• Conducted on

  • Department

  • Inspected By:

  • Semi-Annual

  • Annual

  • 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

  • ES 1. Is overall cleaning satisfactory?

  • ES 2. Are patient care areas clean, sanitary, and free of offensive odors?

  • ES 3. Are non-patient care areas clean, sanitary, and free of offensive odors?

  • ES 4. Are air/exhaust vents free of dust build-up?

  • ES 5. Are patient care areas free of high level dust in the department/unit?

  • ES 6. Are needle disposal boxes not more than 3/4 full.

Facilities Management

  • 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 call light cords accessible from the floor. (Within 6 inches)

  • FM 6. Are positive/negative pressure rooms functioning as designed. (Check pressure relationship)

  • FM 7. Are ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided?


  • SS 1. Are medication cabinets, carts, and supply closets secured when unattended? (Sharps secured)

  • 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 8. Are computers logged off and/or locked when unattended?

  • SS 9. Are electrical panels are not blocked (36 inches of clearance) and secured?

  • SS 10. PHI is secured properly? Shred boxes containing patient information secured?

  • SS 11. Are electrical equipment being used properly? (Extension cords, power strips, three prong adapters)

  • SS 12. Are security doors secured and locked?

  • SS 13. Is property properly secured?

  • SS 14. Are contractors in the area displaying proper identification?

Medical Equipment

  • ME 1. Is medical equipment labeled and have a current inspection sticker?

  • ME 2. Do users know if equipment is safe to use? Do users know who fixes it and how to place a work order?

  • ME 3. Are blanket and fluid warmer temperatures recorded daily and within appropriate range? Are warmers overfilled?

  • ME 4. Are air temperature and humidity logs filled in correctly and current? (When required)

  • ME 5. Are Diagnostic Imaging lead aprons inspected and log completed?

  • ME 6. Are crash carts checked daily; defibilator is plugged in and charging; drawers are properly sealed with tag numbers on log; full O2 cylinder?

Life Safety

  • 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 corridors used by inpatients free and clear up to 5 feet? (Medical Emergency Equipment not in use can be in hallway. Patient lift/transport/beds in use can be in hallway for no more than 30 minutes.)

  • LS 4. Are corridors not used by inpatients free and clear up to 48 inches?

  • LS 7. Are alcohol based hand sanitizers installed properly? (Not above or within 1" beside/below an ignition source)

  • LS 8. For construction or renovation, are temporary construction barriers and sticky pads present and in use?

  • LS 9. Are fire doors free from coverings or decorations (exception of informational signs; laminated)?

  • LS 10. Are corridor walls free from items projecting more than 6" (ADA 4")?

  • LS 11. Are fire doors and exits unobstructed?

  • LS 12. Are exit signs visible and illuminated as necessary?

  • LS 13. Are fire and smoke barrier doors self closing and positively latching? (No more than 1/8th inch gap when closed)

  • LS 14. Are doors into exit stairs rated for at least 1 hour?

  • LS 15. Is sprinkler piping supports secure? Is piping supporting any other items?

  • LS 16. 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 17. Are wall, ceiling and floor penetrations sealed off?

Emergency Management

  • EM 1. Do staff know location of "Red" Emergency Management/EOC book and its function?<br>

  • 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)

Hazardous Materials

  • 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? (Flammable lockers when over 1 gallon, cleaning closets secured)

  • HM 3. Are chemicals and solutions clearly marked for identification?

  • HM 4. Is there a biohazard label on doors and refrigerators where bio-hazards are stored?

  • HM 5. Are appropriate waste disposal processes are being followed? (General, Pharmaceutical, Regulated Medical)

  • HM 6. Is only biohazard waste in biohazard "Red" trash bins; lids closed?

  • HM 7. Are sharps containers closed and secured (lockable box)? No re-capped needles or garbage in box?

  • HM 8. Are eye wash stations available, unobstructed, and serviceable when required? (Inspections complete)

  • HM 9. Does staff know proper procedures for hazardous material spill or exposure? (ACCDR)

Fire Prevention

  • FP 1. Are fire 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 extnguishers have current monthly and annual inspections? Are the fire extinguishers serviceable and instructions facing outward?

  • FP 4. Are medical gas cylinders handled and secured properly? (No bottles stored on floor, no more than 12 full O2 bottles in an area)

  • FP 5. Are medical gas shut-off panels not blocked and labeled with applicable rooms?

  • FP 6. Are doors not propped open with anything?

  • FP 7. Does staff know location of medical gas shut-off panels and who is the authority for shut-off?

Infection Prevention

  • IP 1. Are ice machines clean and in proper working order?

  • IP 2. Are staff, patient, and Bio-hazard refrigerators labeled and clean without 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 and are staff aware of the 5 Moments of Hand Hygiene?

  • IP 6. Are there no food or uncovered beverage items in patient care areas, including nursing stations?

  • IP 7. Supplies are stored in cabinets or on shelves and/or pallets, not on floors.

  • IP 8. Shelving without a solid bottom have plastic sheets under items stored. If shelving is holding bags of IV fluids they should be stored in something that will contain the liquid if there is a leak.

  • IP 9. External cardboard boxes are not used for storage in clinical areas.

  • IP 10. Are items not stored under sinks?

Other Deficiencies/Recommendations

  • Other Deficiencies Noted:

  • Recommendations:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.