Environment of Care Rounds v:3.01 MDL - duplicate - duplicate

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Yes

  No

  N/A

• Yes

  No

  N/A

• 8.16 - Public restrooms are clean, stocked with restroom supplies and smell good.

  Yes

  No

  N/A

• 8.15 - Nourishment area clean.

  Yes

  No

  N/A

• 8.14 - There are no visible insects.

  Yes

  No

  N/A

• 8.11 - Nurses station clean. and staff lounge clean?

  Yes

  No

  N/A

• 8.12 - EVS closets or carts are clean and secure (no personal items being stores in/on either).

  Yes

  No

  N/A

• 8.13 - All high and low level areas are completely dust free.

  Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

1.0 - Previous inspection

• 1.1 - Has the last inspection been reviewed?

  Yes

  No

  N/A

• 1.2 - Are there no outstanding actions?

  Yes

  No

  N/A

2.0 - Fire Prevention

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.8 - Fire Alarm Visuals/Audibles are not obstructed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.10 - Fire Doors close and latch properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.16 - Flammables, stored appropriately?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.18 - Baseboards intact & in good repair?

  Yes

  No

  N/A

• 2.19 - No unauthorized space heaters present?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

3.0 - Electrical Safety

• 3.1 - Electrical outlets are not damaged or loose?

  Yes

  No

  N/A

• 3.2 - Power strips are not plugged into power strips?

  Yes

  No

  N/A

• 3.3 - Extension cords are not in use?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

4.0 - General Safety

• 4.1 - Handrails are attached firmly to the walls?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 4.5 - Stairwell lights working?

  Yes

  No

  N/A

• 4.6 - Storage Rooms clean and orderly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 4.11 - Alternative waterless agent available & hung appropriately?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 4.13 - Area free of fall potentials?

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 4.20 - There are no visible insects.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 4.22 - All surfaces are wipeable.

  Yes

  No

  N/A

5.0 - Hazardous Material

• 5.1 - Eye wash station inspected weekly and documented?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 5.5 - Biohazard signs properly displayed?

  Yes

  No

  N/A

• 5.6 - Biohazard containers are stored properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 5.11 - No cleaning agent accessible or left unattended?

  Yes

  No

  N/A

• 5.12 - Hazardous materials properly stored?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 5.14 - Medication carts or rooms are locked

  Yes

  No

  N/A

• 5.15 - No outdated medications or treatments found in area.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

6.0 - Security Management

• 6.1 - Employee personal items are secured out of sight?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 6.3 - Confidential Material secured /protected?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 6.5 - Doors with security hardware operate properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 6.7 - Code carts locked and in view of staff?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 6.10 - Red phone is available and working.

  Yes

  No

  N/A

• 6.11 All staff have safety guidelines attached to badge.

  Yes

  No

  N/A

7.0 - Utilities Management

• 7.1 - All lights are operational, no lights out?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 7.5 - Ice machine clean and maintenance on schedule?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

8.0 - Primary Care Office Review.

• 8.1 - Are there clearly marked office signs (external)

  Yes

  No

  N/A

• 8.2 - Is the facility assessable to persons with disabilities?

  Yes

  No

  N/A

• 8.3 - Is the waiting rooms adequate for patient volume?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 8.7 - Exam rooms designed to assure privacy of patients?

  Yes

  No

  N/A

• 8.8 - Exam rooms equipped with supplies?

  Yes

  No

  N/A

• 8.9 - Lab Area - Clean and Orgesanized ?

  Yes

  No

  N/A

• 8.10 - Lab Area - Separate from Patient Areas?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 8.12 - Staff know how to label broken equipment?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

9.0 - Food and Nutrition

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Yes

  No

  N/A

• Surveyor's Signature

  Sign

• Additional Comments

Comments