, dosage, physician prescribing, and individual administering the narcotic. This helps to prevent potential abuse of narcotics and accounts for narcotics within the facility.

Medication requiring refrigeration refrigerated (D)
4-D

Medications must be stored as the manufacturer's label requires (refrigerate when necessary), to ensure the integrity and effectiveness of the product. Medications requiring refrigeration must never be left on the counter during the day and simply refrigerated at night, no matter how convenient this may be for staff. Food and medications must never be stored in the same refrigerator to prevent cross contamination.

Thermometer in refrigerator (D)
4-E & F

The optimal temperature for medications that require refrigeration is 36º-46º Fahrenheit or 2º-8º Centigrade, and a thermometer in freezer with a temperature of 0º - 7º F or 0º - -15º C. A thermometer should be placed in the refrigerator and a daily log maintained to monitor adequate temperature control.

Laboratory

Standard 5

License Posted with Expiration Date (C)
5-A

Offices performing laboratory tests must be licensed by the State of Michigan. The CLIA certificate may be posted or placed in a file where it is readily accessible.

Lab Reagents Current (C)
5-B

All lab reagents must be checked regularly to prevent the use of reagents that are beyond the manufacturer's known effective date.

Quality controls on lab tests documented; strep screens, pregnancy tests, glucometer (C)
5-C

CLIA requires quality assurance monitoring to ensure control agents are current and completed according to manufacturer recommendations, thus ensuring appropriate testing results.

Radiology and x-ray unit

Standard 6

License posted with expiration date (D)
6-A

When there is an x-ray machine on the premises, the license must be posted in the facility near the x-ray machine.

Registration tag on control panel (D)
6-B

A registration tag must be present on the control panel.

BHS/HFS-100 form (D)
6-C

A BHS/HFS (formally RH-100 form) form needs to be posted near the x-ray unit.

Part 5 of ionizing rules; protective coverings/aprons and film badges present (D)
6-D

A copy of Radiology Rules must be posted or there should be a notice posted of where the rules may be found in the facility.

Radiation areas must be identified by signs, labels or symbols. Warning signs for pregnant women posted (D)
6-E

Priority Health recommends that a warning sign for pregnant women be posted near the x-ray machine.

Biohazardous waste

Standard 7

Medical waste registration certificate current and posted (D)
7-A

The MDEQ issues medical offices that produce biomedical waste a certificate of registration which must be current and posted.

A medical waste plan is present and SPECIFIC TO EACH OFFICE and is accessible to employees (D)
7-B

All offices must have a medical waste plan. The plan should also be available for staff review. The Department regulates the management of medical waste to ensure that the public health and the environment are adequately protected.

Medical record keeping practices and documentation review

Standard 8

Medical records stored away from patient care areas (D, N)
8-A

Medical records must be stored away from patient care areas to ensure confidentiality.

Organized and legible medical record keeping system (D, N)
8-B

Medical records must be maintained in a manner that is current, detailed, legible and organized, and permits effective and confidential patient care and quality review.

Notice of privacy (HIPAA)/release of confidential information policy exists (N)
8-C

It is recommended that a written policy regarding confidentiality of patient information and records is maintained.

Advance directive information available in prominent part of medical record (C)
8-D

Medicare law requires documentation of whether or not a patient has executed an advance directive. This documentation must be in a prominent place in the record.

Practitioner performance goals

85% and higher

Passing score. No follow-up needed.

75 - 84%

Revisit not indicated. Office asked to send written statement of how they will correct the issues. Response required within 3 months.

74% and below

The office is revisited at least every 6 months for another office site review until deficiencies are improved to an acceptable threshold.