FH Physical Environment Audit

• Audit Campus

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Previous inspection

• Have the last inspection results been reviewed?

  Yes

  No

  N/A

• Did any previous non-compliant issues re-occur during this audit?

  Yes

  No

  N/A

• What issues were re-occurring?

  Yes

  No

  N/A

PE.1 - Facility - Inside

• 1.1 - Floors and walking surfaces even with no trip and fall hazards?

  Yes

  No

  N/A

• 1.2 - Ceiling tile unstained and in good conditions?

  Yes

  No

  N/A

• 1.3 - Wayfinding signage appropriate and clear?

  Yes

  No

  N/A

• 1.4 - Wet floor signs are in place as appropriate?

  Yes

  No

  N/A

• 1.5 - Stairs, ramps, corridors unobstructed and equipped with handrails?

  Yes

  No

  N/A

• 1.6 - Lighting is in good conditions and provides sufficient illumination?

  Yes

  No

  N/A

• 1.7 - Power strips are not plugged into other power strips?

  Yes

  No

  N/A

• 1.8 - Electrical equipment is of appropriate type and rating for use?

  Yes

  No

  N/A

• 1.9 - Extension cords are are UL listed, properly grounded, in good condition, and for temporary use only?

  Yes

  No

  N/A

• 1.10 - Furniture, patient transport equipment, IV poles, etc. in clean and sound condition?

  Yes

  No

  N/A

• 1.11 - Storage areas are clean, orderly, and adequate in space and number?

  Yes

  No

  N/A

• 1.12 - The overall appearance of the area is clean and unobstructed?

  Yes

  No

  N/A

• 1.13 - All patient nutrition and medication refrigerators are clean and have daily temperature checks?

  Yes

  No

  N/A

• 1,14 - Ventilation is adequate and supply and return vents are clean and functional?

  Yes

  No

  N/A

• 1.15 - Patient care areas are free from space heaters and unauthorized appliances?

  Yes

  No

  N/A

• 1.16 - Undersink cabinets are secured in a closed position in patient care areas?

  Yes

  No

  N/A

• 1.17 - Design and safety features are appropriate for the patient occupancy?

  Yes

  No

  N/A

• 1.18 - No more than 300 cubic feet (12 e cylinders) of oxygen stored in a smoke compartment?

  Yes

  No

  N/A

• Enter Comments:

PE.1 - Facility - Construction or Renovation

• Is there a construction or renovation site at this location?

  No construction or renovation - disregard following questions

  Yes, there is a construction or renovation project here

• 1.19 - Has ICRA been evaluated and correctly implemented?

  Yes

  No

  N/A

• 1.20 - Have ILSM been evaluated and correctly implemented?

  Yes

  No

  N/A

• 1.21 - Does the staff in the area understand the changes to ILS?

  Yes

  No

  N/A

• 1.22 - Is the construction / renovation site clean, uncluttered, and with no sign of contaminants released to the occupied area?

  Yes

  No

  N/A

• 1.23 - Is the construction site secured?

  Yes

  No

  N/A

• 1.24 - Are all the designated signs and notifications in place and understandable?

  Yes

  No

  N/A

• 1.25 - Are pressure differentials appropriate to contain contaminants inside the construction barrier?

  Yes

  No

  N/A

• 1.26 - Is the construction barrier intact and appropriate for the project?

  Yes

  No

  N/A

• Enter Comments:

PE.1 - Facility - Grounds and Outside Property

• Did this audit include an outside building tour?

  No construction or renovation - disregard following questions

  Yes, there is a construction or renovation project here

• 1.27 - Grounds are clean, neat, and well maintained?

  Yes

  No

  N/A

• 1.28 - Access to patient entrances and emergency services is clearly marked and unobstructed?

  Yes

  No

  N/A

• 1.28 - Traffic directional signage is understandable and adequate?

  Yes

  No

  N/A

• 1.30 - Sidewalks, drives, roads, curbs, stairs, etc. are unbroken, without holes, and safe?

