Facility Safety & Health Performance Assessment - duplicate

• Audit Title

• Facility Name

• Conducted on

  Date

• Prepared by

• Address
  Address

• Administrations/Programs included

• Select "Add Kudos." Then select "In Place & Effective." Then add the description of the Kudos in the notes, and add photos if desired.

Kudos

• In Place & Effective

• Has the previous SHPA been reviewed?

  Yes

  No

  N/A

• Has the previous Corrective Action Plan (CAP) been reviewed?

  Yes

  No

  N/A

• Have all CAP actions been completed?

  Yes

  No

  N/A

• Has the Safety Program documentation been provided in digital format via access to SharePoint or facility shared files?

  Yes

  No

  N/A

• How many injuries were reported in the previous 12 months?

• Is the injury trend improving?

  Yes

  No

  N/A

• Has the site been free from L&I Citations for the last 3 Years?

  Yes

  No

  N/A

• Describe any L&I Citations:

GENERAL SAFETY [WAC 296-800]

• There is a written Accident Prevention Program that covers the requirements [WAC 296-800-14005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Job Hazard Analyses (JHAs) adequately address job tasks, possible hazards, and mitigation of those hazards. [DSHS AP 9.07, WAC 296-800-11010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• JHAs are updated and reviewed by employees annually (for job classes with a high potential for injury/illness) or every three years (all other job classes) [DSHS AP 9.07]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

ACCIDENT INVESTIGATION [DSHS AP9.07, WAC 296-800, 296-27]

• All incidents are reported and investigated using the Safety Incident/Near Miss reporting process [DSHS AP 9.07]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• All serious employee accidents are investigated, documented and sent to Headquarters (Fatality, Inpatient Hospitalization, Amputation, Loss of an eye) [WAC 296-800-32020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• OSHA 300A forms are completed and have the highest ranking official on-site certified [WAC 296-27-02105(1)(c), (6)] The OSHA 300A Summary is posted Feb 1 through April 30

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• OSHA 300 Log, 300A Summaries are retained for the current year plus five previous years [WAC 296-27-02107]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

ASBESTOS [WAC 296-62-077]

• There is a documented list of locations and quantity of ACM or PACM around the facility [WAC 296-62-07721]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented awareness training is conducted for employees who work around ACM [WAC 296-62-07722(6)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented training is conducted for all employees designated as asbestos workers [WAC 296-62-07722]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Proper labels are used on materials containing asbestos [WAC 296-62-07721(8)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

BBP STANDARD [WAC 296-823]

• There is a written exposure determination that includes job titles and tasks that may have exposure to blood and OPIM [WAC 296-823-11005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a written Bloodborne Pathogens (BBP) exposure control plan that is updated at least annually [WAC 296-823-11010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented training is conducted for all exposed employees in Bloodborne Pathogens annually [WAC 296-823-12005]. There is BBP awareness training for all other employees upon initial hire [DSHS AP 9.06, 18.34]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Hepatitis B vaccines are offered to all exposed employees. Documented declination forms are completed for employees who do not want the HBV vaccine [WAC 296-823-13005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is an investigation for each exposure incident and proper medical follow up with employees [WAC 296-823-16005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Feasible controls, including appropriate equipment and safer medical devices, are used to eliminate or minimize occupational exposure (Sharps containers, splash guards, Needless systems, blunt suture needles, no-hands procedures etc.) [WAC 296-823-14005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *All containers used to store, transport, or ship blood or other OPIM are properly labeled [WAC 296-823-14025]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

CONFINED SPACE [WAC 296-809]

• There is a written Confined Space Program for the facility and reviewed at least annually [WAC 296-809-30002]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• All confined spaces and their hazards have been documented [WAC 296-809-20002]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented Confined Space Entry training is conducted for all authorized entrants, entry supervisors, emergency responders, and persons conducting air sampling [WAC 296-809-40002] The training certifies each employee in the assigned duties [WAC 296-809-40004]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Confined Space Entry Permits are used and contain all required information [WAC 296-809-50004]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Annual hands-on training is provided for all rescue personnel including non-entry rescue [WAC 296-809-50014(2) and 50016]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Access to Confined Spaces are labeled and protected to eliminate unauthorized entry [WAC 296-809-20004]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

