Information
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Audit Title
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Document No.
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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
Housekeeping
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High Reach Horizontal Surfaces are Clean 07.00.00
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Surfaces are uncluttered and free of dust 07.00.00
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Sprinkler Heads and Smoke detectors are free of dust and dirt. 11.04.06
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Vents are free of dust and dirt. 07.00.00
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Environmental Service carts not left unattended in Corridors. (Hospital Only)
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Empty pop cans are not stored with patient care items. 07.03.07
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Vending Machines are clean. 07.03.03
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Wheels on carts are clean and free of dust and/or debris 07.00.00
ENVIRONMENTAL
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Doors are not propped open. 11.04.05
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Ceiling tiles are not stained, missing, or broken. 07.03.04
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In sprinkled areas, supplies are stored 18 inches from ceiling. 11.04.06
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Items are not stored within 30" directly in front of electrical panels. 1910.303/NFPA
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Elevator Areas, Corridors, and Egress routes are free of equipment and any obstructions. 11.04.08
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Furniture and Equipment removed if in poor condition (cracked, torn, broken, ect) and Maintenance notified. 07.00.00
PATIENT CONFIDENTIALITY
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Computers are " Logged-off" when staff is not present.
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Monitor Screens are oriented to protect patient confidential information.
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Doors are locked to Medical record Storage areas. 10.00.04
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Check all areas for HIPPAA violations (check trash cans, patient charts, test results, etc)
WORK PRACTICES
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Staff, Doctors, Volunteers, and Students wearing ID at all times. 04.00.13
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Proper Lifting Equipment available if needed. (Hospital Only)
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Only Hospital approved hand lotion is available and in use.
LIFE SAFETY
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Exit Signs clearly visible and working properly. NFPA 99
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Fire doors and Emergency exits are unobstructed. Fire extinguishes and fire alarm pull stations and accessible (Not Blocked). 11.04.05/11.04.06
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Staff is familiar with the location of fire extinguishers, medical gas shut-off valves (if applicable), fire alarm pull stations (if applicable) and notification procedures if there was an Emergency situation in the department. 11.00.02/11.07.01
STORAGE ISSUES
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Items are not left unattended in corridors. 11.04.08
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Items are not being stored on the floor. 11.04.08
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No items (clean or sterile) stored under sinks. In non-patient areas, no paper items or non-labeled chemicals are stored under sinks. 07.02.04/07.02.07
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Items are not to be stored within the splash zone of the sink (3'). 07.03.05
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All linen items are stored properly-clean with clean, and dirty with dirty, and covered. 07.04.01/07.04.03
HAZARDOUS MATERIALS AND WASTE
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Staff knows how to access MSDS information. 11.05.04
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Tank of Compressed gases (oxygen) are properly stored, not left on empty wheelchairs, stretchers, or left in corridors. Only 1 bottle is allowed to be stored at the Nurse's Station. 1910.253/NFPA 99
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All Biohazard containers are handled and labeled appropriately. 49 CFR
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In areas using hazardous materials, emergency phone numbers are posted in the case of a chemical spill. 1910.120
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All chemicals properly labeled and stored. 11.05.04
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If eyewash stations are in the department, they are inspected and operated weekly to verify working order, and are unobstructed. ANSI Z358.1
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Biohazards are disposed of in the proper containers-sharps, bio-bags, etc. 07.03.07/49 CFR 171/1910.1030
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If a department uses a high level disinfectant for equipment sterilization (Cidex OPA), daily checks are completed and logged.
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Food and Beverages are not stored or consumed in areas where chemicals are used or stored. 1910.120
INFECTION PREVENTION
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Staff food/drink items are not in patient care areas (i.e. nurses stations). Staff do not apply lip products in patient areas. 07.01.10
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Staff belongings are not stored in patient care areas.