  Yes

  No

  N/A

• 1.31 - Lighting at night provides appropriate security and wayfinding?

  Yes

  No

  N/A

• 1.32 - If an outside construction project is present, has a FH Construction Audit been performed?

  Yes

  No

  N/A

• 1.33 - Is the oxygen farm / cylinder storage area neat, clean, and with all cylinders individually chained or secured?

  Yes

  No

  N/A

• 1.34 - Are the Central Energy Plant and storage areas neat, clean, safe, and well maintained?

  Yes

  No

  N/A

• 1.35 - Are fire pumps appropriately tagged?

  Yes

  No

  N/A

• 1.36 - Are the red, biomedical waste roll offs, hazardous chemical storage areas, fuel tanks, compactors and dumpsters properly labeled and secured?

  Yes

  No

  N/A

• 1.37 - Does the external fire department connection have the appropriate FDC sign?

  Yes

  No

  N/A

• 1.38 - Backflow preventers are chained and have switches installed with tamper proof devices?

  Yes

  No

  N/A

• 1.39 - Are roof access points secured?

  Yes

  No

  N/A

• 1.40 - Are roof mechanical rooms, elevator rooms, vents, lightning protection, etc. appropriately labeled and secured?

  Yes

  No

  N/A

• Enter Comments:

PE.2 - Life Safety Management

• 2.1 - Evacuation plan is accurate and displayed in the correct location?

  Yes

  No

  N/A

• 2.2 - If ILSM is in place, are occupants aware of, and understand changes to evacuation routes and exits/

  Yes

  No

  N/A

• 2.3 - Fire extinguishers are in place with tags that are correctly dated and marked?

  Yes

  No

  N/A

• 2.4 - If construction or renovation sites exist, fire extinguishers are properly located?

  Yes

  No

  N/A

• 2.5 - Fire extinguishers, pull stations, medical gas valves, and electric panels are clear of obstructions?

  Yes

  No

  N/A

• 2.6 - Location and distance between extinguishers is code compliant?

  Yes

  No

  N/A

• 2.7 - Egress corridors are clear of obstructions?

  Yes

  No

  N/A

• 2.8 - Exit signs lit and correctly located?

  Yes

  No

  N/A

• 2.9 - Exit doors easily opened from inside?

  Yes

  No

  N/A

• 2.10 - Exits clear of obstructions?

  Yes

  No

  N/A

• 2.11 - Alcohol based hand rub (ABHR) is appropriately mounted and in compliant quantities?

  Yes

  No

  N/A

• 2.12 - Electric panels / breaker boxes are appropriately labeled and secured?

  Yes

  No

  N/A

• 2.13 - Flammable liquids are stored in approved containers or cabinet?

  Yes

  No

  N/A

• 2.14 - Battery charging areas have only closed cell batteries, display appropriate signage, and have adequate ventilation?

  Yes

  No

  N/A

• 2.15 - Fire sprinkler heads are clean, the correct height, and with intact escutcheon plates?

  Yes

  No

  N/A

• 2.16 - Smoke and fire walls have no penetrations or are sealed with appropriate fire stop material?

  Yes

  No

  N/A

• 2.17 - Ceiling tile serving as a smoke barrier have no gaps, holes, or mis-fitting grid?

  Yes

  No

  N/A

• 2.18 - Is the fire sprinkler system appropriately located and spaced?

  Yes

  No

  N/A

• 2.19 - Is there a minimum of 18" clearance below all sprinkler heads?

  Yes

  No

  N/A

• Enter Comments:

PE.3 - Safety Management

• 3.1 - Supplies and equipment are appropriately maintained?

  Yes

  No

  N/A

• 3.2 - Ventilation, light, and temperature control is appropriate?

  Yes

  No

  N/A

• 3.3 - Furnishings are in safe and intact condition?

  Yes

  No

  N/A

• 3.4 - Work spaces are ergonomically sound and appropriately sized and designed?