ELECTRICAL SAFE WORK PRACTICES [WAC 296-24, NFPA 70E]

• Documented training is conducted for electricians regarding electrically related safe work practices related to their job task [WAC 296-24-970(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Training is provided for electricians on the use of test equipment and rated insulated tools and how to recognize defects [WAC 296-24-970(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Safe procedures are developed for all employees working on/near electrically powered equipment or circuits [WAC 296-24-975]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• PPE hazard assessments are completed based on potential electrical hazards for electricians performing work on electrical equipment [WAC 296-24-980(1)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Procedures are in place for electricians to summon emergency assistance if necessary [WAC 296-45-075(3)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• CPR trained personnel are available when working on live electrical systems [NFPA 70E 110.2(C)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Fire Resistant clothing is required for electrical personnel based on the hazard assessments [NFPA 70E 130.5(C)(3)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Electrical panels are properly labeled to identify disconnecting means, i.e., which equipment each breaker controls [WAC 296-800-28022]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Electrical fittings, boxes, cabinets are maintained in good condition [WAC 296-800-28025]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Electrical rooms are maintained in a clean state of housekeeping to permit ready & safe operation & maintenance of the equipment [WAC 296-800-28027(1)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Electrical cabinets have the proper clearance 30" wide and 36" in front [WAC 296-800-28027(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Flexible cords are not frayed or improperly spliced [WAC 296-800-28030(1)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Power strips used as listed (not daisy-chained, overloaded, etc.) [WAC 296-800-28010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Flexible cords are not used as a substitute for permanent wiring [WAC 296-800-28030(4)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Electrical cords are not running through doors, windows or wall openings [WAC 296-800-28030(4)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Electrical enclosures and covers do not have openings [WAC 296-800-28035] Any unguarded electrical parts?

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Exposed electrical equipment less than 8 feet from the floor are guarded [WAC 296-800-28035]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Electrical equipment is properly grounded [WAC 296-800-28040]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Insulated hand tools are provided for work on energized parts or equipment. Documented periodic inspections and replacement of insulated equipment are conducted [WAC 296-24-980]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

EMERGENCY ACTION AND FIRE PREVENTION PLAN [WAC 296-24-567, 296-800-310, Life Safety Code 101]

• There is a written emergency action plan/fire prevention plan for the facility [WAC 296-24-567(1)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The facility conducts and documents training for all employees in the emergency action plan [WAC 296-24-567(1)(e)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The fire prevention plan includes a list of major workplace fire hazards, proper handling and storage, potential ignition sources, ignition control procedures and type of fire protection equipment used [WAC 296-24-567(2)(b)(i)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is documented training for portable fire extinguisher use annually [WAC 296-800-30025]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The facility annually verifies and documents that emergency alarms are audible/visible throughout the facility [WAC 296-800-31080]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented fire drills are conducted according to the 2018 edition of the International Fire Code, adopted by reference in WAC 51-54A-003: <br>Group B (Office): Annually <br>Group I-2 (Mental Hospital, Assisted Living, Nursing Home): Once per quarter per shift

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *The location has posted emergency escape procedures and escape routes [WAC 296-24-567(1)(b)(i)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Adequate first aid supplies are available, clearly marked and easily accessible for the location (periodic documented inspection) [WAC 296-800-15020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Eyewash/Shower stations are functional and easily accessed [WAC 296-800-15030]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Plumbed Eyewash units are inspected/tested weekly.<br>Self-contained Eyewash units are inspected per manufacturer instructions (and at least 1/year)<br>Plumbed Showers at least once per year [WAC 296-800-15035]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Portable fire extinguishers indicate a monthly inspection to verify that they are maintained fully charged and in operable condition and kept in their designated places [WAC 296-800-30020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Exit routes are large enough [WAC 296-800-31010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Exits are free from obstructions [WAC 296-800-31025]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Exits are adequately marked [WAC 296-800-31050]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *There is adequate lighting for exit routes and signs [WAC 296-800-31053]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Illuminated exit lights and emergency lighting are tested according to (must be documented) [LSC101 7.9.3]:<br>1) Functional test once per month for 30 seconds;<br>2) Functional test annually for 1.5 hours;<br>3) Lighting must be operational for the full duration of the test;<br>4) Must have written records of the visual inspection and test

