Information
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Conducted on
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Department
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Inspected By:
- Ron Trucott
- Pat Esgar
- Kelly MacLaurin
- Kendra Jessen-Smith
- Andrew Miller
- Guest
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Semi-Annual
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Annual
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Follow-Up Inspection
NOTE: Department managers overall responsibility for correction of deficiencies and follow-up to ensure completion. A follow-up inspection for corrective action items will be conducted in 30-45 days after the report is shared for all inspections that fall below the 90% passing threshold.
Environmental Services
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ES 1. Is overall cleaning satisfactory?
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ES 2. Are non-patient care areas clean, sanitary, and free of offensive odors?
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ES 3. Are air/exhaust vents free of dust build-up?
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ES 4. Is there any identified High Level Dusting (HDL) needed in the department/unit?
Facilities Management
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FM 1. Is overall maintenance of the area satisfactory? (Fixtures, furnishings, grab bars, outlets, flooring, lighting)
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FM 2. Are ceiling tiles stained, damaged, dirty or missing?
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FM 3. Are the walls in good repair?
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FM 4. Is emergency lighting available and functional?
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FM 5. Are ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided?
Safety/Security
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SS 1. Are floors/equipment not creating a slip hazard?
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SS 2. Are there no expired supplies in the department?
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SS 3. Are heavy items stored within the optimal lifting zone? (Between shoulders and knees)
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SS 4. Are entry control procedures for sensitive areas being followed and are security systems functioning properly? (Lenel Access System, Duress Buttons, Safe Place System, Alarms)
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SS 5. Does the department not contain any unauthorized electrical devices? (Toaster Ovens, personal heaters, humidifiers)
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SS 6. Is staff identifcation properly displayed?
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SS 7. Are electrical panels are not blocked (36 inches of clearance) and secured?
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SS 8. PHI is secured properly? Shred boxes containing patient information secured?
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SS 9. Are electrical equipment being used properly? (Extension cords, power strips, three prong adapters)
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SS 10. Are security doors secured and locked?
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SS 11. Is property properly secured?
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SS 12. Are contractors in the area displaying proper identification?
Life Safety
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LS 1. Is the spray pattern of sprinkler heads unobstructed? Are sprinkler heads undamaged, free of obstruction (dust included), estcheon plate in place?
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LS 2. Are all door latches and jambs unobstructed?
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LS 3. Are kitchen hoods serviceable?
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LS 4. Are corridors not used by inpatients free and clear up to 48 inches?
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LS 5. Are alcohol based hand sanitizers installed properly? (Not above or within 1" beside/below an ignition source)
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LS 6. For construction or renovation, are temporary construction barriers and sticky pads present and in use?
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LS 7. Are fire doors free from coverings or decorations (exception of informational signs; laminated)?
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LS 8. Are corridor walls free from items projecting more than 6" (ADA 4")?
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LS 9. Are fire doors and exits unobstructed?
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LS 10. Are exit signs visible and illuminated as necessary?
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LS 11. Are fire and smoke barrier doors self closing and positively latching? (No more than 1/8th inch gap when closed)
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LS 12. Is sprinkler piping supports secure? Is piping supporting any other items?
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LS 13. Is nothing stored within 18" of sprinkler heads? (Perimeter wall and stack shelving may extend up to ceiling when not directly below sprinkler or within 4" to the side.)
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LS 14. Are wall, ceiling and floor penetrations sealed off?
Emergency Management
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EM 1. Do staff know location of "Red" Emergency Management/EOC book and its function?<br>
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EM 2. Do staff know emergency codes and how to respond?
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EM 3. Do staff know the acronyms RACE and PASS?
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EM 4. Do staff know where to find departmental requirements during a Code Pink - "Missing Person"?
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EM 5. Do staff know how to contact Security for workplace violence issues? (Emergent - Duress, 66/ Non-Emergent - 0)
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EM 6. Do staff know the 3 actions to take in case of an active shooter? (Run, Hide, Fight)
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EM 7. Does staff know evacuation response procedures? ("CLEAR" magnets, difference between horizontal and vertical evacuation)
Hazardous Materials
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HM 1. Does the staff know how to locate SDS sheets and procedures in case the internet is unavailable?
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HM 2. Are chemicals stored properly? (Flamamble lockers when over 1 gallon, cleaning closets secured)
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HM 3. Are chemicals and solutions clearly marked for identification?
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HM 4. Are appropriate waste disposal processes are being followed? (General, Pharmaceutical)
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HM 5. Does staff know proper procedures for hazardous material spill or exposure? (ACCDR)
Fire Prevention
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FP 1. Are fire pull stations, ANSUL pull stations, and fire extinguishers unobstructed? Are pull stations in functional order?
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FP 2. Are fire extinguishers within 75 feet of any location? 50 feet in maintenance shops? 30 feet for Class K in kitchens?
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FP 3. Do fire extinguishers and ANSUL systems (annual only) have current monthly and annual inspections? Are the fire extinguishers serviceable and instructions facing outward?
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FP 4. Are doors not propped open with anything?
Infection Prevention
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IP 1. Are ice machines clean and in proper working order?
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IP 2. Are refrigerators clean and without extensive frost build-up?
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IP 3. Patient refrigerator temperatures are monitored daily, within range, and documented.
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IP 4. Is clean/dirty linen stored properly? (Covered)
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IP 5. Are appropriate hand hygiene products available?
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IP 6. Supplies are stored in cabinets or on shelves and/or pallets, not on floors.
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IP 7. Shelving without a solid bottom have plastic sheets under items stored.
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IP 8. External cardboard boxes are not used for long term storage. (Inspected upon receiving shipments)
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IP 9. Are items not stored under sinks?
Other Deficiencies/Recommendations
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Other Deficiencies Noted:
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Recommendations:
