Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Corridors

  • Are corridors free of stored items?

  • Are corridors free of flammable materials?

  • Are evacuation plans current?

  • Are Exit signs properly lit?

  • Do battery-operated emergency lights work properly (if applicable)?

Stairwells

  • Are stairwell doors clear of blocking materials?

  • Is stairwell lighting working properly?

  • Are all stair treads in tact?

  • Is proper exiting signage posted in stairwell?

  • Are stairwells free of storage?

Anesthesia Work Room

  • Are life safety conditions met in this space?

Equipment Storage/Storage Rooms

  • Do items on the floor meet appropriate storage requirements?

  • Are stored items below the 18" ceiling sprinkler plane?

  • Storeroom doors are not held or wedged open?

  • Is the door to the room kept locked when unoccupied?

  • Are sprinkler heads unobstructed?

PACU

  • Are life safety conditions met in these spaces?

POCU

  • Are life safety conditions met in these spaces?

EVS

  • Are EVS carts being left in the corridors?

  • Are EVS closets kept locked?

  • Is EVS equipment stored in appropriate places?

Fire/Smoke Doors

  • Do fire/smoke doors close properly?

  • Are fire/smoke doors free of blocking items on both sides of the doors?

Electrical/Telephone Rooms

  • Is the door to the room locked when not in use?

  • Rooms do not contain inappropriate storage items?

Medical Gases

  • Are the medical gas shutoff valves labeled clearly?

  • Is staff aware of responsibility for shutting off medical gases during an emergency and where gas shutoff valves are located?

  • Are gas shutoff panels clearly accessible?

  • Are all oxygen tanks secured properly?

Fire Safety

  • Do staff know where fire alarm pull stations are located?

  • Are all fire pull stations accessible and do they appear to be in working order?

  • Have fire extinguishers been checked, and the tag marked properly?

  • Are fire sprinkler escutcheon plates all properly in place?

Surgical Suites

  • All flooring is in good condition?

  • Does surgical suite door positively latch?

  • Do electrical outlets appear to be in good condition?

  • Do all room lights work properly?

Sub-Sterile Alcove

  • Is flooring in alcove in good condition?

Signage

  • Are all rooms clearly labeled to assist emergency response personnel?

Linen/Utility Rooms

  • Linens and pillows are not on the floor?

  • Are items stored on the floor appropriately?

  • Is room storage below the 18" ceiling sprinkler restriction?

  • Is the door to the room kept closed appropriately?

  • Are doors to utility rooms unblocked?

Male Locker Room

  • Are life safety conditions met in this space?

Female Locker Room

  • Are life safety conditions met in this space?

Miscellaneous

  • Extension cords are not in use?

  • No paper signs are posted in the area?

  • All cabling is dressed appropriately under work surfaces?

General Comments

  • Are life safety conditions1 met?

  • Are life safety conditions2 met?

  • Are life safety conditions3 met?

  • Are life safety conditions4 met?

  • Are life safety conditions5 met?

  • Are life safety conditions6 met?

  • Are life safety conditions7 met?

  • Are life safety conditions8 met?

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