DNV Physical Environment Inspection

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• 1. Are ceiling tiles seated flush, stained, missing, or broken

  Yes

  No

  N/A

• 2. Is the floor clean and not damaged?

  Yes

  No

  N/A

• 3. Is the Hand sanitizer installed above, below, or closer than one inch (25 mm) to an electrical receptacle, switch, appliance, device, or other ignition source?

  Yes

  No

  N/A

• 4. Is there damage to walls, wallpaper, baseboards,

  Yes

  No

  N/A

• 5. Is there any evidence of pest or bugs in light fixtures

  Yes

  No

  N/A

• 6. Are ceiling vents free of dust, rust, or dirt

  Yes

  No

  N/A

• 7. Are there outside shipping cardboard boxes in storage areas or any clinical areas

  Yes

  No

  N/A

• 8. Is Clean and Dirty storage separated? No dirty items in clean and no clean items in dirty

  Yes

  No

  N/A

• 9. Eyewash stations have inspection tages and are up to date

  Yes

  No

  N/A

• 10. Refrigerator temperatures are being monitored

  Yes

  No

  N/A

• 1. Are sprinkler heads free of dust

  Yes

  No

  N/A

• 2. Are Oxygen, Med gas shutoff valves, FEs, and pull stations blocked?

  Yes

  No

  N/A

• 3. Are fire extinguishers charged and inspected within 30-day intervals?

  Yes

  No

  N/A

• 4. Storage is below 18 inches of sprinkler heads.

  Yes

  No

  N/A

• 5. All department doors latch properly, and are doors not propped or blocked?

  Yes

  No

  N/A

• 6. Exit signs properly in place and fully illuminated

  Yes

  No

  N/A

• 7. Are hallways free from clutter?

  Yes

  No

  N/A

• 8. Integrity of smoke and fire doors are intact with no paper or decorations

  Yes

  No

  N/A

• 9. No storage in the stairways?

  Yes

  No

  N/A

• 10. Corridor storage of equipment - plugged into outlets - moves in 20 minutes?

  Yes

  No

  N/A

SECURITY/ SAFETY

• 1. Staff wearing ID badges?

  Yes

  No

  N/A

• 2. Have the security doors been comprised (combinations written in view, door propped, staff sharing combination

  Yes

  No

  N/A

INFECTION CONTROL

• 1. Linen carts are covered and nothing on top?

  Yes

  No

  N/A

• 2. No cardboard boxes on floor?

  Yes

  No

  N/A

• 3. Are refrigerator temperature logs current daily / values in range?

  Yes

  No

  N/A

• 4. Refrigerator log form is current

  Yes

  No

  N/A

• 5. Is patient care equipment clean and cleaned between patients, not dusty, free from tape?

  Yes

  No

  N/A

EMERGENCY PREPAREDNESS

• 1. Staff can demonstrate PASS & RACE and what to do if this was an actual fire

  Yes

  No

  N/A

• 2. Does the staff know where to find information on emergency codes and emergency plans?

  Yes

  No

  N/A

• 3. Staff displays knowledge of available evacuation equipment and how to obtain it.

  Yes

  No

  N/A

HAZARDOUS MATERIALS

• 1. Bio-hazard rooms are labeled and secured, including all soiled utility rooms

  Yes

  No

  N/A

• 2. Cleaners, chemicals are properly labeled and secured

  Yes

  No

  N/A

• 3. Sharps containers are secured and not overfilled?

  Yes

  No

  N/A

HIPAA

• 1. Absence of HIPAA violations, no open charts?

  Yes

  No

  N/A

• 2. Is patient health information in the correct containers and not in department wastepaper baskets?

  Yes

  No

  N/A