Environment of Care Rounds Current Version

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Engineering Programs

• Are there loose floor tiles/carpet?

  Yes

  No

  N/A

• Are ceiling tiles stained or other signs of leaks?

  Yes

  No

  N/A

• Are there any floor/ceiling/wall penetrations?

  Yes

  No

  N/A

• Are ceiling tiles missing/broken?

  Yes

  No

  N/A

• Is there any evidence of leaks under sinks, toilets, etc?

  Yes

  No

  N/A

• Is there evidence of moisture/mold intrusion and damage?

  Yes

  No

  N/A

• Are lock out/tag out procedures in place?

  Yes

  No

  N/A

• Are there any electrical hazards present?

  Yes

  No

  N/A

• Are Electrical Power systems working properly?

  Yes

  No

  N/A

• Are emergency and normal electrical Lighting systems working properly?

  Yes

  No

  N/A

• Are Electrical Signal systems working properly (nurse call, fire alarm, etc)?

  Yes

  No

  N/A

• Exit routes and exit signs are illuminated.

  Yes

  No

  N/A

• Are the ventilation, temperature and humidity at suitable levels?

  Yes

  No

  N/A

• Does staff know what to do if the domestic water system fails?

  Yes

  No

  N/A

• Does staff know what to do if the medical gas system alarms or fails (Vacuum, air, oxygen)?

  Yes

  No

  N/A

• Does staff know where the medical gas zone valves are located?

  Yes

  No

  N/A

• Does staff know who is responsible for turning off the medical gas zone valves in the event of an

  Yes

  No

  N/A

• Do personally owned electrical devices have indication that they have been checked and cleared by

  Yes

  No

  N/A

• Are there stops on the exterior windows in patient care areas to prohibit them from opening more than 6 inches in non Mental Health care areas?

  Yes

  No

  N/A

Healthcare Environmental Sanitation

• Is the general appearance of unit neat/organized clear/uncluttered?

  Yes

  No

  N/A

• Are linen and trash chute rooms clean and properly functioning?

  Yes

  No

  N/A

• Are safety procedures being followed in linen and trash chute areas?

  Yes

  No

  N/A

• Are housekeeping closets, equipment and supply rooms clean, organized and adequately stocked?

  Yes

  No

  N/A

• Are areas free of indications of any pest control concerns?

  Yes

  No

  N/A

• Are doors secured on clean and soiled linen rooms? Are carts covered?

  Yes

  No

  N/A

• Are personnel demonstrating proper procedures for handling regulated medical waste?

  Yes

  No

  N/A

• Are personnel able to accurately describe the procedure for reporting a chemical spill and location of spill kits?

  Yes

  No

  N/A

• Are cleaning schedules posted for refrigerators/microwaves, and checks documented per policy?

  Yes

  No

  N/A

• Are vents, lights and ceiling tiles free from dust, water stains, and mold?

  Yes

  No

  N/A

• Are dispensers clean and properly stocked with supplies?

  Yes

  No

  N/A

• Are regulated medical waste and/or biohazard containers properly labeled, covered, stored, and secured?

  Yes

  No

  N/A

• Are housekeeping closets, carts, and equipment clean and secured? Are products properly labeled?

  Yes

  No

  N/A

• Are eyewash stations unobstructed by equipment or other items?

  Yes

  No

  N/A

• Do staff have access to SDS sheets for all chemicals used in the department?

  Yes

  No

  N/A

• Are all Housekeeping chemicals and solutions clearly identified?

  Yes

  No

  N/A

• Are hand hygiene product dispensers with expiration date and filled?

  Yes

  No

  N/A

• Are receptacles for linen and trash in compliance not to exceed 64 gallon requirement?

  Yes

  No

  N/A

Healthcare Technology Management

• Does medical equipment have visible and legible barcode inventory labels?

  Yes

  No

  N/A

• Does service/department have written procedures to follow when medical equipment fails, including using emergency clinical interventions and backup equipment?

  Yes

  No

  N/A

• Does staff know how to report medical equipment problems, failures or malfunctions?

  Yes

  No

  N/A

• Can staff describe the action to be taken if an out-of-date medical equipment inspection sticker is found?

  Yes

  No

  N/A

• Have users received appropriate training on medical equipment?

  Yes

  No

  N/A

• Is the general condition of medical equipment good with no obvious physical damage?

  Yes

  No

  N/A

• Does staff know if this piece of equipment is safe for use (Select a device)? service?

  Yes

  No

  N/A

• Have staff entered work orders for medical equipment with problems or that are in need of immediate service?

  Yes

  No

  N/A

• Does medical equipment have current inspection sticker?

  Yes

  No

  N/A

Infection Prevention and Control

• Is an Infection Control Manual available?

  Yes

  No

  N/A

• Is Personal Protective Equipment(PPE) available and , if so, are supplies adequate (goggles, gowns, masks, gloves)?

  Yes

  No

  N/A

• Is infectious/medical waste disposal in compliance with policy?

  Yes

  No

  N/A

• Is patient care equipment clean including refrigerators and microwaves used for patient food or medications?

  Yes

  No

  N/A

• Do employees know what to do if they have a blood borne pathogen exposure?

  Yes

  No

  N/A

• Do employees know how to clean up/report blood and body fluid spills?

  Yes

  No

  N/A

• Can employees demonstrate how to verify negative pressure?

  Yes

  No

  N/A

• Is there physical separation of clean/dirty storage/work area?

  Yes

  No

  N/A

• Are proper hand hygiene practices observed?

  Yes

  No

  N/A

• Is staff properly observing bloodborne pathogens precautions?

  Yes

  No

  N/A

• Are gloves worn for blood contact?

  Yes

  No

  N/A

• Are there any patient care supplies under sinks, on window sills, or on floor?

  Yes

  No

  N/A

• Are any food/drinks found in patient care areas?

  Yes

  No

  N/A

• Are needle safety devices accessible and being used appropriately?

  Yes

  No

  N/A

• Are the sharps containers less than 3/4 full and securely mounted with nothing stored on top?

  Yes

  No

  N/A

• Is the food in the refrigerator labeled and dated for patients?

  Yes

  No

  N/A

• Are Infection Control Risk Assessments (ICRAs) performed for construction projects?

  Yes

  No

  N/A

• Does staff wear an appropriate N95 respirator mask, or powered air purifying respirator (PAPR) to enter Airborne infection Isolation room?

  Yes

  No

  N/A

• Is the door to Airborne Infection Isolation room closed?

  Yes

  No

  N/A

• Are medication refrigerator temperature logs complete and adhere to appropriate policy?

  Yes

  No

  N/A

• Are staff able to describe the process to follow if the medication refrigerator temperature is out of range?

  Yes

  No

  N/A

Information Privacy

• Employee Health Only: Is access to Employee Health Records maintained in paper form limited to Employee/Occupational Health Staff?

  Yes

  No

  N/A

• Do workforce members practice auditory privacy safeguards to prevent disclosure to unauthorized individuals and are auditory safeguards in place in waiting rooms and check-in areas?

  Yes

  No

  N/A

• Are reasonable safeguards in place to protect Sign-in Sheets from unauthorized disclosure and only include the minimum necessary information?

  Yes

  No

  N/A

• Do workforce members demonstrate General Privacy Knowledge/Awareness specific to Privacy Laws and

  Sign

• Are documents containing PHI/PII secured during business hours from unauthorized access? Are documents containing PHI/PII secured during non-business hours from unauthorized access?

  Yes

  No

  N/A

• Is more than the minimal necessary information (PHI/PII) displayed in public areas?

  Yes

  No

  N/A

• Is equipment reasonably secured from public view or access to prevent unauthorized access to PHI/III/SPI9E.G., Is there any patient information on publicly accessible printers, copiers, or fax machines)?

  Yes

  No

  N/A

• Does fax cover sheet contain the confidentiality clause found in VA Handbook 6500?

  Yes

  No

  N/A

• Are health records in file areas and other areas where health records are temporarily stored (clinic or treatment areas, record review areas, quality assurance areas, release of information, etc.) locked when designated authorized personnel are not present to ensure the security of the area and to ensure health records are not accessible to unauthorized individuals?

  Yes

  No

  N/A

• Are appointment lists containing PHI/PII found in publicly accessible areas only for the current day?

  Yes

  No

  N/A

• Does the facility-wide mail process (receipt, storage, sorting/processing, delivery, and returning) provide

  Yes

  No

  N/A

• Are workforce members wearing properly displayed identification badges at all times while on the premises as required by VA Directive 0730.1 (observation)?

