AHS Regulatory Survey Sweep List

• Conducted on

  Date

• Prepared by

• Campus Location

EOC Exits & Egress; Medication Room

• All Staff must wear name badges with photo ID visible above waist

  Yes

  No

  N/A

  Not Reviewed

• Egress is clear. Exit doors are not blocked and clear of clutter

  Yes

  No

  N/A

  Not Reviewed

• Hallways clear with all equipment parked on one side or in alcoves

  Yes

  No

  N/A

  Not Reviewed

• Fire rated doors must latch & close properly

  Yes

  No

  N/A

  Not Reviewed

• No flammable items on fire rated doors

  Yes

  No

  N/A

  Not Reviewed

• Medical gas shutoff valves, fire extinguishers, and alarm pull stations are not blocked.

  Yes

  No

  N/A

  Not Reviewed

• Nothing stored under sink throughout unit

  Yes

  No

  N/A

  Not Reviewed

• No doorstops used or doors propped open

  Yes

  No

  N/A

  Not Reviewed

• No overfilled sharps containers throughout the unit (replace when ¾ full)

  Yes

  No

  N/A

  Not Reviewed

• Patient Health Information (PHI) protected from public view

  Yes

  No

  N/A

  Not Reviewed

• No food or beverages in patient care areas or nurse’s stations

  Yes

  No

  N/A

  Not Reviewed

• All Pt. equipment labeled with clinical engineering sticker & current PMs

  Yes

  No

  N/A

  Not Reviewed

• Overall cleanliness of unit (floors, walls, clutter, dust)

  Yes

  No

  N/A

  Not Reviewed

• No unattended meds on Pyxis, WOWs, or throughout the unit

  Yes

  No

  N/A

  Not Reviewed

• All insulin or multi-use vials are dated w/discard date in 28 days

  Yes

  No

  N/A

  Not Reviewed

• Med Room: Med Room locked with access for authorized personnel only

  Yes

  No

  N/A

  Not Reviewed

• Med Room: Med Prep areas are clean, uncluttered and separated from other areas

  Yes

  No

  N/A

  Not Reviewed

• Pill cutters are individual use only. Must be labeled with patient name

  Yes

  No

  N/A

  Not Reviewed

• Medication refrigerator and freezer temperatures logged and documented daily

  Yes

  No

  N/A

  Not Reviewed

• Med Room check for expired medications and supplies

  Yes

  No

  N/A

  Not Reviewed

Waived Testing and Infection Control Practices:

• All employees wearing universal COVID mask, covering mouth and nose

  Yes

  No

  N/A

  Not Reviewed

• All employees have been screened according to COVID employee screening guidelines (wearing current date's sticker)

  Yes

  No

  N/A

  Not Reviewed

• Infection Prevention: Contact Precaution sign posted and isolation cart placed outside of room

  Yes

  No

  N/A

  Not Reviewed

• Waived Testing: Glucometer cleaned. Controls and Strips dated w/date opened/expiration date: Toss after 90 days

  Yes

  No

  N/A

  Not Reviewed

• Hand gel stocked in all dispensers

  Yes

  No

  N/A

  Not Reviewed

• No gloves, booties, hanging face masks while in hallway or public areas

  Yes

  No

  N/A

  Not Reviewed

• No open Sani-Cloth containers

  Yes

  No

  N/A

  Not Reviewed

• Hand hygiene performed when staff entering & exiting patient rooms

  Yes

  No

  N/A

  Not Reviewed

EVS, Clean and Soiled Utility Rooms ( C and S)

• EVS/Housekeeping closet, clean and soiled utility doors are closed and secured (not propped open)

  Yes

  No

  N/A

  Not Reviewed

• C: Linen carts must be covered and have solid bottoms throughout the unit

  Yes

  No

  N/A

  Not Reviewed

• C: No supplies stored on the floor. Must be on pallets or wire shelving with solid bottom

  Yes

  No

  N/A

  Not Reviewed

• C: No corrugated shipping boxes. Remove immediately

  Yes

  No

  N/A

  Not Reviewed

• C: O2 tanks are stored upright in the holder. Full (>2000PSI) and empty O2 tanks are separated with signage

  Yes

  No

  N/A

  Not Reviewed

• C: Check for expired medications and or supplies throughout the unit

  Yes

  No

  N/A

  Not Reviewed

• C & S: No supplies stored within 18 inches from the bottom of the sprinkler head

  Yes

  No

  N/A

  Not Reviewed

• S: No clean supplies or clean equipment to be stored in the soiled utility room

  Yes

  No

  N/A

  Not Reviewed

• S: No storage of patient personal belongings

  Yes

  No

  N/A

  Not Reviewed

• S: Floors are clutter free, allowing access to sink, hopper, and door

  Yes

  No

  N/A

  Not Reviewed

• S: Approved enzymatic gel/ instrument cleaning supplies in room (if applicable)

  Yes

  No

  N/A

  Not Reviewed

• S: Instruments in red biohazard bins are wet (sprayed) and in open position

  Yes

  No

  N/A

  Not Reviewed

• S: Hazardous waste containers are closed/covered and labeled with biohazard sticker on lid and 3 sides of container

  Yes

  No

  N/A

  Not Reviewed

• S: Equipment requiring cleaning or services must be clearly marked

  Yes

  No

  N/A

  Not Reviewed

• Time outs are performed for all required invasive procedures; total team participation with active pause

  Yes

  No

  N/A

  Not Reviewed

• Medications are labeled when removed from the original manufacturer container

  Yes

  No

  N/A

  Not Reviewed

• Patient Consent, completed H&P on file in the medical record prior to start of procedure

  Yes

  No

  N/A

  Not Reviewed

• Required PPE is worn by all staff in procedure rooms/ ORs

  Yes

  No

  N/A

  Not Reviewed

• All PPE except head coverings (e.g. bonnets, skull caps) removed when going outside procedural areas – no booties in hall; gloves are removed upon exit

  Yes

  No

  N/A

  Not Reviewed

• General cleanliness; no extra linen / supplies out in the open

  Yes

  No

  N/A

  Not Reviewed

• All syringes/meds/specimens must be secured and attended by authorized individuals

  Yes

  No

  N/A

  Not Reviewed

• Pre Anesthesia documentation complete include ASA level and/or appropriate assessment

  Yes

  No

  N/A

  Not Reviewed