Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

  • Flooring surfaces are: ▪ Intact ▪ Undamaged ▪ Clean and free of slip and trip hazards ▪ Wet floor signs are used appropriately

  • Ceiling surfaces are: ▪ Intact ▪ Undamaged ▪ Clean and free of stains ▪ No Gaps

  • Wall coverings and protections are: ▪ Intact ▪ Undamaged ▪ Clean and free of stains

  • Laminates, countertops, and other solid surfaces are: ▪ Intact ▪ Undamaged ▪ Clean and free of stains

  • Lighting is suitable for the care, treatment, and services provided? ▪ Bulbs illuminated ▪ Lens/globe secure ▪ Fixtures clean

  • Temperature & humidity: ▪ Suitable for the care, treatment and services provided ▪ Monitored and/or recorded according to policy ▪ Logs are maintained & actions are documented for failed readings

  • Nursecall emergency pull stations comply with the following: ▪ Equipped with pull cords that are reachable from the floor position ▪ Pull cords do not touch the floor ▪ Pull cords are not entangled around grab bars or other objects

  • Stored supplies are elevated off the floor with solid surface bottom shelving?

  • Electrical distribution panels: ▪ Secured in areas accessible to public ▪ Maintained accessible with 36" clearance in all directions ▪ Accurate panel directory present ▪ No "spare breakers" in use ▪ No uncovered knockouts or openings

  • Ground fault receptacles provided in wet locations?

  • Tamper resistant receptacles provided in waiting areas?

  • Medical gas alarms/zone valves: ▪ Unobstructed/readily accessible ▪ Accurately labeled ▪ Audible and visual alarms function properly

  • Bulk medical gas storage: ▪ Correct signage ▪ Cylinders are secured ▪ Room is clean/no trash

  • Fire alarm pull stations: ▪ Maintained accessible with 36" clearance in all directions

  • Fire sprinkler heads: ▪ Properly oriented and spaced ▪ Undamaged ▪ Escutcheons and cover plates securely in place ▪ Free of corrosion, dust and debris

  • A minimum of 18" clearance is maintained between fire sprinkler heads and adjacent storage?

  • Fire extinguishers: ▪ Appropriate for area hazard(s) ▪ Clearly marked ▪ Maintained accessible with 36" clearance in all directions ▪ In good condition & free from tampering ▪ Monthly inspections are maintained current

  • The means of egress is maintained clear and unobstructed to public way with the following exceptions: ▪ Emergency resuscitation carts (crash carts) ▪ PPE carts (in use) ▪ Patient transportation equipment

  • Stair exit enclosures: ▪ Free of storage ▪ Free of penetrations other than those that serve the enclosure

  • Spaces around pipes, conduits, bus ducts, cables, wires, air ducts, etc. that penetrate fire and smoke rated walls, floors and ceilings are protected with an approved firerated material/assembly? (Inspect at least three locations)

  • Fire rated /Hazard Room doors: ▪ Legibly labeled ▪ Self-closing ▪ Positive latching ▪ Not wedged or manually held open

  • General Maintenance Items: Item not listed above

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