  Yes

  No

  N/A

• Do workforce members know their responsibilities to ensure only authorized persons enter areas not publicly accessible?

  Yes

  No

  N/A

• Are health records in file areas and other areas where health records are temporarily stored (clinic or treatment areas, record review areas, quality assurance areas, release of information, etc.) locked when designated authorized personnel are not present to ensure the security of the area and to ensure health records are not accessible to unauthorized individuals?

  Yes

  No

  N/A

• Is there a shredder or locked container in the area and do workforce members appropriately dispose of documents and non-paper items per policy?

  Yes

  No

  N/A

• Are privacy screens placed on computer monitors as needed?

  Yes

  No

  N/A

• Are there any logbooks in the area; are they secured; are they approved?

  Yes

  No

  N/A

• Can staff state their assigned functional category?

  Yes

  No

  N/A

• Do employees know where or to whom they need to refer patients when they request to have their records amended?

  Yes

  No

  N/A

Information Security

• Are doors locked if unattended?

  Yes

  No

  N/A

• Are access/verify codes stored in a secured location?

  Yes

  No

  N/A

• Are computers locked if unattended?

  Yes

  No

  N/A

• Are laptops physically secured, including those associated with medical devices?

  Yes

  No

  N/A

• A list of personnel authorized access to areas of the facility that contain information systems exists; list is posted in appropriate area and reviewed by ISO by initialing and dating; or by electronic means.

  Yes

  No

  N/A

• Physical controls are in place to control all access points to areas containing information systems and verifies an individual's access authorization before granting physical access to information system area; review of documentation of the access is completed by the ISO.

  Yes

  No

  N/A

• Physical access to information system distribution and transmission lines is controlled to prevent accidental damage, eavesdropping, in-transit modification, disruption, or physical tampering; access to locations that contain equipment or data critical to the information infrastructure is limited to authorized personnel (Computer room, Telephone switch rooms and Data-telecommunication closets).

  Yes

  No

  N/A

• Display medium are positioned, whenever possible to prevent unauthorized individuals from observing sensitive information on the display output; computer monitors that cannot be positioned to eliminate viewing by unauthorized personnel a privacy screen is deployed.

  Yes

  No

  N/A

• Physical access to information systems is monitored to detect and respond to incidents; records are maintained that show monitoring responsibility has been assigned; real-time intrusion alarms and surveillance equipment have been implemented. Incident reported and managed in VA incident reporting tool. a. Incident reported and managed in VA incident reporting tool.

  Yes

  No

  N/A

• Visitors to areas containing information systems is controlled by authenticating before authorizing access to facilities or areas other than those areas that are designated as publicly accessible; visitors are logged and escorted.

  Yes

  No

  N/A

• Visitor access logs are maintained (except for areas designated as publicly accessible); name and organization of the person visiting; signature of the visitor; form of identification; date of access; time of entry and departure; purpose of visit; name and organization of person visited and tools in and out are documented and audited by the ISO quarterly.

  Yes

  No

  N/A

• Power equipment and power cabling for the information systems are protected from damage and destruction, and redundant and parallel power cabling paths for the computer room are in place.

  Yes

  No

  N/A

• Emergency Shutoff for the computer room is in place to provide the capability of shutting off power to any information system component that may be malfunctioning, or threatened, without endangering personnel by requiring them to approach the equipment; emergency shutoff is tested at least annually.

  Yes

  No

  N/A

• Short-term uninterruptible power supply for information systems is in place to facilitate an orderly shutdown; emergency generators are on station to provide long-term alternate power supply for the information system and is capable of maintaining minimally required operational capability in the event of an extended loss of the primary power source; testing of power supplies is completed at least annually.

  Yes

  No

  N/A

• Emergency lighting is in place in the event of a power outage or disruption and cover emergency exits and evacuation routes; testing is completed at least annually.

  Yes

  No

  N/A

• The facility employs and maintains fire suppression and detection devices/systems that can be activated in the event of a fire; fire detection devices/systems activate automatically and notify the IT staff and emergency responders in the event of a fire; fire suppression devices/systems provide automatic notification of any activation to the IT and emergency responders; computer room and telecommunications closets are protected by automatic fire suppression capabilities.

