Information
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Document No.
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Audit Title
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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
Life Safety (Departments are responsible for corrective actions.)
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Fire exits are clear from obstructions.
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Hallways are clear.
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Fire alarm pull stations are not blocked.
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Fire extinguishers are not blocked.
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Electrical panels are not blocked. (Nothing within the yellow taped areas)
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Sprinklers have 18 inch clearance.
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Toasters are not located near combustibles.
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Multi-outlet strips are not plugged into other multi-outlet strips.
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Extension cords are not used. (unless approve by Facilities) (this excludes multi-outlet strips)
Safety (Departments are responsible for corrective actions.)
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Gas cylinders are stored in proper holders. (Single dollies are for in-use cylinders)
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Floors are free of boxes and articles being stored.
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Ladders & stools are solid & equipped w/ non-skid feet.
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Emergency pull cords are free hanging and accessible. (Within 4 inches of the floor)
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Cords & tubings are not obstructing walkways.
Hazardous Materials and Waste (Departments are responsible for corrective actions.)
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Hazardous substance containers are properly labeled.
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Medical waste is bagged appropriately at point of origin & at point of collection.
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Sharps containers are secured, contain only sharps waste, emptied when 3/4 full. (No recapped needles)
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Flammable materials are properly stored.
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Waste is disposed in the appropriate containers.
Staff Knowledge (Departments are responsible for corrective actions.)
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Location of manuals (Disaster, Safety, Infection Control) known by staff.
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Location of MSDS known by staff.
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Location of flashlights known by staff.
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Staff know how to unlock Pt. bathroom doors.
Infection Control - (Departments are responsible for corrective actions.)
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Linen carts (primary and secondary carts) and supplies are appropriately covered. The bottom shelves are solid
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Storage areas are clean and uncluttered. Sterile/supplies should be 12 inches from the floor. Storage supplies are covered, as appropriate to area.
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Sterile supplies/medications are current (not outdated) upon random survey.
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Syringes and needles are secured (locked).
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Use of needle-less and sharps protective devices are used appropriately.
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IV tubing dated and changed every 96 hours.
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Head of Bed (HOB) up signs are posted above beds of patients with tube feedings. HOB up to 30 degrees for patients with ventilator or tube feedings.
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Appropriate isolation precaution signs are posted.
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Staff are observed using appropriate infection control measures/techniques. (Hand washing, PPE, spill clean up)
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There is no staff/physician food or drink in nurses station, where specimens are placed, or patient care areas.
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Food brought in for patients by others is covered, labeled, and dated.
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Nourishment refrigerator or freezer temperatures are checked daily and logged. Interventions are noted when out of range.
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Nourishment refrigerator?s freezers are regularly defrosted.
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Medications are not stored in patient nourishment refrigerators.
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Medication refrigerator or freezer temperatures are checked daily and logged. Interventions are noted when out of range.
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Medications are secured or locked with access by unauthorized persons prohibited.
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Multi-dose vials will be discarded 28 days from date of opening or per product manufacturer recommendation for discarding, if less than 28 days.
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Graduates/sanipans are labeled with the patient?s name.
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Personal hand lotions are not observed in the work areas.
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Patient Rooms: Under sink storage is free from hazardous materials and clean/sterile items.
Additional Comments / Findings (Departments are responsible for corrective actions.)
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Dept. Notes:
Facilities (Items in this section will be corrected by the Facilities dept.)
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Doors latch properly & smoke seal is in good condition.
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Exit signs are illuminated.
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Fire escutcheons are in place & fit properly.
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Fire extinguishers have current inspection date.
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Linen & trash chute doors latch & fire links are in place.
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Ceilings are in good repair, free of loose tiles.
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Lighting - corridors & work areas are properly illuminated.
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Walls free of damage. Fire walls free of penetrations.
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Floors are in good repair (No loose tiles or carpet damage).
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Cords, Plugs & Switches in good repair.
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Toasters & microwaves have attended while in-use signs.
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Construction areas have ILSM (Interim Life Safety Measures) in place.
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Equipment PM labels are current. (Next due date can be determined)
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Equipment & appliances in patient care vicinity (6 foot radius) are double insulated or are equipped with a grounded plug.
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Facilities Dept: Additional Comments / Findings
Environmental Services (Items in this section will be corrected by the Environmental Services dept.)
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Bio-medical waste containers are labeled on all sides
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Trash cans are not overflowing.
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Lights & vents are free of dust.
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Ledges & walls are clean & free of dust.
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Floors & kick plates are clean & unsoiled.
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Furniture is clean & orderly.
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Ice machines are clean.
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Blinds & Privacy curtains are clean & work properly
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Sinks areas are clean.
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Bathrooms are clean & odor free.
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Adequate paper supplies are available.
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EVS Dept: Additional Comments / Findings
Signatures
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Attendee Signature (if available)
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Auditor Signature