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

FALL PROTECTION [WAC 296-880, WAC 296-874]

• There is a written Fall Protection and Prevention plan that covers all aspects of fall protection [WAC 296-880]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a documented inspection of all fall protection systems and equipment. [WAC 296-880-10005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a Fall Protection Work Plan in use for all work over 10' in height [WAC 296-880-10020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Scaffolds are assembled, altered, moved, maintained and inspected by a competent person [WAC 296-874-20004, 20034]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented scaffold training for erection, dismantling, operating, maintaining, inspection and use is conducted by a competent person [WAC 296-874-20072, 20074]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented training is conducted for employees exposed to fall hazards [WAC 296-880-10015]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Stairs have handrails and railings (including midrails or vertical members) [WAC 296-800-25015]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Walking/Working surfaces with unprotected sides or edges four feet or more above the ground or lower level are protected. Floor openings, floor holes and open sided platforms are covered or protected [WAC 296-880-20005, 10010, 40015]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Fall protection (PFAS or guardrails) is provided on scaffolds when more than 10 feet above a lower level [WAC 296-880-30030]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

HAZARDOUS DRUGS [WAC 296-62-500]

• There is a written hazardous drug program [WAC 296-62-50015(1)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Written plan is reviewed and updated annually or whenever changes that affect occupational exposure occur, or a change in handling practices [WAC 296-62-50015(3)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Safe handling practices are developed for handling hazardous drugs (including disposal) [WAC 296-62-50035]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

HAZCOM PROGRAM [WAC 296-901]

• There is a written site-specific Chemical Hazard Communication program [WAC 296-901-14010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a hazardous chemicals list for the facility and it is current [WAC 296-901-14010(1)(a)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Safety Data Sheets (SDSs) are available for all chemicals used on site and are current [WAC 296-800-14014(7)] SDSs are archived for all discontinued chemicals

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented HAZCOM training is conducted for all employees [WAC 296-901-14016]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Employees have easy access to the hazard communication program, chemical list, and SDSs [WAC 296-901-14010(4)] (Employee Demonstration)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *All containers, storage tanks, and secondary containers have proper labeling [WAC 296-901-14012]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

HEARING CONSERVATION [WAC 296-817]

• There is a Hearing Conservation program for noise levels that exceed 85 dBA [WAC 296-817-100]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Noise exposure monitoring is conducted to determine actual exposure to noise [WAC 296-817-20005] (Sound level surveys and personal noise dosimetry)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented training is conducted for all employees that may have occupational exposure to noise [WAC 296-817-20020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Baseline audiograms are conducted for all employees exposed to 85dBA TWA or greater [WAC 296-817-40010] (Must be conducted within 180 days unless a mobile van is used, then 1 year)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• STS audiograms are reviewed by a qualified person and the employee notified, retrained and refitted with hearing protection within 21 days of audiogram [WAC 296-817-40020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Audiometric tests are kept as medical records [WAC 296-817-40030]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Recordable STS are recorded onto OSHA 300 Logs within 37 calendar days [WAC 296-27-01113(2)(c )]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *At least two types of hearing protectors are provided (such as molded earplugs, foam earplugs, custom-molded earplugs, canal caps, or earmuffs) [WAC 296-817-20015]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

HEAT STRESS [WAC 296-62-095]

• There is a written outdoor heat exposure program [WAC 296-62-09530]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented training is conducted for employees and supervisors prior to outdoor work exceeding DOSH prescribed temperatures, and annually thereafter [WAC 296-62-09560]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

HOT WORK [296-24-695]