  Yes

  No

  N/A

• 3.5 - Risk of infection is reduced by adequate sanitation facilities and protective equipment?

  Yes

  No

  N/A

• 3.6 - Noise levels are within allowable levels?

  Yes

  No

  N/A

• Enter Comments:

PE.4 - Security Management

• 4.1 - Access to sensitive areas is controlled?

  Yes

  No

  N/A

• 4.2 - Risk of theft is reduced through occupant awareness and action?

  Yes

  No

  N/A

• 4.3 - Occupants know how to contact Security?

  Yes

  No

  N/A

• 4.4 - Access to emergency service areas is unobstructed?

  Yes

  No

  N/A

• 4.5 - Personal identification policy is followed?

  Yes

  No

  N/A

• Enter Comments:

PE.5 - Hazardous Materials and Waste Management

• 5.1 - Occupants know how to retrieve MSDS from Intranet?

  Yes

  No

  N/A

• 5.2 - A current inventory of chemicals is available in this location?

  Yes

  No

  N/A

• 5.3 - Black boxes are correctly labeled and secured?

  Yes

  No

  N/A

• 5.4 - Sharps containers are correctly labeled and secured?

  Yes

  No

  N/A

• 5.5 - Occupant exposure levels are monitored as per OSHA requirements?

  Yes

  No

  N/A

• 5.6 - If required is PPE available and used?

  Yes

  No

  N/A

• 5.7 - Is adequate ventilation provided in areas in which hazardous substances are used?

  Yes

  No

  N/A

• 5.8 - Are eye washes and showers easily accessed?

  Yes

  No

  N/A

• 5.9 - If an eyewash or shower is present, is a log present and current?

  Yes

  No

  N/A

• 5.10 - Chemicals are properly stored and labeled?

  Yes

  No

  N/A

• Enter Comments:

PE.6 - Emergency Management

• 6.1 - Can occupants answer correctly when asked what actions they take during a Code Pink?

  Yes

  No

  N/A

• 6.2 - Do occupants know the hospital's process for response to a disaster (ICS process)?

  Yes

  No

  N/A

• Enter Comments:

PE.7 - Medical Equipment Management

• 7.1 - Hospital owned medical equipment has a current PM sticker or a green Surveillance Program tag?

  Yes

  No

  N/A

• 7.2 Occupants know which sticker to apply to a piece of equipment that needs repair or service?

  Yes

  No

  N/A

• 7.3 - There is clear distinction between clean and soiled medical equipment?

  Yes

  No

  N/A

• Enter Comments:

PE.8 - Utility Management

• 8.1 - Non-essential equipment is not plugged into red emergency power outlets?

  Yes

  No

  N/A

• 8.2 - Are lockout procedures implemented and followed when working on energized equipment?

  Yes

  No

  N/A

• 8.16 - Are gas bottles secured?

  Yes

  No

  N/A

• Enter Comments:

9 - Area Specific Topics

• 9.1 - In the Clinical Laboratory, Pharmacy, Kitchen, Radiology, etc., are all posted staff licenses current?

  Yes

  No

  N/A

• 9.2 - In the Clinical Laboratory or Pharmacy Department, do protective chemical or biological cabinets, or chemotherapy hoods have current inspection tags?

  Yes

  No

  N/A

• 9.3 - In patient care units, are nurse call devices the appropriate type and in the appropriate location?

  Yes

  No

  N/A

• 9.4 - In Kitchen areas, is the hood fire suppression system clean, intact, and displaying an in-date inspection tag?

  Yes

  No

  N/A

• 9.5 - In Kitchen areas, are the temperatures of dishwashers in compliance and recorded?

  Yes

  No

  N/A

• 9.5 - In Kitchen areas, are there K class fire extinguishers in any cooking area in which grease laden vapors can be released?

  Yes

  No

  N/A

• Enter Comments:

Sign Off

• On site representative

  Sign

• Auditor's signature

  Sign

• Audit Summary and Action Items: