Life Safety

Fire doors are unobstructed

Action Plan:

Exit paths and 8' corridors are maintained and unobstructed

Action Plan:

Medical gas panels are properly labeled and unobstructed

Action Plan:

Fire extinguishers are unobstructed and monthly checks are up to date

Action Plan:

Exits are not obstructed or blocked

Action Plan:

Sprinkler heads are free of dust or debris and 18" clearance is maintained

Action Plan:

Smoke/Fire doors close and latch properly

Action Plan:

Ceiling tiles clean and without evidence of water damage

Action Plan:

Exit signs are lit and direction arrow is accurate

Action Plan:

Pull stations are unobstructed

Action Plan:

Electrical panels are locked in public areas and free of obstructions

Action Plan:

Work areas are free of extension cords and adaptors

Action Plan:

No space heaters in patient care areas

Action Plan:

Alcohol gel dispensers installed appropriately; not above or within 6" of ignition source

Action Plan:

Check doors for positive latching

Action Plan:

Check gaps and undercuts in doors. No more than 1/8" gap and 3/4" undercut

Action Plan:

Hazardous Materials are stored and labeled properly

Action Plan:

Eye Wash Test: Tepid water, 6" high 3 gal a minute. Check Dept Log

Action Plan:

Misc. Findings/Notes

Corrective Action Plans:

Date All Corrective Actions Implemented
Surveyor Signature:
Department Representative 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.