Northside Hospital Environment of Care Inspection - Outpatient Facilities Rev. # 2

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1. Previous Inspection

• 1.1 Has the last EoC Inspection been reviewed?

  Yes

  No

  N/A

• 1.2 Are there any outstanding concerns?

  Yes

  No

  N/A

A. Life Safety Management

• A1. Doors: Latch properly, free of doorstops, closures on storage room doors are functional?

  Yes

  No

  N/A

• A2. Are exit doors and stairwells unobstructed and clearly marked/illuminated EXIT?

  Yes

  No

  N/A

• A3. Are pull stations, fire extinguishers, electrical panels and medical gas shut-offs unobstructed?

  Yes

  No

  N/A

• A4. Are fire extinguisher monthly checks completed?

  Yes

  No

  N/A

• A5. Is material stored 18" below sprinkler heads?

  Yes

  No

  N/A

• A6. Is the area free of signs of smoking?

  Yes

  No

  N/A

B. Safety Management

• B1. Are corridors and passageways unobstructed with undamaged floors, walls, ceilings and handrails?

  Yes

  No

  N/A

• B2. Are general areas clean and clear of clutter, with furnishings, floors, walls and ceilings in good conditions?

  Yes

  No

  N/A

• B3. Are storage and equipment rooms clean and free of clutter?

  Yes

  No

  N/A

• B4. Are needle boxes less than 2/3 full?

  Yes

  No

  N/A

• B5. Are eyewash stations inspected weekly?

  Yes

  No

  N/A

C. Security Management

• C1. Are employees wearing ID badges?

  Yes

  No

  N/A

• C2. Are medication carts locked and crash carts checklist completed, up to date?

  Yes

  No

  N/A

• C3. Are mechanical, electrical, janitorial, communication rooms and electrical panels locked?

  Yes

  No

  N/A

• C4. Are staff's personal belongings properly safeguarded to prevent theft?

  Yes

  No

  N/A

D. Infection Prevention

• D1. Is clean linen covered and kept separate from soiled linens?

  Yes

  No

  N/A

• D2. Are patient's refrigerators clean, free of unopened & unlabeled containers and temp checks completed?

  Yes

  No

  N/A

• D4. Is medical waste kept in red biohazard bags or containers?

  Yes

  No

  N/A

• D3. Is medication and food kept in separate refrigerators?

  Yes

  No

  N/A

• D5. Are underneath sink areas clear of any storage?

  Yes

  No

  N/A

• D6. Is PPE readily available?

  Yes

  No

  N/A

• D7. Are employees eating and drinking in designated areas?

  Yes

  No

  N/A

E. Utility Management

• E1. Are electrical outlets in good condition with wires safely maintained?

  Yes

  No

  N/A

• E2. Are compressed gases stored properly, (empty separated from full) no more than 12 full E cylinders stored in one smoke area?

  Yes

  No

  N/A

F. Medical Equipment Management

• F1. Is medical equipment clean, properly inspected and tagged?

  Yes

  No

  N/A

G. Hazardous Material Management

• G1. Are Chemicals stored away from patient contact and clean items?

  Yes

  No

  N/A

• G2. Are primary and/or secondary chemical containers properly labeled?

  Yes

  No

  N/A

H. Emergency Management

• H1. Do written Emergency plans exist for this site and were they reviewed (to include: Emergency Operations All Hazards Plan, Code Red Plan, Code Amber Plan, Code White Plan, Code Grey Plan, Code Orange Plan, Code Brown Plan and Emergency Transport Plan)?

  Yes

  No

  N/A

• H2. Has Fire Drill been completed and documented for this location?

  Yes

  No

  N/A

• H3. Has an Emergency Drill been completed and documented for this location?

  Yes

  No

  N/A

• H4. Has HVA been completed and documented for this location?

  Yes

  No

  N/A

• H5. Has HVA been reviewed for this calendar year?

  Yes

  No

  N/A

• Department/Unit Representative

  Sign

• Inspector

  Sign