Title Page
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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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Attendees
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Facility Overview
Infection Control
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Employee control: signs posted for Hand washing & Hygiene guidelines; Touch-less sanitizing stations, Faucets & Paper towels; Cleaning & Sanitizing schedule is followed?
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Infection Control written policy and procedures for: Guests, Patients, Vendors or Customers? Controls may include: Entry protocols, Touch less Sanitizing stations that are secured & Self locking, Ventilation controls, PPE use, Staff safety training?
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Management oversight of the Infection Control program?
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Staff training is documented? Revised as needed?
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Laundry. Sanitizing detergents; scrubs cleaned and laundered daily?
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Stay home protocols for physically sick workers?
General Policies, Procedures & Training
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Is there a comprehensive written Health, Safety and Environmental policy & procedures plan in place?
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1.H.14. Health and safety Self-Inspections are conducted at least Semi-Annually on each shift?
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Written Emergency Procedures and Program for fires, bomb threats, natural disasters, utility failures, medical emergencies, violent or other threatening situations?
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Records Management and Storage via keypad or electronic lock in separate rooms?
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Personnel received documented competency-based training?<br>Upon hire and Annually - outline what type of training<br>in the following areas:<br>- Health and safety practices<br>- Identification of unsafe environmental factors<br>- Emergency & Evacuation procedures<br>- Identification & Reporting of critical incidents<br>- Medication management, if appropriate <br>- Reducing physical risks <br>- Workplace violence
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Isolation Practices - Written Policy & Procedures?
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Emergency Evacuation Written Program: Fire, Bomb Threats, Natural Disasters, Utility Failures, Medical Emergencies, Violent or Threatening Situations?
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Required Postings posted?
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Consumer Rights and Privacy Protection posters?
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Medical Facility - First Aid/CPR/AED? Training?
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Ventilator Competency Training?
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HazCom: Policy, SDS management?
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PPE training and refresher training as required?
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Other?
General Safety
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Facility is clean and organized?
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Is adequate and functioning lighting provided in all areas?
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Is the elevator(s) inspection certificate(s) up to date?
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Elevator in good working condition?
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Are work areas free of tripping hazards (cords, frayed carpet, free standing electrical fixtures, broken floor tiles, etc.)?
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Is furniture (i.e. desks, chairs, filing cabinets) in safe condition?
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Is overhead storage utilized properly?
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Are filing cabinets free of items stored on top?
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Are all stored items 18 inches below ceilings equipped with fire sprinkler heads?
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Other Comments:
Fire & Electrical Hazards
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Does the facility have a fire suppression system in place and what type: Automatic Fire Suppression System or Standpipe System?
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Does the facility have Fire Extinguishers?
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Are fire extinguishers adequate. 1 every 75' and located in high hazard areas?
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Are fire extinguishers mounted with overhead locator signs?
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Are fire extinguishers inspected annually by a Servicing provider?
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Are monthly fire extinguishers inspections performed and inspections tags filled out?
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Are employees trained in the PASS system for extinguisher use?
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Smoke Detectors and Fire Alarms in working condition?
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Are Fire Risers serviced annually by a servicing company?
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Are all alarms functioning properly and routinely tested?
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Are planned and/or unplanned fire evacuation drills routinely conducted?
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Are electrical outlets adequate with no overloading, no missing grounding conductors or insulation damage?
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Are power and extension cords in good condition, no missing grounding conductors or insulation damage?
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Are circuits locations identified with a legend on the inside cover of the circuit panel doors?
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Are circuits panels free of uncapped or exposed openings "voids" in the circuit panel?
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Are 3' clearances maintained around all circuit panels & fire extinguishers?
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Are electrical closets free of storage?
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Other Comments:
General Environmental Control/Sanitation & Housekeeping
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Carpeted floors are clean, no frayed edges or damage?
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Are non-carpeted floors clean and in good condition?
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Are warning signs used during mopping procedures?
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Are floor mats in good condition, no curled edges, and not overlapped or placed on carpet?
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Are restrooms clean and sanitary?
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Are staff lounge and eating areas clean and sanitary?
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Are drinking fountains clean and in good working order?
