Title Page

  • Conducted on

  • Prepared by

  • Location

HGH ACT

  • EVS cleaning solution on approved list. Near eyewash station is required?

  • Are oxygen tanks secured?

  • Are oxygen tanks stored in correct full/empty designated location?

  • Are negative and positive pressure rooms correct?

  • Are ceiling tiles clean and intact?

  • Are eyewash stations unobstructed? Able to use hands-free?

  • Are electrical panels & pull stations are unobstructed?

  • Are paths of egress unobstructed?

  • Are patient care areas clean, free of debris?

  • Are patient care equipment free of tape residue?

  • Are PM's current?

  • Are supplies current? (Not outdated?

  • Are crash cart logs current and complete? (Issues are addressed?)

  • Are crash cart components clean and ready for use?

  • Are IV medications are discarded correctly?

  • Do IV bags have revised expiration dates written on bag?

  • Are defibrillator pads in packaging and ready for patient use? (i.e. they're secure in packaging)

  • No other areas of non-compliance.

  • Staff Interviewed:

  • Honorable Mentions

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