Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

1.0 - Previous inspection

  • 1.1 - Has the last inspection been reviewed?

2.0 - Fire Prevention

  • 2.1 - Door wedged or propped open, none found?

  • 2.2 - Fire doors are not blocked by carts, equipment, or materials?

  • 2.3 - Extinguishers is not missing damaged, or discharged?

  • 2.4 - Extinguishers has current inspection documentation?

  • 2.5 - Extinguishers clear of obstructions?

  • 2.6 - Sprinkler Heads/Smoke Detectors are clean & intact?

  • 2.7 - Indicator Lights are not obstructed?

  • 2.8 - Fire Exit signs are illuminating and working properly?

  • 2.9 - Fire Doors close and latch properly?

  • 2.10 - Storage is less than 18" from ceiling?

  • 2.11 - Doors to Soiled/Clean/Hazardous Materials Rooms closed locked?

  • 2.12 - Emergency Exit Corridors / Doors are clear?

  • 2.13 - All wheeled equipment in corridor is "attended"?

  • 2.14 - Flammables, stored appropriately?

  • 2.15 - Penetrations to Walls / Ceilings / Floors, not present?

  • 2.16 - No unauthorized space heaters present?

  • 2.17 - No unauthorized heat producing equipment present (Toasters, etc)

  • 2.18 -Trash containers are no more than 32-gallons in capacity.

3.0 - Electrical Safety

  • 3.1 - Electrical outlets are not damaged or loose?

  • 3.2 - Critical equipment is plugged into Red Outlet?

  • 3.3 - All extension cords are equipped with a ground prong?

  • 3.4 - All switches, receptacles and computer boxes have covers or plates?

  • 3.5 - Electrical panels are accessible - 36" clearance around panels.

4.0 - General Safety

  • 4.2 - All wheelchairs are in good repair and with both footrest?

  • 4.1 - Handrails are attached firmly to the walls?

  • 4.4 - Floors - tiles, carpet in good repair - no trip hazards?

  • 4.5 - Stairwell lights working?

  • 4.6 - Storage Rooms clean and orderly?

  • 4.7 - No items are being stored under the sinks?

  • 4.8 - Step ladders available to reach high places are in good shape?

  • 4.9 - No electrical cords, telephone and computer wires in area that might entangle feet?

  • 4.10 - Desk, chairs, furniture in safe condition?

  • 4.11 - Patient Room furniture in safe condition?

  • 4.12 - No evidence of food, drinks or eating occurring around computers or nurse station?

  • 4.3 - Storage is at least 6" from the floor. No boxes on the floor?

5.0 - Hazardous Marerial

  • 5.1 - Eye wash station inspected weekly and documented?

  • 5.2 - High level disinfectant policy being followed - QC, documentation, etc?

  • 5.3 - Medical gas cylinders are stored where full and empties are separated?

  • 5.4 - Medical gas cylinders are restrained properly in bins, racks, or hand carts?

  • 5.5 - Biohazard containers are stored properly?

  • 5.6 - Sharps boxes are no more than 3/4 full; syringe disposed of properly?

  • 5.7 - Staff are able to obtain a MSDS?

  • 5.8 - Secondary container are labeled properly?

  • 5.9 - Hazardous materials properly stored?

6.0 - Security Management

  • 6.1 - Employee personal items are secured out of sight?

  • 6.2 - Employee I.D. Badges visible and worn properly?

  • 6.3 - Confidential Materal secured /protected?

  • 6.4 - High risk patient's, equipment areas, hazardous material area rooms are secure?

  • 6.5 - Medications secured?

  • 6.6 - Doors with security hardware operate properly?

  • 6.7 - Code carts locked and in view of staff?

7.0 - Utilities Management

  • 7.1 - All lights are operational, no lights out?

  • 7.2 - Ceiling tiles, none discolored,/wet/damaged?

  • 7.3 - HVAC System - Air temperature within condor table range?

  • 7.4 - Plumbing, faucets,, toilets operational (no leaks)?

  • 7.5 - Ice machine clean and maintenance on schedule?

  • 7.6 - lights in nearest stairwell operational?

Comments

  • Additional Comments

  • Surveyor's Signature

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