1.0 - Previous inspection

1.1 - Has the last inspection been reviewed?

1.2 - Are there no outstanding actions?

2.0 - Fire Prevention

2.1 - Doors not wedged or propped open?

2.2 - Fire doors are not blocked by carts, equipment, or materials?

2.3 - Extinguishers is not missing damaged, or discharged?

2.3a - Is chalk present for marking doors?

Notify Engineering of Deficiency

2.4 - Extinguishers has current inspection documentation?

2.5 - Extinguishers clear of obstructions?

2.6 - Sprinkler Heads/Smoke Detectors are clean & intact?

2.7 - Indicator Lights are not obstructed?

2.8 - Fire Exit signs are illuminating and working properly?

Notify Engineering

2.9 - Fire Doors close and latch properly?

2.10 - Storage is less than 18" from ceiling?

2.11 - Doors to Soiled/Clean/Hazardous Materials Rooms closed?

2.12 - Emergency Exit Corridors / Doors are clear?

2.14 - Flammables, stored appropriately?

2.15 - Penetrations to Walls / Ceilings / Floors, not present?

2.16 - No unauthorized space heaters present?

2.17 - No unauthorized heat producing equipment (toasters, hot plates, etc).

2.18 - Are evacuation routes properly posted (location indicated, oriented properly, etc)?

2.19 Can staff identify the closest fire extinguisher?

2.10 Can staff explain the types of fire extinguishers and their purposes?

2.11 Are emergency evacuation illustrations posted in every room?

3.0 - Electrical Safety

3.1 - Electrical outlets are not damaged or loose?

3.2 - Critical equipment is plugged into Red Outlet?

3.3 - All extension cords are equipped with a ground prong?

3.4 - All switches, receptacles and computer boxes have covers or plates?

3.5 - Electrical panels are accessible - 36" clearance around panels.

3.6 Are electrical appliance inspection stickers up-to-date?

3.7- Only terminal strips are utilized. No extension cords

3.8 are vapor or explosion proof switches and covers utilized where necessary?

4.0 - General Safety

4.1 - Handrails are attached firmly to the walls?

4.2 - All wheelchairs are in good repair and with both footrest?

4.3 - Storage is at least 6" from the floor. No boxes on the floor?

4.4 - Floors - tiles, carpet in good repair - no trip hazards?

4.5 - Stairwell lights working?

4.6 - Storage Rooms clean and orderly?

4.7 - Are the areas under sinks empty?

4.8 - Step ladders available to reach high places are in good shape?

4.9 - No electrical cords, telephone and computer wires in area that might entangle feet?

4.10 - Desk, chairs, furniture in safe condition?

4.11 - Patient Room furniture in safe condition?

4.12 - No evidence of food, drinks or eating occurring around computers or nurse station?

4.13 - Are documents posted in areas other than bulletin boards laminated?

4.14 - Are refrigerators, coffee makers, and/or microwave ovens properly labeled?

4.14a - Is the Engineering inspection label up-to-date?

4.15 - Are HVAC vents clean?

Notify Housekeeping

4.16 Can staff explain the definition of a Sentinel Event?

A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury

4.17 Do staff know the location of the decon shower?

4.18 Do employees know the location of emergency eyewashes?

4.19 Can staff explain the procedure for cleaning up a blood spill when Environmental Services staff are not available?

4.20 Is a copy of the Emergency Alert Codes posted in an easily accessible location?

5.0 - Hazardous Material

5.1 - Eye wash station inspected weekly and documented?

5.2 - High level disinfectant policy being followed - QC, documentation, etc?

5.3 - Medical gas cylinders are stored where full and empties are separated?

5.4 - Medical gas cylinders are properly secured?

5.5 - Biohazard containers are stored properly?

5.6 - Sharps boxes are no more than 3/4 full; syringe disposed of properly?

5.7 - Staff are able to obtain a MSDS?

Demonstrate MSDS Online on PC desktop.

5.8 - Secondary container are labeled properly?

5.9 - Hazardous materials properly stored?

5.10 - Are "Oxygen in Use" signs properly displayed?

5.11 Biohazard containers are free of non-biohazard items?

5.12 Can a staff member locate the online MSDS program?

6.0 - Security Management

6.1 - Employee personal items are secured out of sight?

6.2 - Employee I.D. Badges visible and worn properly?

6.3 - Confidential Materal secured /protected?

6.4 - High risk patient's, equipment areas, hazardous material area rooms are secure?

6.5 - Medications secured?

6.6 - Doors with security hardware operate properly?

