Audit

Mat-Su Regional Medical Center

Physical Environment & Infection Control Rounds - Non-Clinical Areas -Business Occupancy 2013

EC.04.01.01.14.a

Surveyed By:

Surveyed By:

FIRE SAFETY MANAGEMENT

Are the means of egress corridors/exit doors:

A) Clearly and correctly marked for EXIT, including when fire doors are closed?

B) Are lights in exit signs functional?

C) Clear of any obstructions/equipment?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are all fire extinguishers:

A) Clearly marked for identification and installed at correct height (maximum of sixty inches)?

B) Inspection tags current? (monthly and annual)

C) Safety seals intact and in place?

D) Accessible, with three foot clearance in all directions?

E) Within seventy five feet in any direction in the area? (main corridors only)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are the fire alarm pull stations:

A) Accessible, with three foot clearance in all directions?

B) In good condition, free from tampering and glass bar in place where applicable?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are combustible materials: cardboard, boxes, paper, linen, wastes)

A) Stored in proper containers? (32 gallons or less)

B) Kept to a minimum for daily use in department? (no over flowing containers)

C) Properly labeled and identified?

D) Are alcohol-based hand rubs properly mounted from electrical devices? (6 inch's from the center)

E) Kept in a safe and acceptable location?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Fire Building Systems, components and Safety Practices:

A) Are all doors free from being propped, wedged or held open in any way?

B) Are all doorways clear to close properly?

C) Are escutcheons in place on sprinkler heads and are they clean and free of debris?

D) Do fire and stairwell doors latch positively and maintain closure?

E) Are all doors physically in good condition to prevent the spread of smoke or fire?

F)Are portable heaters being using ? (Heaters must have hospital inventory sticker)

G) Is the area free from any evidence of smoking in the area?

H) Are furnishing and decorations fire-rated?

I) Is there at least 18 inches; clearance between storage and sprinkler heads?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

SAFETY MANAGEMENT

Are the floors in hallways:

A) In good physical condition?

B) Clean and dry?

C) Free from trip/fall hazards?

D) Wet floor signs used properly?

E) Carpet free of wrinkles or tears?

F) Free from obstruction? ( wires/cords etc.)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are the walls:

A) Painted and in good physical condition? (Free of holes or water damage)

B) Free from exposed wiring of any kind?

C) Are electrical covers/plates in place and in good condition?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are ceiling tiles:

A) In place and in good condition?

B) Free of dirt, mold, dust and stains?

C) Free from evidence of water stains?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

INFECTION CONTROL & RISK MANAGEMENT

Infection Control Practices:

A) Are refrigerators labeled to identify - Patient; Staff; Medication; use?

B) Are cardboard boxes off the floor, with no corrugated shipping containers present?

C) Is personal protective equipment readily available for use?

D) Are the cabinets under the sinks free from storage of clean supplies/equipment?

E) Have all product recalls been corrected by department?

F) Are floors, fixtures and equipment in clean condition?

G) Are emergency showers and eye washes tested?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

HAZARDOUS MATERIAL AND WASTE MANAGEMENT

Hazardous chemicals used in the area:

A) Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc.)

B) Labeled correctly?

C) Disposed of correctly? (Are there procedures for disposal?)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

MSDS Manual in the Area:

A) Are the department inventory (online) & updated within the past 12 months?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Electrical panels and devices:

A) Are breakers in distribution panels labeled?

B) Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?

C) Are all covers free from damage and securely in place?

D) Are waiting rooms provided with tamper-resistant outlets?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

SECURITY MANAGEMENT

SECURITY

A) Are all employees wearing identification badges in plain view?

B) Are all computer rooms locked?

C) Are all computers that are not in use - logged out?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

EMERGENCY MANAGEMENT

EOP

A) Are the Emergency Procedures charts easily accessible?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

HAZARDOUS AREAS - (LS 19.3.5.4)

Soiled Utility Rooms and Storage Rooms > than 50 Square Feet (Example 5X10)

A) Clean, neat and orderly?

B) Items stored greater than 18 inches from fire sprinklers, unless fixed shelving against the wall?

C) Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?

D) Do doors to Hazardous Areas have automatic closers?

E) Do doors to corridors and rated rooms positively latch?

Deficiency

Responsible Person for Addressing Deficiency:

STAFF QUESTIONS: 1 (Must Interview a minimum of one staff member)

Staff Member Job Title:

FIRE SAFETY MANAGEMENT

A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

B) How do you alert everyone that there is a fire? (Dial 911 and or Pull a fire alarm box)

SAFETY MANAGEMENT

A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

B) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. Examples like PPE)

C) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC/Safety Manual Link)

HAZARDOUS MATERIALS & WASTE:

A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)

B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)

D) Can staff explain what the Code is for a large HazMat spill? (Call 911)

SECURITY:

A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 911)

EMERGENCY MANAGEMENT:

A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

STAFF QUESTIONS: 2 (Must Interview a minimum of one staff member)

Staff Member Job Title:

FIRE SAFETY MANAGEMENT

A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

SAFETY MANAGEMENT

A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

B) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. Examples like PPE)

C) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC/Safety Manual Link)

HAZARDOUS MATERIALS & WASTE:

A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)

B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)

SECURITY:

A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 911)

EMERGENCY MANAGEMENT:

A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Comments/Observations

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Date Corrected:

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