• Document No.

  • Department

  • Conducted on

  • Prepared by

  • Personnel

Fire Safety

  • 1. Are exit doors and stairwells clear? <br>Main, corridor, and stairwell exits cannot be blocked.

  • 2. Are exit doors clearly marked "exit" and illuminated?<br>Check for burnt out bulbs.<br>EC.02.05.03

  • 3. Do fire doors latch properly?<br>Close the fire doors to see if they latch properly and see that there is no gap<1/8 inch in the middle.<br>EC.02.03.05<br>LS.02.01.10<br>NFPA 101<br>

  • 4. Are corridors and passageways free of obstructions? <br>The corridors can have mobile items (wheels on them) that are emergency needed items and are in use. (8 ft corridor and 6 in projections followed with nothing remaining in the hall <30 min)<br>EC.02.05.07<br>LS.02.01.20<br>LS.03.01.20<br>

  • 5. Are pull stations or fire extinguishers unlocked and obstructed?<br>There must be nothing to obstruct access.<br>EC.02.03.01<br>EC.02.03.05<br>NFPA 101<br>

  • 6. Are doors propped / held open? <br>Doorstops or homemade held open devices are not allowed.<br>EC.02.03.05<br>NPFA 105<br>NPFA 80<br>

  • 7. Are materials stored a minimum of 18 inches from sprinkler deflectors?<br>The distance between sprinkler deflector and stored items is 18 inches for sprinkled buildings. Check storage rooms, med rooms, patient rooms, etc.<br>LS.02.01.10<br>LS.03.01.35<br>

  • 8. Are stored rooms and equipment rooms free from clutter and unsafe conditions?<br>Make sure that items are not falling down or overstocked. Can you confirm there is no storage on the floor, including closet floors?<br>EC.02.06.01

  • 9. Do fire extinguishers have monthly and yearly checks?<br>

  • 10. Are linen, trash, and recycle bins < 32 gallons?<br>LS.02.01.70

  • 11. Sprinkler heads clean and free from debris?

Fire Safety Staff Knowledge Questions

  • 12. Does staff know the meaning of R.A.C.E.?

  • 13. Does staff know the location of exit route?

  • 14. Does staff know the meaning of P.A.S.S.?

Utilities Physical Inspection

  • 15. All lighting is operational?

  • 16. Can you confirm there is no storage under the sink?<br>UT 3. EC.01.01.01

  • 17. Is there at least 36” of clearance from electrical panels, fire and pull stations? Are electrical panels locked?<br>LS.02.01.20<br>NFPA 101<br>

  • 18. Are all mechanical, electrical, janitorial, communications rooms clean with no storage?

  • 19. Is Med Gas, O2 shut off location labeled and clear of obstruction?<br>EC.02.05.07<br>EC.02.05.09<br>

Utilities Staff Knowledge Questions

  • 20. Does staff know how to identify an emergency outlet? (Red outlets are fail-safe)

Safety & Security Management Physical Inspection

  • 21. Are floors and hallways in good condition?

  • 22. Walls are free from damage (chips, scuffs, or gouges)?

  • 23. Are ceiling tiles clean, stain free, and in good condition?<br>Indicate where these bad tiles are located in the comments.<br>EC.02.06.01

  • 24. Are heavy items stored at low levels or mid levels in storage?<br>Make sure heavy items are stored at waist level or lower shelves.

  • 25. Is there an Emergency Operations Plan available? Check area for red emergency procedures guidebook.

  • 26. Are staffs personal items properly secured?<br>RI.01.01.01

  • 27. Are all employees wearing their I.D badges properly?

  • 27. Does area have access control or intercom system and are the functioning properly?

  • 28. Are medications kept in locked rooms?

  • 29. Are compressed gases stored properly?

  • 30. Does security access exist for med rooms, nuclear hot lab, procedural areas, (including NICU)?

  • 31. No space heaters present

Safety & Security Staff Knowledge Questions

  • 32. Does staff know what a tornado watch and a warning are? (Code gray and code black)

  • 33. Does staff know how to contact Security? 5550 non-emergent, 2222 for emergency

Hazardous Materials & Waste

  • 34. Is medical waste kept in red biohazard bags or containers? Bags no filled more that 3/4 full?<br>CMS 482.42

  • 35. Are appropriate procedures, instructions, or directions available for obtaining MSDS? MCL intranet page, HAZSOFT link.

  • 36. All chemicals contain a manufactures label? Ensure all containers have a label.<br>EC.02.02.01<br>EC.04.01.01

Medical Equipment Physical Inspection

  • 36. Does equipment have cords in good condition (no cracks or exposed wires)?

  • 37. Are all medical equipment inspection tags current?<br>EC.02.04.01<br>EC.02.04.03<br>

Infection Control Physical Inspection

  • 38. Hand-washing soap dispensers are in place and filled?

  • 39. Alcohol hand sanitizers are in place and not expired?

  • 40. PPE (gloves, gowns, face masks, protective eyewear, and respirators are readily accessible?

  • 41. Is microwave clean?

  • 42. Is refrigerator clean?

  • 43. No dirty equipment in clean storage. No clean (bagged) equipment in Soiled Utility.<br>EC.01.01.01<br>

  • 44. Clean linen is covered?

  • 45. Sharps containers are <2/3 full?

  • 46. Food items in refrigerators/cabinets/freezers are not opened or uncovered or outdated? Patient food is labeled.

  • 47. Supplies stocked have not reached their expiration date?<br>MM.03.01.01<br>MM.05.01.19

  • 48. Open multi-use vials/containers dated and have not reached their expiration dates? Glucometer test strips dated: Open date and exp date 6 mo after opened. Controls dated: Open date and 3 mo after opened.

  • 49. Precaution signs are posted clearly on patient doors?

  • 50. Hand hygiene is performed according to policy?

  • 51. Behavior - eating, drinking, applying cosmetics in work areas where there is reasonable likelihood of exposure to blood/body fluid?<br>NPSG 07.03.01

  • 52. Ice machines are clean and free of rust, dirt and stains?

  • 53. High dust areas, computer carts are dust free, top of monitors are dust free, Arjo equipment is clean, data-scopes are clean, pill crushers are clean, carpet is free of tears, and etc. these are examples the list can include other items depending on the unit.

Notes or work orders needed:

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