6.7 - Code carts locked and in view of staff?

6.8 Can control desk personnel verbalize policies for visitor entrance after hours?

7.0 - Utilities Management

7.1 - All lights are operational, no lights out?

7.2 - Ceiling tiles, none discolored,/wet/damaged?

7.3 - HVAC System - Air temperature within condor table range?

7.4 - Plumbing, faucets,, toilets operational (no leaks)?

7.5 - Ice machine clean and maintenance on schedule?

7.6 - Are lights in nearest stairwell operational?



Can staff explain the procedure for taking verbal or telephone orders?

Document VORB or TORB for order readback

Is there a Poison Control Center phone number posted prominently in each department?

Are function checks conducted on defibrillators?

Are function checks conducted weekly on suction equipment?

Are crash carts secured

Do wheelchairs have working locks?

Do floor scales have wheels? (They should not move when stood upon)

Are narcotics kept under dual locks?

Do staff utilize 2 forms of identifying patients?

Can staff demonstrate the location of PPE to include PAPRs?

Are soiled linens placed in leakproof containers and covered?

Are counter areas cleaned properly?

Operating Room

Is traffic control of unauthorized personnel adequate?

Are only non-flammable germicides used for preoperative patient preparation?

Are table wheels locked?

Are dress requirements enforced?

Is OR locked when not in use?

Is relative humidity maintained at 50% or greater?

Can staff explain if a patient with signs/symptoms of TB is scheduled for surgery?

If elective, consult surgeon about postponing until TB ruled out.

Are heated instruments spark restricted in the presence of flammable anesthetics?


Is there adequate documentation of checks of the laminar flow hood?

Is decon shower inspected monthly?

Are staff aware of the Chemical Hygiene plan?

Are counters cleaned per policy?

Is the Decontamination shower inspected monthly and tested annually?

Is the shower handle/cord accessible to the shortest staff member in the area?

Are specimens contained in leakproof, biohazard labeled containers?

Are discarded specimens contained in a leakproof red bag?


Are gloves worn for all patients who are to be administered IV contrast or when patient is to have barium enema?

Are women of childbearing age screened for pregnancy?

Are med cabinets in Nuclear Medicine locked when unattended?

Are rooms with radiation sources properly secured?

Are controls arranged to prevent external energizing?

Are radiation exposure badges worn by all persons exposed to radiation?

Are lead aprons, gowns, or shields worn when necessary?

Do nuclear med and x-ray machines maintain a secondary radiation cone and filters?

Nuclear Medicine: Are face shields worn when opening and administering medications?

Nuclear Medicine: Is there a suitable container to store contaminated items?

Is there an emergency code box in close proximity?

Are the oxygen and suction analyzed daily and working?


Is an antidote list available for easy reference?

Are standard reference materials immediately available?

Are look-alike/sound-alike medications segregated by label or location?

Does the pharmacy remained locked when unattended?

Emergency Department

Is the Poison Control Antidote Chart visible?

Are pediatric crash cart supplies immediately accessible?

Can staff demonstrate the use of the security intercom?

Critical Care Unit


Can staff demonstrate one-handed scoop method for recapping after drawing ABG?

Can staff locate the Nitroglycerin tablets in the Stress lab? Are the tablets in date?


Plant Engineering

Can staff explain when eye protection is required and where it is stored?

Are safe methods used when changing light bulbs and tubes?

Are all electrical cords, switches and plugs in good working order?

Are flammable liquids stored in safety cans?

Are electrical appliances brought in by staff tagged appropriately?

Are gas cylinders kept clear of heat sources?

Are ladders in good working condition?

Environmental Services

Is ladder in good working condition?

Is clean linen maintained in a covered container?

Are patient care areas cleaned according to policy (top to bottom, clean to dirty)?

Food Services

Are food carts in good working order?

Is there physical separation of food from non-food items?

Are food prep areas separate from cleaning/sanitizing areas and are they adequate?

Is food protected from contamination and spoilage?

Are gloves and head coverings worn as appropriate?

Are staff members eating or drinking in food prep areas?

Are food refrigerator temperatures checked daily?

Are scoops with handles properly used and stored?

Are acceptable temperature parameters posted?

Can staff explain how to test sanitizing chemical concentration?

Are cutting boards clean, rinsed, and sanitized prior to use?

Are cutting boards constructed of hard maple or other non-toxic material?

Are all vent hood filters clean?

Control Desk

Can staff verbalize visitor policies (after hours)?


Additional Comments

Surveyor's Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.