• Prohibited hot work areas are specified in the program [WAC 296-24-69503(6)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a list of personnel who can authorize hot work [WAC 296-24-69503(13)(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Hot work permits are used for required areas [WAC 296-24-69503(4)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Training is conducted for fire watch personnel (fire extinguishers & hoses) [WAC 296-24-69803(3)(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Fire watch is provided during hot work and at least 30 minutes after work completion [WAC 296-24-69503(3)(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Oxygen and acetylene gas cylinders are separate and not stored within 20 feet of each other [WAC 296-24-68203(2)(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Compressed gas cylinders are secure [WAC 296-24-68203(2)(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Flammable, combustible or explosive material(s) is removed or protected from the hot work area (within a 35-foot radius) [WAC 296-24-69503(3)(a)(i)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

LAB SAFETY [WAC 296-828-200]

• If there is a lab, a written comprehensive Chemical Hygiene Plan is completed and reviewed annually [WAC 296-828-20005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Chemical hygiene plan training addresses chemical hazards and plan requirements [WAC 296-828-20015]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Employee monitoring records are maintained as required [WAC 296-828-20030]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

LADDERS [WAC 296-876]

• Documented ladder inspection is performed on all ladders [WAC 296-876-30005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented ladder training is conducted for employees that use ladders (performed by a competent person) [WAC 296-876-15005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Ladders are supported and protected where they are stored [WAC 296-876-30015]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Ladders are in good, usable condition [portable WAC 296-876-30005; fixed WAC 296-876-700] (Only Type IA, I or II ladders allowed)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Ladders are used for their intended purpose [WAC 296-876-40005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

LEAD-BASED PAINT [WAC 296-62, WAC 296-155-176]

• If the facility had lead-based paints, there is a comprehensive Lead Compliance plan [WAC 296-155-17611(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented Exposure Assessment has been conducted to determine employee exposure to lead from activities that may disturb lead-based paint [WAC 296-155-17609]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented training is provided for employees allowed to disturb lead-based paint [WAC 296-155-17625(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented lead awareness training is conducted for every employee who may have potential exposure to lead [WAC 296-62-07521(13)(a)(i)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

LOCKOUT/TAGOUT [WAC 296-803]

• There is a written Lockout/Tagout program [WAC 296-803-20005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Written energy control procedures are created for complex equipment to ensure it is rendered inoperative [WAC 296-803-50005] Are they reviewed every year?

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented Lockout/Tagout training is conducted for each authorized person who will be performing maintenance covered under the lockout/tagout program [WAC 296-803-60005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented annual evaluations of lockout in progress are conducted to ensure those procedures are being followed as written and that authorized personnel understand the procedures [WAC 296-803-70005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Lockout devices are provided to all required employees [WAC 296-803-40005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Tags are distinctive, durable, and have a warning about not starting or operating equipment [WAC 296-803-40020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *LOTO procedures implemented & followed [WAC 296-803-50005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Lockout/Tagout devices are not used for any other purpose (maintenance, adjustment and repair of equipment only) [WAC 296-803-40010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

MACHINE GUARDING [WAC 296-806]

• *All non-portable power tools are permanently mounted to the floor [WAC 296-806-20002]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Work areas are arranged to reduce hazards [WAC 296-806-20006]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Starting & stopping devices within easy reach of operator [WAC 296-806-20008]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Machines are designed to not start if power is interrupted [WAC 296-806-20010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *All hand feeding and retrieval tools are in good condition [WAC 296-806-20018]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Machines and equipment have proper guarding in good condition [WAC 296-806-20028]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Bench grinders have the tongue guards within 1/4 inch of wheel and tool rests within 1/8 inch of wheel [WAC 296-806-40508]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

MOBILE EQUIPMENT, CRANES & RIGGING [WAC 296-863, 296-869, 296-24]

• There is a removal from service procedure for any mobile equipment that is not safe to operate [WAC 296-863-30005, WAC 296-869-60045]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented training is conducted for all PIT & Aerial Lift operators. Operators must be trained prior to use. Retraining is required after an accident, observed unsafe operation, or a change in vehicle types or work place. PIT operators must be re-evaluated at least every three years. [WAC 296-863-600, WAC 296-869]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a preventive maintenance program for mobile equipment [WAC 296-863-30020; WAC 296-24-23523] Service records are retained for the life of the equipment

