| Standard |
Rationale |
| EXTERIOR |
STANDARD 1 |
Handicapped Entrance (O)
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. |
Parking Adequate (O)
1-B |
Adequate parking must be available to provide accessibility to the facility in a safe and convenient manner for all patients. |
Handicapped Parking Space (O)
1-C
|
Part 4 of the Building Code rules from the Michigan Department of Labor, (1987) states that off street parking for 1-25 cars must include one (1) handicapped marked parking space. |
Adequate Lighting (O)
1-D
|
Proper lighting for safety in parking lots is necessary to ensure patient safety. |
Adequate Maintenance/Cleaning (O)
1-E
|
Adequate maintenance/cleaning is necessary to ensure patient safety. |
| INTERIOR/GENERAL PREMISES |
STANDARD 2 return to top |
Adequate Lighting (O)
2-A
|
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. |
Handicapped Restroom with Rails (O)
2-B
|
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. |
Waiting Room Seating Adequate (O)
2-C
|
Adequate waiting room seating must be provided for patients. |
Hallways Clear (O)
2-D
Exits Clear (at least two) (O)
2-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. |
Proper Storage of Toxic/Hazardous/Combustible Materials (O)
2-F
|
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 Patient Care Supplies Stored Off the Floor (O)
2-G
|
To prevent both contamination of patient supplies and injury due to accidents, patient care supplies are to be stored off the floor.
|
Gasses (O)
1. Oxygen
2. Properly Stored
3. Other Gasses
4. Properly Stored
2-H
|
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 (A, S, J)
1. Airways & Bag Mask Respirator
2. Suitable Resuscitative Drugs
3. Blood Pressure Apparatus
4. Oxygen Source
5. Suction Equipment
2-I
|
To provide treatment/monitoring during the perioperative period as well as in the event of medical emergency. |
Office Equipment Cleaning Method Acceptable, i.e., Waiting Room (A, S, M, J)
2-J |
Entrances and waiting rooms should be cleaned regularly, including floors and other horizontal surfaces.
|
Medical Records Stored Away from Patient Care Areas (O, N)
2-K
|
Medical records must be stored away from patient care areas to ensure
confidentiality.
|
Organized Medical Record-Keeping System (N)
2-L
|
Medical records must be maintained in a manner that is current, detailed and
organized, and permits effective and confidential patient care & quality review.
|
Release of Confidential Information (N)
2-M
|
Medical records that contain private and privileged information could be
harmful to the member if the information is divulged for other than appropriate, approved purposes. A signed release of information needs to be obtained prior to releasing medical information in order to protect the member's privacy.
|
Written Policies & Procedures Address Confidentiality (N)
2-N
|
It is recommended that a written policy regarding confidentiality of patient information and records is maintained. Priority Health's policy on confidentiality is available upon request.
|
| EXAM ROOMS |
STANDARD 3 return to top |
Soap Dispensers (O)
3-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.
|
Paper Towel Dispensers (O)
3-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.
|
Biomedical Waste Container Covered, Opaque, Impervious Liners (O)
3-C
|
Biomedical waste containers must be covered and lined with opaque, impervious liners.
|
Acceptable Use of Under-Sink Storage (O)
3-D
|
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.
|
Suitable Surgical Lighting Present (A, S, O, J)
3-E
|
To provide optimal conditions to ensure patient safety.
|
Handwipes/Liquid Disinfectant Available in Rooms Without Sink (O)
3-F
|
To prevent cross contamination. It is recommended that disinfectant handwipes 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.
|
RADIOLOGY/X-RAY UNIT
|
STANDARD 4 return to top
|
License Posted - Expiration Date (O)
4-A
|
When there is an x-ray machine on the premises, the license must be posted in the facility near the x-ray machine.
|
RH-100 Form Posted (O)
4-B
|
An RH-100 form needs to be posted near the x-ray unit.
|
Registration Tag on Control Panel (O)
4-C
|
The Registration tag must be located on the control panel of the machine.
|
Part 5 of Ionizing Rules (O)
4-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.
|
Warning Signs for Pregnant Women (PH)
4-E
|
Priority Health recommends that a warning sign for pregnant women be posted near the x-ray machine.
