Total Number of Findings
Total number of Facilities/Engineering work orders
Total number of EVS work orders
Total number of educational opportunities
1.1 Has the last audit been reviewed?
1.2 Are there any outstanding concerns?
A1. Warning signs or barricades are placed when work creates a hazard (wet floor, maintenance work in ceiling)?
A2. Medication cart is locked, neat and tidy, without expired medicines/products?
A3. Clean linen is covered with nothing on top of cart?
A4. All furniture and equipment is in sound condition? (no chipped or torn surfaces- no leaky faucets)
A5. This area is free from sharp objects?
A6. All wall-mounted devices (lights, TV’s, pictures, signs, containers, handrails, etc.) are secure and not loose?
A7. Cleaning chemicals are properly labeled and are not accessible by residents and visitors?
A8. Quality Control logs for Refrigerators/Freezers, freezers, and warmers are complete and corrective actions documented as appropriate?
A9. Boxes of patient care items/supplies are not stored directly on the floor? (must be elevated 6")
A10. Items are not stored under sink(s)? (If items found - list in comment section.)
B1. Items are not stored within 30” of an electrical panel?
B2. Electrical cords, plugs, plates and switches are in good repair?
B3. Extension cords only used temporarily but not on a permanent everyday basis?
B4. The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?
C1. Medications/medical supplies - have not passed expiration dates?
C2. All syringes, basins, cups, containing medication or solutions are labeled with the name of the contents?
C3. Med Carts/Med Rooms are secured at all times?
D1. Staff food is not stored in patient refrigerators?
D2. Refrigerators/Freezers are clean, frost free, and labeled for type of storage with only those items present (no food and medication in the same refrigerator).
D3. Refrigerators/Freezers contain thermometers and the refrigerator graphs are up-to-date? (thermometer should be located in the back)
D4. No open or expired patient nourishment containers in refrigerator?
D5. Ice machines are clean, no signs of deposits in tray or dispensing mechanism?
D6. Anti-microbial soap and paper towels are available for hand washing?
D7. Containers used for regulated or infectious waste are covered, leak proof, and clearly labeled as a biohazard?
D8. Disposed sharps are in an approved container?
D9. Sharps containers are secured in their holders, not accessible to residents and not more than three-fourths full?
D10. Staff (including contracting physicians) perform hand hygiene when entering room?
D11. Staff (including contracting physicians) perform hand hygiene while providing care.
D12. Staff (including contracting physicians) perform hand hygiene when exiting the patient room.
E1. Floors free of dirt, dust and litter?
E2. Ledges, walls and air vents free of dust?
E3. Toilets and sinks secure?
E4. Privacy curtains clean and unsoiled?
F1. ** How can you access Material Safety Data Sheets (MSDS)?
F2. ** Do you know where your PPE is located?
F3. Material Safety Data Sheets available for all chemicals in this unit?
G1. ** Can you explain when you would implement R.A.C.E. and what does it stand for?
G2. ** Can you explain P.A.S.S. and what does it stand for?
G3. ** Where are the fire extinguishers and pull stations located in your department?
G4. Two exit signs visible from each corridor?
G5. Halls/Corridors uncluttered and accessible?
G6. Wheeled items such as the WOW’s are stored in corridor less then 30 minutes at a time?
G7. Are ceiling tiles in place, not stained and not broken?
G8. Are the sprinkler heads free of dust?
G9. Fire extinguisher (s) recently serviced? (monthly)
G10. Automatic fire doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.)
G11. Eighteen-inch clearance from sprinkler head ensuring no obstruction?
G12. Are compressed gases stored in designated areas only?
G13. Are full and empty cylinders stored separately according to sign/labels?
G14. All lights are working properly?
G15. Flammable and hazardous materials properly stored and labeled?
G16. Fire extinguishers and pull stations clear of obstructions?
G17. Placement of Hand Sanitizer is not adjacent(with-in 6”) to a potential ignition source?
G18. Exits clear of obstructions?
H1. ** Can you tell me the number you would dial to initiate an emergency response?
H2. ** Where are your IT Downtime Forms? Do you have an IT Downtime Box? Are the forms current?
I1. ** How do you notify Security in a non-emergency?
I2. Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges @ eye level?
I3. Are valuables properly stored in department?
J1. ** What are the procedures if a device/equipment does not work properly OR if the device is involved in a resident related incident?
J2. All medical equipment/devices has a current Bio-Medical sticker?
K1. ** Where are your emergency backup procedures located for a loss of utility services?
K2. ** In case of a fire on the unit, who is authorized to shut off medical gases?
L2. Patient Health Information is not visible(computer screens protected, hard copies covered, patient charts closed)
M1. ** Name two patient identifiers?
M2. ** Describe the Falls Prevention efforts in your department.
N1. FREE OF PERVASIVE ODORS?