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 Inspection
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Has the last inspection been reviewed?
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Have all outstanding actions/issues been completed from the previous audit?
Emergency Preparedness
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EM 1: Is staff able to locate the disaster, SDS and policy manuals?<br>*All manuals contain current information.
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EM 2: Is the Emergency Manual available?
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EM 3: Can the staff locate the medical zone shutoff valves?
General Safety
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GS 1: GENERAL AREA:<br>1. Temperature Comfortable?<br>2. Areas free from odors?<br>3. Noise levels is acceptable/adequately controlled?<br>4. Ventilation is adequate?<br>5. Stair treads and handrails present, safe & secured?
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GS 2: No items stored under sinks that can absorb moisture?
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GS 3: No broken/damaged/unused equipment or furniture stored on the patient care units?<br> Coverings are intact - no rips or repairs needed?
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GS 4: Are all electrical appliances (coffee makers, microwaves, radios, etc.) properly wired (3 prong/UL) & appear to be in good working condition?
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GS 5: Potential Safety Hazards: <br> 1. Housekeeping & Maintenance carts & buckets are attended and lock?<br> 2. ALL FLUIDS ARE LABELED?
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GS 6: LADDERS<br> 1. Are all ladders industrial strength (Non Household rated, check label)? <br> 2. Are ladders in good condition?<br> 3. Are ladders non conductive (Fiber glass)?<br>
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GS 7: Are entry & walkways kept clear?
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GS 8: Are parking lots properly maintained to provide a safe driving & walking area?
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GS 9: Is handicapped parking available?
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GS 10: Are docks, ramps & stairways in good repair and properly lighted?
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GS 11: Are floor surfaces even & uncluttered, free of cracks, holes & tipping hazards?
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GS 12: Is the floor clean & well maintained?
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GS 13: Are non-slip surfaces provided?
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GS 14: Is the use of extension cords prohibited?
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GS 15: Laundry chute accesses are latched?
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GS 16: Hazardous rooms are locked: EVS closets, supply closets, mechanical/electrical rooms & electrical panels?
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GS 17: Are utility rooms in good order?
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GS 18: Is waste managed appropriately?
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GS 19: Are oily rags and combustible refuse in covered metal containers (Shops)?
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GS 20: Are needles, syringes, sharps & glass disposed of properly?
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GS 21: Is there a 44 inch clearance in corridors (Business Occupancies)?
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GS 22: Is 36" clearance maintained around electrical panels?
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GS 23: Are sterile supplies & soiled equipment stored seperately?<br>
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GS 24: Refrigerators: Contain only those items designed for the refrigerator (specimen, medications or patient/employee food)?
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GS 25: Are blanket warmers set to maintain temperature of 130 degrees?
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GS 26: Electrical Safety<br> 1. Use of hospital grade power strips, plugs & receptacles in good condition?<br> 2. Wires neat and controlled with no trip hazards?
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GS 27: Outer shipping carton boxes are empty & removed as soon as possible?
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GS 28: Is equipment properly stored when not in use?
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GS 29: Caution X-Ray signs are posted?
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GS 30: Are all MRI Safety Zones posted?
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GS 31: Are pregnancy warning signs posted?
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GS 32: There are no other abnormalities or infractions?
HAZ
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HAZ 1: Does staff know RIN (Recognize, Identify, Notify) with a spill?
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HAZ 2: If required is PPE available?
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HAZ 3: Is adequate ventilation provided?
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HAZ 4: Is chemical signage appropriately displayed?
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HAZ 5: Are hazardous chemicals and flammable agents labeled and stored properly?
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HAZ 6: Are gas cylinders stored appropiately?
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HAZ 7: Is the HMI (Hazardous Material Inventory) current (Sample one product)? Online?
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HAZ 8: Can the staff locate the HMI?
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HAZ 9: No hazardous chemicals /materials stored over shoulder high or where it can be knocked over?
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HAZ 10: Are cleaning products & chemicals stored properly & away from food and clinical supplies?
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HAZ 11: Are emergency eye washes & safety showers tested routinely and the inspection tags are present and up to date?
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HAZ 12: Are eye washes & showers easily accessed?
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HAZ 13: Are all containers properly marked, labeled & safe? Housekeeping carts?
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HAZ 14: Are Hazardous Materials Disposed of properly?
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HAZ 15: Are all portable tanks securely mounted?
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HAZ 16: Is there inadequate spill containment (Eng., EVS., Shops, Etc.)?
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HAZ 17: Are all flammable liquids kept in approved containers?
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HAZ 18: Is there excessive quantities stored on site?
Life Safety
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LS 1: Is the fire alarm system functioning (look for in-terminate lights) correctly?
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LS 2: Nothing stored on top of flammable cabinets? Not more than 3 flammable storage cabinets may be present in a single storage area?
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LS 3: Appropriate storage of boxes and patient care items:<br> 1. Not directly on floor<br> 2. 18" clearance from ceiling<br> 3. Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping<br> 4. Volume of combustible material is not stored in large quantity as top create a fire hazard
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LS 4: Oxygen or other combustible compressed gas cylinders are stored properly:<br> 1. Secured in floor stand, carrier or secured to the wall by a mount (not laying on the floor or against the wall).<br> 2. Labeled and separated, full from empty.
