• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Total Number of Findings

  • Total number of Facilities/Engineering work orders

  • Total number of EVS work orders

  • Total number of educational opportunities


  • 1.1 Has the last audit been reviewed?

  • 1.2 Are there any outstanding concerns?


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

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

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

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

  • This area is free from sharp objects?

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

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

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

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

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


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

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

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

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

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


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

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

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


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

  • All personal items in patient bathrooms are labeled?

  • All OPEN solution containers are dated?

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

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

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

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

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

FOOD and NUTRITION PC.02.02.03

  • Staff food is not stored in patient refrigerators?

  • 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).

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

  • No open or expired patient nourishment containers in refrigerator?


  • Floors free of dirt, dust and litter?

  • Ledges, walls and air vents free of dust?

  • Toilets and sinks clean & secure?

  • Privacy curtains clean and unsoiled?

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

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


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

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

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

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

  • Disposed sharps are in an approved container?

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


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

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

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

  • Two exit signs visible from each corridor?

  • Halls/Corridors uncluttered and accessible?

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

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

  • Are the sprinkler heads free of dust?

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

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

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

  • Are compressed gases stored in designated areas only?

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

  • All lights are working properly?

  • Flammable and hazardous materials properly stored and labeled?

  • Fire extinguishers and pull stations clear of obstructions?

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

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

  • 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.)

FIRE SAFETY EC.02.03.01, FIRE DRILLS EC.02.03.03


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

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

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

  • Are valuables properly stored in department?

  • Employee personal items locked and secured?

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


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

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

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

  • Perform Tracer on 3 medical equipment items.

  • Asset #

  • Asset #

  • Asset #


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

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

  • Electrical rooms and panels are clearly identified and locked?

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


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

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

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


  • Construction does not affect Building Life Safety features.

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


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


  • ** Name two patient identifiers?

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



  • Department/Unit Representative

  • Auditor

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