1.0 - Previous inspection

1.1 - Has the last inspection been reviewed?

1.2 - Are there no outstanding actions?

2.0 - Fire Prevention

2.1 - Doors are held open only with magnetic hold open devices (no wedges, paper card boards, etc)?

2.2 - Fire doors are not blocked by carts, equipment, or materials?

2.3 - Fire extinguishers have been checked monthly and have a current annual inspection tag?

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?

2.5 - No materials are blocking/hindering access to or hanging off the fire extinguisher, fire pull, or emergency shut off (3 foot rule)?

2.6 - Sprinkler Heads/Smoke Detectors are clean & intact?

2.7 - Are Fire Department Connections Secure & Free From Foreign Objects or Not Blocked

2.8 - Fire Alarm Visuals/Audibles are not obstructed?

2.9 - Exit signs are illuminated and at least two are always visible (all lights burning)?

2.10 - Fire Doors close and latch properly?

2.11 - There are no materials stored within 18 inches of any sprinkler head or 12 inches of lights if non-sprinkled?

2.12 - There is no excessive trash or linen in the room?

2.13 - Corridors, fire exits and stairwell are clear and unobstructed?

2.14 - "Stairs" signs are displayed at elevator lobbys & stair entrances including No Exit signs where applicable.

2.15 - Equipment in Corridors is in use and not stationary > 30 minutes?

2.16 - Flammables, stored appropriately?

2.17 - Penetrations to Walls / Ceilings / Floors, not present?

2.18 - Baseboards intact & in good repair?

2.19 - No unauthorized space heaters present?

2.20 - No unauthorized heat producing equipment present (Toasters, plug-in air freshner, etc)

2.21 - Trash containers are no more than 32-gallons in capacity per 64 sqft area.

2.22 - Ceilings & Walls do not have excessive combustibles hanging or attached (bulletin boards, art work, decorations,must meet policy)

3.0 - Electrical Safety

3.1 - Electrical outlets are not damaged or loose?

3.2 - Power strips are not plugged into power strips?

3.3 - Extension cords are not in use?

3.4 - All switches, receptacles and junction boxes boxes have covers or plates

3.5 - Electrical panels are accessible & secured - 36" clearance around panels.

3.6 - Electrical cords do not run under carpets, through walls or doors, or into cabinets?

3.7 - Nurse pull cords are within 6 inches of the floor, but not touching the ground.

4.0 - General Safety

4.1 - Handrails are attached firmly to the walls?

4.2 - Do all clinical equipment items have current inspection tag?

4.3 - Storage is on shelves. No items on the floor?

4.4 - Floors - tiles, carpet in good repair - no trip hazards?

4.5 - Stairwell lights working?

4.6 - Storage Rooms clean and orderly?

4.7 - No unapproved items are being stored under the sinks?

4.8 - Patient.OR/Treatment rooms free of dust/dirt/biohazard?

4.9 - Work surfaces are clean, free of dust, clutter & hazards?

4.10 - Reusable equipment is clean, intact and in safe condition? (ex: Desk, chairs, mattress, wheelchair)

4.11 - Alternative waterless agent available & hung appropriately?

4.12 - All rooms in the facility are numbered & labeled?

4.13 - Area free of fall potentials?

4.14 - Patient Equipment found with no visible signs of contamination?

4.15 - Emergency pull cords hanging 6" from floor; no wrapping of cord around hand rail?

4.16 - Blanket Warmer at appropriate temp? Blankets not > than 130 deg & liquids not > 110 deg?

4.17 - Are appropriate logs being utilized? ( Ref Temp, tracking logs, etc..)

4.18 - EVS closets or carts are clean and secure (no personal items being stored).

4.19 - Public restrooms are clean, stocked with restroom supplies and smell goods.

4.20 - There are no visible insects.

4.21 - Patient supplies are not expired, open, torn or compromised.

4.22 - All surfaces are wipeable.

5.0 - Hazardous Material

5.1 - Eye wash station inspected weekly and documented?

