Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Safety programs

  • OSHA postings/ state law postings/ WC procedures posting

  • Hazard tracking log

  • Evacuation routes posted

  • Monthly facility inspection performed by clinic

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Emergency Action Plan

  • Annual Review of the emergency Action Plan - 29 CFR 1910.38(e)

  • Emergency Action Plan (EAP) containing emergency reporting, evacuation, and accounting for all employees following an evacuation. 29 CFR 1910.37<br>At UKP it is titled Area Emergency Action Plan (AEMP)

  • Exit routes are maintained free and unobstructed.

  • Each exit visible and marked by a sign reading "exit". 1910.37(b)(2)

  • Persons aware what is expected in emergency situations to provide for their safety during fire or other emergencies. 29 CFR 1910.38 and 1910.39 (Appendix to Subpart E)

  • Signs posted indicating the direction of travel to the nearest exit and exit discharge. Line-of-sight to an exit sign must clearly be visible at all times. 29 CFR 1910.37(b)(4)

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Fire Prevention

  • Portable fire extinguishers must be visually inspected monthly. An annual, documented, maintenance check is required and documented (1 year). 29 CFR 1910.157(e) GSM 03 Section 27 Fire Extinguishers - 7.1

  • Fire extinguishers must be located, mounted, and identified so that they are readily accessible. 29 CFR 1910.157(c)(1)

  • Personal, portable space heaters present a significant fire risk. They must be anti-tip auto shut off equipped, cords not frayed, good working condition, and not plugged into and not plugged into an extension cord or power strip. When occupying Hospital or University buildings abide by their corporate policy.

  • Storage areas kept free from accumulation of materials that constitute a fire hazard.

  • Persons must be informed of the fire hazards to which they are exposed. 29 CFR 1910.39(d)

  • Compressed gas cylinders restrained to prevent rolling or tipping. Stored cylinders (not in use) require a protective valve cover. 29 CFR 1910.253(2)

  • Chemicals separated by hazard class to prevent mixing of incompatible materials in the event of a fire or accidental release. 29 CFR 1910.253(4)(iii)

  • Cylinders not kept away from sources of heat. Cylinders must be stored away from areas such as elevators, stairs, or exits. 29 CFR 1910.253 (b)

  • A minimum of 18" vertical clearance between the sprinklers and the materials stored below must be maintained. 29 CFR 1910.159(c)(10)

  • Cabinets shall be labeled in conspicuous lettering, "Flammable - Keep Fire Away." 29 CFR 1910.106(d)(3)(ii)

  • Ceiling tiles are not damaged

  • Sprinklers not painted over

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Housekeeping/Aisles and Passageways

  • Storage of materials may not create a hazard. Materials must be stacked, blocked, interlocked, and limited in height so that they are stable and secure against sliding or collapse. 29 CFR 1910.176(b)

  • Walking and working surfaces must be maintained in a clean and safe condition to prevent slip and trip hazards. 29 CFR 1910.22

  • All places of employment, passageways, storerooms, and service rooms must be kept clean, orderly, and in a sanitary condition. 29 CFR 1910.176(c)

  • Mold - Employers must protect employees from serious and recognized hazards. Section 5(a)(1) of the Occupational Safety and Health Act (OSH Act)

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Hazard Communication

  • SDSs must be available for all chemicals and they must be readily available at all times. 29 CFR 1910.1200(g)(10)

  • Chemical containers must be labeled with the name of the material contained within and the appropriate hazard warnings. This includes secondary containers such as cups and bottles. 29 CFR 1910.1200(f)(5)(i) & (ii)

  • Employees must be informed of the hazardous chemicals in their work areas, the physical and health hazards, and the steps necessary to protect themselves. 29 CFR 1910.1200(h)(2)(ii) and 1910.1200(3)(ii)

  • Safety instruction signs are to be used when there is the need for general instructions and suggestions relative to safety measures. 29 CFR 1910.145

  • Eyewashes should be checked weekly to ensure they are clean and sanitary, an adequate supply of solution is available, and to monitor the expiration date of the solution. ANSI 358.1 (2004)

  • Plumbed eyewashes shall have a monthly and annual inspection. These inspections should be documented. ANSI 358.1 (2004)

  • Cabinets shall be labeled in conspicuous lettering, "Flammable - Keep Fire Away." 29 CFR 1910.106(d)(3)(ii)

  • Location has provided updated training to employees regarding upcoming switch to SDS sheets and pictograms under the Global Harmonization Standard.

