Life Safety

Smoke/Fire doors close and latch properly

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

Smoke/Fire doors are unobstructed

Fire extinguishers are unobstructed and monthly checks are up to date; Mounted < 5'

Exits are not obstructed or blocked

Exit paths and 8' corridors are maintained and unobstructed

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

Exit signs are lit and direction arrow is accurate

Pull stations are unobstructed

Trash & linen chutes latch properly

Battery back up lighting in "anesthetizing" locations (OR, CathLab, etc.)

Staff can articulate the meaning of RACE & PASS: question a sampling of staff

ILSM/IRCA active/in place in area, if so is it being followed?

General EOC

Medical gas panels are properly labeled and unobstructed

Ceiling tiles clean and without evidence of water damage

Negative & positive pressure relationships are maintained appropriately

Electrical panels are locked in public areas and free of obstructions

Work areas are free of extension cords and adaptors
- Electrical power strips not daisy chained
- Only approved re-locatable power taps are in use in patient areas

No space heaters in patient care areas

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

Appropriate Trash containers in correct locations: <32 gal

Area in good repair: wall, flooring, window covering, counter tops, light & electrical outlets, doors etc..

Humidity sensors and pressure monitors are working properly

Fans are clean & covered; Stored properly

Hazardous Materials

General Safety

Hazardous Materials are stored and labeled properly

O2 storage area properly labeled; Separate rack for full tanks and partial/empty tanks; <12 e-cylinder stored in non-rated room

Satellite Accumulation Area

Containers labeled "Hazardous Waste"

Containers have "Accumulation start date"

Start date <90days (No storage >90 Days)

Containers in good condition/not leaking

Containers kept closed

Containers stored to prevent rupture/leakage

Waste compatible with container

Incompatible wastes separated

Adequate aisle space between containers (30 inches)

Accumulation area at or near point of generation

<55gals DW or 1 quart Acutely Haz Waste

Misc. and Survey End

Misc. Findings/Notes

Corrective Action Plans:

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.