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LS 5: Fire exits and hallways are cleared:<br> 1. Egress corridors must have 8' clearance.<br> 2. Equipment in corridors must be in use within 30 minutes to remain in corridor.
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LS 6: Are fire hydrants and standpipes accessible?
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LS 7: Fire alarm pull stations, fire extinguishers, medical gas shutoff valves and electrical panels are not blocked?
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LS 8: Fire extinguishers have been inspected monthy?
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LS 9: Are fire extinguishers proper size and type (Surgery,. MRI., Food Service, IT., etc.)?
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LS 10: Maximum of 2-32 gallon trash cans in a 10x10 room (unless fire rated)?
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LS 11: Are "EXIT" doors unlocked or equipped with "panic bars"?
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LS 12: Are fire doors kept closed or magnetically held open?
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LS 13: Fire doors are not blocked, wedged or propped and when closed is positive latching?
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LS 14: Are fire doors free of damage and do they close properly?
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LS 15: Is 20% rule being violated? No combustibles on fire rated doors and walls?
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LS 16: Exit signs are illuminated and readily visible/undamaged?
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LS 17: Are all sprinkler heads clean, in good shape and escutcheons tight/in place?
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LS 18: Ceiling tiles are in place, no cracks, holes, misaligned or visible stains?
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LS 19: Is space being utilized appropriately?
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LS 20: Is staff lounge guidelines being followed?
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LS 21: Are stairways free of storage?
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LS 22: Floors, ceilings, walls and other surfaces intact and free from holes, damage and soiling?
Medical Equipment
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ME 1: Are bio-medical equipment stickers on patient equipment current?
Security
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SEC 1: Everyone has ID badges and visible?
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SEC 2: Are valuables secured (purses, expensive equipment, etc.)?
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SEC 3: Does the area appear to be safe and secure?
Utilities Management
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UM 1: Are switch plates & outlets covered?
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UM 2: Are all electrical cords, plugs and switches in good order?
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UM 3: Are Medical Gas Valve accessible, labeled & clean?
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UM 4: Is electrical equipment equipped with ground wire?
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UM 5: No power leads or cords across walkways?
Exteriors
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EX 1: No damage, uneven surfaces, surface quility?
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EX 2: Surface differences more the 1/2" accross?
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EX 3: Are cracks greater than 1/2" accross?
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EX 4: Are manholes and vault covers secure?
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EX 5: Is the vehicles barriers undamaged and properly placed?
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EX 6: Are the walkways clear, unobstructed by bushes etc.?
Information Management
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IM 1: Confidential Patient Information: Cannot be overhead or seen by unauthorized persons:<br> 1. Computer terminals signed off when not in use.<br> 2. Patient information is not discussed in public areas.<br> 3. No patient information visible to unauthorized persons.
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IM 2: No clipboards displayed as sign-in sheets when multiple patient names on the list?
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IM 3: If fax machine is in public area, patient information is quickly removed.
Infection Prevention
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IP 1: Food and drink in designated areas: no employee food of drinks in the public/patient areas, should be limited to private offices or break rooms.
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IP 2: Hand hygiene products:<br> 1. No empty alcohol gel bottles<br> 2. No empty soap or paper towels<br> 3. Hospital approved products being use
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IP 3: PPE:<br> 1. Readily available<br> 2. Clearly marked<br> 3. Worn correctly
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IP 4: Biohazard waste:<br> 1. Discard in Red Bags with a biohazard symbol<br> 2. Not overfilled<br> 3. Covered containers<br> 4. Contains only biohazards waste, no trash<br> 5. Stored in a secure area
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IP 5: Soiled Linen: Properly stored in closed container and not overfilled.
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IP 6: Linen and Linen Carts:<br> 1. Covered and carts have solid bottoms.<br> 2. Pillows are cleaned and bagged for storage or considered dirty, to be cleaned prior to use.<br> 3. If dirty not stored with clean linens.
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IP 7: Sharps Waste:<br> 1. Placed in punctured resistant sharps container with lid.<br> 2. Disposed of when 3/4 full or "full" indicator.<br> 3. Mounted appropriately.<br> 4. Stored in secure location.
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IP 8: General Cleanliness:<br> 1. Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, lobby, exam rooms, bathrooms, equipment, decorative items, curtains, blinds or drapes.<br> 2. No blood or bodily fluids.<br> 3. Staff using hospital approved cleaning products according to manufacturer's recommendations.
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IP 9: Air vents: Clean
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IP 10: Coverings are clean and intact on exam tables, phlebotomy chairs, chairs in waiting areas and exam rooms - no rips or repairs needed. Coverings can be cleaned/disinfected with hospital approved product.
Notes and Comments
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Report conclusion including any other recommendations.
Sign Off
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Your signature or reply (email) acknowledgement when the recommended corrective actions are completed.
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Auditors Signature
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Required
