Information
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Areas Surveyed
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Conducted on
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Area Details
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Names of Area Managers
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Prepared by
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Document No.
Safety Management
1.0 Electrical Safety
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1.1 Cords, plugs, outlets, power strips & surge protectors are in good condition, are permanently attached and not hanging free or touching the floor
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1.2 Electrical panels have 36”clear access in front and Arc flash labeling.
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1.3 Child resistant outlets located in child accessible areas
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1.4 Extension cords are not used as a substitute for fixed wiring.
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1.5 Flexible cords are not run through doorways or similar openings.
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Repeat Violation
2.0 Slip/Trip/Fall Hazards
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2.1 Carpeting, vinyl and floor tiles are in good repair (no bumps or tears)
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2.2 Walking and working surfaces are free of tripping hazards
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2.3 Wet floor signs are used consistently and appropriately
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Repeat Violation
3.0 Storage
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3.1 Shelving is secured
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3.2 Items over 45 lbs are stored low
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3.3 No boxes or paper items on floor
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3.4 Shelving is at least 6" off floor and bottom shelf is solid and cleanable
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3.5 Storage areas are used appropriately and are clean and dry
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3.6 Only cleaning supplies stored under sink and locked if in patient accessible area
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Repeat Violation
4.0 Lighting
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4.1 All lights work in area
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4.2 Battery operated lighting functions
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4.3 Exit signs are illuminated
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4.4 Lighting is suitable for the care, treatment and services provided
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Repeat Violation
5.0 Egress
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5.1 Stairwells and exit corridors are not obstructed or used for storage
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5.2 Access to exit doors is not obstructed or blocked by storage or other items
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Repeat Violation
6.0 Staff and Lip Knowledge/Safety
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6.1 Can describe or demonstrate methods of minimizing or eliminating physical safety risks
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6.2 Can describe or demonstrate actions to take in a Safety incident
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6.3 Can describe or demonstrate how to use reporting system to report Safety risks
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(Score:____ out of _____people questioned could describe)
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Repeat Violation
7.0 Furnishings & Equipment
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7.1 Are safe and kept in good repair
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7.2 Soiled linen and trash containers are 32 gal or less except in Utility Rooms
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7.3 Decorations, except paintings and photos, are non-combustible or treated to be fire retardant
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7.4 No photos of patients are visible
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7.5 Only GSO approved space heaters are used and only in non-sleeping staff areas
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7.6 Toasters, microwaves, and coffee makers are commercial grade only. Coffee makers have auto shutoff feature.
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7.7 No toaster ovens are present or in use
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7.8 Other than above, no heat producing cooking appliances are present or in use
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7.9 Compressed gas cylinders are used, handled & stored properly with required signage (Score ____ number of locations/_________ deficiencies)
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Repeat Violation
8.0 Compliance with the Smoking Policy
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8.1 No evidence of smoking in unauthorized areas
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8.2 Designated smoking areas are physically separate from care, treatment and service areas
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8.3 Authorized smoking areas are clean, safe and kept in good repair
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Repeat Violation
9.0 Emergency Communications
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9.1 All phones have legible stickers with the 3499 emergency number
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9.2 Where applicable, RED telephones are available and accessible
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9.3 Staff know how to use the RED phones
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9.4 Where required, weather radios are operable with fully charged back up batteries
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Repeat Violation
