EC.04.01.01 ENVIRONMENTAL ROUNDS

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

RESULTS

• Total Number of Findings

• Total number of Facilities/Engineering work orders

• Total number of EVS work orders

• Total number of educational opportunities

1. PREVIOUS AUDITS

• 1.1 Has the last audit been reviewed?

  Yes

  No

  N/A

• 1.2 Are there any outstanding concerns?

  Yes

  No

  N/A

SAFETY/GENERAL SAFETY

• Warning signs or barricades are placed when work creates a hazard (wet floor, maintenance work in ceiling)?

  Yes

  No

  N/A

• A2. Medication cart is locked, neat and tidy, without expired medicines/products?

  Yes

  No

  N/A

• Clean linen is covered with nothing on top of cart?

  Yes

  No

  N/A

• All furniture and equipment is in sound condition? (no chipped or torn surfaces- no leaky faucets)

  Yes

  No

  N/A

• This area is free from sharp objects?

  Yes

  No

  N/A

• All wall-mounted devices (lights, TV’s, pictures, signs, containers, handrails, etc.) are secure and not loose?

  Yes

  No

  N/A

• Cleaning chemicals are properly labeled and are not accessible by residents and visitors?

  Yes

  No

  N/A

• Quality Control logs for Refrigerators/Freezers, freezers, and warmers are complete and corrective actions documented as appropriate?

  Yes

  No

  N/A

• Boxes of patient care items/supplies are not stored directly on the floor? (must be elevated 6")

  Yes

  No

  N/A

• Items are not stored under sink(s)? (If items found - list in comment section.)

  Yes

  No

  N/A

B. ELECTRICAL SAFETY

• All electrical items within a six (6) foot radious of patient bed is UL Approved and inspected?

  Yes

  No

  N/A

• Items are not stored within 30” of an electrical panel?

  Yes

  No

  N/A

• Electrical cords, plugs, plates and switches are in good repair?

  Yes

  No

  N/A

• Extension cords only used temporarily but not on a permanent everyday basis?

  Yes

  No

  N/A

• The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?

  Yes

  No

  N/A

MEDICATION/MEDICAL SUPPLIES

• Medications/medical supplies - have not passed expiration dates?

  Yes

  No

  N/A

• All syringes, basins, cups, containing medication or solutions are labeled with the name of the contents?

  Yes

  No

  N/A

• Med Carts/Med Rooms are secured at all times?

  Yes

  No

  N/A

D. INFECTION CONTROL

• No UNAUTHORIZED SOLUTIONS in patient rooms. (items brought in by family)

  Yes

  No

  N/A

• All personal items in patient bathrooms are labeled?

  Yes

  No

  N/A

• All OPEN solution containers are dated?

  Yes

  No

  N/A

• Ice machines are clean, no signs of deposits in tray or dispensing mechanism?

  Yes

  No

  N/A

• Anti-microbial soap and paper towels are available for hand washing?

  Yes

  No

  N/A

• Staff (including contracting physicians) perform hand hygiene when entering room?

  Yes

  No

  N/A

• Staff (including contracting physicians) perform hand hygiene while providing care.

  Yes

  No

  N/A

• Staff (including contracting physicians) perform hand hygiene when exiting the patient room.

  Yes

  No

  N/A

FOOD and NUTRITION PC.02.02.03

• Staff food is not stored in patient refrigerators?

  Yes

  No

  N/A

• Refrigerators/Freezers are clean, frost free, and labeled for type of storage with only those items present (no food and medication in the same refrigerator).

  Yes

  No

  N/A

• Refrigerators/Freezers contain Aero-Scout Tags and the refrigerator graphs are up-to-date? (thermometer should be located in the back)

  Yes

  No

  N/A

• No open or expired patient nourishment containers in refrigerator?

  Yes

  No

  N/A

ENVIRONMENTAL SERVICES

• Floors free of dirt, dust and litter?

  Yes

  No

  N/A

• Ledges, walls and air vents free of dust?

  Yes

  No

  N/A

• Toilets and sinks clean & secure?

  Yes

  No

  N/A

• Privacy curtains clean and unsoiled?

  Yes

  No

  N/A

• Soiled linen and trash receptacles larger than 32 gallons are located in a rated room?

  Yes

  No

  N/A

• Lint trap in dryers are cleaned, maintained and documented weekly?

  Yes

  No

  N/A

HAZARDOUS MATERIALS EC.02.02.01

• ** How can you access Material Safety Data Sheets (MSDS)?

  Yes

  No

  N/A

• ** Do you know where your PPE is located?

  Yes

  No

  N/A

• Material Safety Data Sheets available for all chemicals in this unit?

  Yes

  No

  N/A

• Sharps containers are secured in their holders, not accessible to residents and not more than three-fourths full?

  Yes

  No

  N/A

• Disposed sharps are in an approved container?