|
PCP - % of X-Rays Overread (O)
4-F
|
The State of Michigan recommends that a percentage of x-rays be overread by a radiologist.
|
LABORATORY
|
STANDARD 5 return to top
|
License Posted with Expiration Date (C)
5-A
|
Offices performing laboratory tests must be licensed by the State of Michigan. The CLIA license may be posted or placed in a file where it is readily accessible.
|
Lab Reagents Current (C)
|
All lab reagents must be checked regularly to prevent the use of reagents that are beyond the manufacturer's known effective date.
|
PHARMACY/MEDICATIONS
|
STANDARD 6 return to top
|
Medications Stored Away from Patient Care Areas (except Local Anesthetics) (O)
6-A
|
All medications (except for injectable local anesthetic agents) must be stored away from patient care areas to ensure patient safety.
|
Sample Medications Dispensed Intact (O)
6-B
|
Only physicians licensed by the State Board of Pharmacy may dispense and/or repackage medications. All sample medications must be dispensed intact.
|
All Medications/Emergency Medications are Current (O)
1. Expiration dates checked monthly
2. Monthly log maintained
6-C
|
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 monthly for expiration dates. It is recommended that a medication review log be used to ensure that this activity is routinely performed.
|
Narcotics Double-Locked (O)
1. Sign-out sheet
2. Restricted access to keys
6-D
|
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.
|
Medications Requiring Refrigeration are Refrigerated (O)
6-E
|
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.
|
Thermometer in Refrigerator (O)
6-F
|
The optimal temperature for medications that require refrigeration is 36º-46º Fahrenheit or 2º-8º Centigrade. A thermometer should be placed in the refrigerator and a daily log maintained to monitor adequate temperature control.
|
Varivax - Thermometer in Freezer (O)
6-F
|
The manufacturer's temperature guidelines for storing Varivax are +5º F (-15º C) or colder. A thermometer should be placed in the freezer and a daily log maintained to monitor adequate temperature control.
|
Medications Only in Refrigerator/Freezer (O)
6-H
|
To prevent cross-contamination, food and medications must never be stored in the same refrigerator.
|
Prescription Pads/Syringes Stored Away from Patient Care Areas (O)
6-I, J
|
Prescription pads and syringes need to be stored away from patient care areas to eliminate the potential for theft and illicit use.
|
BIOMEDICAL WASTE
|
STANDARD 7 return to top
|
Medical Waste Plan Pesent (O)
7-A
|
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.
|
Employee Access to Medical Waste Plan (O)
7-B
|
The medical waste plan must be readily accessible.
|
Syringes Disposed Of in Puncture-Proof Containers (O)
7-C
|
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 Bagged & Labeled (O)
7-D
|
Medical waste needs to be disposed of in a covered container or bag that is
color-coded or labeled.
|
EQUIPMENT/STERILIZATION
|
STANDARD 8 return to top
|
Thermometers (O)
1. Glass
2. Disposable
3. Electronic/Digital
4. Cleaning Method/Storage Acceptable
8-A
|
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.
|
Vaginal Speculums (O)
1. Metal
2. Cleaning Method/Storage Acceptable
3. Disposable
8-B
|
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 (O)
1. Disposable
2. Reusable
3. Cleaning Method/Storage Acceptable
8-C
|
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.
|
Autoclave Supplies/Instruments Have Date on Package (O)
1. Monthly Spore Check Documented
2. Weekly Spore Check Documented
3. Heat-Sensitive Indicators Used
8-D
|
Autoclaved supplies can be marked with either the date of sterilization OR the date of expiration, for time frames specified by individual office policy. Autoclaved supplies must be checked regularly for expiration of sterility. 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.
A live spore test must be done at least monthly and immediately after servicing. Priority Health, however, recommends weekly spore checks to ensure consistent sterilization. A record of spore tests must be maintained for one year.
