Barrington Life Safety Final Version 3

FACILITY ENTRY & FIRST IMPRESSION

• Date Of Inspection Or Visit

  Date

• While Driving Up / Driving Around / Or Entering The Facility, Was There Anything That Caught Your Attention To Report ( Trash, Safety Concerns , Lights Out etc etc )

  No Concerns

  Concerns

• Are You Satisfied With Your Initial First Impressions Of The Facility ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

LIFE SAFETY DRAWING, YEAR BUILT ETC

• Life Safety Drawings Present ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Year Built

  Date

• How Many Smoke Compartments ?

• Base On Review Of Documentation, Does Documentation's Meet Compliance

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

FIRE ALARM ANNUAL INSPECTIONS

• Fire Alarm Company Name

• Fire Alarm Annual Date

  Date

• Any Discrepancy Found Or Is It In Compliance?….. (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was The Annual Fire Alarm Inspection Discrepancies Corrected And Now In Compliance ?

  Compliant

  Non-Compliant

  N/A

• When Was It Corrected ?

  Date

ALARM DEVICE TESTING

• Verify Proper Location Of Smoke , Heat , Strobes And (CO) Detectors

  Compliant

  Non-Compliant

  N/A

• Are Tamper Switches Being Tested ?

  Compliant

  Non-Compliant

  N/A

• Pull Station Inspected Or Tested ?

  Compliant

  Non-Compliant

  N/A

• Required Documentation Located At The Fire Panel ?

  Compliant

  Non-Compliant

  N/A

• Fire Inspections ( Current At Least Through Past 2 Years )

  Compliant

  Non-Compliant

  N/A

DUCT DETECTOR PRESSURE DIFFERENTIAL ANNUAL TESTING

• Company Name

• Annual Pressure Differential Testing Date

• Duct Detectors Pressure Differential ( Shall Include Factory Parameters And Actual Test Reading), Was This Observed ?

  Compliant

  Non-Compliant

  N/A

• Any Discrepancy Found Or Is It In Compliance?

  Compliant

  Non-Compliant

  N/A

SENSITIVITY TESTING

• Company Name

• Sensitivity Testing Date

• Smoke Sensitivity ( Shall Include Factory Parameters And Actual Test Reading ) , Was This Observed ?

  Compliant

  Non-Compliant

  N/A

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

FIRE ALARM SEMI-ANNUAL

• Company Name

• Fire Alarm Semi-Annual Date

  Date

• Any Discrepancy Found Or Is It In Compliance?…. (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Corrected ?

  Date

ANNUAL SPRINKLER INSPECTION

• Sprinkler Company Name

• Sprinkler Annual Date

  Date

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Fire Inspections ( Current At Least Through Past 2 Years )

  Compliant

  Non-Compliant

  N/A

MISCELLANEOUS INSPECTIONS # 1

• Proper amount of Sprinkler Heads Located in spare box with correct wrench: Y/N ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• List of Sprinkler type(s) installed in spare Sprinkler cabinet: Y/ N ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Revision Date: Listed For Sprinklers In Sprinkler Box ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

ANNUAL BACKFLOW

• Company Name

• Annual Back Flow Date

  Date

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

SPRINKLER SEMI - ANNUAL

• Company Name

• Sprinkler Semi-Annual Date

  Date

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

QUARTERLY SPRINKLER #1

• Company Name

• Quarterly Sprinkler # 1 Date

  Date

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

QUARTERLY SPRINKLER # 2

• Company Name

• Quarterly Sprinkler #2 Date

  Date

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Compliant

  Yes

  Non Compliant

  No

  N/A

5 YEAR HYDROSTATIC/ FDC INSPECTION

• Company Name

• 5yr Hydrostatic FDC Inspection Date

  Date

• FDC Hydrostatic ( Fire Department Connection ) Tested At 150 Psi For Two Hours And Documented On Inspection Report ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

5 YEAR INTERNAL BACKFLOW

• Company Name

• 5 Year Internal BackFlow Date

  Date

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was It Corrected ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

