Title Page
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Site conducted
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Conducted on
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Prepared by
Department:
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Safety Management
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- Compressed gas cylinders properly secured, categorized full vs empty, and do not exceed q’ty limits
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- Flammable liquids properly stored
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Flooring/Ceiling Surfaces are intact, undamaged, and free of stains
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- Chemicals labeled and properly stored
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- Walking surfaces in good repair
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- Tripping hazards are not present
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- Adequate precautions taken during remodeling or construction
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- Radiation, laser, biological hazards clearly identified
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Pt care and medication refrigerators are labeled, clean, and logs current
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Pt foods are dated and within expiration ranges
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Cabinets under sinks are clean and not used for storage
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Proper hand hygiene is followed
Fire Safety Management
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- Fire doors, pull stations, and egress routes are clear
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Trash/Linen Chutes are secured and properly close & latch
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- Storage at least 18” below sprinkler heads
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Stored supplies are elevated off the floor with solid shelving
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- Fire extinguishers inspected monthly
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Fire Extinguishers are mounted properly and at within appropriate heights
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Sprinkler heads are clean and unobstructed
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Fire doors latch and close properly w/ < 1/8” gap
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- Patient rooms doors close and latch properly
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- Satisfactory housekeeping/sanitation
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- Exhaust ventilation system functioning
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- Stairway, ramps, handrails in good condition, free of obstacles and storage
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- No flammable decorations
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- No doors propped open
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- Electrical panels are closed, latched, and unobstructed
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Hand foam canisters are within expiration date
Security
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- Personal belongings secure
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- Medication room secure
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- Co-workers wearing identification badges
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Staff can explain security process for forensic patients
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Access control properly functions
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Staff can explain their role in an infant abduction
Hazmat & Waste
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Staff can demonstrate SDS
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Hazardous waste is properly stored
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Janitors closets are secured
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Eyewash station is current on logs
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There is appropriate PPE in area
Infection Control
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- Soiled linen covered and not overflowing
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Medical equipment is clean (sticker free) and in good repair
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- Sharps containers not overfilled
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Clean utility is segregated from dirty
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Proper Air pressure is maintained
Utilities Management
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- Lights in good working order
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- Extension cords not in use for permanent power
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- Multistrip outlets are hospital-grade
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- Air supply and returns clean
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- Medical gas zone valves in good condition, properly labeled, clean, and unobstructed
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- Emergency lighting for exit signs operable and arrows pointed correctly
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- Air pressure relationships are correct (clean rooms are positively pressured, dirty rooms are negative)
HIPPA Concerns
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- Inappropriate staff discussion of PHI overheard in area
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- Documents containing PHI concealed from public access and view
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- Pt info boards include minimum pt information
Water Management Optional
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Water Sample Location 1
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Temperature
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Water Sample Location 2
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Temperature
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Water Sample Location 3
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Temperature
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Water Sample Location 4
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Temperature
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Water Sample Location 5
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Temperature
Other Deficiencies Noted
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