QHS - Environment of Care Rounds 2017a

• Document No.

• Audit Title

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Previous Inspections

• Items from previous inspections have been addressed ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Safety

• Work/Storage Areas <br>

  Yes

  No

  N/A

• Safety - Criteria

  Select Above head hazards. Area not accessble/safe. Cleaning needed. Excessive clutter. Shelving not secured/improper. Other - see comments.

  • Above head hazards.
  • Area not accessble/safe.
  • Cleaning needed.
  • Excessive clutter.
  • Shelving not secured/improper.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Security

• Appropriate identification used?

  Yes

  No

  N/A

• Criteria

  Select Staff. Vendors. Volunteers. Other - see comments.

  • Staff.
  • Vendors.
  • Volunteers.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Patient valuables secured ?

  Yes

  No

  N/A

• Criteria

  Select Staff. Vendors. Volunteers. Other - see comments.

  • Staff.
  • Vendors.
  • Volunteers.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Hazardous Materials/Waste

• Hazardous Chemicals/Waste

  Yes

  No

  N/A

• Criteria

  Select Area not secured. Improper disposal. Label needed. Other - see comments.

  • Area not secured.
  • Improper disposal.
  • Label needed.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Lead Aprons

  Yes

  No

  N/A

• Criteria

  Select Not in good condition. Not uniquely identified. Other - see comments

  • Not in good condition.
  • Not uniquely identified.
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Infectious Waste

  Yes

  No

  N/A

• Criteria

  Select Area not secured. Container not rigid. Container not labeled. Container needs to be covered. Improper disposal. Other - see comments.

  • Area not secured.
  • Container not rigid.
  • Container not labeled.
  • Container needs to be covered.
  • Improper disposal.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Emergency Preparedness

• Emergency numbers posted (6666 on the phones) ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Fire Safety

• Fire Doors

  Yes

  No

  N/A

• Criteria

  Select Not latching Propped open Other - see comments

  • Not latching
  • Propped open
  • Other - see comments

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Fire Exits

  Yes

  No

  N/A

• Criteria

  Select Not clear. Not correctly marked (exit signs). Other - see comments

  • Not clear.
  • Not correctly marked (exit signs).
  • Other - see comments

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Sprinklers

  Yes

  No

  N/A

• Criteria

  Select < 18" clearance. Needs to be cleaned. Other - see comments.

  • < 18" clearance.
  • Needs to be cleaned.
  • Other - see comments.

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Fire Alarm/Pull Station

  Yes

  No

  N/A

• Criteria

  Select < 3 ft. clearance. Needs to be repaired. Other - see comments.

  • < 3 ft. clearance.
  • Needs to be repaired.
  • Other - see comments.

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Oxygen/Gas Cylinders

  Yes

  No

  N/A

• Criteria

  Select > 12 "E" cylinders per smoke compartment. Not secured on the top and bottom 3rd to prevent falling. Other - see comments

  • > 12 "E" cylinders per smoke compartment.
  • Not secured on the top and bottom 3rd to prevent falling.
  • Other - see comments

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Electrical cords / strip outlets

  Yes

  No

  N/A

• Criteria

  Select Daisy chained. Extension cords used. Not in good repair. Overloaded. Other - see comments.

  • Daisy chained.
  • Extension cords used.
  • Not in good repair.
  • Overloaded.
  • Other - see comments.

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Fire Extinguishers

  Yes

  No

  N/A

• Criteria

  Select < 3 ft. clearance. Not clearly marked. Not on wall or in cabinet. Pressure gauge not in range. Other - see comments.

  • < 3 ft. clearance.
  • Not clearly marked.
  • Not on wall or in cabinet.
  • Pressure gauge not in range.
  • Other - see comments.

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Appliances<br>

  Yes

  No

  N/A

• Criteria

  Select Hot-plates, fryers, hot air or easybake ovens, toasters, or toaster ovens not allowed. Hot shots are clearly marked as 'hot, boiling water'. Major appliances (high wattage) plugged directly into a wall outlet, Clear from combustibles. Microwave/toaster not clean and free from loose debris inside and/or vents not clear. Open element space heaters. Other - see comments.