Heat sensitive indicators must be used every time the autoclave is used. Results of the heat strip indicators should be documented at least weekly. A record must be maintained for one year.
|
Separate Clean/Dirty Work Areas (O)
8-E
|
A distinction must be made between clean and dirty work areas to prevent cross-contamination.
|
Instrument Disinfectant Labeled with:
1. Type of Solution
2. Date Solution Last Changed/Needs to be Changed
(O)
8-F
|
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.
|
BLOOD/BODY FLUID
|
STANDARD 9 return to top
|
Employees Involved in Direct Patient Care Have Been Offered the Hepatitus B Vaccine at No Charge (O)
9-A
|
Hepatitis B vaccines must be provided for employees who are at risk. If the employee declines the Hepatitis B vaccines, a signed declination form must be on file.
|
Written Exposure Control Plan (O)
9-B
|
To comply with OSHA's bloodborne pathogen standard, offices must develop a written exposure control plan detailing who in the office is at risk for exposure to blood- borne pathogens, how to protect staff and patients from exposures, what to do in case of exposures, etc. Also, any training related to this OSHA standard must be documented. OSHA resource www.OSHA.gov.
|
Documentation of Annual Employee Training (O)
9-C
|
To comply with OSHA's bloodborne pathogen standard, offices must perform and document annual employee training.
|
Universal Precautions (O)
9-D
|
Universal precautions should always be followed for the protection of patients
and staff.
|
Gloves Worn During Blood/Body Fluid Handling (O)
9-E
|
Universal precautions should always be followed for the protection of patients
and staff.
|
Safety Glasses/Face Masks/Gowns Available (O)
9-F
|
To comply with OSHA's bloodborne pathogen standard, gloves, face masks, gowns and safety glasses should be available to staff. Personal protection equipment decreases the risk of exposure to blood and body fluids.
|
MSDs Sheets for Non-Household Items (O)
9-G
|
Material Safety Data Sheet (MSDS) sheets must be obtained for all chemicals used in the office. An MSDS is a form that the supplier or manufacturer of a product must provide, upon request, describing the hazards of the product.
|
Hazardous Chemicals are Labeled (O)
9-H
|
All containers of hazardous chemicals must be labeled to identify, for employees, the contents in the container. Appropriate use and cautions can then be employed.
|
Laundry Handled Appropriately (O)
9-I
|
OSHA prohibits employees from taking laundry home. Laundry must be done at the office or by a laundry service that has been contracted by the employer.
|
MISCELLANEOUS
|
STANDARD 10 return to top
|
Signature Register (O)
10-A
|
If initials are used instead of signatures in medical records, a signature register needs to be kept on file to readily identify clinicians by their initials.
|
Quality of Care Issues Addressed (A, J)
10-B
|
To correct aspects of care that would put a patient at risk or deprive them of care.
|
Quality of Care Issues/Actions Documented and Reported Appropriately (A, J)
10-C
|
To correct aspects of care that would put a patient at risk or deprive them of care.
|
URGENT CARE CENTERS
|
STANDARD 11 (see separate page)
|
ACCESS/AVAILABILITY
|
STANDARD 12 return to top
|
Emergency Care (N)
12-A
|
Within 24 hours or less, depending on the nature of the illness.
|
Urgent Care (N)
12-B
|
Within 2 business days*
|
Symptomatic Non-Urgent Care (N)
12-C
|
Within 4 business days
|
Routine Care (N)
12-D |
Within 14 business days (excludes annual physicals)* |
Preventive/Wellcare (N)
12-E
|
Within 90 business days*
|
Waiting Time in Office, Established Patients (N)
|
Within 20 minutes (average)
|
After-Hours Availability (N)
12-F
Random Phone Call (N)
12-G
|
Primary Care Physicians
Article II, section 2.1-A of the Physician's Agreements and Obligations states that as a Primary Care Physician you "shall be accessible by telephone or otherwise to Members, either personally or through back-up coverage from other Participating Providers twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365) days per year in accordance with the Member's Plan."
Specialty Care Physicians
Article II, section 2.1-B of the Physician's Agreements and Obligations states that as a Specialty Care Physician you "will provide Medically Necessary Covered Services within his or her designated specialty for a Member upon referral from a Primary Care Physician and shall be accessible by telephone or otherwise to Members, twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365) days per year in accordance with the Member's
Plan."
|
