Facility Inspection Survey

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1. Facility Inspection Survey Information

• Location

  Select Emerus - Sugarland Emerus - Tomball Emerus - McKinney Baylor - Aubrey Baptist - Thousand Oaks Baptist - Westover Hills Baptist - Overlook Baptist - Hausman Baptist - Schertz

  • Emerus - Sugarland
  • Emerus - Tomball
  • Emerus - McKinney
  • Baylor - Aubrey
  • Baptist - Thousand Oaks
  • Baptist - Westover Hills
  • Baptist - Overlook
  • Baptist - Hausman
  • Baptist - Schertz

• SurveyDate

  Date

• Surveyor

• Surveyor's Title

• Surveyor's Signature

  Sign

• Facility Representative

• Facility Representative's Title

• Facility Representative's Signature

  Sign

2. Interior Survey Rounds

• Corridors and open alcoves are free from trash, material, and carts?

  Yes

  No

  N/A

• Fire exits, cross corridors and stairwell doors are equipped with self closing devices and/or panic hardware?

  Yes

  No

  N/A

• Corridors, fire exits, and accessible routes are clear and unobstructed?

  Yes

  No

  N/A

• Exit signs are illuminated and visible?

  Yes

  No

  N/A

• Doors are held open only with magnetic hold open devices (no wedges, paper, sticks, etc.)?

  Yes

  No

  N/A

• Corridor,cross-corridor, and stairwell doors close and positive latch?

  Yes

  No

  N/A

• Electrical room doors are locked and properly labeled?

  Yes

  No

  N/A

• Electrical panels are accessible, properly labeled, and have no penetrations or openings?

  Yes

  No

  N/A

• There are no penetrations in fire or smoke walls?

  Yes

  No

  N/A

• All light fixtures are operating, not broken, and protected as required?

  Yes

  No

  N/A

• There is no excessive trash or linen stored within the facility?

  Yes

  No

  N/A

• All hazardous and secure area doors are properly labeled and secured?

  Yes

  No

  N/A

• Biohazard bags are being used properly throughout the facility?

  Yes

  No

  N/A

• Fire extinguishers are being inspected monthly, are properly labeled, and secured?

  Yes

  No

  N/A

• Fire extinguishers are accessible and free of obstructions?

  Yes

  No

  N/A

• No material is stored within 18 inches of a sprinkler head or within 12 inches of any light fixture.

  Yes

  No

  N/A

• Storage rooms are clean, free of dust, and clutter?

  Yes

  No

  N/A

• No items are stored directly on the floor.

  Yes

  No

  N/A

• Extension cords are not being used.

  Yes

  No

  N/A

• All junction boxes and electrical boxes have proper covers and are not broken.

  Yes

  No

  N/A

• Sharps containers are less than 3/4 full.

  Yes

  No

  N/A

• Sharps containers are properly mounted and secured.

  Yes

  No

  N/A

• Eyewash stations are operational and flushed routinely.

  Yes

  No

  N/A

• All rooms within the facility are clearly labeled.

  Yes

  No

  N/A

• The facility is free of trip hazards.

  Yes

  No

  N/A

• All employees are wearing identification badges.

  Yes

  No

  N/A

• Is the roof free of any leaks?

  Yes

  No

  N/A

• Ceiling tiles are clean and undamaged.

  Yes

  No

  N/A

• Furnishings are in good condition, free of cuts, or tears.

  Yes

  No

  N/A

• All clinical equipment have current inspection tags.

  Yes

  No

  N/A

• Hand sanitizer units are distributed appropriately throughout the facility.

  Yes

  No

  N/A

• No items are stored beneath sinks.

  Yes

  No

  N/A

• No cleaning agents are left unattended when not in use.

  Yes

  No

  N/A

• Floors are clean and free of clutter.

  Yes

  No

  N/A

• Work surfaces are clean, free of dust, clutter, and potential hazards.

  Yes

  No

  N/A

• No environmental or personal heating devices.