5.2 - High level disinfectant policy being followed - QC, documentation, etc? (Sterile Processing Areas)

5.3 - Medical gas cylinders are stored where partials and empties are separated?

5.4 - Medical gas cylinders are restrained properly in bins, racks, or hand carts? Do not exceed maximum storage requirements

5.5 - Biohazard signs properly displayed?

5.6 - Biohazard containers are stored properly?

5.7- Appropriate bags are in use (red-biohazard, blue-recyle, & yellow-chemotherapy)?

5.8 - Sharps containers are no more than 3/4 full; syringe disposed of properly?

5.9 - Sharps container in appropriate rack or dog bowl on counter and not accessible to the public?

5.10 - Staff are able to obtain a Safety Data Sheet (SDS)

5.11 - No cleaning agent accessible or left unattended?

5.12 - Hazardous materials properly stored?

5.13 - Doors to Soiled/Clean/Hazardous Materials Rooms closed locked?

5.14 - Medication carts or rooms are locked

5.15 - No outdated medications or treatments found in area.

5.16 - Medication refrigerator labeled "Medication Only" and contains medication.

5.17 - Pill slicers and crushers are clean and free of pill debris.

6.0 - Security Management

6.1 - Employee personal items are secured out of sight?

6.2 - Employee I.D. Badges visible and worn properly?

6.3 - Confidential Material secured /protected?

6.4 - High risk patient's, equipment areas, medications, & High risk offices are secure?

6.5 - Doors with security hardware operate properly?

6.6 - Evacuation equipment (Paraslydes, Medsleds, Evacusleds) intact and readily.

6.7 - Code carts locked and in view of staff?

6.8 - Emergency preparedness guide (EPG/red manual) has the most up-to-date content.

6.9 - Emergency patient bathroom keys are in place (if applicable)

6.10 - Red phone is available and working.

6.11 All staff have safety guidelines attached to badge.

7.0 - Utilities Management

7.1 - All lights are operational, no lights out?

7.2 - Ceiling tiles, none discolored,/wet/damaged?

7.3 - Medical Gas Panels & Shut off Valves are properly labeled?

7.4 - Plumbing, faucets,, toilets operational (no leaks)?

7.5 - Ice machine clean and maintenance on schedule?

7.6 - Approved 700 ml alcohol hand sanitizer and hand lotion available and not expired.

7.7 - soiled utility/Decon rooms negative pressure and clean/sterile rooms positive pressure?

6.12 - Power outage kit is accessible, stored correctly, all contents are inside (locked/secure) and staff know how to locate kit.

8.0 - Primary Care Office Review.

8.1 - Are there clearly marked office signs (external)

8.2 - Is the facility assessable to persons with disabilities?

8.3 - Is the waiting rooms adequate for patient volume?

8.4 - Is there a mechanism to inform patients of office hours?

8.5 - Is the department of insurance complaint process/800 number displayed?

8.6 - Provisions for patients who don't speak English or are visually or hearing impaired?

8.7 - Exam rooms designed to assure privacy of patients?

8.8 - Exam rooms equipped with supplies?

8.9 - Lab Area - Clean and Orgesanized ?

8.10 - Lab Area - Separate from Patient Areas?

8.11 - Clean and dirty activities performed in separate, clearly distinct areas.

8.12 - Staff know how to label broken equipment?

8.13 - Area is free from external shipping boxes and patient care items not stored in cardboard boxes.

9.0 - Food and Nutrition

9.1 - No evidence of food, drinks or eating occurring around direct patient areas or nurse's station?

9.2 - Refrigerators and freezers are properly labeled (patient, staff or medication>

9.3 - Patient food is not expired, covered; dated & labeled if belongs to patient.

9.4 - All the refrigerators and freezers are clean, without ice build up and with seals in good conditon.

9.5 - Kitchen appliances (ex: microwave, coffee maker drawers, etc) and pantry are clean.

Surveyor's Signature

Additional Comments

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.