Information
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Document No.
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Audit Title
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Site
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Conducted on
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Prepared by
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Location
Previous Inspections
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Items from previous inspections have been addressed ?
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Current floor plan with fire walls and doors pulled from FM drawing database ?
Safety
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Work/Storage Areas - safe and accessible (proper shelving used/secure, no above head hazards, heavier items on the bottom) ?
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Work/Storage Areas - Clean and Clear (no excessive clutter) ?
Security
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Staff, volunteers, vendors appropriately identified ?
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Valuable items secured ?
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Other
Hazardous Materials/Waste
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Hazardous Chemicals - properly labeled/stored ?
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Infectious Waste Containers (rigid, labeled, covered) ?
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Infectious Waste Storage (Soiled Utility Rooms) - Doors to storage area closed/monitored or secured ?
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Waste Disposal - Appropriate disposal of waste in proper container ?
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Lead Aprons - Uniquely identified ?
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Other
Emergency Preparedness
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Emergency numbers posted (6666 on the phones) ?
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Other
Fire Safety
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Fire Doors - Not propped open (door wedges), Unit entrance doors - positively latch ?
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Fire Exits - Clear, Correctly marked (Exit Signs), unlocked from inside, clear of debris/equipment ?
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Sprinklers - 18" clearance ?
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Fire Alarm/Pull Station - 3 ft. clearance ?
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Oxygen/Gas Cylinders - Stored upright, secured on the top and bottom 3rd to prevent falling, in a stand/ cart, no more than 12 "E" cylinders per smoke compartment ?
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Electrical Cords / strip outlets Not overloaded/daisy chained, In good repair, Extension cords not used ?
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Fire Extinguishers Clearly marked, 3 ft. clearance, On wall or in cabinet, Pressure gauges read full ?
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Appliances<br>- Major appliances (high wattage) plugged directly into a wall outlet, Clear from combustibles<br>- All appliances (especially those with a metal exterior) must have a three-prong plug (ground wire) to prevent fire and electrocution<br>- No hot-plates, fryers, hot air or easybake ovens, toasters, or toaster ovens allowed<br>- Microwaves are clean and free from loose debris inside and all vents are clear<br>- No open element space heaters<br>- Hot shots are clearly marked as 'hot, boiling water'
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Ceiling tiles set in place properly and no gaps in the ceiling to allow smoke to enter ?
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Other
Medical Equipment
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Other
Physical Environment
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Work/Storage Areas - Clean, Free from hazards/clutter ?
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Floors/Walkways/Walls/Ceilings - In good condition, Clean, Dry, No penetrations, Adequate lighting, Construction-no signs of dust/debris ?
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All items in storage are at least 4" off the floor
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Other
Dietary / Nutrition
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Refrigerators - Clean, Employee and Patient Food separated, Patient food labeled/dated, Temperature Logs current (for patient refrigerators only)?
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Other
Infection Prevention
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Staff eating or drinking in designated areas only ?
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Hand gel/soap dispensers functioning and contain current product ?
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Under sink storage clear (nothing allowed under sinks)?
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Cubicle curtains are free of visible soil ?
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Dirty linen storage - room secured?
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Linen covered in (inside or outside of the clean utility room)?
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Medication refrigerators log maintained (review follow up if temperatures were out of range)?
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High Level Disinfection - Daily and QC logs complete?
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Test Strips in a closed bottle and inside a cabinet?
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Other
Utilities
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Fixtures in good condition (no damage to outlets, outlet cover and light switches (char marks, cracks, discoloration ?)
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Mechanical / Electrical / Communication rooms – clear of combustible material storage ?
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Lights/Fixtures - covered/protected (diffusers not cracked or missing) ?
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Med Gas Panel - 3 ft. clearance, Shut off zone identified ?
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Electrical Panels - closed/covered, secured ?
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Return / Supply air ducts in the ceiling clean (not covered with dust) ?
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Appropriate areas (isolation rooms, toilets, soiled utility rooms, etc.) have negative pressure.
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Other
Staff Knowledge
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Reporting Accidents/Incidents ?
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Back up/alternate communication systems ?
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Code Pink ?
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Code Gray ?
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Hazardous Chemicals in the Area ?
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Accessing SDSs ?
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Code Violet ?
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Code Red - RACE, PASS, Extinguisher/Fire Alarm Pull Station locations, Primary/Secondary Exits, Evacuation - horizontal/vertical ?
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Oxygen Shut Off ?
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Code Triage (Staff's role in a disaster - stand by and respond when/where needed) ?
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Clinical Interventions for Equipment Failures ?
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Utility Failure Procedures ?
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How do you know if equipment is clean?
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How and when to use the proper PPE?