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Electrical Safety

  • Electrical panels must have 36" of clearance to provide access to the electrical equipment. 29 CFR 1910.303(g)(1)(ii) GSM 03 Section 06 General Electrical Safety-5.6

  • Temporary wiring must be removed immediately upon completion of the project for which the temporary wiring was used. 29 CFR 1910.305(a)(2)(ii) GSM 03 Section 06 General Electrical Safety-5.5. Extension cords are considered temporary wiring.

  • Flexible cords and cables shall be protected from accidental damage, as might be caused, for example, by sharp corners, projections, and doorways or other pinch points. 29 CFR 1910.305(a)(2)(ii)

  • If there is damage to electrical cords that may exposed a person to electrical injury, the exposed/damaged wiring must be removed from service. 29 CFR 1910.334 GSM 03 Section 06 General Electrical Safety-5.5

  • All lighting fixtures less than 7 feet from the floor or working surfaces must be covered or guarded. 29 CFR 1910.303

  • Coffee makers, toasters, microwave ovens and/or refrigerators must be plugged directly into a wall outlet, not extension cord or power strip as per Company Policy

  • Safety signs and symbols must be used to warn persons about electrical hazards to which they may be exposed. 29 CFR 1910.335(b)(1), NFPA 70E, GSM 03 Section 06-6 Safe Electrical Work Practices -14.0

  • Electric equipment shall be free from recognized hazards that are likely to cause death or serious physical harm to employees. 29 CFR 1910.303(b)(1)

  • In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. 29 CFR 1910.303(g)(2)(ii)

  • All pull boxes, junction boxes, and fittings shall be provided with covers identified for the purpose. 29 CFR 1910.305(b)(2)(i)

  • Employees shall be trained in and familiar with the electrical safety-related work practices. 29 CFR 1910.332(b)(1) GSM 03 Section 06-6 Safe Electrical Work Practices -7.0

  • Daisy Chaining - Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling. 29 CFR 1910.303(b)(2) GSM 03 Section 06 General Electrical Safety-5.6

  • Flexible cords and cables may not be used as a substitute for the fixed wiring of a structure. 29 CFR 1910.305(g)(1)(iv)(A) GSM 03 Section 06 General Electrical Safety-5.5

  • Unused openings in cabinets, boxes, and fittings shall be effectively closed. 29 CFR 1910.305(b)(1)(ii)

  • Outlet and switch plate covers are in place and not broken

  • Outlets near water are grounded fault circuit interrupter (GFCI) equipped and are at least 4 feet away from water

  • Medical equipment is not plugged into a power strip because power strips are not UL approved for medical equipment

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Lockout - Tagout

  • Equipment specific lockout/tagout procedures must be developed which identify the specific procedural steps that need to be followed when performing lockout/tagout. 29 CFR 1910.147(c)(4)(ii) GSM 03 Section 18 Lockout Tagout - 7.1

  • Persons authorized to perform lockout/tagout must be trained. 29 CFR 1910.147(7)(i)(A) GSM 03 Section 18 Lockout Tagout - 14.1

  • An inspection of the lockout/tagout procedures must be performed annually to ensure that the procedure is up-to-date and is being followed. 29 CFR 1910.147(c)(6)(i) GSM 03 Section 18 Lockout Tagout - 13.1

  • Persons who work in areas where lockout procedures are used must be informed of the lockout procedures. 29 CFR 1910.147(c)(7)(i)(B) GSM 03 Section 18 Lockout Tagout - 14.4

  • Lockout and tagout devices must be standardized and must not be used for any other purpose. Each employee performing lockout/tagout must apply their own lock. 29 CFR 1910.147(c)(5)(ii) GSM 03 Section 18 Lockout Tagout - 8.0

  • The employer shall maintain a written copy of the procedures and shall make it available for inspection by employees. 29 CFR 1910.333(b)(2)(i)

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Walking Working Surfaces and Fall Protection

