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					Installation/Activity: Date of Visit: Auditor's Name & Phone #:

Materiel Management

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Question Materiel Management Is the current version of the following publications on hand or readily accessible: AR 190-51

Reference

Date of Checklist: 1/24/2007 Assesed Finding Pos Adv Def JCAHO Yes Def w/ L N/A Remarks

1. 1.1. 1.2. 1.3. 1.4. 1.5. 1.6. 1.7. 1.8. 1.9.

AR 190-51 AR 385-10 AR 385-10 AR 40-61 AR 40-61 AR 700-68 AR 700-68 AR 710-2 AR 710-2 AR 735-5 AR 735-5 AR 740-1 AR 740-1 DA Pam 710-2-1 DA Pam 710-2-1 DA Pam 710-2-2 DA Pam 710-2-2 1.10. SB-8-75-11 SB-8-75-11 1.11. SB-8-75-S3 SB-8-75-S3 1.12. TB 43-0142 TB 43-0142 1.13. USACHPPM MEIS 2. Has a written external SOP been distributed outlining standing supply procedures to be followed by supported activities when requesting, receiving, and turning in supplies and equipment? USACHPPM MEIS AR 40-61 AR 710-2 AR 710-2-1 AR 710-2-2 SB 8-75-11, 3-70 ('06) 3. Is the activity maintaining DA Form 1687 (Notice of Delegation of Authority - Receipt for Supplies) for customers receiving medical supplies and equipment? Is the activity using Defense Medical Logistics Standard Support System (DMLSS) functionality to maintain POC information of the name of the responsible individual listed on the DA Form 1687 (Notice of Delegation of Authority - Receipt for Supplies) in the POC block of the systems services (SVC/CUS) basic tab? SB 8-75-11 3-30c ('06) AR 710-2-1

4.

SB 8-75-11 3-30c ('06) SB 8-75-11 2-4a ('06)

5.

6. 7.

8.

information of the name of the responsible individual listed on the DA Form 1687 (Notice of Delegation of Authority - Receipt for Supplies) in the POC block of the systems services (SVC/CUS) basic tab? Is the activity checking customers, ordering and receiving supplies thru DMLSS, insuring they are correctly loaded in DMLSS and listed on DA Form 1687 (Notice of Delegation of Authority - Receipt for Supplies)? Go to DMLSS online help for adding a role to a user's privileges, Updating user information at users first login, updating your user information through the login process and updating your user information in System Services. Are receipt documents processed within 1 day? Is there a statement of transfer of accountability on hand transferring the account between the out-going and incoming accountable officer? Is a location survey conducted/documented annually?

AR 710-2-1?

SB 8-75-11 3-30c ('06) SB 8-75-11 2-4a ('06)

SB 8-75-11 3-65b ('06)

AR 735-5 5-2a Fig 5–1 & Fig 5-2 2006 SB 8-75-11 AR 710-2, 4-28 b1

9.

Was an annual (or cyclic) inventory conducted?

AR 710-2, 4-28a SB 8-75-11 2-4a ('06)

10.

11.

12.

13.

14.

Are annual (or cyclic) inventories conducted by using DMLSS handheld AIT devices in a manner that assures each item is verified at least annually? Is the location survey (comparing location accuracy with actual physical location of assets) at least 95%? Is the number of lines at zero balance equal to or less than 8 percent of the total stocked lines? Are issue documents (DMLSS Delivery List ) properly signed by the authorized customer as listed on the DA Form 1687 (Notice of Delegation of Authority - Receipt for Supplies)? Note: Initials only are not adequate. Are all IMSA transactions loaded into a logistics information system database (DMLSS/TAMMIS accountable records)? Is the IMSA purchasing items through ECAT? Are equipment requirements reviewed against ECAT as an acquisition source before purchases are made? Is the number of zero balance lines equal to or less that 8 percent of the total stocked lines? Is monthly customer due-out reconciliation conducted in DMLSS with supported customers? Are customers furnished supply status information as received and other status at least monthly?

AR 710-2, 3-24c

SB 8-75-11 3-66b ('06)

SB 8-75-11 3-64a ('06) DA PAM 710-2-1 2-8, 2-9 Fig 2-2 SB 8-75-11 2-30c ('06) AR 40-61 3-7a, b SB 8-75-11 2-3d

15. 16.

OMB 17-05

OMB 17-05 4b

17.

