Northside Hospital Environment of Care Inspection - Outpatient Facilities/Business Offices

• 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 Have previous EOC issues been resolved?

  Yes

  No

  N/A

A. Life Safety Management

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

  Yes

  No

  N/A

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

  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 extinguishers tagged appropriately and 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 any sprinkler deficiencies if required per NFPA 13, 2013 Edition, Installation of Sprinkler Systems, and NFPA 101, 2012 Edition, Life Safety Code?

  Yes

  No

  N/A

• A7. 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 condition?

  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 with proper documentation?

  Yes

  No

  N/A

• B6. Are patient care areas without relocatable power strips?

  Yes

  No

  N/A

C. Security Management

• C1. Are employees wearing ID badges?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  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, medication refrigerators, and specimen refrigerators clean, free of unopened and unlabeled containers and temp checks completed with proper documentation?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  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

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

  Yes

  No

  N/A

H. Emergency Management

• H1. Do written Emergency Plans exist for this site and were they reviewed (to exclude: Emergency Operations All Hazard 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 a 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 an HVA been completed and documented for this location.

  Yes

  No

  N/A

I. Acknowledgement: Leadership of this location is responsible to correct all items found not in compliance. Leadership will submit a written plan of action to correct all items not in compliance to the inspector within 10 business days of the above date. The Inspector will 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.

Signatures

• Department/Unit Representative

  Sign

• Inspector

  Sign