Environmental Rounds

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel

Fire Safety - (FS 1-10)

• 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 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

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

  Yes

  No

  N/A

• FS 6. Are doors propped / held open? <br>Doorstops or homemade held open devices are not allowed.

  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 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

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Fire Safety Staff Knowledge Questions - (FS 11-13)

• FS 11. Does staff know the meaning of R.A.C.E.?

  Yes

  No

  N/A

• FS 12. Does staff know the location of exit route?

  Yes

  No

  N/A

• FS 13. Does staff know the meaning of P.A.S.S.?

  Yes

  No

  N/A

Utilities Physical Inspection - (UT 1-11)

• UT 1. All lighting is operational?

  Yes

  No

  N/A

• UT 2. GFCI's within 6-foot of water?<br>Tested and worked?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• UT 6. All electrical outlets have cover plates?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Utilities Staff Knowledge Questions - (UT 12-13)

• UT 12. Does staff know how to identify an emergency outlet?

  Yes

  No

  N/A

• UT 13. Does staff know the locations of the O2 zone valves?

  Yes

  No

  N/A

• Completed the Fire Safety & Utilities Section

  Sign

Safety & Security Management Physical Inspection - (SS 1-20)

• SS 1. Is area free from smoking?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  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

• SS 7. Glow in dark flashlights in place and working?

  Yes

  No

  N/A

• SS 8. Is there an Emergency Operations Plan available?

  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

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

  Yes

  No

  N/A

• SS 12. Are punch code doors working properly?

  Yes

  No

  N/A

• SS 13. Is there a procedure for notifying Security?

  Yes

  No

  N/A

• SS 14. Is there a procedure for reporting Security incidents?

  Yes

  No

  N/A

• SS 15. Are there Security cameras in the area and are they functioning properly?

  Yes

  No

  N/A

• SS 16. Does area have access control or intercom system and are the functioning properly?

  Yes

  No

  N/A

• SS 17. Are medications kept in locked rooms?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• SS 19. Are compressed gases stored properly?

  Yes

  No

  N/A

• SS 20. Space heaters are correct type (oil filled "Dakota" brand)?

  Yes

  No

  N/A

Safety & Security Staff Knowledge Questions - (SS 21-28)

• SS 21. Employee I.D. Badges are visible?

  Yes

  No

  N/A

• SS 22. Does staff know the different color I.D. badges stand for?

  Yes

  No

  N/A

• SS 23. Does staff know where the the lost and found is located?

  Yes

  No

  N/A

• SS 24. Does staff know how to request a escort for a team member or a visitor?

  Yes

  No

  N/A

• SS 25. Does staff know what a tornado watch and a warning are?

  Yes

  No

  N/A

• SS 26. Does staff know to dial "71" for an emergency?

  Yes

  No

  N/A

• SS 27. Does staff know how to contact Security?

  Yes

  No

  N/A

• SS 28. Does staff know what a "109" is?

  Yes

  No

  N/A

• Completed the Safety & Security Section

  Sign

Hazardous Materials & Waste - (HM 1-7)

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

  Yes

  No

  N/A

• HM 2. Is hazardous chemical inventory adequate and available to all employees?

  Yes

  No

  N/A

• HM 3. Are appropriate procedures, instructions, or directions available for obtaining MSDS?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  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

Hazardous Materials & Waste Staff Knowledge Questions - (HM 8)

• HM 8. Does staff know how to use 3E to get MSDS?

  Yes

  No

  N/A

• Completed the Hazardous Materials Section

  Sign

Medical Equipment Physical Inspection - (ME 1-6)

• ME 1. Does equipment have cords in good condition (no cracks or exposed wires)?

  Yes

  No

  N/A

• ME 2. Are all medical equipment tags current?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  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

Medical Equipment Staff Knowledge Questions - (ME 7)

• ME 7. Does staff know how to initiate a medical equipment repair request?

  Yes

  No

  N/A

• Completed the Medical Equipment Section

  Sign

Infection Control Physical Inspection - (IC 1-32)

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

  Yes

  No

  N/A

• IC 2. Sharps containers are readily accessible?

  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

• 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 7. Blood spill decontamination solution is available?

  Yes

  No

  N/A

• 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

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

  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 11. Supplies are not found under sinks?

  Yes

  No

  N/A

• IC 12. Sinks are functioning properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• IC 18. Refrigerator temperature-thermometer in refrigerator/freezers are at appropriate temperatures?

  Yes

  No

  N/A

• IC 18a. Has appropriate action taken place for out of range temperatures?

  Yes

  No

  N/A

• IC 19. Blanket warmer temperatures-thermometer in blanket warmer are at appropriate temperatures?

  Yes

  No

  N/A

• IC 19a. Has appropriate action taken place for out of range temperatures?

  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

• IC 22. Supplies stocked 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

• 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. Expired medications stock have not reached their expiration date?

  Yes

  No

  N/A

• IC 26. Collection times, linen - is collected in a timely manner (not overflowing)?

  Yes

  No

  N/A

• IC 27. Collection times, waste is collected in a timely manner (not overflowing)?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  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

• IC 31. Traffic flow hallways are uncluttered, allowing for free traffic flow?

  Yes

  No

  N/A

• IC 32. High dust areas, computer carts are dust free, top of monitors are dust free, Arjo equipment is clean, data-scopes are clean, pill crushers are clean, ceiling titles are not stained, carpet is free of tears, and etc. these are examples the list can include other items depending on the unit.

  Yes

  No

  N/A

Infection Control - (IC 33)

• IC 33. Where is the blood borne pathogen plan located?

  Yes

  No

  N/A

• Completed the Infection Control Section

  Sign

Notes Section