Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Mat-Su Regional Medical Center
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Physical Environment & Infection Control Rounds - Food Services 2013
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EC.04.01.01.14.a
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Surveyed By:
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Surveyed By:
FOOD SAFETY
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Food and food storage temperatures:
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A) Are all foods dated and labeled?
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B) Are steam table temperatures within parameters as indicated on the log sheet?
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C) Are refrigerators and freezers within parameters as indicated on the log sheet?
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D) Are dish machine temperatures within parameters as indicated on the log sheet?
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E) Is adequate follow-up documentation shown on the log sheet when ranges are outside of parameters?
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F) Does the department have a current state or county license?
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G) Was there a inspection by the state within the last 18 months?
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H) Were all deficiency corrected per last inspection?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
FIRE SAFETY MANAGEMENT
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Are the means of egress corridors/exit doors:
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A) Clearly and correctly marked for EXIT, including when fire doors are closed?
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B) Are lights in exit signs functional?
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C) Clear of any obstructions/equipment?
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D) Are doors in and around the kitchen that can be confused for an exit marked, NOT AN EXIT?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are all fire extinguishers:
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A) Clearly marked for identification and installed at correct height (maximum of sixty inches)?
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B) Inspection tags current? (monthly and annual)
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C) Safety seals intact and in place?
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D) Accessible, with three foot clearance in all directions?
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E) Within seventy five feet in any direction in the area?
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F) Is there a K-Type fire extinguisher located within 30 feet of grease producing equipment?
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G) Is the kitchen hood system free of grease build-up?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are the fire alarm pull stations:
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A) Accessible, with three foot clearance in all directions?
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B) In good condition, free from tampering and glass bar in place where applicable?
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C) In the manual pull station for the kitchen hood suppression systems conspicuously labeled for staff?
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are combustible materials: cardboard, boxes, paper, linen, wastes)
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A) Stored in proper containers? (32 gallons or less)
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B) Kept to a minimum for daily use in department?
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C) Properly labeled and identified?
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D) Are alcohol-based hand rubs properly mounted from electrical devices? ( 6in from center)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Fire Building Systems, components and Safety Practices:
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A) Are all doors free from being propped, wedged or held open in any way?
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B) Are all doorways clear to close properly?
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C) Is the area free from any evidence of smoking in the area?
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D) Are fire doors labeled properly and free of paint?
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E) Do fire and stairwell doors latch positively and maintain closure?
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F) Are stairwells free of storage and penetrations?
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G) Do door coordinators function properly where installed?
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H) Are all doors physically in good condition to prevent the spread of smoke or fire?
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I) Is there at least 18in.; clearance between storage and sprinkler heads?
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J) Are escutcheons in place on sprinkler heads and are they clean and free of debris?
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K) Is the area free from portable heaters and heating devices? (Per CHS Policy)
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L) Are furnishing and decorations fire-rated?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
SAFETY MANAGEMENT
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Are the floors in hallways:
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A) In good physical condition?
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B) Clean and dry?
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C) Free from trip/fall hazards?
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D) Wet floor signs used properly?
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E) Carpet free of wrinkles or tears?
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F) Free from obstruction? ( wires/cords etc.)
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G) Are the Emergency Procedures flip charts easily accessible?
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H) Are all guards on equipment? i.e. - Slicer and Mixer
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I) Equipment and staff to pass with adequate clearance?
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J) Are floors clear and slip-resistant finishes in place?
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K) Are staff wearing slip-resistant shoes?
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L) Are all drain covers in-place?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are the walls:
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A) Painted and in good physical condition? (Free of holes or water damage)
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B) Free from exposed wiring of any kind?
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C) Are electrical covers/plates in place and in good condition?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are ceiling tiles:
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A) In place and in good condition?
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B) Free of dirt, mold, dust and stains?
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C) Free from evidence of water stains?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
INFECTION CONTROL MANAGEMENT
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Infection Control Practices:
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A) Are clean utensils and cookware protected from contamination?
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B) Are emergency showers and eye washes tested?
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C) Are cardboard boxes off the floor, with no corrugated shipping containers present?
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D) Is there evidence of BLOOD BORNE PATHOGEN PRECAUTION procedures in place? (gloves, masks, gowns, separation of waste, etc.)
