*EOCOP‐1* Cost Center

ENVIRONMENT OF CARE SITE SURVEY—OUTPATIENT AREAS

Surveyor’s
Date: / / and Unit: - - - - Initials:

I. Disinfection: YES NO NA COMMENTS

1. Equipment / surfaces appropriately disinfected.
2. Hospital approved germicide.
3. Instrument disinfection / sterilization logs maintained.
4. Individuals properly trained to perform disinfection / sterilization.
5. Disinfectants properly stored.
6. Disinfectants labeled and dated.
7. Sterilizer type is appropriate.
II. Sharps:
1. Sharps containers located at point of use.
2. Sharps containers disposed of properly.
3. Staff utilize Sharps safety devices.
4. Staff utilize blood transfer device.
5. Sharps are secured / locked.
III. Infectious Waste Disposal:
1. Red bag trash cans located at point of use.
2. Red bags used only for infectious waste.
3. Red bag trash awaiting p/u is properly stored.
IV. Cleanliness:
1. The unit / facility is clean and orderly.
2. The ice machine / water cooler is clean and free of standing water.
3. The halls are free of clutter.
4. Public areas are free of paper signage except on enclosed bulletin boards.
5. Furnishings are clean and in good repair.
6. Walls are clean and in good repair.
7. Flooring (carpet an other) is clean and in good repair.
8. Routine maintenance in area is adequate.
V. Isolation:
1. Negative pressure rooms available and properly used.
2. Appropriate signage present.

Location Name:____________________________________________________

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 *EOCOP‐2* ENVIRONMENT OF CARE SITE SURVEY—OUTPATIENT AREAS

VI. Storage: YES NO NA COMMENTS

1. Clean and sterile supplies stored in "clean" area.
2. Clean and sterile supplies have seals intact.
3. Clean & dirty equipment / supplies stored separately.
4. Specimens are processed and stored in designated areas.
5. Linens stored in covered area or cart with a solid bottom shelf.
6. All supplies are at least 6" off the floor.
7. Under sink storage for cleaning supplies only. (only items not damaged by water)
8. Med/surg supplies are date current.
9. All substances placed in secondary containers are properly labeled.

Additional Comments:

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 *EOCOP‐3* Cost Center
ENVIRONMENT OF CARE SITE SURVEY—OUTPATIENT AREAS

Surveyor’s
Date: / / and Unit: - - - - Initials:

VII. General Responsibilities: YES NO NA COMMENTS

1. All corridor and chart racks are closed when not in use.
2. Resuscitation mask present in each patient room / practice area.
3. Eat / Drink in designated area only.
4. Confidentiality maintained (chart access, Shred-It, etc.)
5. Emergency cart / box has serial lock.
6. Emergency cart / box is up to date.
7. Staff can verbalize how to check defibrillator.
8. Staff can verbalize when to use PPE.
9. Patient Rights Poster/brochures present.
10. Advance Directive information available.
VIII. Refrigerator Monitoring:
1. Medicine refrigerator temperature logged.
2. Nutrition refrigerator temperature logged.
3. Weekend check plan is in effect (nutrition / medicine / specimen).
4. Specimen refrigerator temperature logged.
5. Miscellaneous refrigerator temperature logged.
6. Staff know what to do if refrigerator temperatures are out of range.
IX. Medications:
1. Medications, prescription pads secured.
2. Open vials dated / initialed.
3. Medications date current.
4. Internal / external meds stored separately.
5. Meds stored at proper temperature.
X. Hand Hygiene:
1. Adequate supplies for handwashing present.
2. No artificial, acrylic nails or nail jewelry (direct care providers)
3. Nails and polish without chips (direct care providers)

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 *EOCOP‐4* ENVIRONMENT OF CARE SITE SURVEY—OUTPATIENT AREAS

XI. Manuals YES NO NA COMMENTS

1. Safety Manual / Quick Reference
2. MSDS (includes list of chemical hazards; reviewed & updated annually)
3. Staff can access on-line policies.
XII. Education
1. There is a plan for verifying competencies for all staff.
2. Current continuing education opportunities are posted.

Additional Comments:

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 *EOCOP‐5* Cost Center
ENVIRONMENT OF CARE SITE SURVEY—OUTPATIENT AREAS

Surveyor’s
Date: / / and Unit: - - - - Initials:

XIII. Safety: YES NO NA COMMENTS

1. O2 stored in rack or push cart if portable.
2. Compressed gas cylinders / storage areas labeled appropriately.
3. All staff wear ID badge.
4. All computer components are off floor.
5. All medical equipment has a current inspection tag.
6. All fire extinguishers have a current inspection tag (checked monthly)
7. All ceiling tiles are in place, no stains or damage.
8. All doors equipped with positive latches & closures work properly.
9. All pictures in public areas secured with security hangers.
10. All doors closed/closable, free of door wedges & foreign objects.
11. Equipment, receptacles, cords, plugs (hazard free & approved for use).
12. Electrical panels & fire response equipment are unobstructed.
13. Supplies / equipment storage is 18” below ceiling in sprinkled areas.
14. Corridors and fire exits are unlocked and unobstructed.
15. Safety eyewash is present & checked weekly. (logs maintained)
16. Exit signs are illuminated.
17. Handrails are appropriately placed and secure.

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 *EOCOP‐6* ENVIRONMENT OF CARE SITE SURVEY—OUTPATIENT AREAS

XIV. Disaster/Safety: YES NO NA COMMENTS

1. External / Internal disaster sub-plans in place and current.
2. Staff verbalize location of Emergency shut off valves.
3. Staff verbalize responsibilities during a fire.
4. Staff verbalize responsibilities during a Mass Casualty activation.
5. Staff verbalize responsibilities during a Code Adam.
6. Staff verbalize responsibilities during a Internal Disaster.
7. Staff verbalize responsibilities during a bomb threat.
8. Staff verbalize responsibilities during a Medical Gas failure.
9. Staff verbalize responsibilities during Mercury spills.
10. Staff verbalize responsibilities during radioactive material spills.
11. Staff verbalize location of Safety / Disaster references.
12. Staff verbalize how to release / remove patient from locked bathroom.
13. Staff verbalize appropriate disposal of chemicals, radioactive matls/chemo.
14. Staff verbalize the location of designated smoking areas.
15. Staff verbalize the different color alerts for disaster response.

Additional Comments:

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