MISCELLANEOUS INSPECTIONS #2

• Annual Dry Partial Trip:

  Compliant

  Non-Compliant

  N/A

• Pre-Action Systems:

  Compliant

  Non-Compliant

  N/A

• Type:

• Date:

• Isolation Valves: Y/N

  Compliant

  Non-Compliant

  N/A

• Reported Discrepancy(s): Y/N

  Compliant

  Non-Compliant

  N/A

• Diesel: Electric: Weekly: Monthly:

• Company:

• Annual Date

• Comapny

• Annual Date

• 3 Year / 5 Year Internal

FIRE HYDRANT INSPECTION

• Public Or Private Hydrant

• Annual Done ? ( Answer YES Or NO Only If It’s A Private Hydrant ), ( If It’s A Public Hydrant Please Select N/A)

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

• 5 Year Hydrant Inspection Including Flow Test / Pressure Testing Done ? (Answer YES Or NO Only If It’s A Private Hydrant ), ( If It’s A Public Hydrant Please Select N/A)

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

HOOD INSPECTION

• Company Name

• Semi Annual Being Done Or In Compliance Within The Last 12 Months ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

• Annual Being Done Or In Compliance Within The Last 12 Months ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

Monthly Kitchen Quick Hood Check

• Monthly Hood Check Been Done ? ( Kitchen Quick Check )

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

HOOD CLEANING

• Company

• Semi Annual Was Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

• Annual Was Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

SMOKING REGULATION QUICK CHECK

• Smoke-Free Building ?

• Smoking Policies Available ? ( A Smoking Policy Is Needed Regardless If It’s A Smoke Free Facility Or Not )

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Meets NFPA 101

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Smoking Area Available ? ( If It’s A Smoke Free Building Then Click N/A )

  Compliant

  Non-Compliant

  N/A

• Ashtrays On Site ( Compliant / Non-Compliant ) ( ( If It’s A Smoke Free Building Then Click N/A )

  Compliant

  Non-Compliant

  N/A

• Permitted Ashtrays ( Are They The Correct Ashtrays As Required By Code ) ? . ( ( If It’s A Smoke Free Building Then Click N/A )

  Compliant

  Non-Compliant

  N/A

• Self Closing Metal Can ? . ( ( If It’s A Smoke Free Building Then Click N/A )

  Compliant

  Non-Compliant

  N/A

• Smoking Aprons Available ?. ( ( If It’s A Smoke Free Building Then Click N/A )

  Compliant

  Non-Compliant

  N/A

• Smoking Blankets Available . ( ( If It’s A Smoke Free Building Then Click N/A )

  Compliant

  Non-Compliant

  N/A

• Smoking Blankets Refolded Annually ? . ( ( If It’s A Smoke Free Building Then Click N/A )

  Compliant

  Non-Compliant

  N/A

FIRE EXTIGUISHER

• Comapany

• Annual Date ?

  Date

• Any Discrepancy Found Or Is It In Compliance?… (Please note : If at the time of visit , Discrepancies were Found but proof of corrections were found and made then Compliant will be selected with comments made in the note section )

  Compliant

  Non-Compliant

  N/A

• Was Corrections Done To Bring Report Back Into Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

FIRE DAMPER INSPECTION ( 4 YEARS FOR NURSING HOMES , 6 YEARS FOR HOSPITALS )

• Company

• Was This Done ( Links: Y/N (6yr Hospital, 4yr ALL others):

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was This Done ?

  Date

GENERATOR INSPECTION, ANNUAL, LOAD BANK, FEUL TESTING, WEEKLY , MONTHLY ETC

• Company

• How Many Generator Are On Site

• Generator (s) Spec ( KW)

• Generator (s) Specs ( Fuel Gallon Capacity )

• Transfer Switch Automatic: Y /N

  Yes

  No

  N/A

• Manual: Y/N

  Yes

  No

  N/A

• If Manual is someone trained onsite: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Is Annual Generator Testing Been Done And In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was This Done

  Date

• Type Of Fuel

• Fuel Analysis Done And In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was This Done ?

