Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Flooring surfaces are: ▪ Intact ▪ Undamaged ▪ Clean and free of slip and trip hazards ▪ Wet floor signs are used appropriately
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Ceiling surfaces are: ▪ Intact ▪ Undamaged ▪ Clean and free of stains ▪ No Gaps
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Wall coverings and protections are: ▪ Intact ▪ Undamaged ▪ Clean and free of stains
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Laminates, countertops, and other solid surfaces are: ▪ Intact ▪ Undamaged ▪ Clean and free of stains
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Lighting is suitable for the care, treatment, and services provided? ▪ Bulbs illuminated ▪ Lens/globe secure ▪ Fixtures clean
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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
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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
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Stored supplies are elevated off the floor with solid surface bottom shelving?
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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
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Ground fault receptacles provided in wet locations?
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Tamper resistant receptacles provided in waiting areas?
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Medical gas alarms/zone valves: ▪ Unobstructed/readily accessible ▪ Accurately labeled ▪ Audible and visual alarms function properly
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Bulk medical gas storage: ▪ Correct signage ▪ Cylinders are secured ▪ Room is clean/no trash
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Fire alarm pull stations: ▪ Maintained accessible with 36" clearance in all directions
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Fire sprinkler heads: ▪ Properly oriented and spaced ▪ Undamaged ▪ Escutcheons and cover plates securely in place ▪ Free of corrosion, dust and debris
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A minimum of 18" clearance is maintained between fire sprinkler heads and adjacent storage?
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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
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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
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Stair exit enclosures: ▪ Free of storage ▪ Free of penetrations other than those that serve the enclosure
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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)
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Fire rated /Hazard Room doors: ▪ Legibly labeled ▪ Self-closing ▪ Positive latching ▪ Not wedged or manually held open
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General Maintenance Items: Item not listed above