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Sterile/Clean equipment stored (6" from outside wall, 18" from the ceiling, and 6" from the floor) and rotated appropriately. 07.02.04/07.02.07
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Sterile/Clean equipment not stored together with "dirty" utility items or in traffic areas. 07.02.04/07.02.07
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Specimens are transported correctly (gloves are used when transporting to soiled utility room, specimens are in bio-hazard whenexiting the department). 1910.1030
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Linen is covered during transport. 07.04.01/07.04.03
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All clean linen carts are covered, or in an enclosed room. All dirty linen hamper lids are closed. 07.04.01/07.04.03
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Areas under sinks show no evidence of mold/mildew growth.
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Opened and outdated nourishments are removed from refrigerators. 07.02.07
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Refrigerators and freezers for specimens are properly labeled with a biohazard label. 07.03.07
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Refrigerated specimens are not stored in with refrigerated food items, and patient food is not stored with staff food in refrigerators. 07.00.00/07.03.07
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Refrigerators are periodically cleaned inside and out.
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Dirty Equipment is cleaned before being sent to CPD.
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PPE is available and used properly. 07.01.01/OSHA 1910.1030
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Alcohol based hand hygiene products are available for staff. 07.03.05
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Soap and hand towels are available at each hand washing sink. 07.03.05
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Sterile supplies are not expired and are labeled with a lot number. 07.02.07
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No evidence of pests or entranceways for pests. 07.05.01
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No evidence of poisons used to exterminate pests. 07.05.02
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Brushes used for cleaning medical equipment evaluated and cleaned daily.
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Upon opening an in-house processed sterile tray or set, the chemical indicators are validated. 07.02.04
MEDICAL EQUIPMENT
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Preventive maintenance stickers are up-to-date. 11.08.06
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ERT carts are checked daily ( seals are not broken).
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ERT Carts are plugged into red outlets. 11.08.04
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Emergency equipment/supplies (ambu bag, Ephinephrine, Benadryl, airways) are monitored monthly for expiration.
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Blanket warmer temperature set at 130 degree F (if not automatically monitored)
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IV solutions in volumes of 150 ml or greater are warmed to 104 degree F for no longer than 14 days
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Pour bottle solutions are warmed to 150 degree F for no longer than 3 days
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All comfort bath warmers are set to 125 degree F +5 degrees
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Non-functioning electrical and patient care equipment removed from service and Clinical Engineering notified
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Your HEPA hoods are present, labeled correctly for your department, and plugged in. The hood itself is free from damage or tears.
ELECTRICAL
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Extension cords are not in use (power strips are permitted). 1910.303/1910.334/NFPA 99 & 70E
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Electrical equipment (including outlets) are in good repair and are secure. 1910.305/NFPA 70E
MEDICATION SAFETY
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Medications are secure. 25.01.03
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Medications are not outdated. 07.00.00
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Medications are properly labeled with the name of the medication, manufacturer, concentration, lot number, and expiration date in month/day/year format. 25.01.07
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Multi-dose vials are labeled with the initials of person who opened the vial, and the expiration date (28 days after opening). 07.00.00
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Pill crushers are clean.
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Medication refrigerator temperature logs current?
RADIATION SAFETY ISSUES
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Staff members are wearing appropriate badges (radiation dosimeter). 19.00.01
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Appropriate shielding is available for patients, staff and visitors. 19.00.01
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Rooms housing radiation sources are labeled.
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Lead aprons and gloves are worn when necessary. 19.00.01
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Lead apron checks are completed annually. 19.00.01
PATIENT CARE AND NURSING (HOSPITAL ONLY)
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All audible alarms are set on patient care equipment.
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Emergency pull cords are 4 inches from the floor and free hanging.
STAFF INTERVIEWS (Instructions: Interview 3 staff members(from different shifts if possible) with the below questions)
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How can you access an MSDS sheet?
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Do you know who the Safety Officer is and how to contact him/her?
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How are employees notified if our disaster plans are activated?
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Where are the nearest fire extinguishers and AND fire alarm pull station located?
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How is the fire code announced overhead?
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Where is the medical gas shutoff valve located?