  Date

• Load Bank Done And In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was This Done

  Date

• Annual Main Breaker Exercise Been Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

WEEKLY AND MONTHLY TESTING

• Weekly Inspections Been Done And In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Monthly Inspection Been Done Under At Least 30 % Load ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Conductance Testing Been Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Weekly Voltage Been Checked ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

GENERATOR OPERATION IN-SERVICE / EDUCATION AND QUESTIONS

• Can Maintenance Director Demonstrate How Operate Generator In The Event Of An Emergency ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Is Annual In-Service Been Done To Show And Demonstrate To Key Personnel How To Properly Operate The Generator ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• In-service Present ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• If there’s An Optional Standby Generator On Site , Is Maintenance and Testing per Manufacture Recommendations or NFPA 110 Been Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Generator Manual Located On Site ? (At Least 2 Manuals)

  Compliant

  Non-Compliant

  N/A

• Does Generator Powers Entire Facility ?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Cool Zone Plan For Facility ( For Facility Without Full House Generator ) Present And In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

GENERATOR HIGH MORTALITY PARTS

• High Mortality Parts (NFPA 110 8.2.4) . NFPA 110 8.2.4 focuses on emergency power supply system (EPSS) maintenance and testing. It specifically requires that high-mortality parts, which are components with a higher likelihood of failure, be identified and either provided in a parts inventory or a plan be in place for their prompt replacement. This ensures that emergency power systems remain reliable and functional in critical situations. Examples of high-mortality parts in a generator, as mentioned in NFPA 110, could include components like fuel filters, belts, hoses, and batteries. These parts are subject to wear and tear or have a limited lifespan, making them more likely to fail over time. Regular inspection and replacement of these parts are crucial for ensuring the reliability of the generator system. Does Facility Have These Spare Parts On Site And Are In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Where Is It Located ?

MAIN FEEDER BREAKER ESS ( ANNUAL )

• Company Name

• When Was It Done ? (Annual)

  Date

• Base On Review Of Documentation, Does Documentation's Meet Compliance

  Compliant

  Yes

  Non Compliant

  No

  N/A

HVAC, PTAC , MECHANICAL EQUIPMENT

• - Mechanical Equipment HVAC: Inspected / Maintained And Being Cleaned : Y/N

  Yes

  No

  N/A

• Maintenance Of Critical Equipment Being Done : Y/N

  Yes

  No

  N/A

• Duct Cleaned: Y/ N

  Yes

  No

  N/A

• Area Clear of Obstructions: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Panel Labels Correct: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

BATTERY EMERGENCY LIGHTS TESTING

• Company / In-house ?

• Was Annual Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was This Done ?

  Date

• Are Monthly Been Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

RECEPTACLE INSPECTION

• Company / In house ?

• Is The Annual Being Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

BIO-MEDICAL

• Company Name

• Is The Annual Been Done ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When Was It Done ?

  Date

LINE . ISOLATION . MONITOR TESTING

Is a procedure to check the functionality of a device called a Line Isolation Monitor, primarily used in healthcare facilities to monitor for electrical faults within isolated power systems, ensuring patient safety by detecting potential leakage currents to ground. Key points about L.I.M testing: PURPOSE: To identify potential electrical faults in isolated power systems, commonly found in operating rooms and critical care areas within hospitals. WHAT IT MEASURES : The Line Isolation Monitor continuously monitors the current balance between the lines of an ungrounded electrical system, alerting if there is an imbalance indicating a fault. TESTING FREQUENCY : Typically conducted annually as per healthcare facility codes and standards like NFPA 99.

