Environment of Care Rounds

• Document No.

• Audit Title

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Previous Inspections

• Items from previous inspections have been addressed ?

  Yes

  No

  N/A

Safety

• Work/Storage Areas - safe and accessible (proper shelving used/secure, no above head hazards, heavier items on the bottom) ?

  Yes

  No

  N/A

• Work/Storage Areas - Clean and Clear (no excessive clutter) ?

  Yes

  No

  N/A

• Eye wash/shower station are tested weekly and documented?

  Yes

  No

  N/A

Security

• Staff, volunteers, vendors appropriately identified ?

  Yes

  No

  N/A

• Valuable items secured ?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Hazardous Materials/Waste

• Hazardous Chemicals - properly labeled/stored ?

  Yes

  No

  N/A

• Infectious Waste Containers (rigid, labeled, covered) ?

  Yes

  No

  N/A

• Infectious Waste Storage (Soiled Utility Rooms) - Doors to storage area closed/monitored or secured ?

  Yes

  No

  N/A

• Waste Disposal - Appropriate disposal of waste in proper container ?

  Yes

  No

  N/A

• Lead Aprons - Uniquely identified ?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Emergency Preparedness

• Emergency numbers posted (33333 on the phones) ?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Fire Safety

• Fire Doors - Not propped open (door wedges), Unit entrance doors - positively latch ?

  Yes

  No

  N/A

• Fire Exits - Clear, Correctly marked (Exit Signs), unlocked from inside, clear of debris/equipment ?

  Yes

  No

  N/A

• Sprinklers - 18" clearance ?

  Yes

  No

  N/A

• Fire Alarm/Pull Station - 3 ft. clearance ?

  Yes

  No

  N/A

• Oxygen/Gas Cylinders - Stored upright, secured on the top and bottom 3rd to prevent falling, in a stand/ cart, no more than 12 "E" cylinders per smoke compartment ?

  Yes

  No

  N/A

• Electrical Cords / strip outlets Not overloaded/daisy chained, In good repair, Extension cords not used ?

  Yes

  No

  N/A

• Fire Extinguishers Clearly marked, 3 ft. clearance, On wall or in cabinet, Pressure gauges read full ?

  Yes

  No

  N/A

• Appliances<br>- Major appliances (high wattage) plugged directly into a wall outlet, Clear from combustibles<br>- All appliances (especially those with a metal exterior) must have a three-prong plug (ground wire) to prevent fire and electrocution<br>- No hot-plates, fryers, hot air or easybake ovens, toasters, or toaster ovens allowed<br>- Microwaves are clean and free from loose debris inside and all vents are clear<br>- No open element space heaters<br>- Hot shots are clearly marked as 'hot, boiling water'

  Yes

  No

  N/A

• Ceiling tiles set in place properly and no gaps in the ceiling to allow smoke to enter ?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Medical Equipment

• Other

  Yes

  No

  N/A

Physical Environment

• Work/Storage Areas - Clean, Free from hazards/clutter ?

  Yes

  No

  N/A

• Floors/Walkways/Walls/Ceilings - In good condition, Clean, Dry, No penetrations, Adequate lighting, Construction-no signs of dust/debris ?

  Yes

  No

  N/A

• All items in storage are at least 4" off the floor

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Dietary / Nutrition

• Refrigerators - Clean, Employee and Patient Food separated, Patient food labeled/dated, Temperature Logs current (for patient refrigerators only)?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Infection Prevention

• Staff eating or drinking in designated areas only ?

  Yes

  No

  N/A

• Hand gel/soap dispensers functioning and contain current product ?

  Yes

  No

  N/A

• Under sink storage clear (nothing allowed under sinks)?

  Yes

  No

  N/A

• Cubicle curtains are free of visible soil ?

  Yes

  No

  N/A

• Dirty linen storage - room secured?

  Yes

  No

  N/A

• Linen covered in (inside or outside of the clean utility room)?

  Yes

  No

  N/A

• Medication refrigerators log maintained (review follow up if temperatures were out of range)?

  Yes

  No

  N/A

• High Level Disinfection - Daily and QC logs complete?

  Yes

  No

  N/A

• Test Strips in a closed bottle and inside a cabinet?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Utilities

• Fixtures in good condition (no damage to outlets, outlet cover and light switches (char marks, cracks, discoloration ?)

  Yes

  No

  N/A

• Mechanical / Electrical / Communication rooms – clear of combustible material storage ?

  Yes

  No

  N/A

• Lights/Fixtures - covered/protected (diffusers not cracked or missing) ?

  Yes

  No

  N/A

• Med Gas Panel - 3 ft. clearance, Shut off zone identified ?

  Yes

  No

  N/A

• Electrical Panels - closed/covered, secured ?

  Yes

  No

  N/A

• Return / Supply air ducts in the ceiling clean (not covered with dust) ?

  Yes

  No

  N/A

• Appropriate areas (isolation rooms, toilets, soiled utility rooms, etc.) have negative pressure.

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Staff Knowledge

• Reporting Accidents/Incidents ?

  Yes

  No

  N/A

• Back up/alternate communication systems ?

  Yes

  No

  N/A

• Code Pink ?

  Yes

  No

  N/A

• Code Gray ?

  Yes

  No

  N/A

• Hazardous Chemicals in the Area ?

  Yes

  No

  N/A

• Accessing SDSs ?

  Yes

  No

  N/A

• Code Violet ?

  Yes

  No

  N/A

• Code Red - RACE, PASS, Extinguisher/Fire Alarm Pull Station locations, Primary/Secondary Exits, Evacuation - horizontal/vertical ?

  Yes

  No

  N/A

• Oxygen Shut Off ?

  Yes

  No

  N/A

• Code Triage (Staff's role in a disaster - stand by and respond when/where needed) ?

  Yes

  No

  N/A

• Clinical Interventions for Equipment Failures ?

  Yes

  No

  N/A

• Utility Failure Procedures ?

  Yes

  No

  N/A

• How do you know if equipment is clean?

  Yes

  No

  N/A

• How and when to use the proper PPE?

  Yes

  No

  N/A