  Yes

  No

  N/A

Interior Design

• Is furniture in good condition and free from damage?

  Yes

  No

  N/A

• Is the furniture and decorative items appropriate for the functional area?

  Yes

  No

  N/A

• Are window treatments in good condition and free from damage/operational?

  Yes

  No

  N/A

• Is furniture free from tears and rips?

  Yes

  No

  N/A

• Is Artwork secured to the wall with 3 or 4 point anchor system?

  Yes

  No

  N/A

• Does personal furniture or equipment have an approved VA Form 2235?

  Yes

  No

  N/A

• Is Life Safety signage accurate?

  Yes

  No

  N/A

• Is Directional Signage/Room Numbers accurate?

  Yes

  No

  N/A

• Are "Authorized Personnel Only" signs posted at all restricted areas?

  Yes

  No

  N/A

• Are signs posted at entrances noting that the "Introduction of weapons, unauthorized drugs, and alcoholic beverages on the property is prohibited"?

  Yes

  No

  N/A

• Is signage in good repair and free from damage?

  Yes

  No

  N/A

• Is signage compliant with ADAAG? (braille)

  Yes

  No

  N/A

• Are surfaces free from taped and tacked items? (Decorations, paper signs, posters)

  Yes

  No

  N/A

Patient Safety

• Is medication cart lock functioning properly?

  Yes

  No

  N/A

• Is the door to the medication room locked?

  Yes

  No

  N/A

• Are medications stored appropriately?

  Yes

  No

  N/A

• Are medications expired?

  Yes

  No

  N/A

• Are multi-use medications current (not expired) and correctly labeled?

  Yes

  No

  N/A

• Are high-risk tubings and catheters (such as epidural, intrathecal, arterial lines) labeled?

  Yes

  No

  N/A

• Is there a standardized method in place to verify that code carts are fully stocked, properly equipped, and stock is within expiration date?

  Yes

  No

  N/A

• Are code carts equipped with working C02 detectors and other esophageal detection devices for use in out of operating airway management?

  Yes

  No

  N/A

• Are emergency crash carts checked and documented per policy?

  Yes

  No

  N/A

• Are defibrillators tested and documented daily?

  Yes

  No

  N/A

• If defibrillators/code carts are not provided, are operational Automatic External Defibrillators (AEDs) available for emergencies?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• If bed rails are installed/used, are they free of entrapment potential (for patients identified as high risk for entrapment) A. Rail to mattress, B. Between split rails, C. Rail to board -either end, D. Board to mattress, or, E. within rail?

  Yes

  No

  N/A

• Is the bed placement appropriate for the room (without gaps that may entrap a patient in the event of a fall or impede a code team)?

  Yes

  No

  N/A

• Are bed (and/or chair) alarms audible and configured to reduce the number of false/unwanted alarms?

  Yes

  No

  N/A

• Are beds with built-in weight scales accurate and functioning correctly?

  Yes

  No

  N/A

• Are all beds are in a low position unless patient is receiving care?

  Yes

  No

  N/A

• If BCMA is used, is there evidence of work-arounds or shortcuts.

  Yes

  No

  N/A

• Is water temperature accurately monitored before and during each bath?

  Yes

  No

  N/A

• Is patient nourishment properly labeled and dated?

  Yes

  No

  N/A

• Are temperatures for all refrigerators/freezers checked and documented per policy with corrective actions, as indicated?

  Yes

  No

  N/A

• Is piped-in oxygen and compressed air identified by a prominent label and not merely by color adapters?

  Yes

  No

  N/A

• Does Area/Unit personnel know how to correctly handle oxygen cylinders?

  Yes

  No

  N/A

• Are at least two patient identifiers used when providing care, treatment and services?

  Yes

  No

  N/A

• Can staff verbalize process for reporting close call/adverse event?

  Yes

  No

  N/A

• Are all staff properly trained in infusion pump usage?

  Yes

  No

  N/A

• Does staff know what a "sentinel event" is?

  Yes

  No

  N/A

• Is close-loop communication (handoff, repeat/read back) evident?

  Yes

  No

  N/A

• Is the call system audible/light functioning at Nurse Station?