SB 8-75-11 3-64a ('06)

18.

SB 8-75-11 3-31a ('06)

19.

AR 710-2, 4-11f

19.

20.

21.

22.

1.

2.

3.

4.

5.

6. 7.

8.

1.

2.

Are customers furnished supply status information as received and other status at least monthly? Is the activity achieving a 60% e-commerce utilization rate for MEDCENs (70% for MEDDACs)? Does the activity have a Contracting Officer Representative (COR) on appointment orders for the Prime Vendor MedicalSurgical and Pharmaceutical contracts? Is the Commander conducting a semiannual review of the top 20 durable items with the greatest expenditures in the past year? Materiel Management Refrigerator/Freezer Storage Does the MTF SOP require that the alarm system be tested at least monthly and that the documentation of the testing be kept on file? Does the MTF SOP cover all refrigerator/freezer units in the MTF and external facilities such as an Immunizations Clinics and SRP sites? If the storage area where the refrigerator/freezer is located is in a secure area, is there a device installed indicating that the temperature is out of range that can be checked without physically entering the restricted area? Are all refrigerators/freezer storage units connected to emergency or battery powered temperature alarms that are monitored on a 24hr basis? Does the AOD or other designated individual physically check all refrigerator/freezer units at least twice during an evening/weekend shift? Is the emergency contact/notification information listed correctly in the SOP? Is the alarm hardwired to ring at the AOD or appropriate Fire Stations, Provost Marshal Office or other location monitored 24hours/seven days a week? Are alternate storage facilities identified in the SOP with back up power to temporarily store TSMPs? Materiel Management - Hazardous Items/Medical Gases Have designated personnel working with hazardous chemicals received the proper initial training and is it documented with sufficient detail to show the identity of the employee, dates of training, and the means used to verify that the employee understood the training? Is refresher training being given at least every three years?

AR 710-2, 4-11f

OMB 17-05 7a & b

SB 8-75-11 3-61b ('06)

SB 8-75-11, 3-67a ('06)

SB 8-75-11, 3-67a ('06)

SB 8-75-11, 3-67a ('06)

SB 8-75-11, 3-67a ('06)

SB 8-75-11, 3-67a ('06) SB 8-75-11, 3-67a ('06)

SB 8-75-11, 3-67a ('06)

SB 8-75-11, 3-67a ('06)

29 CFR 1910.119 OSHA 2245 29 CFR 1910.119 OSHA 2245

3.

Has a written Oxygen Quality Assurance Program (OQAP) been established?

SB 8-75-11 4-10a ('06)

4.

5.

Do local purchase requests for hazardous chemicals items and nonstandard stock for hazardous chemicals contain contractually required information? Is there an inventory of all hazardous chemicals prepared and posted in a visible location? Are compressed gasses and liquids stored and maintained as prescribed by? Does the OQAP establish written procedures for receipt: quality assurance, testing, and storage of oxygen? Does the OQAP require individuals monitoring oxygen deliveries be designated in writing and receive training in the use of an oxygen analyzer? Does the OQAP require an oxygen concentration for bulk and cylinders of not less than 95 percent? Does the OQAP prescribe actions to be taken and list responsible personnel to notify in the event oxygen deliveries are determined to be less than 95 percent at the time of delivery? Does the OQAP allow for the testing of medical gas alarms system and the actions to be taken when an alarm is activated? Does the OQAP Identify those clinical areas requiring an alternate oxygen supply until the central oxygen supply is restored and functional? Is the concentration, amount, oxygen analysis, test results, and name of individual accepting delivery retained on file for 2 years? Are No Smoking signs posted in those areas where compressed gas is stored? Are flammable gasses being stored separately from oxidizing gasses? Are filled and empty cylinders stored separately? Is there a procedure in effect to properly identify and separate cylinders by gas type as required? Note: Check procedure for identification and separation of cylinders. Are filled medical gas cylinders tagged with DD Form 1191, Warning Tag for Medical Oxygen Equipment?

AR 710-2, 1-30 AR 700-141 7 29 CFR 1910.1200 (e)(1)(i) JCAHO EC.3.10.2

6. 7.

AR 700-68 5-7 through 5-10

SB 8-75-11 4-10 ('06)

8.

9.

SB 8-75-11 4-10a ('06) SB 8-75-11 4-10a ('06) MEDCOM Reg 385-2 8-d

10.