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Facility is free of evidence of rodents, insects or vermin?
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Are ceiling fan blades clean and in safe working condition>
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Are walls and woodwork clean?
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Are cleaning schedules followed for refrigerators, microwaves, stoves and other kitchen appliances?
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Are Waste receptacles emptied nightly?
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Are Biohazard wastes collected separately in BioHazard identifiable waste receptacles and stored properly for collection?
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Other Comments:
Egress
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Are alarms installed to restrict improper use of exits and are they tested to ensure proper function?
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Are Evacuation routes Accessible & Understandable to: Persons served, Personnel & Other stakeholders including visitors?
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Are all exit doors marked with illuminated exit signs or by external sources providing a minimum of 5 foot candles of light?
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Are panic hardware (push bars) used at exit doors?
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Are emergency and exit lights working properly?
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Are doors designated to open outward?
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Are Exit discharges clear of obstructions inside and outside?
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Are Emergency Evacuation Plans posted and revised as needed?
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Are hallways & stairways maintained free of obstructions?
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Are stairways well lighted?
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Are stairway handrails secured?
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Are non-exiting doorways marked as "Not an Exit"?
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Other Comments:
Maintenance
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Are door closures and locks in good working order?
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Are ceiling tiles intact, undamaged?
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Is the building free from mold growth?
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Are HVAC ducts and filters clean and serviced?
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Are outside lights adequate and in working order?
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Are gates and fences in good condition?
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Is the building exterior in good condition?
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Is the building roof in good condition, no evidence of leaks?
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Sidewalks are free of raised adjoining slabs that are 1/4" or higher or have serious cracks or other damage?
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Are parking lots free of potholes?
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Are concrete tire stops and curbs in good condition?
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Other Comments:
Playground
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Swimming / Therapeutic Pools
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Is the equipment age appropriate?<br>
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Toddler - Under 2<br>* Climbing equipment under 32" high<br>*ramps<br>*Single file step ladders<br>*Spring rockers<br>*Swings with full bucket
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Preschool - Ages 2-5<br>* Horizontal ladders less than 60" (ages 4-5)<br>*Ramps<br>*Merry-go-round<br>*Single file ladders<br>*Slides, Spiral up to 360 deg<br>*Spring rockers<br>*Stairways<br>*Swings-belt, full bucket seats(2-4 yrs) & rotating tire
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Grade School - Ages 5-12<br>*Arch climber<br>*Cable walks<br>*Fulcrum seesaws<br>*Ladder (horizontal, rung & step)<br>*Stairways<br>*Swings - belt & rotating tire<br>*Vertical slide poles
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Protective surface (impact attenuating) material in use beneath all equipment: sand, pea gravel, wood chips, untreated wood mulch, rubber mulch or unitary surfaces rubber flooring (grass and dirt are unacceptable)?
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Loose fill material depths: Shredded rubber 6”, all others 9" deep and maintained level.
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Are 6' clearances maintained around the entire equipment and 9' whenever adjacent equipment is more than 30" high
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Are all components and fasteners tight, no protruding sharp edges (bolts should not expose more than two threads)?
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Rusted or corroded metal?
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Wood splitting or insect damage?
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Are all "S" hooks and "C" hooks closed to within the thickness of a dime?
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Head Equipment: Are there any openings between 3.5" and 9"?
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Are there any suspended hazards (cables, wires, ropes or similar flexible parts suspended? between play units or from the ground to a play unit within 45 deg of horizontal?
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Are protective guardrails and barriers in place on elevated platforms (designed to prevent falls and entrapment)?
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Fall heights limited to:<br>a) Toddlers - 32"<br>b) Preschool - 60"<br>c) School age - 84"
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Are slides provided with a hood or other channeling devise to properly position the user?
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Is the playground free of trash, broken glass and debris?
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Tripping Hazards:<br>a) Are anchoring devices below grade?<br>b) Are loose fill containment walls painted a contracting color?
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Is there a sun exposure that can heat bare metal?
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Is there a protective canopy offering adequate shade?
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Is there adequate drinking water?
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Is the playground supervised?
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Overall General Comments or Concerns