Title Page
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Document No.
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Audit Title
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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
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Add location
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1. Fire Extinguishers inspected and tags initialed monthly
fire extinguisher
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Compliance Score
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Correction plan:
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Target completion date
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2. Fire doors functional and unobstructed
fire doors
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Compliance Score
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Correction plan:
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Target completion date
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3. Exits and entrances clear and marked
exits and entrances
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Compliance Score
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Correction plan:
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Target completion date
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4. Hallways and corridors clear
hallways and corridors
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Compliance Score
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Correction plan:
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Target completion date
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5. Stairs and stairways clear
stairs and stairways
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Compliance Score
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Correction plan:
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Target completion date
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6. Storage (e.g, clean and uncluttered, 18" clear in sprinkled areas, clean storage houses clean items only)
storage
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Compliance Score
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Correction plan:
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Target completion date
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7. No Internal Storage of flammables
storage of flammables
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Compliance Score
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Correction plan:
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Target completion date
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8. Storage of gas cylinders (chained to wall or secured in carrier), not in violation of storage requirements
storage of gas cylinders
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Compliance Score
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Correction plan:
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Target completion date
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9. Rolling items clean and in good repair (e.g, carts, IV poles, wheel)
condition of rolling items
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Compliance Score
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Correction plan:
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Target completion date
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10. Medical records area lockable
medical records
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Compliance Score
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Correction plan:
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Target completion date
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11. Work surfaces clean
work surfaces
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Compliance Score
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Correction plan:
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Target completion date
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12. Smoking regulations enforced
smoking regulations
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Compliance Score
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Correction plan:
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Target completion date
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13. Safety Manual/Environment of Care Manual in place with required policies and Material Safety Sheets (MSDS)
manuals
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Compliance Score
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Correction plan:
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Target completion date
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14. Refrigerator/freezer temperature checks current
refrigerator and freezer
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Compliance Score
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Correction plan:
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Target completion date
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15. Expiration dates checked (mess,food,supplies)
expiration dates
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Compliance Score
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Correction plan:
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Target completion date
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16. Personal protective equipment available
protective equipment
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Compliance Score
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Correction plan:
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Target completion date
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17. Emergency exit signs and lighting tested for 30 seconds
exit signs
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Compliance Score
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Correction plan:
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Target completion date
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18. Syringes/needles in secured Sharps Container
sharps container
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Compliance Score
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Correction plan:
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Target completion date
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19. Eyewash station available and unobstructed
eyewash station
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Compliance Score
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Correction plan:
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Target completion date
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20. Ceiling tile not stained or dirty
ceiling tile
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Compliance Score
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Correction plan:
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Target completion date
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21. UA specimens stored in refrigerator free from patient contact, separate from clean areas, and labeled bio-hazardous
UA storage
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Compliance Score
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Correction plan:
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Target completion date
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22. UA specimen refrigerator is labeled bio-hazardous
UA storage
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Compliance Score
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Correction plan:
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Target completion date
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23. Hand-washing facilities readily accessible (I.e, easy access, soap dispenser present and functional, paper towels present)
hand washing facilities
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Compliance Score
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Correction plan:
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Target completion date
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24. Sharps containers are located as close as possible to where sharps are used
sharps containers
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Compliance Score
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Correction plan:
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Target completion date
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25. Sharps containers are not overfilled and replaced routinely
sharps containers
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Compliance Score
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Correction plan:
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Target completion date
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26. Sharps containers contain appropriate materials (i.e, no gloves, gauze, tubing)
sharps containers
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Compliance Score
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Correction plan:
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Target completion date
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27. All chemicals are properly labeled with names and hazard identified
chemical labeling
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Compliance Score
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Correction plan:
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Target completion date
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28. Patient care items not stored under sinks
patient items storage
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Compliance Score
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Correction plan:
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Target completion date
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29. Not able to overhear any patient information in public areas (e.g, elevators, cafeteria, no clinical areas)
patient information
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Compliance Score
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Correction plan:
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Target completion date
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30. Not able to observe information on an unattended computer screen
patient information
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Compliance Score
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Correction plan:
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Target completion date
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31. Not able to see unattended patient-identifiable information while in area (e.g, copies of medical record
patient information
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Compliance Score
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Correction plan:
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Target completion date
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32. Not able to find any patient-identifiable information in trash cans
patient information
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Compliance Score
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Correction plan:
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Target completion date