  Yes

  No

  N/A

• Patient equipment is free of visible signs of soil contamination.

  Yes

  No

  N/A

• Baseboards are intact and in good repair.

  Yes

  No

  N/A

• Flooring is without evidence of cracks or separations.

  Yes

  No

  N/A

• All doors close and properly latch.

  Yes

  No

  N/A

• Handicap accessories are properly installed and secure.

  Yes

  No

  N/A

• All plumbing fixtures operate properly.

  Yes

  No

  N/A

• All patient privacy curtains are clean and operate properly.

  Yes

  No

  N/A

• The nurse call system is operational and in a normal state.

  Yes

  No

  N/A

• The nurse call system operates when activated in each zone.

  Yes

  No

  N/A

• Nurse call cords are not more than 6 inches from the floor.

  Yes

  No

  N/A

• Nurse call cords are not tangled or tied up in any way.

  Yes

  No

  N/A

• Med gas alarm panels are operable and in a normal state.

  Yes

  No

  N/A

• Med gas alarm panel sounds when tested in each zone.

  Yes

  No

  N/A

• Med gas bottles are properly secured.

  Yes

  No

  N/A

• Spare med gas bottles are present and ready for use.

  Yes

  No

  N/A

• Preventative inspection reports are displayed within the med gas room.

  Yes

  No

  N/A

• Current certification is displayed within the med gas room.

  Yes

  No

  N/A

• Have the vacuum pumps been drained of any water build up?

  Yes

  No

  N/A

• Are patient refrigerators clean?

  Yes

  No

  N/A

• Is the employee lounge clean (including refrigerator and microwave)?

  Yes

  No

  N/A

• Are there installation tags on any water filter devices?

  Yes

  No

  N/A

• Is the dietary area clean and free of clutter (including refrigerator, microwave, and storage areas)?

  Yes

  No

  N/A

• Is all dietary equipment operational?

  Yes

  No

  N/A

• Are chemicals sufficiently supplied to the dishwasher and washing areas?

  Yes

  No

  N/A

• Is there evidence of proper HVAC maintenance and filter log?

  Yes

  No

  N/A

• Is there evidence of proper fire protection maintenance?

  Yes

  No

  N/A

• Is there evidence of proper emergency power maintenance?

  Yes

  No

  N/A

• Comments or suggestions

3. Exterior Survey Rounds

• Is the facility clean and free of debris or clutter?

  Yes

  No

  N/A

• Is the signage clean and without the need of repair?

  Yes

  No

  N/A

• Is the parking and sidewalk areas free of visible trip hazards or concerns?

  Yes

  No

  N/A

• The exterior of the building is free of the need of repairs?

  Yes

  No

  N/A

• Are the landscape areas clean and maintained properly?

  Yes

  No

  N/A

• Does the exterior presentation meet company expectations?

  Yes

  No

  N/A

• Comments or suggestions

4. Post Survey Interview

• Is the facility free of any cooling or heating related concerns after interviewing the facility represntative?

  Yes

  No

  N/A

• Is the facility free of any water or sewer related concerns after interviewing the facility representative?

  Yes

  No

  N/A

• Is the facility free of safety related concerns after interviewing the facility representative?

  Yes

  No

  N/A

• Is the facility free of security related concerns after interviewing the facility reprentative?

  Yes

  No

  N/A

• Is the facility free of any life safety related concerns after interviewing the facility reprentative?

  Yes

  No

  N/A

• Is the facility free of any waste removal concerns after interviewing the facility representative?

  Yes

  No

  N/A

• Have we done all that we can for the facility today?

  Yes

  No

  N/A

• Comments or suggestions

5. Wrap Up and Review

• Has the surveyor answered all of your concerns and questions for today?

  Yes

  No

  N/A

• Have we fully met your needs today?

  Yes

  No

  N/A

• Are there any items or issues that we can assist with?

• Are there any suggestions that you have to make your facility better?

• Please include any additional comments that you may have.