  Yes

  No

  N/A

Privacy and Dignity

• Are privacy curtains/screens present and functional in all examination rooms? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Do women have access to women-only/unisex toilets and showers in close proximity to their room? (At a minimum, needs to be in the same subunit where their assigned room is located) (Inpatient, Residential, Domicilliary, and Hospital Facilities)

  Yes

  No

  N/A

• Is a family or unisex restroom/toilet room available? (Public Areas)

  Yes

  No

  N/A

• Are sanitary napkin and tampon dispensers (or any other way to provide, ie basket, etc) and disposal bins in ALL women's/unisex public restrooms/toilet rooms, at no cost? (Public Areas)

  Yes

  No

  N/A

• Do all women have separate and secured sleeping accommodations? (Inpatient, Residential, Domiciliary, and Hoptel Facilities)

  Yes

  No

  N/A

• Do exam rooms open into public waiting rooms or corridors? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Do exam rooms have locks? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Can gowned patients access sex-specific or unisex restrooms/toilet rooms without entering public areas? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Are examination tables placed in such a way that the genital area is not visible from the doorway? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Is there a system in place to obtain appropriate clothing sizes at all times? (Inpatient, Residential, Domiciliary, and Hoptel Facilities)

  Yes

  No

  N/A

• Do mixed gender units ensure safe and secure sleeping and bathroom/toilet room arrangements, including, but not limited to door locks and proximity to staff? (Inpatient, Residential, Domiciliary, and Hoptel Facilities)

  Yes

  No

  N/A

• Are changing tables available in public restrooms/toilet rooms? (Public Areas)

  Yes

  No

  N/A

• Do privacy curtains/screens fully shield the patient during examination, while dressing/undressing, and provide sufficient work space for the provider to perform the examination? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Do individual restrooms/toilet rooms have locks? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Are cameras (telehealth, computer, teaching) shielded/covered/in locked cabinet/room when not in use? (Examination, Procedures and Testing Areas)

  Yes

  No

  N/A

• Do individual restrooms/toilet rooms have locks? (Inpatient, Residential, Domiciliary, and Hospital Facilities)

  Yes

  No

  N/A

Safety

• Are means of egress clear of obstructions and other impediments?

  Yes

  No

  N/A

• Fire and smoke barrier doors are not blocked and operate properly (self-closing/no gaps/fire doors must latch)?

  Yes

  No

  N/A

• Do exit signs lead you to an appropriate exit?

  Yes

  No

  N/A

• Are stairwells free of clutter (no storage is permitted in any part of a stairwell)?

  Yes

  No

  N/A

• Do combustible decorations comply with NFPA standards?

  Yes

  No

  N/A

• Are there penetrations in fire/smoke barriers?

  Yes

  No

  N/A

• Is there anything stored within 18 inches of sprinkler deflectors?

  Yes

  No

  N/A

• Are there excessive amounts of combustibles in any area/room that is not protected as a hazardous area?

  Yes

  No

  N/A

• For construction activities, has an Interim Life Safety Measures (ILSM) assessment been done and if required, are ILSMs implemented?

  Yes

  No

  N/A

• Are the fire extinguishers marked with signs or other means used to indicate the location?

  Yes

  No

  N/A

• Are fire extinguishers inspected monthly?

  Yes

  No

  N/A

• Are the fire extinguishers and manual fire alarm boxes accessible?

  Yes

  No

  N/A

• Does staff know locations for the manual fire alarm box, extinguisher, oxygen shut offs and fire exits?

  Yes

  No

  N/A

• Does staff know the meanings of PASS and RACE?

  Yes

  No

  N/A

• Have staff been trained in proper use and storage of Personal Protective Equipment (PPE)?

  Yes

  No

  N/A

• Are compressed gas cylinders secured and stored properly?

  Yes

  No

  N/A

• Are SDS sheets current and properly displayed?

  Yes

  No

  N/A

• Is chemical inventory current?

  Yes

  No

  N/A

• Are chemicals labeled, stored properly and in good condition?

  Yes

  No

  N/A

• Are chemical disposal procedures known?

  Yes

  No

  N/A

• Are staff familiar with spill kits and spill response procedures?

  Yes

  No

  N/A

• Are hazardous waste containers properly stored and labeled?

  Yes

  No

  N/A

• Do storage rooms and hazardous area locations have self-closing doors and are the doors not wedged

  Yes

  No

  N/A

• Are fume hoods and biological safety cabinets operational with current inspection date?