SB 8-75-11 4-10a ('06)

11.

SB 8-75-11 4-10a ('06) 12.

SB 8-75-11 4-10a ('06)

13.

SB 8-75-11 4-10a ('06) AR 700-68 5-10a (1) (b) AR 700-68 5-10b (1) (a) AR 700-68 5-9a

14. 15. 16. 17.

18.

AR 700-68 5-7 a, b, c 1 2 3 SB 8-75-11 4-10b ('06) AR 700-68 2-2 TB MED 245 para 2 & 3

19.

When cylinders are not in use or being transported, are valve protector caps installed?

AR 700-68 5-9-G (6) TB MED 245

20.

Are cylinders of pure ethylene oxide specially identified (DoT Red Flammable Liquid Tag) and are cylinders of gas mixtures of ethylene oxide specifically identified as to mixture? AR 700-68 2-2L & 2-2M Are cylinders protected from dampness, excessive rise in temperature from direct rays of the sun or from other sources of heat not to exceed 125 degrees Fahrenheit? AR 700-68 5-9E Does the bulk liquid oxygen storage container have an outlet that allows access for testing the purity of the oxygen? Is the activity using safe handling methods?

21.

22.

23.

SB 8-75-11 4-10a ('06) SB 8-75-11 4-10b ('06) TB MED 245 1

1.

2.

3. 4.

Materiel Management - Controlled Substance/Security Is an SOP for the activation, deactivation and daily testing of the Intrusion Detection system (IDS) established with instructions for maintaining an accurate IDS Log? Has the commander designated key personnel within the IMSA to sign exempt certificates for the purchase of controlled substances? Are the DEA Registration and order forms on file? Is the DEA Certificate less than three years old? Note: Procedures should be established to maintain security and control of the forms. Is a disinterested officer appointed each month in writing by the hospital commander to conduct the monthly controlled substances inventory/audit. The disinterested officer cannot be a person assigned to logistics or pharmacy. Does the IMSA/MEDLOG Bn/USAMMCE have a copy of the prior month's controlled substances inventory/audit report completed by the disinterested officer? Is a copy of the physical security inspection record on file showing that an inspection has been conducted every 2 years and deficiencies corrected? Are items identified as Note "R" stored in an approved safe or vault with a class 5 vault door? Are containers for Notes "R" and "Q" medical items, or the vault, room or structure in which the containers are located, protected with an IDS? Is there a continuous surveillance of bulk storage facilities where Note "R" and "Q" items are stored provided either by guard personnel or IDS (when duty personnel are not present)? Are vault procedures for lock and key control included in the SOP?

AR 190-13 AR 190-51 4-13 AR 40-61 3-24e SB 8-75-11 3-35b ('06)

SB 8-75-11 3-21 (1)

SB 8-75-11 3-35b ('06) 5.

AR 40-61 3-27 SB 8-75-11 3-35

5.1.

SB 8-75-11 3-35.d.(3)

6.

AR 190-13 2-11b(6)

7.

AR 190-51 4-7, 4-8 & 4-11

8.

AR 190-51 4-6 & 4-13

9.

AR 190-51 4-11 AR 190-51 4-14

10.

10. 11.

Are vault procedures for lock and key control included in the SOP? Is the locking and checking of containers used to store controlled medical substances made a matter of record (SF 702)? Is a Security Container Check Sheet (SF 702) located on the vault door? Is a reversible OPEN-CLOSED sign located on the vault door? Have personnel with assigned duties to access controlled medical substances and medically sensitive items undergone a local files check with the area Provost Marshal and/or other agencies with personal character information? Note: Is the request for a file check on file for all personnel with access and was there a satisfactory files check? Has the HCA Commander appointed the MSO and at least one alternate to serve as the custodian of the controlled medical items (pharmacy officers may be appointed where logistics no longer maintains a functioning vault)? Are precious metals treated as Notes R and Q items, posted to DA Form 1296 in the vault, and inventoried monthly? Is access to storage areas controlled to prohibit entry of unauthorized personnel?

AR 190-51 4-14

AR 190-51 4-11a(2) 12. 13. 14. AR 190-51 4-11 SB 8-75-11 3-36b ('06)

AR 190-51 4-3 AR 190-27

15.

SB 8-75-11 3-36b ('06) AR 40-61 3-26 (1) (2)

16.

