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? Securely mounted?

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? Caps and escutcheon rings are in place.

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, positioned correctly and at least two are always visible (all lights burning)?

2.10 - Fire rated Doors close, latch properly, and are smoke-tight (stairwells included)?

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,unobstructed, and properly lit?

2.14 - "Stairs" signs are displayed at elevator lobbys & stair entrances including No Exit signs where applicable identifying the floor and exit discharge level.

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 and hot plates 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)

2.23 - Ceiling tiles and grids are in place, free from stains, cracks, and a holes.

2.24 - 8ft. Passageway maintained in corridor.

2.25 - Red reflector tape on smoke compartment cross-Corridor doors.

2.26 - Delayed egress doors have correct signage on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1" inch high and not less than 1/8 in. In stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.

2.27 - Recall boxes separated by 8 feet.

2.28- Evacuation routes in elevator lobby are posted and in good condition.

FS/FP Other Observation

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 - Only approved Power strips are used in the area. Office space (UL 1363) patient care area (UL 1363a).

3.8 - El/ Other Observations

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 - Desk, chairs, furniture and safe condition?

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? No tripping/slipping hazards present?

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

4.15 - Emergency pull cords hanging 6" from floor; but not touching the ground and 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 - No evidence of food, drinks or eating occurring around direct patient areas or nurse's station?

4.19 - Staff know how to label broken equipment?

4.20 - All medical equipment PM's up-to-date and equipment does not need repair.

5.0 - Hazardous Material

5.1 - Eye wash station inspected weekly and documented?

5.2 - Eyewash station signage is posted and the path to station is unobstructed

5.3 - High level disinfectant policy being followed - QC, documentation, etc? (Sterile Processing Areas) and only approved cleaning/disinfecting supplies are being used.

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

5.5 - Medical gas cylinders are restrained properly in bins, racks, or hand carts? Do not exceed maximum storage requirements inside a single smoke compartment. 1 E-Cylinder = 25cu, 1 H Cylinder = 250cu ft. In use tanks do not count 300cu ft. - for non-rated storage 3000cu ft. - for 1 hour rated storage.

5.6 - Biohazard containers are stored properly and are identified with biohazard sticker or red color.

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? Nothing stored on top and 46"-52" from floor to opening.

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 and labeled? All chemicals stored below eye level.

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

5.14 - Correct PPE and spill kits are easily accessible.

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?

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

8.0 - Housekeeping

8.1 - Trash is correctly disposed of and not overflowing or stored on floor.

8.2 - Linen rooms clean, carts covered and it with solid bottom

8.3 - Floors, walls, vents, and light fixtures are clean.

8.4 - Sinks and water fountains clean.

8.5 - Nurses station clean.

8.6 - Clean utility or supply rooms are clean and organized.

8.7 - Dirty utility or soiled utility rooms are clean.

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

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

8.10 - Equipment is dust free.

8.11 - There are no visible insects.

8.12 - Nourishment area is clean.

8.13 - Staff lounge is clean.

8.14 - Public rest rooms are clean, stocked with restrooms supplies, and smell good.

8.15 - Visitor waiting and common areas are clean.

9.0 - Food and Nutrition

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

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

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

9.4 - Patient refrigerator and/or freezer logs are recorded daily or fresh loc system is in.

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

9.6 - Water, ice or drink dispensers are clean and have inspection sticker when required.

10.0 - Infection Prevention

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

10.2 - Staff food or drink only located in designated areas.

10.3 - Appropriate Storage (cleaning supplies only) under sinks.

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

10.5 - No expired items found in the area.

10.6 - Storage bins/units/shelving are clean.

10.7 - Storage or supply carts have solid bottoms.

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

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

10.10 - All rooms with specific air pressurization requirements correct (negative-soiled linen, Decontamination Rooms, bronchoscopy rooms, isolation rooms, etc. Positive-ORs, procedural rooms, supply rooms, etc.)

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

10.12 - Precaution tools available and being used correctly (signage and PPE).

10.13 - Clean Linen is covered or stored in a room or cabinet by itself.

10.14 - All surfaces are wipeable.

11.0 - Medication Safety

11.1 - Crash cart log current; no expired meds (date stickers); drawers locked and oxygen tank attached.

11.2 - Medication/Code carts locked and in view of staff and med rooms locked?

11.3 - No outdated medications or treatments found in area.

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

11.5 - No medications or sharps are located in the hallway or easily accessible to the public.

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

12.0 - Emergency Management

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

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

12.3 - Emergency patient bathroom keys are in place (if applicable) or check to see if they know how to get the door open.

12.4 - Red phone/Flat Business line is available and working.

12.5 - All staff have safety guidelines attached to badge.

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

13.0 - Patient Experience

13.1 - Is The patient room functional for the patient? (I.e Trash can located closer to patient bed for convenience, patient welcome folder in appropriate location, etc.

13.2 - Is Way-finding/signage on the unit easy to understand?

13.3 - Are patient/visitor communication boards easy to understand?

14.0 - Primary Care Office Review

14.1 - Are there clearly marked office signs (external)

14.2 - Is the facility assessable to persons with disabilities?

14.3 - Is the waiting rooms adequate for patient volume?

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

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

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

14.7 - Exam rooms designed to assure privacy of patients?

14.8 - Exam rooms equipped with supplies?

14.9 - Lab Area - Clean and Orgesanized ?

14.10 - Lab Area - Separate from Patient Areas?

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.