  Yes

  No

  N/A

• Are there any visible slips, trips, or falls hazards?

  Yes

  No

  N/A

• Are electrical panels closed and circuits properly labeled?

  Yes

  No

  N/A

Supply Chain Management

• Are the clean/sterile supply areas clean and neat, dust and contaminate free?

  Yes

  No

  N/A

• If there are windows in the clean or sterile storage areas, are the windows covered or treated for UV protection?

  Yes

  No

  N/A

• Are the doors to clean/sterile supply rooms locked at all times and not propped open?

  Yes

  No

  N/A

• Are the supplies neat and orderly for ease of access (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are supplies expired?

  Yes

  No

  N/A

• Are supplies stocked directly on the floor (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are supplies stored next to or underneath sinks or ice machines (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are the bottom shelves solid and/or are there coverings to make it solid (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are the shelves 2 inches from any outside wall (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are the bottom shelves at least 8 inches from the floor (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are all items 18 inches from any fire apparatus (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Is temperature and humidity monitored (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are there bar code labels on the bins, shelves, and general area of the items stocked (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Is there any corrugated cardboard or outer shipping containers (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Is there any food, drink, or cork boards (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are there any opened, damaged, or compromised medical supplies (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Are there any outdated medical supplies/ is there a weekly posted schedule (ALL clean/sterile storage areas)?

  Yes

  No

  N/A

• Is their evidence of hoarding of supplies outside of the clean/sterile supply rooms?

  Yes

  No

  N/A

• Is access to clean/sterile storerooms restricted to authorized personnel only?

  Yes

  No

  N/A

• Is the dirty equipment area separate from clean/sterile storage area?

  Yes

  No

  N/A

• Are there bar code labels on the equipment?

  Yes

  No

  N/A

• Is their evidence of unnecessary or unused equipment?

  Yes

  No

  N/A

• Are refrigerators clearly marked: "for personal use only" or "for medication only"?

  Yes

  No

  N/A

Veterans Canteen Service

• Are proper hand hygiene practices observed? Staff observed washing their hands, changing gloves?

  Yes

  No

  N/A

• Is all equipment cleaned and in sanitary condition?

  Yes

  No

  N/A

• Are icemaker & bin cleaned and sanitized quarterly?

  Yes

  No

  N/A

• Are exhaust hoods free of excess build up of grease/dust (including light fixtures, fire suppression nozzles, filters)?

  Yes

  No

  N/A

• Have exhaust hoods been cleaned by professional vendor in the last 3 month (quarterly)?

  Yes

  No

  N/A

• Is entire food department free from insects & rodents or their signs (droppings)?

  Yes

  No

  N/A

• Is trash removed from the Canteen in a timely manner?

  Yes

  No

  N/A

• Is the Trash Dumpster maintained so there are no pest issues?

  Yes

  No

  N/A

• Are food/supplies stored 6" from the floor and 18" from sprinkler heads?

  Yes

  No

  N/A

• Is a Wireless temp system installed on all refrigerators/freezers (monitors temperatures 24/7)?

  Yes

  No

  N/A

• Is lighting adequate in walk-in refrigerators and freezers (cannot fully assess cleanliness of environment or equipment without proper lighting)?

  Yes

  No

  N/A

• Are ceiling vents, sprinkler heads, tiles/grids free from soil, dust, rust flaking paint?

  Yes

  No

  N/A

• Are walls, ceilings and floors free of cracked/missing tiles, holes, flaking paint?

  Yes

  No

  N/A

• Are light fixtures free of dust/rust/debris; diffusers free from cracks?

  Yes

  No

  N/A

• Are floors free of soil/debris (under equipment, in corners, next to baseboards)?

  Yes

  No

  N/A

• Are wall/floor tiles in good repair (free from cracks, holes or missing)?

  Yes

  No

  N/A

• Are floor drains free from food/debris? Grease traps clean?

  Yes

  No

  N/A

• Is insulation on pipes/conduits in good condition (cooking equipment, sinks and walk in refrigerator/freezers)?

  Yes

  No

  N/A

• Are electrical conduits/outlet plates, gas conduits, etc, clean and free of soil/grease/dust?

  Yes

  No

  N/A

• Is Walk-In freezer free of ice on floor, walls and condenser?

  Yes

  No

  N/A

• Are compressor units in walk-in refrigerators/freezers free from dust/mildew/rust?