• Company / InHouse

• Monthly: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Annual: datetime

• O.R. Risk Assessment: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Base On Review Of Documentation, Does Documentation's Meet Compliance

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

MED GAS PIPED INSPECTION

• Company

• Annual: datetime

• Reported Discrepancy(s): Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Repaired: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Base On Review Of Documentation, Does Documentation's Meet Compliance

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Qualifications and Training of Personnel: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

OXYGEN AND OXYGEN STORAGE

• Proper signage/labels: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Five feet from combustibles: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• - Storage racks: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Does Portable Holders Have Locks / Are Tanks Secured ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Does Facility Have Oxygen Threshold Policy ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

BOILERS

• Boiler(s) - Company:

• Boiler(s) - Date:

• Boiler(s) - Annual / Biennial Jurisdiction #

• Base On Review Of Documentation, Does Documentation's Meet Compliance

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

NFPA 80 / FIRE / SMOKE / ATTIC DOORS

• Fire Doors - Company / In-house:

• Annual Fire Door Inspection Been Done And In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Fire Doors - Any Discrepancy(s) Found ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Was Corrections Made ? Back In Compliance ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Fire Doors - Repaired: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

ATTIC DOORS

• Attic - Rated Access Doors: Y/ N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Attic - Inspected/Maintained: Y / N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Attic - Sprinkled: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Attic - Hazards: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Attic - Insulated: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

SMOKE DOORS

• Smoke Doors - In-House Inspection and Maintenance: ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Smoke Doors - Issues: ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

ELEVATOR INSPECTION

• Elevator - Maintenance: Company

• Elevator - Inspection: Date

• Elevator - Recall Key Per NFPA 1: Y/N

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Elevator Certificate Up - To - Date ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• When was it renewed or when does it expire ?

PATIENT ROOM AND QUICK OBSERVATION TOUR

• Patient Rooms - Windows sill height:

• Patient Rooms - Room size:

• Patient Rooms - Nurse call/controller: Y/N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Oxygen Compliant: Y/N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Emergency/electrical receptacle count:

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Bathroom nurse call: Y/N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Closet/Wardrobe, Closet Sprinkled: Y/N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Trash can size:

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Bath Exhaust working: Y/N And In Compliance ?

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Tripping hazards: Y/N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Hazardous Storage areas: Door Closers: Y/N Square Footage:

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Sprinkler Coverage: Y/ N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Rated Wall: Y/N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - ABHR in Storage:

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - gal/fl (640fl = 5gal max per smoke compartment) Condition Met: Y/N

  Compliant

  Non-Compliant

  N/A

• Patient Rooms - Ceiling Tiles & Ceiling Assemblies (per NFPA 1 - 13.3.3.3): Y/N

  Compliant

  Non-Compliant

  N/A

COMPREHENSIVE EMERGENCY MANAGEMENT PLAN (CEMP)

• CEMP - County:

• CEMP - Date Submitted:

• CEMP - Date Approved:

• Was It Approved Before The Expired Date Of The Previous Approval Letter/Plan ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• CEMP - CEMP Emergency Environmental Control Plan 59A-4.1265, Review Plan of Cool Areas. ( Plan Reviewed And Meet Compliance)

  Compliant

  Non-Compliant

  N/A

• CEMP - Receiving Residents from other Facility: Y/ N ?

  Yes

  No

  N/A

• ( If so, How Many) Number of additional Residents ?

FIRE PLAN / ACTION PLAN

• Fire Plan - Department:

• Fire Plan - Date Approved:

• Fire Plan - Review Fire Plan Components for Compliance: Y/N (See Requirements NFPA 101 (2012 For CMS - 19.7.2.2)

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

DISASTER DRILLS

INTERNAL DRILL

• Disaster Drills - Type # 1 (Internal)

• Disaster Drills - Date:

  Date

• 100 % In- Service ( All Staff )

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Disaster Drills - (Synopsis / Critique Or Evaluation Completed: Y/N

  Yes

  No

  N/A

EXTERNAL DRILL

• Disaster Drills - Type #2 ( External)

• Disaster Drills - Date:

• 100 % In- Service ( All Staff )

  Yes

  No

  N/A

• Disaster Drills - (Synopsis / Critique Or Evaluation Completed: Y/N

  Yes

  No

  N/A

Disaster Drills FeedBack

• Are You Happy Or Satisfied With The Disaster Drills ? ( example: scenarios, randomness of drill, drill types, drill critique etc )

  Yes

  No

  N/A

• What Were Your Concerns ? And Or What Needs To Be Done ?

