Title Page
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SAF
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Audit Title (Unit/Location)
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Conducted on
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Prepared by
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Maine Medical Center’s Safety-Emergency Management (S-EM) Department visited your unit and a Safety Survey was conducted utilizing the Maine Medical Center Safety - Emergency Management Department’s Survey Tool for Healthcare Occupancy to cover the following topics: General safety, staff knowledge, life safety, electrical safety, medical equipment, hazardous materials & waste, emergency management, & security. The following is a list of the S-EM Department’s findings and recommendations. A Corrective Action Plan must be completed online by the Unit Director or Manager and within 30 days. Please visit the following link to complete the Corrective Action Plan: https://my.mainehealth.org/mmc/Departments/SafetyEmergencyManagement/Pages/Safety.aspx If you have any additional questions, concerns or need further clarification on any of the recommendations, please feel free to contact the Safety-Emergency Management Department at 207-662-2513.
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Unit Name
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Date of Survey
General Safety / Healthy Environment
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Environment is clean, odorless, well lit, and trash is not overflowing.
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No evidence of water damage is visible, ceiling tiles are not stained.
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Ceiling tiles are not broken or missing.
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There are no tripping hazards.
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PPE is appropriate and available for types of hazards present.
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Patient Rest Rooms have working emergency pull cords that are 8" off the floor
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Alcohol based hand rub in appropriate locations mounted 48" from the floor, spaced 48" apart and at least 1" from potential ignition sources.
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Under sink storage is not being utilized.
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Additional staff safety concerns have been addressed
Staff Knowledge - All Topics
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Staff able to verbalize evacuation/relocation plan including location of at least two separate exit routes, including assembly location.
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Staff can locate at least two fire extinguishers and fire alarm pull stations.
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Staff able to verbalize emergency Codes (Red, Pink, Purple, Green, Blue, Grey, Silver, White, Orange, Yellow & Triage) and able to verbalize RACE and PASS.
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Staff knows how to identify medical equipment in need of inspection or repair.
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Staff knows where and how to access SDS online.
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Staff know how to report an incident resulting in harm to a patient, visitor, co-worker, or themselves. (R.L Solutions - home page intranet - Incident Reporting)
Life Safety - Compartmentalization and Egress
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Fire Rated walls are in good repair with all penetrations fire stopped (Enclosures of stairs, shafts/chases, mechanical/electrical, soiled linen, trash and storage rooms)
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Penetrations of floor/ceiling assemblies are smoke resistive (cabling, plumbing, HVAC ducts). Fire stopping is recommended.
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Corridor walls are smoke resistive.
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Ordinary hazard mechanical or storage rooms in sprinkler protected building has smoke resistive walls with self closing positive latching door.
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Mechanical or storage rooms in non sprinkler protected building has 1 hour rated enclosure with 3/4 hour self closing positive latching fire door.
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Stairway landings are free of storage.
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Storage in corridors does not impede egress (36" min. corridor width).
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No doors are propped open and fire doors self close and positively latch.
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All EXIT signs are in working condition with at least two light sources and are properly placed.
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Egress to public way is maintained in Winter with snow and ice conditions.
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Emergency lighting is present and functional (Battery operated emergency lighting, 10 seconds)
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Elevator emergency phone is functional.
Life Safety - Detection / Suppression / Decorations / Furnishings
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Fire alarm pull stations, electrical panels, fire hose connections and Med gas controls are unobstructed.
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Emergency Strobe lights are present in all patient care areas including public access conference rooms, exam rooms, waiting areas and public restrooms.
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Extinguishers are present in cabinets, on brackets, etc. Have been inspected monthly / annually and appropriate for the hazards present.
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18" vertical clearance from sprinkler heads is maintained.
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Storage is 8" off floor and bottom shelf is solid. (no outer card board boxes on shelving).
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Combustible decorations and postings are protected behind glass, Lexan or Plexiglas. Temporary postings (30 days or less) are laminated or are made of fire retardant materials.
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If there is a Life Safety Code deficiency has an ILSM assessment been done?
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Additional staff Life Safety concerns have been addressed. (ie no evidence of smoking on grounds)
Electrical Safety
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Extension cords/power taps are used temporarily only in construction areas or for maintenance activity.
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Electrical circuit panels have 36" clearance, all circuits identified, panels locked or in locked rooms.
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Surge suppressor cords are not interconnected together.
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Space heaters are not used. (Permissible by medical clearance only)
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Only Commercial Grade heat producing appliances are in use. Examples: coffee makers, electric tea kettles, microwave ovens, toasters.
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Additional staff electrical safety concerns have been addressed.
Medical Equipment
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Medical equipment has a current inspection date.
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Equipment is clean and in proper working order.
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Additional staff medical equipment concerns have been addressed.
Hazardous Materials & Wastes
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Proper containers are present for segregation of Hazardous, Universal and Bio-hazardous wastes as needed.
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Spill kits are appropriate for the risks that are present.
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Proper eye wash stations and signage are present and logs are being completed weekly.
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Oxygen storage rooms are identified by signage. Cylinders are labeled ‘Full/Partial’ or ‘Empty’.
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Oxygen cylinders are in holder and not laying or standing on floor. (Up to 12 E cylinders or 1 H cylinder in mixed use storage)
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Housekeeping chemical containers are properly labeled.
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Sharps containers less then 3/4 full and clear access.
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Are critical storage areas locked (pyxis, med rooms, biohazard rooms & mini-bins).
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Refrigerators are property labeled for allowed use.
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Additional staff HAZMAT concerns have been addressed.
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There is proper segregation of "clean" and "potentially contaminated" areas (chemical, nuclear, biological and food and drink).
Emergency Management
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Staff can verbalize their roles and responses during Code Triage.
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Additional staff EM concerns have been addressed.
Security
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All employees are wearing and have visible ID badges.
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Visitors in sensitive areas are wearing proper ID (i.e. Guests & Contractors)
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Barriers, locks and security hardware are functioning properly. (This would be a brief check, including windows, roof hatches and open core stairs)
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Security system(s), if any, are operational per staff (Panic buttons, electric door strikes)
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Additional staff security concerns have been addressed (ie parking lot lighting and call boxes).
ADA
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Entrance is ADA accessible and 18" clear floor space to latch side.
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Handicap parking is present
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Are there ADA accessible restrooms?
Additional comments
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