Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
1.0 - Previous inspection
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1.1 - Has the last inspection been reviewed?
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1.2 - Are there no outstanding actions?
2.0 - Fire Prevention
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2.1 - Doors are held open only with magnetic hold open devices (no wedges, paper card boards, etc)?
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2.2 - Fire doors are not blocked by carts, equipment, or materials?
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2.3 - Fire extinguishers have been checked monthly and have a current annual inspection tag?
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2.4 - Extinguishers less than 40 lbs must be no higher than 5 ft (measured from the floor to the top of the extinguisher), extinguishers greater than 40 lbs must be no higher than 3.5 ft (measured from the floor to the top of the extinguisher). Note: the clearance between the bottom of the extinguisher and the floor shall not be less than 4 inches?
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2.5 - No materials are blocking/hindering access to or hanging off the fire extinguisher, fire pull, or emergency shut off (3 foot rule)?
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2.6 - Sprinkler Heads/Smoke Detectors are clean & intact?
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2.7 - Are Fire Department Connections Secure & Free From Foreign Objects or Not Blocked
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2.8 - Fire Alarm Visuals/Audibles are not obstructed?
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2.9 - Exit signs are illuminated and at least two are always visible (all lights burning)?
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2.10 - Fire Doors close and latch properly?
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2.11 - There are no materials stored within 18 inches of any sprinkler head or 12 inches of lights if non-sprinkled?
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2.12 - Doors to Soiled/Clean/Hazardous Materials Rooms closed locked?
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2.13 - There is no excessive trash or linen in the room?
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2.14 - Corridors, fire exits and stairwell are clear and unobstructed?
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2.15 - "Stairs" signs are displayed at elevator lobbys & stair entrances including No Exit signs where applicable.
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2.16 - Equipment in Corridors is in use and not stationary > 30 minutes?
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2.17 - Flammables, stored appropriately?
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2.18 - Penetrations to Walls / Ceilings / Floors, not present?
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2.19 - Baseboards intact & in good repair?
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2.20 - No unauthorized space heaters present?
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2.21 - No unauthorized heat producing equipment present (Toasters, plug-in air freshner, etc)
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2.22 -Trash containers are no more than 32-gallons in capacity per 64 sqft area.
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2.23 -Work surfaces are clean, free of dust, clutter & hazards?
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2.24 - Ceilings & Walls do not have excessive combustibles hanging or attached (bulletin boards, art work, decorations,must meet policy)
3.0 - Electrical Safety
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3.1 - Electrical outlets are not damaged or loose?
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3.2 - Power strips are not plugged into power strips?
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3.3 - Extension cords are not in use?
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3.4 - All switches, receptacles and junction boxes boxes have covers or plates
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3.5 - Electrical panels are accessible & secured - 36" clearance around panels.
4.0 - General Safety
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4.1 - Handrails are attached firmly to the walls?
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4.2 - Do all clinical equipment items have current inspection tag?
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4.3 - Storage is on shelves. No items on the floor?
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4.4 - Floors - tiles, carpet in good repair - no trip hazards?
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4.5 - Stairwell lights working?
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4.6 - Storage Rooms clean and orderly?
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4.7 - No unapproved items are being stored under the sinks?
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4.8 - Patient.OR/Treatment rooms free of dust/dirt/biohazard?
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4.9 - Electrical cords do not run under carpets, through walls or doors, or into cabinets?
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4.10 - Desk, chairs, furniture in safe condition?
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4.11 - Patient Room furniture in safe condition?
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4.12 - Alternative waterless agent available & hung appropriately?
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4.13 - No evidence of food, drinks or eating occurring around direct patient care areas or nurse's station?
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4.14 - All rooms in the facility are numbered & labeled?
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4.15 - Area free of fall potentials?
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4.16 - Patient Equipment found with no visible signs of contamination?
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4.17 - Emergency pull cords hanging 6" from floor; no wrapping of cord around hand rail?
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4.18 - Medical Gas Panels & Shut off Valves are properly labeled?
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4.19 - Blanket Warmer at appropriate temp? Blankets not > than 130 deg & liquids not > 110 deg?
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4.20 - Are appropriate logs being utilized? ( Ref Temp, tracking logs, etc..)
5.0 - Hazardous Material
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5.1 - Eye wash station inspected weekly and documented?
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5.2 - High level disinfectant policy being followed - QC, documentation, etc? (Sterile Processing Areas)
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5.3 - Medical gas cylinders are stored where full and empties are separated?
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5.4 - Medical gas cylinders are restrained properly in bins, racks, or hand carts? Do not exceed maximum storage requirements
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5.5 - Biohazard signs properly displayed?
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5.6 - Biohazard containers are stored properly?
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5.7- Appropriate bags are in use (red-biohazard, blue-recyle, & yellow-chemotherapy)?
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5.8 - Sharps containers are no more than 3/4 full; syringe disposed of properly?
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5.9 - Sharps container in appropriate rack or dog bowl on counter?
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5.10 - Staff are able to obtain a MSDS?
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5.11 - No cleaning agent accessible or left unattended?
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5.12 - Hazardous materials properly stored?
6.0 - Security Management
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6.1 - Employee personal items are secured out of sight?
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6.2 - Employee I.D. Badges visible and worn properly?
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6.3 - Confidential Material secured /protected?
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6.4 - High risk patient's, equipment areas, medications, & High risk offices are secure?
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6.5 - Doors with security hardware operate properly?
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6.6 - Code carts locked and in view of staff?
7.0 - Utilities Management
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7.1 - All lights are operational, no lights out?
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7.2 - Ceiling tiles, none discolored,/wet/damaged?
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7.3 - HVAC System - Air temperature within range?
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7.4 - Plumbing, faucets,, toilets operational (no leaks)?
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7.5 - Ice machine clean and maintenance on schedule?
Comments
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Additional Comments
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Surveyor's Signature
