Environmental Rounds

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel

Fire Safety - (FS 1-10) physical inspection/utilities

• FS 1. Are exit doors and stairwells clear? <br>Main, corridor, and stairwell exits cannot be blocked by any means.

  Yes

  No

  N/A

• FS 2. Are exit doors clearly marked "exit" and illuminated?<br>Check for burnt out bulbs.

  Yes

  No

  N/A

• FS 3. Do fire doors latch properly?<br>Close the fire doors to see if they latch properly and see that there is no gap<1/8 inch in the middle.

  Yes

  No

  N/A

• FS 6. Are doors closed with no props / held open? <br>Doorstops or homemade held open devices are not allowed.

  Yes

  No

  N/A

• FS 9. Do fire extinguishers have monthly and yearly checks?<br>

  Yes

  No

  N/A

• FS 5. Are pull stations or fire extinguishers unobstructed?<br>There must be nothing to obstruct access.

  Yes

  No

  N/A

• FS 4. Are corridors and passageways free of obstructions? <br>The corridors can have mobile items (wheels on them) that are emergency needed items and are in use.

  Yes

  No

  N/A

• SS 5. Are ceiling tiles in place, clean, stain free, and in good condition?<br>Indicate where these bad tiles are located in the comments.

  Yes

  No

  N/A

• FS 7. Are materials stored a minimum of 18 inches from sprinkler deflectors?<br>The distance between sprinkler deflector and stored items is 18 inches for sprinkled buildings.

  Yes

  No

  N/A

• FS 10. Sprinkler heads clean and free from debris?

  Yes

  No

  N/A

• SS 11. Are all mechanical, electrical, janitorial, and communications rooms locked?

  Yes

  No

  N/A

• UT 11. Are all mechanical, electrical, janitorial, communications rooms clean with no storage?

  Yes

  No

  N/A

• UT 7. Circuit breaker boxes are unobstructed and properly labeled?

  Yes

  No

  N/A

• FS 8. Are stored rooms and equipment rooms free from clutter and unsafe conditions?<br>Make sure that items are not falling down or overstocked.

  Yes

  No

  N/A

• ME 4. The equipment storage room doors will self close and latch?

  Yes

  No

  N/A

• IC 9. Clean supplies are stored appropriately in clean area?

  Yes

  No

  N/A

• IC 11. Supplies are not found under sinks?

  Yes

  No

  N/A

• UT 3. Plumbing lines under sinks adequately sealed (no evidence of leakage)?

  Yes

  No

  N/A

• IC 12. Sinks are functioning properly?

  Yes

  No

  N/A

• IC 22. Supplies stocked have not reached their expiration date?

  Yes

  No

  N/A

• SS 6. Are heavy items stored at low levels or mid levels in storage?<br>Make sure heavy items are stored at waist level or lower shelves.

  Yes

  No

  N/A

• Are boxes and patient care items off floor?

  Yes

  No

  N/A

• SS 2. Are floors and hallways in good condition?

  Yes

  No

  N/A

• UT 4. All penetrations in the walls and ceilings have been appropriately filled?

  Yes

  No

  N/A

• UT 6. All electrical outlets have cover plates?

  Yes

  No

  N/A

• UT 5. Drawer / cabinet handles function properly ( no loose handles )?

  Yes

  No

  N/A

• UT 9. Door hinges are working properly ( no loose hinges )?

  Yes

  No

  N/A

• SS 12. Are punch code doors working properly?

  Yes

  No

  N/A

• SS 4. Wires are in good physical condition (no cracks, tears, or exposed wires)?

  Yes

  No

  N/A

• UT 8. There are no extension cords being used?

  Yes

  No

  N/A

• UT 10. Are telephone cords out of the way?

  Yes

  No

  N/A

• UT 1. All lighting is operational?

  Yes

  No

  N/A

• SS 18. Are general areas clean and free of clutter?

  Yes

  No

  N/A

• SS 3. Walls are free from damage (chips, scuffs, or gouges) and clean?

  Yes

  No

  N/A

• IC 32. High dust areas, computer carts are dust free, top of monitors are dust free?

  Yes

  No

  N/A

• Is furniture clean and free of tears, broken parts etc.?

  Yes

  No

  N/A

• SS 19. Are compressed gases stored properly?

  Yes

  No

  N/A

Employee checks - (SS 1-20)

• IC 8. Lounge area is maintained in a clean sanitary condition?

  Yes

  No

  N/A

• IC 8a. Is microwave clean?

  Yes

  No

  N/A

• IC 8b. Is refrigerator clean?

  Yes

  No

  N/A

• SS 9. Are staffs personal items properly secured?