17.

SB 8-75-11 3-62 AR 190-51 3-15 (4),(5) JCAHO EC.2.10.6

18. 19.

20.

21.

1.

Are requests for controlled items edited by materiel personnel prior to issue? Are issues of controlled substances made only to the pharmacy or other activities authorized by the MEDCEN/MEDDAC Commander? Are current DA Forms 1687 for Note "R" and "Q" items on hand for all authorized customers and does DMLSS data reflect the same in the System Services/Environmental File? If the IMSA/MEDLOG BN/USAMMCE provides controlled substances storage for TOE or other units located on the installation, is there a plan for accounting for stocks? Materiel Management - DMLSS System Administration Is DMLSS administrator or other designated personnel adding point of contact (POC) information in DMLSS for the following accounts (MA) - Maintenance, (FM) Facilities, (EM) Equipment, (MM) Material, and (LOG) Logistics department?

SB 8-75-11 3-191

SB 8-75-11 3-19

DA PAM 710-2-2 23-27

SB 8-75-11 3-40b

SB 875-11 3-4 3

2.

Is (are) DMLSS Administrator(s) managing and reviewing user accounts, access and logins, and suspending or terminating accounts in accordance with local policy. Is the Activity removing: (a) inactive accounts that exceed 45 days and (b) departing users’ accounts before departure? AR 25–2 3-3a 11 Are DMLSS Administrators performing backups and storing tapes at the MTF (IAW DMLSS Server Backup Procedures, Policy Definition and Guidance). Is DMLSS Administrator of other designated personnel performing a monthly reboot of the DMLSS server? Materiel Management - Excess and Destructions/Quality Control Are suspended items awaiting disposition instructions or destruction identified and stored in a separate area, designated for storage of suspended material and marked with authority for suspension? Is the disposal and destruction of medical materiel accomplished utilizing DMLSS IAW the procedures outlined? Are items coded as hazardous waste (HW/RW) being disposed of , IAW military item disposal instructions and military environmental information source (MIDI/MEIS)? Have local procedures for turn-in to DRMO or DPW been established and is the IMSA managing the turn-in of all medical materiel from the installation and supported activities? Is the amount of excess inventory less than the management level of 15% and being reported to USAMMA? If the IMSA/MEDLOG BN/USAMMCE provides controlled substances storage for TOE or other units located on the installation, is there a plan for accounting for stocks? Are the proper method of destruction codes applied in destruction of materiel and certified by the environmental science/preventive medicine officer? Are written procedures for managing medical material complaints (locally Generated complaints /MMQC messages) incorporated the MEDCEN/MEDDAC Quality Assurance program (QAP)? Are the proper method of destruction codes being used in destruction of material using DMLSS functionality applied?

3.

OMB 01-06

4.

OMB 01-06

1.

SB 8-75-11 4-4 a10

2.

SB 8-75-11 2-4, 3-45 & 4-1 USACHPPM MEIS TB 126

3.

4.

SB 8-75-11 3-45

5.

SB 8-75-11 3-2 & 3-26

6.

7.

SB 8-75-11 3-34 USACHPPM (MEIS) SB 8-75-11 2-4 & 4-1

8.

9.

SB 8-75-11 4-1, 4-2 and 4-8 ('06) the MODF TB 126 SB 8-75-11 2-4 USACHPPM

SB 8-75-S7 10. 11. Is activity using DMLSS functionality to perform quality control/ destruction? Is the Quality Control Clerk registered on the USAMMA website to automatically receive MMQC messages as a back up to DMLSS functionality? Materiel Management Safety/Equipment/Storage/Medical Instrument Recycling Has the Logistics Division established management procedures for a Medical Instrument Recycling Program? Is the plumbed eyewash equipment activated weekly to verify operation and ensure that the flushing fluid is available? Is the Fork Lift load rating and date of the next periodic (within one year) inspection stenciled on the unit? Does the activity perform daily checks (inspection) on Fork Lifts? Are Lifting devices (Pallet Jacks) being tested at least annually?

SB 8-75-11 2-4a ('06)

SB 8-75-11 2-4a and 4-2 ('06)

1.

SB 8-75-11 3-69 ('06)

2.

ANSI Z358.1-2004 5.5.2

3.

TB 43-0142 4a TB 43-0142 App D TB 43-0142 3 a, b, c

4. 5.


				
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