ES 1. Is overall cleaning satisfactory?
ES 2. Are non-patient care areas clean, sanitary, and free of offensive odors?
ES 3. Are air/exhaust vents free of dust build-up?
ES 4. Is there any identified High Level Dusting (HDL) needed in the department/unit?
FM 1. Is overall maintenance of the area satisfactory? (Fixtures, furnishings, grab bars, outlets, flooring, lighting)
FM 2. Are ceiling tiles stained, damaged, dirty or missing?
FM 3. Are the walls in good repair?
FM 4. Is emergency lighting available and functional?
FM 5. Are ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided?
SS 1. Are floors/equipment not creating a slip hazard?
SS 2. Are there no expired supplies in the department?
SS 3. Are heavy items stored within the optimal lifting zone? (Between shoulders and knees)
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)
SS 5. Does the department not contain any unauthorized electrical devices? (Toaster Ovens, personal heaters, humidifiers)
SS 6. Is staff identifcation properly displayed?
SS 7. Are electrical panels are not blocked (36 inches of clearance) and secured?
SS 8. PHI is secured properly? Shred boxes containing patient information secured?
SS 9. Are electrical equipment being used properly? (Extension cords, power strips, three prong adapters)
SS 10. Are security doors secured and locked?
SS 11. Is property properly secured?
SS 12. Are contractors in the area displaying proper identification?
LS 1. Is the spray pattern of sprinkler heads unobstructed? Are sprinkler heads undamaged, free of obstruction (dust included), estcheon plate in place?
LS 2. Are all door latches and jambs unobstructed?
LS 3. Are kitchen hoods serviceable?
LS 4. Are corridors not used by inpatients free and clear up to 48 inches?
LS 5. Are alcohol based hand sanitizers installed properly? (Not above or within 1" beside/below an ignition source)
LS 6. For construction or renovation, are temporary construction barriers and sticky pads present and in use?
LS 7. Are fire doors free from coverings or decorations (exception of informational signs; laminated)?
LS 8. Are corridor walls free from items projecting more than 6" (ADA 4")?
LS 9. Are fire doors and exits unobstructed?
LS 10. Are exit signs visible and illuminated as necessary?
LS 11. Are fire and smoke barrier doors self closing and positively latching? (No more than 1/8th inch gap when closed)
LS 12. Is sprinkler piping supports secure? Is piping supporting any other items?
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.)
LS 14. Are wall, ceiling and floor penetrations sealed off?
EM 1. Do staff know location of "Red" Emergency Management/EOC book and its function?
EM 2. Do staff know emergency codes and how to respond?
EM 3. Do staff know the acronyms RACE and PASS?
EM 4. Do staff know where to find departmental requirements during a Code Pink - "Missing Person"?
EM 5. Do staff know how to contact Security for workplace violence issues? (Emergent - Duress, 66/ Non-Emergent - 0)
EM 6. Do staff know the 3 actions to take in case of an active shooter? (Run, Hide, Fight)
EM 7. Does staff know evacuation response procedures? ("CLEAR" magnets, difference between horizontal and vertical evacuation)
HM 1. Does the staff know how to locate SDS sheets and procedures in case the internet is unavailable?
HM 2. Are chemicals stored properly? (Flamamble lockers when over 1 gallon, cleaning closets secured)
HM 3. Are chemicals and solutions clearly marked for identification?
HM 4. Are appropriate waste disposal processes are being followed? (General, Pharmaceutical)
HM 5. Does staff know proper procedures for hazardous material spill or exposure? (ACCDR)
FP 1. Are fire pull stations, ANSUL pull stations, and fire extinguishers unobstructed? Are pull stations in functional order?
FP 2. Are fire extinguishers within 75 feet of any location? 50 feet in maintenance shops? 30 feet for Class K in kitchens?
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?
FP 4. Are doors not propped open with anything?
IP 1. Are ice machines clean and in proper working order?
IP 2. Are refrigerators clean and without extensive frost build-up?
IP 3. Patient refrigerator temperatures are monitored daily, within range, and documented.
IP 4. Is clean/dirty linen stored properly? (Covered)
IP 5. Are appropriate hand hygiene products available?
IP 6. Supplies are stored in cabinets or on shelves and/or pallets, not on floors.
IP 7. Shelving without a solid bottom have plastic sheets under items stored.
IP 8. External cardboard boxes are not used for long term storage. (Inspected upon receiving shipments)
IP 9. Are items not stored under sinks?
Other Deficiencies Noted: