Hazard Surveillance Inspection Report - Healthcare Occupancy

• Document No.

• Building, Floor, Department

• Conducted on

  Date

• Prepared by

• Add signature

  Sign
• Location
  Address

• Director: Manager:

• Please Note: This Information Is Reported To The Director And Manager For Corrective Action For Clinical Issues Only. All Facility Related Issues Will Be Entered Into Archibus via Safety Operations.

Fire Prevention

• 001. Are waiting areas open to corridors equipped with smoke detection?

  Yes

  No

  N/A

• 002. Are exit signs readily visible and illuminated?

  Yes

  No

  N/A

• 003. Smoke barrier doors have proper gaps (1/8" max opening between doors and 1/4" from door to floor)?

  Yes

  No

  N/A

• 004. Are smoke barrier doors self closing/automatic?

  Yes

  No

  N/A

• 005. Are windows in smoke doors or walls made of fixed wire glass?

  Yes

  No

  N/A

• 006. Is there a clear space of 18 in. Below sprinkler heads?

  Yes

  No

  N/A

• 007. There are no voids in fire or smoke barriers?

  Yes

  No

  N/A

• 008. Are fire doors free of damage and do they close properly? There are no doors propped or wedged open.

  Yes

  No

  N/A

• 009. Are stairways free of storage?

  Yes

  No

  N/A

• 010. Are pull stations visible?

  Yes

  No

  N/A

• 011. Are fire extinguishers properly charged?

  Yes

  No

  N/A

• 012. Does fire extinguisher inspection tag indicate extinguishers are being inspected monthly?

  Yes

  No

  N/A

• 013. Are fire extinguishers accessible?

  Yes

  No

  N/A

• 014. Are emergency evacuation route signs current?

  Yes

  No

  N/A

• 015. Are wall mounted computers maintained in the closed position when not in use.

  Yes

  No

  N/A

• 016. Are corridor unconstructed by equipment or furniture?

  Yes

  No

  N/A

• 017. Are No Smoking rules followed?

  Yes

  No

  N/A

• 018. Are stairwell doors unlocked going into the stairs from the unit?

  Yes

  No

  N/A

• 019. Can windows in patient rooms be opened in the event event of a fire (using a key or an unlocking tool)? Does staff know location of the tool?

  Yes

  No

  N/A

• 020. Are there at least two posted emergency exits on each unit or floor?

  Yes

  No

  N/A

• 021. Do patient sleep rooms open directly onto a corridor with an exit?

  Yes

  No

  N/A

• 022. Are patient room doors are positive latching?

  Yes

  No

  N/A

• 024. Are all decoration flame retardant?

  Yes

  No

  N/A

Medical Equipment

• 101. Is new, demo, or patient owned equipment checked by Biomed before being placed in service?

  Yes

  No

  N/A

• 102. Staff know the proper procedure for impounding the device following a patient incident?

  Yes

  No

  N/A

• 103. Are crash carts and defibrillators checked daily (checked by unplugging from power source)?

  Yes

  No

  N/A

• 104. Are defibrillators pads current and do not have expired dates?

  Yes

  No

  N/A

• 105. Are wheelchairs, IV poles, walkers, and crutches clean and in good condition?

  Yes

  No

  N/A

• 106. Does all medical equipment and inspection tags/stickers as to when the next inspection is due?

  Yes

  No

  N/A

• 107. Are inspections on medical equipment being completed in a timely manner?

  Yes

  No

  N/A

• 108. Are equipment operators manuals readily available?

  Yes

  No

  N/A

Utilities Management

• 201. Are fluorescents lights equipped with working bulbs?

  Yes

  No

  N/A

• 202. Do emergency lights work properly in areas provided?

  Yes

  No

  N/A

• 203. Are wall outlets child proof in areas needed?

  Yes

  No

  N/A

• 204. All electrical panels in closets are secured and are not hampered by items being stored in closets?

  Yes

  No

  N/A

• 205. Is electrical equipment and wiring undamaged?

  Yes

  No

  N/A

• 206. There are no portal space heaters in the area?

  Yes

  No

  N/A

• 207. Extension cords are not used (Exception: Emergency and/or single not ganged fused circuit breaker bars)?

  Yes

  No

  N/A

• 208. Wall outlets are not overloaded?

  Yes

  No

  N/A

• 209. Are isle ways obstructed by computer/phone cables?

  Yes

  No

  N/A

• 210. Are medical Gas Valves accessible, labeled, and clean?

  Yes

  No

  N/A

• 217. Are all heat producing devices (toaster, coffee pots, etc.) unplugged when not in use?

  Yes

  No

  N/A

Hazardous Materials

• 301. Is the hazardous chemical inventory current?

  Yes

  No

  N/A

• 302. Staff know how to retrieve SDS (MSDS)?

  Yes

  No

  N/A

• 303. Are all chemicals properly labeled?

  Yes

  No

  N/A

• 304. Are stored chemicals properly secured?

  Yes

  No

  N/A

• 305. Is the soiled utility room secured and/or toxic material secured?

  Yes

  No

  N/A

• 306. Are cleaning products/chemicals stored properly and away from clinical supplies?

  Yes

  No

  N/A

• 307. Are waist/used chemicals disposed of properly?

  Yes

  No

  N/A

• 308. Are chemicals stored in the proper storage cabinets according to their compatibility?

  Yes

  No

  N/A

• 309. Are emergency eyewash stations and safety showers available in required areas?

  Yes

  No

  N/A

• 310. Are plumbed emergency eyewash station tested weekly?

  Yes

  No

  N/A

Safety Management

• 401. Are medication and specimen refrigerators free of food?

  Yes

  No

  N/A

• 402. Are refrigerators clean?

  Yes

  No

  N/A

• 403. Are refrigerator temperature logs current?

  Yes

  No

  N/A

• 404. Are specimens and medications stored in a separate refrigerators? (In patient care areas, a separate refrigerator is used for the following: unit medications, patient food, staff food, and patient specimens.)

  Yes

  No

  N/A

• 405. Is food consumption, including drinking, prohibited in patient care areas?

  Yes

  No

  N/A

• 406. Is infectious waist disposed of properly?

  Yes

  No

  N/A

• 407. Are medications and/ supplies current and do not have expiration dates?

  Yes

  No

  N/A

• 408. Are sterile and clean supplies stored separately?

  Yes

  No

  N/A

• 409. Are all sterile/high level disinfected items are stored at least 10" off the floor, 6" from outside walls, and 18" from ceiling fixtures?

  Yes

  No

  N/A

• 410. Are linen cart flaps maintained in the closed position when not in use?

  Yes

  No

  N/A

• 411. Are Sharps containers less than 3/4 full?

  Yes

  No

  N/A

• 412. Are gas cylinders properly stored?

  Yes

  No

  N/A

• 414. There are no damaged floor tiles, torn carpet, or trip hazards?

  Yes

  No

  N/A

• 415. There are no damaged/missing ceiling tiles?

  Yes

  No

  N/A

• 416. Glutaraldehyde/Cidex is not used in this area?

  Yes

  No

  N/A

• 417. Cidex OPA Test strips are present if OPA is used and the test strip bottle is dated with discard date?

  Yes

  No

  N/A

Emergency Management

• 501. Is there an Emergency Procedure Manual (EPM) posted?

  Yes

  No

  N/A

• 502. Is the Emergency Procedure Manual up to date?

  Yes

  No

  N/A

• 503. Th fire alarm location page and other emergency announcements are clearly audible in this area?

  Yes

  No

  N/A

• 504. Does the department have a current staff recall list?

  Yes

  No

  N/A

Security

• 601. Are valuables secured (purses, expensive equipment, etc.)?

  Yes

  No

  N/A

• 602. Are code cart medications secure?

  Yes

  No

  N/A

• 603. Are medication secure - (Note - none should be left in open accessible to patients or on anesthesia carts)?

  Yes

  No

  N/A

• 604. Are fax machines in non-public areas to protect confidential information?

  Yes

  No

  N/A

• 605. Are copy machines in non-public areas to protect confidential information?

  Yes

  No

  N/A

• 606. Patient information is not visible from public spaces?

  Yes

  No

  N/A

• 608. Staff is trained to question unknown individuals and report suspicious behavior?

  Yes

  No

  N/A

• 609. Hazardous material is secured?

  Yes

  No

  N/A

• 610. Name tags available or being worn?

  Yes

  No

  N/A

Miscellaneous

• 999. Any additional items not noted on the inspection form?

  Safe

  At Risk

  N/A