• In Your Overall Assessment Of The Fire Drills And Standard That Is Required By AHCA, CMS And Others, Do You Find These Disaster Drills In Compliance ?

  Compliant

  Non-Compliant

  N/A

FIRE DRILLS

JANUARY DRILL

• SHIFT

• DRILL CONDUCTED ?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

FEBRUARY DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

MARCH DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

APRIL DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

MAY DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

JUNE DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

JULY DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

AUGUST DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

SEPTEMBER DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

OCTOBER DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

NOVEMBER DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

DECEMBER DRILL

• SHIFT

• DRILL CONDUCTED?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• TIME OF DRILL

  Date

• (DAYS) AND (TIMES) OF CORRESPONDING SHIFT…

Fire Drill Feed Back

• Are You Happy Or Satisfied With The Drills ? ( example: scenarios, randomness of drill, drill critique, drills been done at least a hour apart from the last corresponding shift ( ( this is to ensure that each corresponding shifts are at least at a one hour gaps from each other… For Example, if the 1st shift was done at 7:20am then the next 1st shift should be at a minimum either a hour before or a hour after the last 1st shift drill etc. So if the 1st shit was 7:20am then the next first shift should be at minimum 8:20am since 8:20am is at least an hour before 7:20am or it can be at least 6:20am since that’s also a hour minimum apart)

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• What Were Your Concerns ? And Or What Needs To Be Done ?

SECURITY VULNERABILITY ASSESSMENT (SVA)

• SVA ( Security Vulnerability Assessment) Review And Update And Done Up To Compliance?

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

• Drills are been done for vulnerabilities identified within the last 12 months and are they in compliance

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

NURSE CALL SYSTEM

• Tested Random Room Nurse Call System

  Yes

  No

  N/A

• Nurse Call Over The Light Dome Worked ?

  Yes

  No

  N/A

• System Communication Worked At The Nursing Station ?

  Yes

  No

  N/A

ANY CONSTRUCTION AND OFFICE OF PLANS AND CONSTRUCTIONS (OPC)

OTHER COMPLIANCE

• Any Major Construction/Renovations Happening?

  Yes

  No

  N/A

• OPC Project #

INFECTION CONTROL RISK ASSESSMENT ( ICRA )

• ICRA ( If ICRA Is Not Required Then Click N/A )

  Yes

  No

  N/A

LOCKING ARRANGEMENTS AND DOOR SIGNAGE

• Special locking arrangements

  Yes

  No

  N/A

• Door Signage

  Yes

  No

  N/A

OTHER #2

• Soiled Linen and Trash Containers: Proper location

  Yes

  No

  N/A

• Roof/Exterior of Building: Over hangs

  Select Good Fair Poor N/A

  • Good
  • Fair
  • Poor
  • N/A

• Vegetation Growing in Gutters

  Yes

  No

  N/A

• Exit discharge to public way (hard packed all-weather surface)

  Yes

  No

  N/A

• Lighting to Public Way

  Compliant

  Non-Compliant

  N/A

• Walls: Check Finish and coverings

  Yes

  No

  N/A

• List any issues such as Paint, Rotten Wood, Water Damage, Garbage, Broken Windows, Roof Condition, HVAC Unit/s Condition, Rodent Control

WATER TEMPERATURE

• Are Temperature In Rooms Being Checked

  Yes

  No

  N/A

• What Are The Random Rooms That You Checked And What Were The Temp Readings

• Are The Temps In Line With Policy 104 - 110 Degress

  Select Compliant Yes Non Compliant No N/A

  • Compliant
  • Yes
  • Non Compliant
  • No
  • N/A

COMMENTS, OBSERVATIONS , ASSESSMENTS, CONCERNS ETC

• During going through documentations , walking the facility , speaking with ED , Maintenance, or Any Staff , is there anything that stand out that you believed needed addressing , work or any concerns that wasn’t addressed in the questionnaire

  No Concerns

  Concerns

• What’s the comments you want to add