  • Open-sided floors or platforms 4 feet or more above the floor or ground level must be guarded by a standard railing. 29 CFR 1910.23(c)(1) GSM 03 Section 7 Fall Protection and Walking Working Surfaces - 5.3.1

  • Persons working at heights more than 4 feet must use fall protection. Holes, openings and unprotected edges must be protected by covers or guardrail systems. 29 CFR 1926.501(b)(4)(i)

  • All places of employment, passageways, storerooms, and service rooms shall be kept clean and orderly and in a sanitary condition. 29 CFR 1910.22(a)(1)

  • The floor of every workroom shall be maintained in a clean and, so far as possible, a dry condition. 29 CFR 1910.22(a)(2)

  • Where wet processes are used, drainage shall be maintained, and false floors, platforms, mats, or other dry standing places should be provided where practicable. 29 CFR 1910.22(a)(2)

  • Covers and/or guardrails shall be provided to protect personnel from open pits, tanks, vats, ditches, etc. 29 CFR 1910.22(c) GSM 03 Section 7 Fall Protection and Walking Working Surfaces - 5.1.3

  • Storage of materials may not create a hazard. Materials must be stacked, blocked, interlocked, and limited in height so that they are stable and secure against sliding or collapse. 29 CFR 1910.176(b)

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Ladders

  • Ladders must be maintained in good condition at all times29 CFR 1910.25 and 1910.26 GSM 03 Corporate Policies _Section 7 Fall Protection and Walking Working Surfaces - 6.1

  • Ladders must be inspected frequently. 29 CFR 1910.25 and 1910.26 GSM 03 Corporate Policies _Section 7 Fall Protection and Walking Working Surfaces - 6.1.3

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Confined Space Entry

  • The employer shall evaluate the workplace to determine if any spaces are permit-required confined spaces. 29 CFR 1910.146(c)(1) GSM 03 Section 5 Confined Space Entry - 5.1

  • The employer must post danger signs of the existence and location of and the danger posed by permit spaces. 29 CFR 1910.146(c)(1) GSM 03 Section 5 Confined Space Entry - 5.2

  • Confined spaces must be identified as which are permit required? The list must be updated annually or as conditions change. GSM 03 Section 5 Confined Space Entry - 5.1.1-5.1.5

  • Ensure that all outside contractors go through Corporate office to ensure they have and are following appropriate confined space procedures.

  • Employees who work in areas where confined spaces are present must be trained to the "awareness" level. This training must be documented. 29 CFR 1910.146(g) GSM 03 Section 5 Confined Space Entry - 4.1.

  • An appropriate level of training is required for persons who perform confined space entry. 29 CFR 1910.146(g) GSM 03 Section 5 Confined Space Entry - 4.1.

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Personal Protective Equipment

  • Personal protective equipment that is damaged or defective must not be used or worn. 29 CFR 1910.132(e)and(f)

  • Persons must be trained on the limitations of the equipment and well as how to use and maintain it. 29 CFR 1910.132(e)and(f)

  • Training is required for each person who is required to use PPE. 29 CFR 1910.132(f)

  • The employer shall assess the workplace to determine if hazards are present which necessitate the use of personal protective equipment (PPE). 29 CFR 1910.132(d) GSM 03 Section 23-4 PPE Hazard Assessment Form

  • The employer shall enforce the use of PPE if required. 29 CFR 1910.132(d) GSM 03 Section 23-4 PPE Hazard Assessment Form

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Dust and Asbestos Exposure Control

  • Building and facility owners shall inform service providers and employees who will perform housekeeping of areas which contain ACM and/or PACM 29 CFR 1910.1001(j)(2)(iii) GSM 03 Section 3 Asbestos Exposure Control - 4.8

  • Signage is required at the entrance to mechanical rooms/areas in which employees reasonably can be expected to enter and which contain ACM and/or PACM 29 CFR 1910.1001(j)(3)(v) GSM 03 Section 3 Asbestos Exposure Control - 4.9

  • All surfaces shall be maintained as free as practicable of ACM waste and debris and accompanying dust. 29 CFR 1910.1001(k)(1) and 29 CFR 1910.1001(k)(8)

  • Waste, debris and dust in an areas containing accessible ACM and/or PACM or visibly deteriorated ACM, shall not be dusted or swept dry, or vacuumed without using a HEPA filter. 29 CFR 1910.1001(k)(1) and 29 CFR 1910.1001(k)(8)

