Title Page

  • Conducted on

  • Prepared by


Safety Management

  • - Compressed gas cylinders properly secured, categorized full vs empty, and do not exceed q’ty limits

  • - Flammable liquids properly stored

  • Flooring/Ceiling Surfaces are intact, undamaged, and free of stains

  • - Chemicals labeled and properly stored

  • - Walking surfaces in good repair

  • - Tripping hazards are not present

  • - Adequate precautions taken during remodeling or construction

  • - Radiation, laser, biological hazards clearly identified

  • Pt care and medication refrigerators are labeled, clean, and logs current

  • Pt foods are dated and within expiration ranges

  • Cabinets under sinks are clean and not used for storage

  • Proper hand hygiene is followed

Fire Safety Management

  • - Fire doors, pull stations, and egress routes are clear

  • Trash/Linen Chutes are secured and properly close & latch

  • - Storage at least 18” below sprinkler heads

  • Stored supplies are elevated off the floor with solid shelving

  • - Fire extinguishers inspected monthly

  • Fire Extinguishers are mounted properly and at within appropriate heights

  • Sprinkler heads are clean and unobstructed

  • Fire doors latch and close properly w/ < 1/8” gap

  • - Patient rooms doors close and latch properly

  • - Satisfactory housekeeping/sanitation

  • - Exhaust ventilation system functioning

  • - Stairway, ramps, handrails in good condition, free of obstacles and storage

  • - No flammable decorations

  • - No doors propped open

  • - Electrical panels are closed, latched, and unobstructed

  • Hand foam canisters are within expiration date


  • - Personal belongings secure

  • - Medication room secure

  • - Co-workers wearing identification badges

  • Staff can explain security process for forensic patients

  • Access control properly functions

  • Staff can explain their role in an infant abduction

Hazmat & Waste

  • Staff can demonstrate SDS

  • Hazardous waste is properly stored

  • Janitors closets are secured

  • Eyewash station is current on logs

  • There is appropriate PPE in area

Infection Control

  • - Soiled linen covered and not overflowing

  • Medical equipment is clean (sticker free) and in good repair

  • - Sharps containers not overfilled

  • Clean utility is segregated from dirty

  • Proper Air pressure is maintained

Utilities Management

  • - Lights in good working order

  • - Extension cords not in use for permanent power

  • - Multistrip outlets are hospital-grade

  • - Air supply and returns clean

  • - Medical gas zone valves in good condition, properly labeled, clean, and unobstructed

  • - Emergency lighting for exit signs operable and arrows pointed correctly

  • - Air pressure relationships are correct (clean rooms are positively pressured, dirty rooms are negative)

HIPPA Concerns

  • - Inappropriate staff discussion of PHI overheard in area

  • - Documents containing PHI concealed from public access and view

  • - Pt info boards include minimum pt information

Water Management Optional

  • Water Sample Location 1

  • Temperature

  • Water Sample Location 2

  • Temperature

  • Water Sample Location 3

  • Temperature

  • Water Sample Location 4

  • Temperature

  • Water Sample Location 5

  • Temperature

Other Deficiencies Noted

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.