CHI Franciscan Facilities EOC Rounds Checklist v.3

• CHI Franciscan Facilities EOC Rounds Checklist v.3

• Site / Department

• Conducted on

  Date

• Prepared by

• Personnel

• Smoke/Fire doors close and latch properly

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Smoke/Fire doors are unobstructed

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Exits are not obstructed or blocked

  Safe

  At Risk

  N/A

• Exit paths and 8' corridors are maintained and unobstructed

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Exit signs are lit and direction arrow is accurate

  Safe

  At Risk

  N/A

• Pull stations are unobstructed

  Safe

  At Risk

  N/A

• Trash & linen chutes latch properly

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Medical gas panels are properly labeled and unobstructed

  Safe

  At Risk

  N/A

• Ceiling tiles clean and without evidence of water damage

  Safe

  At Risk

  N/A

• Negative & positive pressure relationships are maintained appropriately

  Safe

  At Risk

  N/A

• Electrical panels are locked in public areas and free of obstructions

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• No space heaters in patient care areas

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Appropriate Trash containers in correct locations: <32 gal

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Humidity sensors and pressure monitors are working properly

  Safe

  At Risk

  N/A

• Fans are clean & covered; Stored properly

  Safe

  At Risk

  N/A

General Safety

• Hazardous Materials are stored and labeled properly

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Satellite Accumulation Area

• Containers labeled "Hazardous Waste"

  Safe

  At Risk

  N/A

• Containers have "Accumulation start date"

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Containers in good condition/not leaking

  Safe

  At Risk

  N/A

• Containers kept closed

  Safe

  At Risk

  N/A

• Containers stored to prevent rupture/leakage

  Safe

  At Risk

  N/A

• Waste compatible with container

  Safe

  At Risk

  N/A

• Incompatible wastes separated

  Safe

  At Risk

  N/A

• Adequate aisle space between containers (30 inches)

  Safe

  At Risk

  N/A

• Accumulation area at or near point of generation

  Safe

  At Risk

  N/A

• <55gals DW or 1 quart Acutely Haz Waste

  Safe

  At Risk

  N/A

• Misc. Findings/Notes

  Safe

  At Risk

  N/A

• Corrective Action Plans:

• Surveyor Signature:

  Sign

• Department Representative Signature:

  Sign