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
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1-11-17 rev 3
General Safety
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GS 1: 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 2: 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 3: Is the floor clean & well maintained?
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GS 4: Is extension cord/power tap policy being enforced?
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GS 5: Hazardous rooms are locked: EVS closets, mechanical/electrical rooms & electrical panels?
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GS 6: Linen and Linen Carts are Covered and carts have solid bottoms.
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GS 7: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
HAZ
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HAZ 1: Are the appropriate hazard signs posted (pregnancy, chemical, MRI, etc.)?
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HAZ 2: Are hazardous chemicals and flammable agents labeled and stored properly?
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HAZ 3: Are gas cylinders securely mounted and stored appropiately?
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HAZ 4: Is the HMI (Hazardous Material Inventory) current Online?
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HAZ 5: Can the staff locate the HMI?
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HAZ 6: Are emergency eye washes & safety showers tested and inspection tags are present?
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HAZ 7: Are eye washes & showers easily accessed?
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HAZ 8: Are Hazardous Materials and drugs in proper waste stream?
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HAZ 9: Are needles, syringes, sharps & glass disposed of properly?
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HAZ 10: 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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HAZ 11: 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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HAZ 12: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
Life Safety/Fire Management
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LS 1: Is the fire alarm system functioning (look for in-terminate lights) correctly?
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LS 2: Appropriate storage to maintained 18" clearance from ceiling?
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LS 3: 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 4: Fire alarm pull stations, fire extinguishers, medical gas shutoff valves and electrical panels are <br> not blocked?
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LS 5: Have fire extinguishers been inspected monthly? Annually?
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LS 6: Are fire doors kept closed or magnetically held open?
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LS 7: Fire doors are not blocked, wedged or propped and when closed is positive latching?
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LS 8: Exit signs are illuminated and readily visible/undamaged?
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LS 9: Are all sprinkler heads clean, in good shape and escutcheons tight/in place?
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LS 10: Ceiling tiles are in place, no cracks, holes, misaligned or visible stains?
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LS 11: Are stairways free of storage?
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LS 12: Floors, ceilings, walls and other surfaces intact and free from holes, damage and soiling?
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LS 13: Laundry chute accesses are latched?
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LS 14: Is 36" clearance maintained around electrical panels?
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LS 15: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
Medical Equipment
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ME 1: Are bio-medical equipment stickers on patient equipment current?
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ME 2: Power taps/hospital surge protectors used in patient care areas?
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ME 3: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
Security
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SEC 1: Are valuables secured (purses, expensive equipment, etc.)?
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SEC 2: 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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SEC 3: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
Utilities Management
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UM 1: Are all electrical cords, plugs and switches in good order?
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UM 2: Can the staff locate the medical zone shutoff valves?
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UM 3: 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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UM 4: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
Exteriors/Grounds
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EX 1: Are manholes and vault covers secure?
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EX 2: Are parking lots properly maintained to provide a safe driving & walking area?
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EX 3: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
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: Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage?
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IP 3: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
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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Select date