  Yes

  No

  N/A

• Is interior of trash can cabinets in dining room clean and free from food splashes?

  Yes

  No

  N/A

• Are dining room windows, window sills, blinds, décor clean and free of dust/debris?

  Yes

  No

  N/A

• Is eye wash station functioning properly?

  Yes

  No

  N/A

• Are chemicals properly labeled and stored separately from food?

  Yes

  No

  N/A

• Are Material Safety Data Sheets (MSDS) available and up to date?

  Yes

  No

  N/A

• Are CO2 tanks secured?

  Yes

  No

  N/A

• Is Personal Protective Equipment (PPE) available and in adequate supply (rubber gloves, goggles, face masks, fryer safety kit)?

  Yes

  No

  N/A

VHA Law Enforcement and Security

• Are employee, student, and contractor badges worn and properly displayed?

  Yes

  No

  N/A

• Are access points to restricted areas properly secured when not occupied or monitored when in use?

  Yes

  No

  N/A

• Is the facility smoking policy being enforced in the area?

  Yes

  No

  N/A

• Is the lighting at all entrances and exits fully operational?

  Yes

  No

  N/A

• Are all locks and access control devices on perimeter/interior doors fully functional?

  Yes

  No

  N/A

• Does staff know how to contact VA Police in the case of an Emergency?

  Yes

  No

  N/A

• Is there a dedicated emergency number posted on telephones?

  Yes

  No

  N/A

• For inpatient units: Are patient personal belongings inventoried and contraband addressed/secured upon admission?

  Yes

  No

  N/A

• Are appropriate barriers installed to prevent vehicles from driving directly into the entrance points of the facility?

  Yes

  No

  N/A

• Are all perimeter doors, with the exception of primary access points, secured and monitored to prevent

  Yes

  No

  N/A

• Are all visitors asked to sign in upon entry to the facility?

  Yes

  No

  N/A

• Are lights in employee, patient and visitor parking areas operational?

  Yes

  No

  N/A

• Are entry/exit points to patient care areas monitored?

  Yes

  No

  N/A

• Are SSTV cameras in applicable areas functional?

  Yes

  No

  N/A

• Are duress alarm systems fully functional and regularly tested?

  Yes

  No

  N/A

• Are unidentified personnel questioned and are appropriate personnel notified when appropriate?

  Yes

  No

  N/A

• Have staff in the service/area been queried as to any known safety/security issues that remain

  Yes

  No

  N/A

Nutrition and Food Service

• N&FS - Storage shelves, racks are clean, free of grime, soil build up; sanitized routinely

  Yes

  No

  N/A

• N&FS - Raw meats are stored separately or below ready to eat or cooked foods

  Yes

  No

  N/A

• N&FS - Accurate temperature thermometers are present and temperatures are taken

  Yes

  No

  N/A

• N&FS - Temperatures are appropriate for the storage area

  Yes

  No

  N/A

• N&FS - Foods are inspected upon receipt per HACCP and receipt-dated

  Yes

  No

  N/A

• N&FS - There is appropriate air circulation around food

  Yes

  No

  N/A

• N&FS - FIFO system used; items dated with expiration/use by date or date of receipt

  Yes

  No

  N/A

• N&FS - Foods are properly labeled with identity, whether in original packaging or in another container

  Yes

  No

  N/A

• N&FS - TCS (Time and Temperature Control for Safety) Foods are kept at or below 41ºF during cold holding

  Yes

  No

  N/A

• N&FS - TCS are cooled by an approved method

  Yes

  No

  N/A

• N&FS - TCS are stored under refrigeration except during necessary preparation (limit 30 min)

  Yes

  No

  N/A

• N&FS - TCS (ex: potato/pasta salads) prepared using pre-chilled ingredients (<= 41º F)

  Yes

  No

  N/A

• N&FS - TCS foods are maintained properly to keep hot foods above 135º F

  Yes

  No

  N/A

• N&FS - Proper thawing techniques are used

  Yes

  No

  N/A

• N&FS - Foods cooked to proper temperatures

  Yes

  No

  N/A

• N&FS - Proper utensils used to eliminate bare hand contact w/ cooked or prepared foods

  Yes

  No

  N/A

• N&FS - Food contact surfaces are sanitized before working with ready to eat/serve foods