  Yes

  No

  N/A

• Containers used for regulated or infectious waste are covered, leak proof, and clearly labeled as a biohazard? (Red, Yellow & Blue recycle containers provided?)

  Yes

  No

  N/A

LIFE SAFETY LS.02.02.01

• ** Can you explain when you would implement R.A.C.E. and what does it stand for?

  Yes

  No

  N/A

• ** Can you explain P.A.S.S. and what does it stand for?

  Yes

  No

  N/A

• ** Where are the fire extinguishers and pull stations located in your department?

  Yes

  No

  N/A

• Two exit signs visible from each corridor?

  Yes

  No

  N/A

• Halls/Corridors uncluttered and accessible?

  Yes

  No

  N/A

• Wheeled items such as the WOW’s are stored in corridor less then 30 minutes at a time?

  Yes

  No

  N/A

• Are ceiling tiles in place, not stained and not broken?

  Yes

  No

  N/A

• Are the sprinkler heads free of dust?

  Yes

  No

  N/A

• Fire extinguisher (s) recently serviced? (monthly)

  Yes

  No

  N/A

• Automatic fire/smoke doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.)

  Yes

  No

  N/A

• Eighteen-inch (18") clearance from sprinkler head ensuring no obstruction?

  Yes

  No

  N/A

• Are compressed gases stored in designated areas only?

  Yes

  No

  N/A

• Are full and empty cylinders stored separately according to sign/labels?

  Yes

  No

  N/A

• All lights are working properly?

  Yes

  No

  N/A

• Flammable and hazardous materials properly stored and labeled?

  Yes

  No

  N/A

• Fire extinguishers and pull stations clear of obstructions?

  Yes

  No

  N/A

• Placement of Hand Sanitizer is not adjacent (with-in 6”) to a potential ignition source?

  Yes

  No

  N/A

• ABHD dispensers do not exceed the appoved amount within a Smoke Compartment? (Maximum amount of containers = 25)

  Yes

  No

  N/A

• Exit doors are operable in the path of Exit travel without the use of a key or any special procedure? (Controlled Access - Means of Egress.)

  Yes

  No

  N/A

FIRE SAFETY EC.02.03.01, FIRE DRILLS EC.02.03.03

SECURITY MANAGEMENT EC.02.01.01

• ** How do you notify Security in a non-emergency?

  Yes

  No

  N/A

• Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges @ eye level?

  Yes

  No

  N/A

• Visitors, family, contractors are issued daily badges from E-Z-Lobby Visitor management system?

  Yes

  No

  N/A

• Are valuables properly stored in department?

  Yes

  No

  N/A

• Employee personal items locked and secured?

  Safe

  At Risk

  N/A

• Areas identified as High Security are always locked to prevent unauthorized access?

  Yes

  No

  N/A

MEDICAL EQUIPMENT MANAGEMENT EC.02.04.03

• ** What are the procedures if a device/equipment does not work properly OR if the device is involved in a resident related incident?

  Yes

  No

  N/A

• All medical equipment/devices has a current Bio-Medical sticker?

  Yes

  No

  N/A

• All medical equipment is included in inventory, and has current PM tag?

  Yes

  No

  N/A

• Perform Tracer on 3 medical equipment items.

  Safe

  At Risk

  N/A

• Asset #

• Asset #

• Asset #

UTILITY MANAGEMENT EC.02.05.01

• ** Where are your emergency backup procedures located for a loss of utility services?

  Yes

  No

  N/A

• ** In case of a fire on the unit, who is authorized to shut off medical gases?

  Yes

  No

  N/A

• Electrical rooms and panels are clearly identified and locked?

  Yes

  No

  N/A

• Circuit breaker panels have current and up to date panel index identifying areas served by each breaker?

  Yes

  No

  N/A

EMERGENCY OPERATIONS PROCEDURES

• ** Can you tell me the number you would dial to initiate an emergency response?

  Yes

  No

  N/A

• ** Where are your IT Downtime Forms? Do you have an IT Downtime Box? Are the forms current?

  Yes

  No

  N/A

• Emergency Flip Chart with emergency contacts is located on unit?

  Yes

  No

  N/A

CONSTRUCTION SITES

• Construction does not affect Building Life Safety features.

  Safe

  At Risk

  N/A

• ILSM displayed at construction site entrance? Items are approved and compliant?

  Yes

  No

  N/A

RISK MANAGEMENT

• Patient Health Information is not visible(computer screens protected, hard copies covered, patient charts closed)

  Yes

  No

  N/A

PATIENT SAFETY

• ** Name two patient identifiers?

  Yes

  No

  N/A

• ** Describe the Falls Prevention efforts in your department.

  Yes

  No

  N/A

COMMENTS/OBSERVATIONS

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• Department/Unit Representative

  Sign

• Auditor

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