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Each piece of mobile equipment inspected prior to use on each shift [WAC 296-863-30010, WAC 296-896-20030] (Documented)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Monthly and annual documented crane inspections are being conducted [WAC 296-24-23519(1)(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Mobile equipment is properly labeled with proper nameplates, stickers, stencils or marks that relate to the stability and safety of the equipment [WAC 296-863-20015, WAC 296-869-30010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Battery charging areas are safe, including: spill kits, fire protection, adequate ventilation, and protections to keep the battery charging equipment from being damaged. [WAC 296-863-30035]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *All person's working from aerial lifts or boom-supported elevating work platforms are wearing a full body harness with a lanyard attached to the manufacturer's recommended attachment point [WAC 296-869-20045, 60040]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Overhead gantry cranes and chain hoist equipment have load ratings that are visible from the ground floor [WAC 296-24-23503(5)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Slings and rigging are in good condition and have load rating tag (not damaged or defective) [WAC 296-24-29419]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

PORTABLE POWER TOOLS [WAC 296-807]

• Employees are trained in the safe operation of power tools (conversation with employees/supervisor) [WAC 296-800-14020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Employees understand and follow instructions for operating power mowers [WAC 296-807-16015]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Power mowers have proper labeling and all labels are legible [WAC 296-807-16016]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Power mowers have manufacturer's guards in place [WAC 296-807-16005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Air pressure has been reduced to less than 30-psi at the nozzle or the nozzle has relief holes [WAC 296-807-14020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Tools used are undamaged and kept in a safe condition (cords, guards, switches) [WAC 296-800-11030]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Power tools have safe power switches that make it difficult to accidentally operate, yet easily shut off power when released [WAC 296-807-11005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Power tools have proper guarding [WAC 296-807] (see specific tool type for guarding requirements)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

PPE [WAC 296-800]

• The facility conducts and documents written PPE hazard assessments [WAC 296-800-16005] (can be included in JHA)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented PPE training is conducted to ensure that each employee understands the limitations, use, care and disposal of the PPE [WAC 296-800-16025]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Required PPE is available [WAC 296-800-16020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *PPE is maintained in a sanitary and reliable condition [WAC 296-800-16045]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

RESPIRATORY PROTECTION [WAC 296-842, WAC 296-841]

• There is a written Respiratory Protection program [WAC 296-842-12005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• An exposure evaluation has been conducted to determine if employees are exposed to airborne contaminants above the Permissible Exposure Limit, or other airborne hazards, such as biological hazards. [WAC 296-841-20005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Feasible exposure controls have been implemented to reduce or eliminate employee exposure to airborne contaminants, including elimination, substitution, engineering, or administrative controls [WAC 296-841-20010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a requirement for all employees that voluntarily wear dust masks to complete an initial "Voluntary Use of Dust Masks Information Sheet" [WAC 296-842-11005 Table 2]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Initial Respirator Medical Evaluation Questionnaires are completed for each employee required to wear a respirator [WAC 296-842-14005] (Documented)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Annual fit testing is conducted for all employees required to wear tight fitting respirators [WAC 296-842-15005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented respirator training is conducted that covers respirator limitations, use, care, and storage [WAC 296-842-16005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

SAFETY COMMITTEE/MEETINGS [WAC 296-800-130]

• Does the location have more than 10 employees?

  Yes

  No

  N/A

• The safety committee conducts regular meetings as determined by the committee [WAC 296-800-13020(1)(c)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The safety committee assists in the evaluation of the Accident Prevention Program [WAC 296-800-13020(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The safety committee reviews safety inspection reports to help correct safety hazards [WAC 296-800-13020(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The safety committee evaluates accident investigations to determine if the cause(s) of the unsafe situation were identified and corrected [WAC 296-800-13020(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Safety Committee meetings are documented and attendance is recorded [WAC 296-800-13020(2,3)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Safety meetings are held monthly for all staff and have at least one management representative [WAC 296-800-13025(1)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The safety meetings review safety inspection reports to help correct safety hazards [WAC 296-800-13025(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The safety meetings evaluate accident investigations to determine if the cause(s) of the unsafe situation were identified and corrected [WAC 296-800-13025(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Safety meeting subjects discussed are documented and attendance is recorded [WAC 296-800-13025(2)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

