• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • 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.

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

  • 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.

  • 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.

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

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

  • 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.

  • 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.

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

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

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

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

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

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

Utilities Physical Inspection - (UT 1-11)

  • UT 1. All lighting is operational?

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

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

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

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

  • UT 6. All electrical outlets have cover plates?

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

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

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

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

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

Utilities Staff Knowledge Questions - (UT 12-13)

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

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

  • Completed the Fire Safety & Utilities Section

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

  • SS 1. Is area free from smoking?

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

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

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

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

  • 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.

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

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

  • SS 9. Are staffs personal items properly secured?

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

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

  • SS 12. Are punch code doors working properly?

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

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

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

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

  • SS 17. Are medications kept in locked rooms?

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

  • SS 19. Are compressed gases stored properly?

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

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

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

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

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

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

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

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

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

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

  • Completed the Safety & Security Section

Hazardous Materials & Waste - (HM 1-7)

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

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

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

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

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

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

  • HM 7. All chemicals contain a manufactures label?

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

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

  • Completed the Hazardous Materials Section

Medical Equipment Physical Inspection - (ME 1-6)

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

  • ME 2. Are all medical equipment tags current?

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

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

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

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

Medical Equipment Staff Knowledge Questions - (ME 7)

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

  • Completed the Medical Equipment Section

Infection Control Physical Inspection - (IC 1-32)

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

  • IC 2. Sharps containers are readily accessible?

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

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

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

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

  • IC 7. Blood spill decontamination solution is available?

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

  • IC 8a. Is microwave clean?

  • IC 8b. Is refrigerator clean?

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

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

  • IC 10a. Clean linen is covered?

  • IC 11. Supplies are not found under sinks?

  • IC 12. Sinks are functioning properly?

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

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

  • 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?

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

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

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

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

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

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

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

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

  • IC 20a. Foods are not outdated?

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

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

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

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

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

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

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

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

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

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

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

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

  • 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.

Infection Control - (IC 33)

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

  • Completed the Infection Control Section

Notes Section

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.