Information

  • Document No.

  • Audit Title

  • Site

  • Conducted on

  • Prepared by

  • Location

Previous Inspections

  • Items from previous inspections have been addressed ?

  • Notification

Safety

  • Work/Storage Areas <br>

  • Safety - Criteria

  • Notification

  • Other

  • Notification

Security

  • Appropriate identification used?

  • Criteria

  • Notification

  • Patient valuables secured ?

  • Criteria

  • Notification

  • Other

  • Notification

Hazardous Materials/Waste

  • Hazardous Chemicals/Waste

  • Criteria

  • Notification

  • BioHazardous Waste (i.e. Sharps, Patho, Solids)

  • Criteria

  • Notification

  • Lead Aprons

  • Criteria

  • Notification

  • Other

  • Notification

Emergency Preparedness

  • Emergency numbers posted (6666 on the phones) ?

  • Notification

  • Other

  • Notification

Fire Safety

  • Fire Doors

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Fire Exits

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Sprinklers

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Fire Alarm/Pull Station

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Oxygen/Gas Cylinders

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Electrical cords / strip outlets

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Fire Extinguishers

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Appliances<br>

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Penetrations

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Other

  • Field Assessment - Life Safety Interim Measures

  • Notification

Medical Equipment

  • Other

  • Notification

Physical Environment

  • Structural elements

  • Criteria

  • Notification

  • All items in storage are at least 4" off the floor

  • Notification

  • Other

  • Notification

Dietary / Nutrition

  • Patient Refrigerators: Food labeled and not expired.

  • Criteria

  • Notification

  • Other

  • Notification

Infection Prevention

  • Patient area free of corrugated cardboard ?

  • Notification

  • Staff eating or drinking in designated areas only ?

  • Notification

  • Hand gel/soap dispensers

  • Criteria

  • Notification

  • Linen covered (inside or outside of the clean utility room)?

  • Notification

  • Soiled Utility Room Secured?

  • Notification

  • Medication refrigerators temperature log (checked once for medication & twice for vaccines)

  • Criteria

  • Notification

  • High Level Disinfection Performed?

  • Notification

  • How do you know if equipment is ready for patient use?

  • Notification

  • Under the sink storage? (Only cleaning supplies are allowed)

  • Notification

  • Other

  • Notification

Utilities

  • Fixtures in good condition

  • Criteria

  • Notification

  • Facility/Utility Rooms

  • Criteria

  • Notification

  • Med Gas Panel

  • Criteria

  • Notification

  • Electrical Panels

  • Criteria

  • Notification

  • Return / Supply air ducts (clean/condition) ?

  • Notification

  • Appropriate pressure relationships.

  • Criteria

  • Notification

  • Other

  • Notification

Staff Knowledge

  • Reporting Accidents/Incidents ?

  • Notification

  • Back up/alternate communication systems ?

  • Notification

  • Code Pink ?

  • Notification

  • Code Gray ?

  • Notification

  • Hazardous Chemicals in the Area ?

  • Notification

  • Accessing SDSs ?

  • Notification

  • Code Red - RACE, PASS, Extinguisher/Fire Alarm Pull Station locations, Primary/Secondary Exits, Evacuation - horizontal/vertical ?

  • Notification

  • Oxygen Shut Off ?

  • Notification

  • Code Triage (Staff's role in a disaster - stand by and respond when/where needed) ?

  • Notification

  • Clinical Interventions for Equipment Failures ?

  • Notification

  • Utility Failure Procedures ?

  • Notification

  • How and when to use the proper PPE?

  • Notification

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