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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3-5-15 Revision 2
Previous Inspection
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Have all outstanding actions/issues been completed from the previous audit?
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?
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GS 6: Is the floor clean & well maintained?
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GS 7: Are non-slip surfaces adequate & in good repair?
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GS 8: Is extension cord/power tap policy being enforced?
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GS 9: Hazardous rooms are locked: EVS closets, supply closets, mechanical/electrical rooms & electrical panels?
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GS 10: Refrigerators: Contain only those items designed for the refrigerator (specimen, medications or patient/employee food)?
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GS 11: Is staff able to locate the disaster, SDS and policy manuals?<br>*All manuals contain current information.
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GS 12: Linen and Linen Carts are Covered and carts have solid bottoms.
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GS 13: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
HAZ
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HAZ 1: Caution X-Ray signs are posted?
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HAZ 2: Are the appropriate hazard signs posted (pregnancy, chemical, MRI, etc.)?
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HAZ 3: Are hazardous chemicals and flammable agents labeled and stored properly?
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HAZ 4: Are gas cylinders securely mounted and stored appropiately?
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HAZ 5: 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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HAZ 6: Is the HMI (Hazardous Material Inventory) current Online?
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HAZ 7: Can the staff locate the HMI?
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HAZ 8: Are emergency eye washes & safety showers tested and inspection tags are present?
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HAZ 9: Are eye washes & showers easily accessed?
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HAZ 10: Are Hazardous Materials and drugs in proper waste stream?
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HAZ 11: Are needles, syringes, sharps & glass disposed of properly?
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HAZ 12: 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 13: 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 14: 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 not blocked?
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LS 5: Have Fire extinguishers been inspected monthly? Annually?
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LS 6: Maximum of 2-32 gallon trash cans in a 10x10 room (unless fire rated)?
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LS 7: Are fire doors kept closed or magnetically held open?
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LS 8: Fire doors are not blocked, wedged or propped and when closed is positive latching?
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LS 9: Is 20% rule being violated? No combustibles on fire rated doors and walls?
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LS 10: Anything hung on the wall fire rated? Proof (certificate)?
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LS 11: Exit signs are illuminated and readily visible/undamaged?
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LS 12: Are all sprinkler heads clean, in good shape and escutcheons tight/in place?
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LS 13: Ceiling tiles are in place, no cracks, holes, misaligned or visible stains?
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LS 14: Are stairways free of storage?
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LS 15: Floors, ceilings, walls and other surfaces intact and free from holes, damage and soiling?
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LS 16: Laundry chute accesses are latched?
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LS 17: Is 36" clearance maintained around electrical panels?
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LS 18: 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: Is handicapped parking available?
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EX 4: 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: 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 4: THERE ARE NO OTHER ABNORMALITIES OR INFRACTIONS?
Notes and Comments
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Report conclusion including any other recommendations.
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Certificates, license, etc.
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
