Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

1. PREVIOUS AUDITS

  • Has the last audit been reviewed?

  • Are there any outstanding concerns?

A. SAFETY/GENERAL SAFETY

  • Warning signs or barricades are placed when work creates a hazard (wet floor, maintenance work in ceiling)?

  • 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

  • Quality Control logs for Refrigerators/Freezers, freezers, and warmers are complete and corrective actions documented as appropriate?

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?

  • All syringes, basins, cups, containing medication or solutions are labeled with the name of the contents?

  • Supply area is clean?

  • Med Carts/Med Rooms are secured at all times?

  • Black boxes have been emptied and are not overflowing.

  • Samples are tracked per policy?

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

  • No items stored under the sink

D. INFECTION PREVENTION

  • Staff food is not stored in patient refrigerators?

  • Refrigerators/Freezers are clean, frost free, and labeled for type of storage with only those items present (no food and medication in the same refrigerator).

  • Refrigerators/Freezers contain thermometers and the refrigerator graphs are up-to-date? (thermometer should be located in the back)

  • No open or expired patient nourishment containers in refrigerator?

  • Ice machines are clean, no signs of deposits in tray or dispensing mechanism?

  • Anti-microbial soap and paper towels are available for hand washing?

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

  • Disposed sharps are in an approved container?

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

  • Staff (including contracting physicians) perform hand hygiene?

  • Separation of clean and dirty?

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?

  • Privacy curtains clean and unsoiled?

F. HAZARDOUS MATERIALS

  • Chemicals are properly labeled and secured

  • How can you access Material Safety Data Sheets (MSDS)?

  • PPE is available?

  • Material Safety Data Sheets stickers are intact on phones?

  • Eye wash is flushed and logged?

  • Acids and bases stored separately?

  • Fume hoods have been certified?

G. FIRE PREVENTION/ LIFE SAFETY

  • <br>Can you explain what R.A.C.E stands for?

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

  • Staff know where the fire extinguishers and pull stations located in your department?

  • Confidential shred bins are compliant with NFPA Code

  • Halls/Corridors uncluttered and accessible?

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

  • Are the sprinkler heads free of dust?

  • Fire extinguisher (s) recently serviced? (monthly)

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

  • Eighteen-inch clearance from ceiling is maintained?

  • Are compressed gases stored in designated areas only and secured?

  • Are med gas valves labeled?

  • Are full and empty cylinders stored separately according to sign/labels?

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

  • Flammable and hazardous materials properly stored and labeled?

  • Fire extinguishers and pull stations clear of obstructions?

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

  • Exits clear of obstructions?

H. EMERGENCY MANAGEMENT PROCEDURES

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

  • <br>Staff know where downtime forms are located and they know ow to tell if they are the most current version?

I. SECURITY MANAGEMENT

  • Staff know how to notify Security in a non-emergency?

  • 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?

  • Equipment is clean?

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

  • Defibrillator is plugged in and charging?

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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