Information

  • Audit Title

  • Document No.

  • Conducted on

  • Prepared by

  • Personnel

1. PREVIOUS AUDITS

  • Has the last audit been reviewed?

  • Are there any outstanding concerns?

A. SAFETY/GENERAL SAFETY

  • All furniture and equipment is in sound condition? (no chipped or torn surfaces- no leaky faucets)

  • All wall-mounted devices (lights, TV’s, pictures, signs, containers, handrails, etc.) are secure and not loose?

  • Area is without clutter?

B. ELECTRICAL SAFETY

  • No evidence of daisy chains?

  • Items are not stored within 36" of an electrical panel?

  • Electrical cords, plugs, plates and switches are in good repair?

  • Extension cords only used temporarily but not on a permanent everyday basis?

  • The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?

C. MEDICATION/MEDICAL SUPPLIES

  • Medications/medical supplies have not passed expiration dates?

  • Supply area is clean?

  • Black boxes have been emptied and are not overflowing.

  • Appropriate items in black boxes?

  • No boxes on the floor. All supplies 6 inches off the floor?

  • No items stored under the sink

E. ENVIRONMENTAL

  • Ceiling tiles clean and intact?

  • Floors free of dirt, dust and litter?

  • Ledges, walls and air vents free of dust?

  • Toilets and sinks secure and clean?

  • Separation of clean and dirty?

F. HAZARDOUS MATERIALS

  • Chemicals are properly labeled and secured

  • Staff knows how to access Safety Data Sheets (SDS)?

  • PPE is available?

  • Safety Data Sheet stickers are intact on phones?

  • Eye wash is flushed and logged?

  • Sharps containers are secured in their holders, not accessible to residents and not more than three-fourths full?

  • Containers used for regulated or infectious waste are covered, leak proof, and clearly labeled as a biohazard?

G. FIRE PREVENTION/ LIFE SAFETY

  • Can staff explain what R.A.C.E stands for?

  • Can staff explain P.A.S.S. and what does it stand for?

  • Can staff explain what C.A.L.M. stands for?

  • Smoke detectors with 36" clearance from air supply to return?

  • Are the sprinkler heads free of dust?

  • Fire extinguisher(s) green tag current?

  • Fire extinguishers and pull stations clear of obstructions?

  • Automatic fire doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.)

  • All lights are working properly and flashlights with good batteries?

  • Placement of Hand Sanitizer is not adjacent (within 6”) to a potential ignition source?

  • Exits clear of obstructions?

  • Eighteen-inch clearance from ceiling is maintained?

  • Confidential shred bins are compliant with NFPA Code?

  • Halls/Corridors uncluttered and accessible?

  • Are compressed gas containers stored in designated areas only and secured?

H. EMERGENCY MANAGEMENT PROCEDURES

  • Staff know the number to call to initiate an emergency response?

I. SECURITY MANAGEMENT

  • Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges @ eye level?

  • Are valuables properly stored in department?

J. EQUIPMENT MANAGEMENT

  • Staff know the procedures if a device/equipment does not work properly?

  • All medical equipment/devices has a current Bio-Medical sticker/Asset Tag?

  • Equipment is clean?

  • Crash cart is locked, logs complete, oxygen is full?

  • Defibrillator is plugged in and charging?

  • Equipment Asset numbers for biomed

K. UTILITY MANAGEMENT

  • Staff know what to do for an electrical failure?

  • Staff know who is authorized to shut off medical gases?

OR specific

  • Hyperthermia cart is locked with log completed?

  • Staff know location of hyperthermia cart?

  • Sterilizer is clean and parameters are maintained?

  • Sterilizer has documented PM?

  • Sterilizer testing is up to date?

Mechanical areas

  • Floor is clean?

  • Power tools have guards in place?

  • PPE readily available?

  • 36" clearance maintained around electric panels?

  • Fall protection for areas above 6 feet high?

  • LOTO equipment readily available?

  • Isolation exhaust fans are labeled?

Actions

  • Preventive action is required?

  • Preventive Action Plan:

  • Corrective action is required?

  • Cause of nonconformity

  • Organizational corrective plan:

  • Person/position responsible for implementation do corrective action

  • Date for implementation of Plan

  • Determine actions needed by observing:

  • Results of. Actions taken:

  • Review effectiveness

SIGN OFF

  • Department/Unit Representative

  • Auditor

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