HEALTHCARE JOINT COMMISSION COMPLIANCE CHECKLIST

Created by ChecklistGuro (https://checklistguro.com)

--- PATIENT SAFETY IDENTIFICATION AND PREVENTION OF HARM ---
[ ] Patient Identification Verification Method (Two Unique Identifiers, Barcode Scanning, Photo Identification)
[ ] Fall Risk Score
[ ] Allergies Documented? (Yes, No, NKDA (No Known Drug Allergies))
[ ] Last Fall Risk Assessment Date
[ ] Nurse Signature - Patient ID Verification
[ ] Detailed Description of Patient Education Provided (e.g., Fall Prevention)
[ ] Medication Reconciliation Complete? (Yes, No)
[ ] Relevant Documentation (e.g., Fall Prevention Plan)

--- EMERGENCY MANAGEMENT ---
[ ] Last Disaster Drill Participants
[ ] Last Disaster Drill Date
[ ] Drill Start Time
[ ] Drill Debriefing Notes
[ ] Disaster Plan Document
[ ] Emergency Contact Person (Administrator, Medical Director, Safety Officer)
[ ] Emergency Assembly Point
[ ] Emergency Communication Methods (Phone, Email, Public Address System, Two-Way Radios)
[ ] Date of Next Disaster Drill

--- ENVIRONMENT OF CARE ---
[ ] Fire Alarm System Test Frequency (Months)
[ ] Last Fire Safety Inspection Date
[ ] Hazardous Materials Present? (Chemicals, Medical Gases, Radioactive Materials)
[ ] Location of Fire Extinguishers
[ ] Description of Emergency Power Generator Maintenance Log
[ ] Ventilation System Functionality (Optimal, Needs Adjustment, Malfunctioning)
[ ] Fire Safety Plan Document
[ ] Time of Last Sprinkler System Inspection

--- LEADERSHIP ---
[ ] Number of Ethics Committee Meetings Held Annually
[ ] Last Ethics Committee Review Date
[ ] Ethics Hotline Availability (24/7, Business Hours, Limited Hours) (24/7, Business Hours, Limited Hours)
[ ] Summary of Key Leadership Decisions Regarding Compliance
[ ] Annual Compliance Training Documentation
[ ] Leadership Commitment to Patient-Centered Care (Scale 1-5) (1, 2, 3, 4, 5)
[ ] CEO Commitment to Compliance Program

--- HUMAN RESOURCES ---
[ ] Number of Active Employees
[ ] Last Credentialing Review Date
[ ] Background Check Policy Adherence (Fully Compliant, Partially Compliant, Not Compliant)
[ ] Required Employee Training Modules Completed (HIPAA Privacy, Patient Safety, Emergency Preparedness, Cultural Competency, Cybersecurity Awareness)
[ ] Next Employee Performance Review Due Date
[ ] Summary of Recent HR Policy Updates
[ ] Employee Training Records (Sample)

--- MEDICAL STAFF SERVICES ---
[ ] Physician Signature (Credentialing Verification)
[ ] Credentialing Verification Expiration Date
[ ] Number of Physician Privileges Granted
[ ] Physician Supervision Level (Direct, Indirect, General, Limited, None)
[ ] Clinical Areas of Competency (Cardiology, Neurology, Pediatrics, Surgery, Oncology)
[ ] Last CME Completion Date
[ ] Summary of Peer Review Performance

--- CLINICAL PERFORMANCE IMPROVEMENT ---
[ ] Number of Process Improvement Projects Initiated
[ ] Number of Process Improvement Projects Completed
[ ] Summary of Key Performance Indicators (KPIs) Tracked
[ ] Date of Last Performance Review Meeting
[ ] Data Sources Used for Performance Measurement (Electronic Health Records (EHR), Patient Satisfaction Surveys, Clinical Registries, Incident Reporting System)
[ ] Description of Corrective Actions Implemented based on Performance Data
[ ] Overall Assessment of Clinical Performance Improvement Efforts (Excellent, Good, Fair, Needs Improvement)
[ ] Supporting Documentation (e.g., Performance Reports, Action Plans)

--- INFORMATION MANAGEMENT ---
[ ] Data Encryption Method (AES-256, TLS 1.2, Other (Specify in Long Text))
[ ] Detailed Description of Data Security Policies
[ ] Frequency of Data Backup (in days)
[ ] Last Security Risk Assessment Date
[ ] Access Control Method (Role-Based, Attribute-Based, Other (Specify in Long Text))
[ ] Supporting Documentation (e.g., Security Audit Reports)
[ ] Data Types Protected by HIPAA (Demographic Data, Medical Records, Payment Information, Other (Specify in Long Text))

--- MEDICATION MANAGEMENT ---
[ ] Medication Reconciliation Completed? (Yes, No, Not Applicable)
[ ] Last Medication Reconciliation Date
[ ] Number of Medication Discrepancies Identified
[ ] Description of Medication Discrepancies (if any)
[ ] High-Alert Medications Verified? (Yes, No, N/A)
[ ] Routes of Administration Verified? (Oral, IV, IM, Subcutaneous, Topical)
[ ] Time of Medication Administration
[ ] Pharmacist Signature

--- INFECTION PREVENTION AND CONTROL ---
[ ] Last Environmental Cleaning Date
[ ] Hand Hygiene Compliance Observed (Last Audit) (Excellent, Good, Fair, Poor)
[ ] Number of HAIs (Healthcare-Associated Infections) Reported This Month
[ ] Isolation Precautions Currently in Use (Contact, Droplet, Airborne, None)
[ ] Description of any recent infection control breaches or incidents
[ ] Supporting Documentation (e.g., audit reports, cleaning logs)

--- COMMUNICATION AND TEAMWORK ---
[ ] Team Handoff Communication Method (Verbal, Written, Electronic Health Record, Video Conference)
[ ] Number of Inter-Departmental Meetings Held Monthly
[ ] Last Team Conflict Resolution Training Date
[ ] Summary of Recent Team Communication Challenges
[ ] Communication Tools Utilized by the Team (Email, Instant Messaging, Project Management Software, Video Conferencing, Phone)
[ ] Team's Perceived Level of Psychological Safety (Very High, High, Moderate, Low, Very Low)
[ ] Contact Person for Communication Issues

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