  Yes

  No

  N/A

• N&FS - Shipping cartons not in food preparation or serving areas

  Yes

  No

  N/A

• N&FS - Unwrapped TCS foods are not re-served

  Yes

  No

  N/A

• N&FS - Produce is washed prior to serving

  Yes

  No

  N/A

• N&FS - Shell eggs are pasteurized, not cracked/dirty

  Yes

  No

  N/A

• N&FS - All juices, egg product, dairy products are pasteurized

  Yes

  No

  N/A

• N&FS - Walls, Floors, Ceilings Clean

  Yes

  No

  N/A

• N&FS - Floor drains clear, without debris

  Yes

  No

  N/A

• N&FS - Food trucks gaskets, vents, and coils clean and functional

  Yes

  No

  N/A

• N&FS - No chemical sprays used around food

  Yes

  No

  N/A

• N&FS - Chemicals are separate from foods during delivery and storage

  Yes

  No

  N/A

• N&FS - Food workers wash hands thoroughly for 20 seconds at appropriate times

  Yes

  No

  N/A

• N&FS - Food workers free from illness transmissible by foods

  Yes

  No

  N/A

• N&FS - Employees do not wear jewelry except single plain band

  Yes

  No

  N/A

• N&FS - Employees wear hair/beard/mustache restraints

  Yes

  No

  N/A

• N&FS - Employees wear Personal Protective Equipment appropriately

  Yes

  No

  N/A

• N&FS - Drawers, carts, etc are clean

  Yes

  No

  N/A

• N&FS - Food slicer is clean to sight and touch and sanitized between uses

  Yes

  No

  N/A

• N&FS - All equipment is clean to sight and touch – serving lines, shelves, cabinets, ovens, ranges, fryers, steam equipment, etc.

  Yes

  No

  N/A

• N&FS - Small equipment is inverted, covered, or otherwise protected from dust or contamination when stored

  Yes

  No

  N/A

• N&FS - Kitchen garbage cans are emptied when necessary and clean

  Yes

  No

  N/A

• N&FS - Utensils are scraped and soaked before being washed

  Yes

  No

  N/A

• N&FS - Person in Charge

• N&FS - HAACP plan is present or current

  Yes

  No

  N/A

• EMS - No evidence of insects, rodents – i.e. droppings

  Yes

  No

  N/A

• EMS - Windows/doors screened if opened

  Yes

  No

  N/A

• EMS - Trash area separate from food areas: Container leak proof and covered

  Yes

  No

  N/A

• EMS - Loading dock and area around dumpster is clean

  Yes

  No

  N/A

• EMS - Dumpster is closed

  Yes

  No

  N/A

• IH/Safety/Eng - Chemicals are properly stored, labeled, and up to date SDS information is readily available

  Yes

  No

  N/A

• IH/Safety/Eng - Poisonous/toxic materials in secured, locked areas. Stock dated with receipt date

  Yes

  No

  N/A

• IH/Safety/Eng - Light fixtures covered, in good repair

  Yes

  No

  N/A

• IH/Safety/Eng - Grease traps clean

  Yes

  No

  N/A

• IH/Safety/Eng - Exhaust hood and filters are clean

  Yes

  No

  N/A

• IH/Safety/Eng - Emergency Equipment within date and functional (on 15 page word document, need to discuss reference)

  Yes

  No

  N/A

• IH/Safety/Eng - No dangerous areas for slipping, falling

  Yes

  No

  N/A

• IH/Safety/Eng - Equipment and storage areas in good repair; guards used when appropriate

  Yes

  No

  N/A

• IH/Safety/Eng - Wet floor signs used when floor wet/slippery; floors wet mopped properly

  Yes

  No

  N/A

• IH/Safety/Eng - Locker rooms/rest rooms clean with appropriate handwashing facilities and sign

  Yes

  No

  N/A

• IH/Safety/Eng - Items are stored 6" off floor and 18" from sprinkler heads

  Yes

  No

  N/A

• IH/Safety/Eng - Eye wash station functional; fire extinguisher tags updated

  Yes

  No

  N/A

• IH/Safety/Eng - Employee able to state emergency procedures

  Yes

  No

  N/A

• IH/Safety/Eng - Emergency stock of food/water stored properly and within exp/use-by dates

  Yes

  No

  N/A