  • Annual asbestos awareness training shall be provided to all employees who perform housekeeping work in areas where ACM and/or PACM is present. 29 CFR 1910.1001(j)(vii)(4) GSM 03 Section 3 Asbestos Exposure Control - 4.9

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Flammable and Combustible Material Control

  • The flammable cabinet door shall be provided with a three-point lock, and the door sill shall be raised at least 2 inches above the bottom of the cabinet. 29 CFR 1910.106(d)(3)(ii)

  • Where the eyes or body of any person may be exposed to injurious corrosive materials, facilities for quick drenching or flushing of the eyes and body shall be provided. 29 CFR 1910.151(c)

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Respiratory Protection

  • A designated program administrator who is qualified by appropriate training or shall manage the respiratory protection program. 29 CFR 1910.134(c)(3) GSM 03 Section 23-4 Respiratory Protection - 4.6

  • The employer shall select a NIOSH-certified respirator. The respirator shall be used in compliance with the conditions of its certification. 29 CFR 1910.134(d)(1)(ii) GSM 03 Section 23-4 Respiratory Protection - 3.2 Example N95 mask for protection against TB

  • All respirators shall be stored to protect them from damage, contamination, dust, sunlight, extreme temperatures, excessive moisture, and chemicals. 29 CFR 1910.134(h)(2(i)) GSM 03 Section 23-4 Respiratory Protection - 3.5

  • Annual and documented training must be provided to all respirator users. 29 CFR 1910.134(k)(1)(iv) 29 CFR 1910.134(k)(5) GSM 03 Section 23-4 Respiratory Protection - 3.6.2

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Eyewashes and Showers

  • Plumbed or self-contained eyewashes must be provided in all work areas where an employee's eyes may come into contact with materials that are corrosive, irritating or damaging to the eye. ANSI 358.1 (2004)

  • Eyewash and shower temperature range is 60 degrees Fahrenheit to 100 degrees Fahrenheit. ANSI Z358.1 (2009) This data should be found in the clinic's weekly testing log

  • Emergency eyewash and/or shower fixtures must take no more than 10 seconds (50 feet) to reach and the path to the fixture must not be hindered with obstructions. ANSI Z358.1 (2009)

  • The location must be identified with a "highly visible sign". ANSI Z358.1 (2009)

  • Each month, emergency products must be inspected and activated to ensure they still meet the ANSI Standard compliance requirements and are operational. ANSI 358.1 (2004)

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Patient Handling

  • Location is free of injuries from Patient Lifting/movement/transfer

  • Location has purchased equipment to assist with patient transfers.

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  • Location has developed and communicated plan to employees to avoid patient handling injuries/risks.

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Radiation Safety

  • Appropriate radiation safety garments are professionally checked for integrity and staff clean and store properly

  • Appropriate preventative maintenance (PM) schedule developed for all radioactive equipment.

  • Storage and recovery procedures developed for any loose radioactive materials.

  • Badges collected and monitored or collective dose.

  • Appropriate signs and labels posted indicating radioactive areas.

  • Laser Safety

  • Reflective surfaces are not present in the room during laser procedures

  • Flammable (alcohol, oxygen, anesthetic gasses, etc.) are not present during laser procedures

  • Laser signs are posted and/or illuminated when laser is in use

  • Protective laser eye goggles available for laser class 3b & 4

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Reciprocal

  • The signatures below indicate that a safety review of the area was conducted and presented to a responsible manager

  • Corporate safety rep #1

  • Corporate safety rep #2

  • Location Manager #1

  • Location Manager #2

Bloodborne Pathogens

  • Invasive Procedures

  • Collecting/handling patient body fluids, laboratory controls, etc.

  • Changing Dressings

  • Handling contaminated instruments

  • Administering injections, starting IV's, removing sutures

  • Examination of body orfices

  • Catheterization/cauterization/lacerations

  • X-Ray of open wounds or oral cavity

  • Cleaning of contaminated surfaces

  • Food or beverages in or near contaminated area

  • Presence/use of sharps without safety devices

  • Open sharps containers on moveable carts

  • Unsealed sharps containers transported

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