Information
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CHI Franciscan Facilities EOC Rounds Checklist
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Site/ Department
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Conducted on
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Prepared by
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Personnel
Life Safety
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Fire doors are unobstructed
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Action Plan:
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Exit paths and 8' corridors are maintained and unobstructed
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Action Plan:
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Medical gas panels are properly labeled and unobstructed
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Action Plan:
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Fire extinguishers are unobstructed and monthly checks are up to date
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Action Plan:
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Exits are not obstructed or blocked
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Action Plan:
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Sprinkler heads are free of dust or debris and 18" clearance is maintained
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Action Plan:
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Smoke/Fire doors close and latch properly
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Action Plan:
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Ceiling tiles clean and without evidence of water damage
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Action Plan:
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Exit signs are lit and direction arrow is accurate
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Action Plan:
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Pull stations are unobstructed
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Action Plan:
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Electrical panels are locked in public areas and free of obstructions
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Action Plan:
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Work areas are free of extension cords and adaptors
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Action Plan:
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No space heaters in patient care areas
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Action Plan:
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Alcohol gel dispensers installed appropriately; not above or within 6" of ignition source
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Action Plan:
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Check doors for positive latching
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Action Plan:
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Check gaps and undercuts in doors. No more than 1/8" gap and 3/4" undercut
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Action Plan:
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Hazardous Materials are stored and labeled properly
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Action Plan:
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Eye Wash Test: Tepid water, 6" high 3 gal a minute. Check Dept Log
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Action Plan:
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Misc. Findings/Notes
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Corrective Action Plans:
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Date All Corrective Actions Implemented
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Surveyor Signature:
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Department Representative Signature:
