Title Page

  • Location

  • Conducted on

  • Prepared by

Life Safety

  • Are exit doors. corridors, and stairwells clear?

  • Are fire doors closed and not able to be propped open?

  • Are pull stations, fire extinguishers, and fire doors unobstructed?

  • Corridor sprinkler heads clean and not missing escutcheons or have gaps around escutcheons?

  • Are eyewash stations and showers inspections documented weekly?

Clean Utility/Medication Room/Equipment Storage

  • All clean supplies stored off of the floor. No outside cardboard. Nothing stored under sinks

  • Does the equipment's cleanliness, paint, wiring, and covers appear satisfactory?

  • No equipment or beds stored in hallway?

  • Are supplies within expiration dates. Check drawers for improperly stored items. Glucometer supplies dated with expiration?

  • Crash Cart Checks are completed daily? No expired supplies, oxygen tank has >1500 psi, no dust, plugged into red outlet?

  • Is there 18 inches or more of open space maintained below the sprinkler deflector to the top of storage?

  • Is clean linen covered? No product stored on top of linen cart?

  • Clean utility rooms contain only clean/sterile items? Clean equipment is clean and bagged appropriately?

  • Are oxygen cylinders stored correctly? Empty and full containers physically separated and labeled? Open cylinders not stored with full? No more than 12 cylinders in a room.

  • Are chemicals stored separately from patient contact or other clean items?

  • Medications are secured

Clean Space

  • Ceilings, walls, lighting is clean and intact? No bugs/debris in overhead lights? All light bulbs are functioning?

  • Are walls free from paint or repair needs? All ceiling tiles are clean, no stains or cracks?

  • Countertops, Flooring, Trim, and Handrails are clean and undamaged?

Patient Care

  • Is "Per Shift Staff Assignments Binder/clipboard" up to date?

  • Are nurse call pull cords proper length - 2 to 6 inches from floor, not tied to grab bars, etc?

  • Are sharps containers securely mounted and not overfilled?

Nourishment Rooms

  • Are patient food refrigerator logs maintained and up-to-date? Are temperatures within range?

  • Ice machine is clean?

  • No outside food stored in refrigerator? All patient food is labeled with patient name and date to discard?

Positive/Negative Air

  • Positive Air Pressure for sterile storage, medication rooms, and other clean/sterile areas.

  • Negative Air Pressure for soiled utility, trash, hazardous waste, and other dirty rooms.

Security

  • Are all employees wearing their ID badges in plain view?

  • Confidential patient information is secure and HIPAA practices are followed

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