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