Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Previous department P.E Management survey
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Have all previous non-conformities been corrected?
DNV 2014 Findings
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Bio-hazard rooms are labeled and secured, including all soiled utility rooms and Scope decontamination rooms?
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Eye protection is available in Soiled Utility rooms and decontamination rooms.
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Appropriate use of clean and dirty storage (clean supply not in soiled areas), including all soiled utility rooms?
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Flammables liquids - quantities greater than 1 gallon are stored properly in fire proof cabinet?
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Eyewash station inspected weekly most current form is used (Form NC03100 - rev 01/21/14).
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Junction boxes are covered?
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Nothing is under the sink?
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Storage in stairwell?
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All department doors latch?
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Paper Storage greater than 32 gallons are in proper rated room?
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Electrical panels not blocked, schedule (legends) in place?
Emergency Management
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Does staff know the Code Phrase for "FIRE"
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Does the staff know where to find information on emergency codes and emergency plans?
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Unit specific response plans are known by staff and available?
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Emergency number stickers on all staff phones?
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Staff conversant in RACE and PASS?
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Staff displays knowledge of available evacuation equipment and how to obtain?
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Environmental
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High areas are free from dust?
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Hopper rooms and chemicals are secured, cleaners are labeled, secured carts?
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Floor areas are clean?
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Portable fans if in use are cleaned?
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Overall cleanliness of department is good?
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Equipment and Supplies
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Point of care – QC reagents expiration dates are compliant?
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Integrity of product packaging is intact?
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All Supply expiration dates are compliant?
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Supply carts are dust free?
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Hazardous Materials
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Bio-hazard rooms are labeled and secured, including all soiled utility rooms and Scope decontamination rooms?
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Hazardous "Waste" labels are in place where appropriate ?
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Flammables stored properly, in fire proof cabinet?
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Cleaners, chemicals are properly labeled and secured
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Full and empty 02 tanks are separated and secured, limit 12 full cylinders in storage areas?
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RMW is covered, not mixed and stored appropriately
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Sharps containers are secured and not overfilled?
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Eye protection is available to E.S staff?
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Eyewash stations are inspected weekly?
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HIPAA
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Absence of HIPAA violations, no open charts?
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Availability of designated bins to dispose of patient health information?
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Gray and Blue bins secured?
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Patient health information is in correct containers and not in dept wastepaper baskets?
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Infection Control
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Beverages or food at nurses station or on medication carts?
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Linen carts are covered and nothing on top?
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No cardboard boxes on floor?
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Kitchen is clean, food is dated and not open?
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Refrigerator temperature logs are current daily / values are in range? Temp issues are resolved?
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Refrigerator log form is current (revised 2/24/2014) ?
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Are temperatures complete and appropriate to Celsius and Fahrenheit ?
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Blanket warmer Temperatures have been checked / within range
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Torn or ripped mattress, cart pads, wheelchairs, task chairs?
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Hand washing protocols followed and observed?
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Product packaging integrity maintained?
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Patient care equipment is clean and cleaned between patients, not dusty, free from tape?
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artificial nails not seen?
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Nothing under the sinks?
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Life Safety
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Oxygen, Med gas shutoff valves FE's, pull stations not blocked?
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Corridor storage of equipment - plugged into outlets - moves in 20 minutes?
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Fire extinguishers are charged and inspected within 30 days intervals?
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No storage in the stairways?
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Storage is below 18 inches of sprinkler heads?
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All department Doors latch properly and doors are not propped or blocked?
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Integrity of smoke and fire doors are intact with no paper or decorations?
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Paper storage greater than 32 gallons are in rated rooms.
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< 20% of wall covered (papers notes etc.)?
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Auto shut off coffee pots, no toasters, no toaster ovens, other?
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Lift equipment is stored properly / wheels are in the locked position?
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Exit signs properly in place and fully illuminated?
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Overall, Hallways are free from clutter?
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Pharmacy issues
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Medications are secured?
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Pyxis machine, medication rooms, med carts, medication Refrigerator are secured?
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Open medications are dated?
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Code cart(s) log updated daily, secured and checksheet in use and in view?
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Refrigerator temperature logs are current daily / values are in range? Temp issues are resolved?
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Refrigerator log form is current (revised 2/24/2014) ?
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Are temperatures complete and appropriate to Celsius and Fahrenheit ?
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K solutions stored appropriately ?
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Plant Operations
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Electrical areas and panels are secured and accessible (not blocked by equipment), legends in place?
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Walls free from needing patching or paint?
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Ceiling tiles look good (not stained or broken)?
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Lighting is adequate and covers are clean?
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No broken or missing hardware?
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Plumbing is intact with no leaks?
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Ceiling HVAC vents clean?
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Plant Mechanical Rooms
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Flammable liquid storage?
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Compressed gas storage?
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Junction boxes are covered?
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Chemicals labeled?
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Machine guards in place?
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Leaks?
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Exit signs
Security and Safety
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Staff wearing ID badges?
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Have the security doors been comprised (combinations written in view, door propped, staff sharing combination)
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Valuables are secured?
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Supply/core areas
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Soiled linen bags are not on floor?
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Appropriate use of clean and dirty storage (clean supply not in soiled areas), including all soiled utility rooms?
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Food trays are covered?
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Broken or retired equipment is properly tagged as do not use, staff aware of procedures to remove any broken equipment?
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Final Comments, Issues, Photos
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