STORAGE & HOUSEKEEPING [WAC 296-800, 296-24, 246-360]

• *All areas of the workplace, passageways, storage rooms, and service rooms are in a clean, orderly and sanitary condition [WAC 296-800-22005]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Materials are stored so they do not create a hazard [WAC 296-800-22035]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Storage designed to minimize ergonomic injuries [WAC 296-800-11010]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Materials are stored at least 18 inches below sprinkler heads or 24 inches from ceiling in non-sprinkled buildings [WAC 296-24-60705(10)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Floor loads limits are marked on all floors used for storage purposes [WAC 296-800-27020]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Flammable or combustible liquids are stored in flammable storage cabinets or in flammable storage rooms [WAC 296-24-33011(2)(b)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *Dryer lint is removed daily [WAC 246-360-180] (documented)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

WORKPLACE VIOLENCE [DSHS Administrative Policies; RCW 72.23.400; RCW 49.19]

• The facility has developed a plan to reasonably prevent and protect employees from workplace violence [DSHS AP 9.12; AP 18.67]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• A Physical Security Survey & Vulnerability Assessment that identifies existing/potential hazards for workplace violence is conducted at least annually [DSHS AP 9.12]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Is the location a Hospital or Nursing Home?

  Yes

  No

  N/A

Hospitals must have the following (Nursing Homes/DDA Facilities are recommended):

• The facility has a written plan to reasonably prevent, and protect employees from, workplace violence which includes considerations based on the physical attributes of the facility, staffing, personnel policies, first aid and emergency procedures, reporting procedures, employee education and training, and clinical and patient policies [RCW 72.23.400(1)(a-h)]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The written plan is evaluated, reviewed, and amended as necessary, at least annually, and the evaluation results are shared with all employees [RCW 72.23.400(4); DOSH F417-140-000]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Documented Violence prevention training is conducted for all affected employees (including, but not limited to, food service, custodial, and maintenance staff) initially and at least annually. This training must address the violence escalation cycle; violence prediction; obtaining patient history; de-escalation techniques; restraining techniques; reporting incidents; the facility's debrief process; inter-shift reporting; and more. [RCW 72.23.410]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a record for all violent acts against employees, patients, or visitors and kept for five years [RCW 72.23.420]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Actions taken by the facility, including the workplace violence plan, are effectively managing to reduce workplace violence events (based on measurable data) [DOSH F417-140-000; OSHA 3148-06R]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There is a workplace violence prevention committee/team [including floor staff] at the facility with appropriate expertise and authority [DOSH F417-140-000; OSHA 3148-06R]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Post-workplace violence incident debriefings occur to reduce psychological trauma, and to educate staff to help prevent future incidents [RCW 72.23.410; DOSH F417-140-000; OSHA 3148-06R]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• The workplace violence training program is evaluated at least annually to determine training effectiveness, and is modified accordingly [OSHA 3148-06R]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• *The facility has engineering controls to help prevent workplace violence, such as: panic buttons, alarm systems, employee safe rooms, curved mirrors, bright & effective lighting, glass panels in doors/walls, enclosed workstations, locking doors, patient/resident de-escalation rooms, safe furniture, physical barriers in vehicles [DOSH F417-140-000; OSHA 3148-06R]

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• There are periodic documented inspections of ACM to ensure that it is not friable. (Best Practice - Not Scored)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Calendar year goals have been established and are monitored throughout the year (Best Practice - Not Scored)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Injury trends are used to prevent recurrence of injuries (Best Practice - Not Scored)

  In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A

• Select "Add Additional Finding." Then select "In Place & Effective, Needs Improvement, or Not in Place." Then add the description of the additional finding in the notes, and add photos if desired.

Additional Finding

• In Place & Effective

  Needs Improvement

  Not In Place

  Repeat Finding

  N/A