• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

1. Previous Inspection

  • 1.1 Has the last EOC inspection been reviewed?

  • 1.2 Have previous EOC issues been resolved?

A. Life Safety Management

  • A1. Doors: Latch properly, free of doorstops, closures on fire/smoke, hazardous, and storage room doors are functional?

  • A2. Are emergency lights, EXIT signs, EXIT doors, and stairwells unobstructed, clearly marked, and illuminating properly?

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

  • A4. Are fire extinguishers tagged appropriately and monthly checks completed?

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

  • A6. Is the area free of any sprinkler deficiencies if required per NFPA 13, 2013 Edition, Installation of Sprinkler Systems, fire alarm deficiencies per NFPA 72, 2013 Edition, and NFPA 101, 2012 Edition, Life Safety Code?

  • A7. Is the area free of signs of smoking?

B. Safety Management

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

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

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

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

  • B5. Are eyewash stations inspected weekly with proper documentation?

  • B6. Are relocatable power taps present and in compliance with Northside Hospital Policy?

  • B7. Are nurse call pull cords present and in compliance?

C. Security Management

  • C1. Are employees wearing ID badges?

  • C2. Are medication carts locked and crash cart checklists completed and up-to-date?

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

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

  • C5. Did MRI personnel stop you at the door to Zone III and verify that you have been screened to enter Zone III?

  • C5a. If you have not been screened did they give you a copy of the screening tool to complete?

D. Infection Prevention

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

  • D2. Are patient's refrigerators, medication refrigerators, and specimen refrigerators clean, free of unopened and unlabeled containers and temp checks completed with proper documentation?

  • D3. Is medical waste kept in red biohazard bags or containers?

  • D4. Is medication and food kept in separate refrigerators?

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

  • D6. Is PPE readily available?

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

E. Utility Management

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

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

F. Medical Equipment Management

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

  • F2. Does the department have lead aprons? If so do they have an appropriate and updated identification tag?

G. Hazardous Material Management

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

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

  • G3. Is the staff knowledgable on how to identify and locate Safety Data Sheets for Hazardous Material on the Northside Intranet?

H. Emergency Management

  • H1. Do written Emergency Plans exist for this site and were they reviewed (to include: Emergency Operations All Hazard Plan, Code Red Plan, Code Amber Plan, Code White Plan, Code Grey Plan, Code Orange Plan, Code Brown Plan, Code Pink, Code Dry, Code Purple, Code Blue, Code Silver, and Emergency Transport Plan)?

  • H2. Has a Fire Drill been completed and documented for this location in the last 12 months?

  • H3. Has an Emergency Drill been completed and documented for this location in the last 12 months?

  • H4. Has an HVA been completed and documented for this location and has been reviewed in the last 12 months?

I. Acknowledgement: Leadership of this location is responsible to correct all items found not in compliance or marked no. Depending on the deficiency the inspector may follow up to ensure corrections have been made. If a reinspection is deemed necessary it will be scheduled within 30-45 days of receiving the written action plan to ensure all corrections have been made. Failure to complete corrections and or comply with the above will be reported to the Director with oversight for this location.


  • Were staff members educated and notified of deficiencies found and notified of corrective action process?

  • Inspector

  • Department/Unit Representative

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