  Yes

  No

  N/A

• SS 10. Are all employees wearing their I.D badges properly?

  Yes

  No

  N/A

• HM 8. Does staff know how to get to MSDS?

  Yes

  No

  N/A

• IC 15. PPE-gloves, face masks, protective eyewear, and gowns are worn as required when exposed to blood or other potentially infectious materials is reasonably anticipated?

  Yes

  No

  N/A

• IC 16. PPE are removed at the end of the task/procedure?

  Yes

  No

  N/A

• IC 29. Hand hygiene is performed according to policy?

  Yes

  No

  N/A

• Only hospital lotion being used?

  Yes

  No

  N/A

• IC 17. Sharps and instruments are placed in approved containers as soon as possible?

  Yes

  No

  N/A

• IC 30. Behavior - eating, drinking, applying cosmetics in work areas where there is reasonable likelihood of exposure to blood/body fluid?

  Yes

  No

  N/A

Hazardous Materials & Waste - (HM 1-7)

• HM 1. Is medical waste kept in red biohazard bags or containers?

  Yes

  No

  N/A

• HM 5. Regular and infectious waste trash are separated?

  Yes

  No

  N/A

• IC 1. Linen containers for contaminated linens are readily accessible?

  Yes

  No

  N/A

• IC 14. Bottoms of waste and linen containers are free of debris?

  Yes

  No

  N/A

• IC 13. Pest control-area is free of insects, rodents, and all other vermin?

  Yes

  No

  N/A

• HM 6. An eyewash station is readily available and functioning properly?

  Yes

  No

  N/A

• HM 7. All chemicals contain a manufactures label?

  Yes

  No

  N/A

• HM 4. A spill kit is available for chemical spills?

  Yes

  No

  N/A

Medical Equipment Physical Inspection - and medications. ME 1-6)

• ME 3. Does the equipments cleanliness, paint, wiring, and covers appear satisfactory?

  Yes

  No

  N/A

• ME 5. Does medical equipment have an asset tag and current maintenance sticker?

  Yes

  No

  N/A

• ME 6. Are temperature and other logs current, and are there notes for actions taken if device is operating outside of parameters?

  Yes

  No

  N/A

• Test strips and controls are dated?

  Yes

  No

  N/A

• Crash cart checks are documented daily?

  Yes

  No

  N/A

• SS 17. Are medications kept in locked rooms?

  Yes

  No

  N/A

• Pill splitters or mortar and pestles are clean?

  Yes

  No

  N/A

• IC 23a. Open medications are labeled with date and initials?

  Yes

  No

  N/A

• IC 24. Infusing IV bag, tubing, and tube feeding administration set-ups are labeled?

  Yes

  No

  N/A

• IC 25. Medication stock have not reached their expiration date?

  Yes

  No

  N/A

• IC 23. Open medication/supply expiration open multi-use vials/containers dated and irrigation fluid have not reached their expiration dates?

  Yes

  No

  N/A

Infection Control Physical Inspection - (IC 1-32)

• IC 2. Sharps containers are readily accessible?

  Yes

  No

  N/A

• IC 17a. Sharps containers are <2/3 full?

  Yes

  No

  N/A

• IC 3. Hand-washing soap dispensers are in place and filled?

  Yes

  No

  N/A

• IC 4. Alcohol hand sanitizers are in place and not expired?

  Yes

  No

  N/A

• Hand sanitizer at correct height and distance from electrical source?

  Yes

  No

  N/A

• IC 5. Hand-washing towels are in place and filled?

  Yes

  No

  N/A

• IC 6. PPE (gloves, gowns, face masks, protective eyewear, and respirators are readily accessible?

  Yes

  No

  N/A

• IC 28. Precaution signs are posted clearly on patient doors?

  Yes

  No

  N/A

• IC 19. Blanket and fluid warmers are at appropriate temperatures? Are fluids labeled with use by date?

  Yes

  No

  N/A

• IC 10. Clean linen is stored in clean area?

  Yes

  No

  N/A

• IC 10a. Clean linen is covered?

  Yes

  No

  N/A

• IC 18. Patient Refrigerator/freezer are at appropriate temperatures?

  Yes

  No

  N/A

• Pt and employee food are not stored together?

  Yes

  No

  N/A

• Pt fridge is clean?

  Yes

  No

  N/A

• IC 20. Food items in refrigerators/cabinets/freezers are not opened or uncovered?

  Yes

  No

  N/A

• IC 20a. Foods are not outdated?

  Yes

  No

  N/A

• IC 21. Food items are not stored in areas where blood or other infectious material is present?

  Yes

  No

  N/A

• Are disinfecting wipes available with lids closed when not in use?

  Yes

  No

  N/A

Notes Section