• Location/Department

  • Conducted on

  • Prepared by

  • Personnel Assisting


  • Housekeeping closets are locked (EC.02.01.01 EP8)

  • Soiled utility rooms are locked (EC.02.01.01 EP8)

  • Clean utility rooms are locked (EC.02.01.01 EP8)

  • Oxygen storage rooms are locked (EC.02.01.01 EP8)

  • Medication rooms are locked (EC.02.01.01 EP8)

  • Utility closets are locked (EC.02.01.01 EP8)

  • Handrails are firmly attached to the walls (EC.02.01.01 EP3)


  • All staff members are wearing hospital identification badges (EC.02.01.01 EP7)

  • Your department has flashlights that work properly and are stored in an easily accessible location. (EC.02.02.09 EP2)

  • Clean sharps are secured and locked in cabinets, carts, or locked containers (EC.02.01.01 EP3)

  • Doors that should be locked are locked to control access into your department from patients and visitors (EC.02.01.01 EP3)

  • Childproof protective outlet covers are located in outlets in lobbies, hallways, and public gathering points

  • All medications are secured (MM.03.01.01 EP3)

  • Medical records cannot be seen from the "public's" point of view at the workstations/nurse's station

  • Signage in your department is in good condition and reflects the current operational practices for your unit (LD.03.04.01 EP3)

  • Staff's belongings and personal items are not easily accessible by patients and visitors (EC.02.01.01 EP3)


  • Hazardous chemicals in your department are stored appropriately (EC.02.02.01 EP5)

  • Medical waste containers are not full and labeled with the date installed and expired (NOT MORE THAN 90 DAYS) (EC.02.02.01 EP12)

  • Sharps containers are not full in your unit. If they are please change these appropriately (IC.02.01.01 EP1)


  • Staff's food and beverages are not present in patient care areas (LD.04.01.01 EP2)

  • Personal Protective Equipment (PPE) is adequately stocked and readily available; in good condition; and appropriate for your department (IC.01.02.01 EP3)

  • Linen carts are covered with impervious covering (IC.01.02.01 EP4)

  • Single soiled linen bags are not overfilled (EC.02.01.01 EP3)

  • Trash bags are not overfilled (EC.02.01.01 EP3)

  • No items are stored under sinks (LD.04.01.01 EP2)

  • Storage is at least 6" from the floor and no boxes are stored on the floor (IC.01.02.01 EP3)

  • Areas are clean, sanitary, and free from reoccurring offensive odors. These include lighting, vents, surfaces, walls, ceilings, and equipment (EC.02.06.01 EP20)

  • Paper towels are placed in the dispenser not placed on the countertops (NPSG.07.01.01 EP1)

  • Alcohol based hand rubs are not empty and dispensing properly (IC.01.02.01 EP3)

  • There are no rips or tears on vinyl covered patient equipment or chairs. (Stretchers, treatment table coverings, ect) (EC.02.06.01 EP26)


  • Hallways are free from all obstructions. This does NOT include crash carts, isolation carts, and equipment in use (this means accessed at least every 30 minutes or often) (LS.02.01.20 EP13)

  • Stored items are more than 18" from the bottom of the ceiling in any room (LS.02.01.35 EP6)

  • Sprinklers and smoke detectors look free from dust (LS.02.01.35 EP5)

  • Fire extinguishers and pull stations are not blocked at all times (LS.02.01.35 EP8)

  • Fire extinguishers have been inspected this month (Lock at the backside of the tag) (EC.02.03.05 EP15)

  • Emergency Exit signs are clearly visible and working properly (evenly illuminated) (LS.02.01.20 EP13)

  • Fire doors are not blocked from shutting and latching properly (LS.02.01.30 EP11)

  • Doors are not wedged open (LS.03.01.20 EP8)

  • Flammable decorations like natural Christmas trees are not present in the hospital at any time (LS.02.01.70 EP1)


  • Sinks, showers, toilets, and water lines are in good repair (not leaking and working appropriately) (EC.02.06.01 EP1)

  • Extension cords are not used in your department (EC.02.03.01 EP1)

  • Electrical outlets are not damaged or loose and have covers. This also includes switches, and network connections (EC.02.03.01 EP1)

  • Electrical panels are labeled as such and locked (locked in public areas) (EC.02.05.01 EP8)

  • Medical gas shut offs are properly labeled and clear of obstructions (EC.02.05.9 EP3)


  • Are there any slip and fall hazards in your department? (EC.02.01.01 EP3)

  • Any other concerns for your unit or area of inspection?

  • Please add and additional photos during this audit that are of a concern but do not fit into any of the above categories.


  • Please complete this survey once a month. When complete, sign the document electronically and email it to

  • Please Sign to Complete

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