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E) Is personal protective equipment readily available for use?
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F) Are the cabinets under the sinks free from storage of clean supplies/equipment?
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G) Are all sharps storage areas kept locked at all times?
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H) Have all product recalls been corrected by department?
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I) Are floors, fixtures and equipment in clean condition?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
HAZARDOUS MATERIAL AND WASTE MANAGEMENT
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Hazardous chemicals used in the area:
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A) Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc.)
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B) Labeled correctly?
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C) Disposed of correctly? (Are there procedures for disposal?)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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MSDS Manual in the Area:
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A) Has the department chemical inventory been updated within the past 12 months?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
UTILITY MANAGEMENT
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Are emergency power outlets:
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A) Clearly marked by red covers and outlets?
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B) Being used for critical equipment only?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Electrical, Steam and Gas:
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A) Is the main gas valve for the kitchen conspicuously labeled for staff?
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B) Are steam systems in proper working order, free from leaks and corrosion?
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C) Is the steam piping effectively insulated to protect staff from potential burns?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Electrical panels and devices:
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A) Are breakers in distribution panels labeled?
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B) Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?
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C) Are all covers free from damage & securely in place?
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D) Are dinning areas provided with tamper-resistant outlets?
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E) In the area free of extension cords and multi plug-in outlet strips?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
SECURITY MANAGEMENT
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SECURITY
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A) Are all employees wearing identification badges in plain view?
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B) ) Are all computers that are not in use - logged out?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
HAZARDOUS AREAS - (LS 19.3.5.4)
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HAZARDOUS AREAS
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Are Dry Storage Rooms:
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A) Secure, neat and orderly?
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B) Free of storage?
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C) Do all doors have closures?
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D) Do all doors positively latch?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Soiled Utility Rooms and Storage Rooms >50 Square Feet (Example 5X10)
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A) Clean, neat and orderly?
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B) Items stored greater than 18 inches from fire sprinklers, unless fixed shelving against the wall?
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C) Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?
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D) Do doors to Hazardous Areas have automatic closers?
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E) Do doors to corridors and rated rooms positively latch?
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Deficiency
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Responsible Person for Addressing Deficiency:
STAFF QUESTIONS: 1 (Must Interview a minimum of one staff member)
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Staff Member Job Title:
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FIRE SAFETY MANAGEMENT
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A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate
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B) How do you alert everyone that there is a fire? ( Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box)
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C) What is the K type extinguisher used for? (Grease fire).
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SAFETY MANAGEMENT
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A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)
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B) What equipment should employees wear while caring for T.B. patients? ( N95 Mask or Orange Duck Bill or PAPR)
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C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)
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D) 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)
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HAZARDOUS MATERIALS & WASTE:
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A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)
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B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)
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C) Can staff explain the code for a large HazMat spill? (Code Orange)
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SECURITY:
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A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)
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B) Can staff explain their role to get help with an uncontrollable person? ( Dial 6999 and have operator call a Code Strong)
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C) Can staff explain where to go and what to do when a Code Pink is called? (Should know what exit their department is assigned to cover during a Code Pink.)
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EMERGENCY MANAGEMENT:
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A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)
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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)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
STAFF QUESTIONS: 2
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Staff Member Job Title:
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FIRE SAFETY MANAGEMENT
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A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)
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B) How do you alert everyone that there is a fire? ( Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box)
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C) What is the K type extinguisher used for? (Grease fire).
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SAFETY MANAGEMENT
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A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)
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B) What equipment should employees wear while caring for T.B. patients? ( N95 Mask or Orange Duck Bill or PAPR)
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C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)
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D) 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)
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HAZARDOUS MATERIALS & WASTE:
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A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)
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B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)
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C) Can staff explain the code for a large HazMat spill? (Code Orange)
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SECURITY:
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A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)
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B) Can staff explain their role to get help with an uncontrollable person? ( Dial 6999 and have operator call a Code Strong)
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C) Can staff explain where to go and what to do when a Code Pink is called? (Should know what exit their department is assigned to cover during a Code Pink.)
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EMERGENCY MANAGEMENT:
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A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)
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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)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Comments/Observations
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Department Director or Representative:
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Lead Surveyor:
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