  • Hot-plates, fryers, hot air or easybake ovens, toasters, or toaster ovens not allowed.
  • Hot shots are clearly marked as 'hot, boiling water'.
  • Major appliances (high wattage) plugged directly into a wall outlet, Clear from combustibles.
  • Microwave/toaster not clean and free from loose debris inside and/or vents not clear.
  • Open element space heaters.
  • Other - see comments.

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Penetrations

  Yes

  No

  N/A

• Criteria

  Select Ceiling tiles not properly set in place. Wall penetrations. Other - see comments.

  • Ceiling tiles not properly set in place.
  • Wall penetrations.
  • Other - see comments.

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Field Assessment - Life Safety Interim Measures

  Select Finding does not significantly compromise area, no interim life safety measures needed. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Finding does not significantly compromise area, no interim life safety measures needed.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Medical Equipment

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Physical Environment

• Structural elements

  Yes

  No

  N/A

• Criteria

  Select Ceiling(s). Floor(s). Wall(s). Not clean. Not dry. Not in good condition. Other - see comments.

  • Ceiling(s).
  • Floor(s).
  • Wall(s).
  • Not clean.
  • Not dry.
  • Not in good condition.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Dietary / Nutrition

• Patient Refrigerators: Food labeled and not expired.

  Yes

  No

  N/A

• Criteria

  Select Food expired. Needs to be cleaned. Temperature logs not current. Patient food needs to be labeled/dated. Employee and patient food not separated.

  • Food expired.
  • Needs to be cleaned.
  • Temperature logs not current.
  • Patient food needs to be labeled/dated.
  • Employee and patient food not separated.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Infection Prevention

• Patient area free of corrugated cardboard ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Staff eating or drinking in designated areas only ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Hand gel/soap dispensers

  Yes

  No

  N/A

• Criteria

  Select Not functioning. Product expired. Other - see comments

  • Not functioning.
  • Product expired.
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Soiled Utility Room Secured?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Criteria

  Select Log not up to date. No follow up when temperatures were out of range Other - see comments

  • Log not up to date.
  • No follow up when temperatures were out of range
  • Other - see comments

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• High Level Disinfection Performed?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Utilities

• Fixtures in good condition

  Yes

  No

  N/A

• Criteria

  Select Electrical. Plumbing. Cosmetic. Not functioning. Other - see comments.

  • Electrical.
  • Plumbing.
  • Cosmetic.
  • Not functioning.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Facility/Utility Rooms

  Yes

  No

  N/A

• Criteria

  Select Communication room. Electrical room. Mechanical room. Needs to be cleaned. Needs to be cleared. Other - see comments.

  • Communication room.
  • Electrical room.
  • Mechanical room.
  • Needs to be cleaned.
  • Needs to be cleared.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Med Gas Panel

  Yes

  No

  N/A

• Criteria

  Select < 3 ft. clearance. Shut off zone not identified. Other - see comments.

  • < 3 ft. clearance.
  • Shut off zone not identified.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Electrical Panels

  Yes

  No

  N/A

• Criteria

  Select < 3 ft. clearance. Not closed/covered, secured Other - see comments.

  • < 3 ft. clearance.
  • Not closed/covered, secured
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Appropriate pressure relationships.

  Yes

  No

  N/A

• Criteria

  Select Negative Isolation. OR/Sterile area. Soiled utility/restroom. Negative. Positive. Other - see comments.

  • Negative Isolation.
  • OR/Sterile area.
  • Soiled utility/restroom.
  • Negative.
  • Positive.
  • Other - see comments.

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Other

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

Staff Knowledge

• Reporting Accidents/Incidents ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Back up/alternate communication systems ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Code Pink ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Code Gray ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Hazardous Chemicals in the Area ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Accessing SDSs ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Code Violet ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Oxygen Shut Off ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

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

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Clinical Interventions for Equipment Failures ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• Utility Failure Procedures ?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.

• How and when to use the proper PPE?

  Yes

  No

  N/A

• Notification

  Select Addressed at the time of Inspection. Manager notified via the report. EVS notified via the report. Facilities notified via the report. Life safety assessment completed - interim life safety measures required. Other - see comments.

  • Addressed at the time of Inspection.
  • Manager notified via the report.
  • EVS notified via the report.
  • Facilities notified via the report.
  • Life safety assessment completed - interim life safety measures required.
  • Other - see comments.