PREPAREDNESS CHECKLIST
This checklist serves to provide assistance in preparedness for unannounced regulatory surveys. These
hot-button items can be checked off quickly in each area to prepare for the unannounced regulatory
surveyors’ review. It is important to be aware of and follow your hospital policy when considering certain
checklist items, such as appropriate items at workstations.
I. GENERAL CONSIDERATIONS
All associate ID badges are above the waist and clearly visible.
Mandatory signage is visible and in place in public areas: license, interpreter
assistance, financial assistance, patient rights, etc.
II. PATIENT IDENTIFICATION
Employees can clearly state primary patient identifiers.
III. CULTURAL COMPETENCIES
Employees can clearly state practices related to patient self-reporting on
preferred language, race, and ethnicity.
IV. PATIENT PRIVACY
Copies of the HIPAA Notice of Privacy Practice are available for distribution.
Associates are aware of and follow HIPAA guidelines for appropriate use.
Associate is never away from screen while computer is logged into patient
record.
Associate is aware when people are walking or standing in view of the computer
screen.
Associates use good practice concerning the creation and security of computer
passwords.
Computer screen visibility is capable of being minimized or hidden when
necessary.
Check open access areas: There are no unsecured patient records in open access
areas (including patient profiles, physician orders, patient insurance information,
etc.) or left unattended.
Check printers: There are no unsecured patient records in open access areas
(including patient profiles, physician orders, patient insurance information, etc.)
or left unattended.
NAHAM PREPAREDNESS CHECKLIST
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Check copiers: There are no unsecured patient records in open access areas
(including patient profiles, physician orders, patient insurance information, etc.)
or left unattended
V. INFECTION, PREVENTION & CONTROL
Employees can clearly state infection control practices.
Employees know where infection control materials and personal protective
equipment (PPE) are kept (hand sanitizer, masks, tissue, gloves, etc.).
Employees can access infection control materials and personal protective
equipment (PPE).
Infection control materials and personal protective equipment (PPE) is readily
available for public utilization (hand sanitizer, masks, tissue, gloves, etc.).
Refrigerator logs have been updated.
Refrigerators are clean.
Items inside refrigerators are appropriate.
No staff lunches are inside patient refrigerators.
Subject to hospital policy, there are no food items or drinks at work stations.
Subject to hospital policy, there are no unapproved items, such as hand lotions,
at work stations.
Only cleaning supplies are under sinks and/or in cabinets.
VI. ENVIRONMENT OF CARE
Environment of care resources are readily visible and accessible.
All fire safety resources are readily visible and accessible.
All surrounding halls are passable (eight feet in patient access hallways).
All unused COWs (computers on wheels) and other wheeled items are stored out
of the hallways.
Check all fire doors: No fire door is blocked.
NAHAM PREPAREDNESS CHECKLIST
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NOTES & REFERENCES
I. GENERAL CONSIDERATIONS
See Standards FAQ Details (“Identification Badge Requirements”) at http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=99&
StandardsFAQChapterId=64
See FAQ. Are evacuation maps required to be posted in health care organizations? If so, where
and how many are needed?
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=72&
StandardsFAQChapterId=73
II. PATIENT IDENTIFICATION
See NPSG.01.01.01 (Identify patients correctly) - Use at least two ways to identify patients. For
example, use the patient’s name and date of birth. This is done to make sure that each patient
gets the correct medicine and treatment.
See Standards FAQ Detail for multiple questions and answers regarding patient identifiers –
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=145
&StandardsFAQChapterId=77
Q. What is the intent of the requirement for using two identifiers?
A. The intent here is two-fold: first, to reliably identify the individual as the person for whom the
service or treatment is intended; second, to match the service or treatment to that individual.
Therefore, the two patient/client/resident-specific identifiers must be directly associated with the
individual and the same two identifiers must be directly associated with the medications, blood
products, specimen containers (such as on an attached label), other treatments or procedures.
III. CULTURAL COMPETENCIES
IV. PATIENT PRIVACY
V. INFECTION, PREVENTION & CONTROL
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See NPSG.07.01.01 (prevent infection) – Use the hand cleaning guidelines from the Centers for
Disease Control and Prevention or the World Health Organization. Set goals for improving hand
cleaning. Use the goals to improve hand cleaning.
See also The Joint Commission’s Hand Hygiene Project:
http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=3
See Standards FAQ Details on Hand Hygiene:
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=391
&StandardsFAQChapterId=77
Also See Standards FAQ Details on Monitoring of Hand Hygiene:
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=380
&StandardsFAQChapterId=77
See FAQ: Is there a Joint Commission standard which requires us to maintain temperature logs
for staff only refrigerators?
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=291
&StandardsFAQChapterId=64
See FAQ: Are food and drinks for staff members allowed in patient care areas?
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=87&
StandardsFAQChapterId=69
See FAQ: Do the Joint Commission standards prohibit use of under sink cabinets for storage?
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=305
&StandardsFAQChapterId=64
VI. ENVIRONMENT OF CARE
See FAQ: How long can computers on wheels be in corridors? Are they allowed to charge in the
corridors?
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=33&
StandardsFAQChapterId=73
NAHAM PREPAREDNESS CHECKLIST
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