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?
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 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
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
Corrective Action Plans: