HS Audit Guidelines FY19 06292018

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Document #: 1.

1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 1 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

FY19
Health and Safety
Audit Guidelines

1
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 2 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

FY19 Health and Safety Audit Guidelines


Table of Contents

• Health and Safety Audit Summary…............………….…….….Page 3


• Health and Safety Audit Guidelines………………………….…….Page 4
• Healthcare Specific Guidelines…………………………….…........Page 37
• Food Services Specific Guidelines…………………………..………Page 38
• Facilities Services Specific Guidelines……………………………..Page 40
• Patient Transport Specific Guidelines……………….……………Page 49
• Clinical Technology Management Guidelines…………………Page 50

Health, Safety & Environment - ensures that our employees, clients, contractors, visitors and
guests are safe while at Sodexo locations.

2
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 3 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Health and Safety Audit Summary:

Sodexo is the leader for Quality of Life Services. A safe and healthy workplace is essential to our well-being as 133,000
employees as well as that of our 9,000 clients (including 700 facilities management sites), and 15 million customers
served daily, and thousands of communities.

The Health and Safety Audit is built around Sodexo Health and Safety Strategic Objectives:

• A culture built around a zero harm mindset


• Integrate Health & Safety into everything we do
• Risk-based: We identify hazards and invest in the required technical skills and training to manage the risks to
prevent accidents.
• A common approach to Health & Safety and sharing of best practice.

A key component of our program is the Health and Safety Audit, which beyond providing point in time account
compliance, serves as a leading indicator for exposure by service, business line, and operational area. This Audit can also
be used by onsite management to assess their account’s Health & Safety program against Sodexo, state and/or federal
OSHA regulations. This ensures a proactive approach to continuous improvement to the Sodexo Health and Safety
Management systems.

GENERAL MANAGER ACTION ITEM: Conduct the Health and Safety Audit biannually and when senior on-site management
changes to ensure that all key safety activities are in-place.

The Health and Safety Audit Program is part of Sodexo’s Health & Safety Management System. These audits are performed by
a reputable third-party company in order to receive a professional, independent and unbiased evaluation of Sodexo
operations against our Health & Safety policies and procedures.

These guidelines were created to assist operations in preparing for the Health and Safety Audit.

Health and Safety Audit

Audit Scoring Criteria

Meets Standards: 100%

Progressing: 90 – 99.9%

Below Standards: 89.9% or lower

3
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 4 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Management Commitment and Employee Rights


A.
Post: Are all required safety posters Auditor to verify the following signage is posted.
posted in a place that is readily
visible to employees, clients, and
contractors?
➢ OSHA "Job Safety & Health
(It's the Law" Poster)
➢ Global Health & Safety Policy
➢ Safety Pledge
➢ Health & Safety objectives and
targets
➢ Emergency Phone Numbers
➢ Fire Evacuation Diagram
➢ Choking First Aid Poster
(Food Accounts only)
➢ Safety Committee Member
Names
• The poster must be displayed in a conspicuous place
➢ Safety Committee Meeting
where employees and applicants for employment can
Minutes
see it.
• The OSHA Job Safety and Health: It's the Law poster
A1 (OSHA 3165) is available for free on Sodexo or from
OSHA.gov
https://www.osha.gov/Publications/poster.html
• General Managers do not need to replace previous
versions of the poster.
• Reproductions of the poster shall be at least 8 1/2 by 14
inches with 10-point type.
• All of the 26 State Plan States have posters on their
occupational safety and health program that employers
must post in the workplace. Twenty (20) of these States
have an English poster available on the State website
and 15 States have a Spanish poster electronically
available.
• Specific state posters include: Arizona, California,
Hawaii, Indiana, Iowa, Kentucky, Maryland, Michigan,
Minnesota, Nevada, New Mexico, North Carolina,
Oregon, Puerto Rico, South Carolina, Tennessee, Utah,
Vermont, Virginia, Washington, and Wyoming
• Resource: Sodexo managers can order the Federal
Labor Laws poster from United Print Group. An English
and Bilingual version of the poster is available. The

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 5 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

direct link to United Print Group is


http://sodexo.unitedpgremote.com/.
• Additionally, individual components of the 8-in-1 and 4-
in-1 federal and employment law posters are available
for download below. Each is 8.5 x 11" in size.
Predefined Auditor notes may include:
• No Federal Job Safety & Health Poster
• No State Plan Safety & Health Poster
• Order poster via direct link to United Print Group on
Sodexo Net
• Job Safety & Health Poster Obstructed
• Job Safety & Health Poster Not Readable
• For State Plan Posters and Information:
https://www.osha.gov/dcsp/osp/index.htmll

Global Health and Safety Policy


Auditor to verify the Global Health and Safety policy is part of
the new hires training and annually to all employees. The Global
Health & Safety Policy is posted on a bulletin board in an
employee accessible area.

Poster can be printed from SodexoNet in the forms center.


Key words: Global Health and Safety Policy

5
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 6 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Safety Pledge Poster


Poster can be printed from SodexoNet in the forms center.
Key words: Safety Pledge

Older versions are acceptable.

Health and Safety Objectives and Targets


Auditor to verify current health and safety objectives and
targets are being displayed in an employee accessible area.
Can be ordered on SodexoNet from Sodexo Print Management.
Item Numbers:
• Safety Begins Here: P-840-2 (New version)

Older versions pictured below are acceptable.


• Safety Tracking: P-840 (No longer available)
• Safety Scorecard: P-820 (No longer available)

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 7 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Emergency Phone Numbers posted


• The Emergency Phone Number posting can take many
forms.
• Displayed in a conspicuous location.
• Emergency directions may be part of I.D. Cards, like
those used to access hospital and senior services
secured areas.

Predefined Auditor notes may include:


• Emergency phone numbers obstructed
• No emergency phone numbers posted
• Emergency phone numbers not readable

Emergency Phone Numbers


Poster can be printed from SodexoNet in the forms center.
Key words: Emergency Phone Numbers

Fire Evacuation Diagram


Any form of posting is acceptable as long as it:
• Easily accessible to all employees and visitors
• Identifies the primary and secondary exits
Sample

Predefined Auditor notes may include:


• Fire Evacuation Diagram difficult to understand with no
exits identified
• Fire Evacuation Diagram not posted

7
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 8 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Choking First Aid Poster “Food Accounts Only”


Auditor to verify the Choking First Aid Poster is posted on a
bulletin board in an employee accessible area.

Poster can be ordered from Sodexo Print Management Item


Number:
• Choking First Aid Poster P-180

Safety Committee Member Names posted


(Applies to accounts with 10 or more employees)
Sample:

Any form of documentation showing who is on the committee


Safety Committee Meeting Minutes posted
(Applies to accounts with 10 or more employees)
Auditor to verify if safety committee minutes are posted on a
bulletin board for employees to access.

Any form of documentation that outlines who attended, topics


discussed, incident and accident mitigation.
Safety Committee Meeting Minutes form can be found on
SodexoNet in the forms center.
Key words: Safety Committee Meeting Minutes

8
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 9 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Post: Does the account have a Auditor to verify the Medical Provider poster is posted.
Poster located prominently on an Medical Provider Poster can be found on SodexoNet in the
employee bulletin board listing Report Claims Section.
Medical Providers for utilizing should
Exception: IL, OR, and NY not posted
employees be injured on the job
(Workers Compensation)? Key words: Medical Provider
Sample Medical Provider poster

A2

Post: Is the disaster/emergency Auditor to verify an earthquake preparedness plan is posted on


preparedness plan with evacuation a bulletin board in an employee accessible area. Identify and
routes /point of assembly location post point of assembly location.
posted?

A3

S.A.F.E. Card Poster available on Sodexo Print Management


Item number:
• SAFE Cards Z-500

9
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 10 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Is there documented evidence that Auditor to verify by asking a random employee when the last
disaster/emergency preparedness emergency drill was conducted. Documentation showing a drill
drill(s) have been conducted and was conducted in the last year.
A4 communicated to all employees Documentation of client based drill is acceptable.
within the last year? Additional resources:
California Suggestion: http://www.shakeout.org/california/

Can a random employee show (with Auditor to verify by asking one employee at random if they
a phone number, email, office, or know who to report a serious, immediate hazard to.
person) who to contact for reporting Sodexo values employee input and feedback.
A5
a serious, immediate hazard? Actively encourage employee involvement if you want your
program to succeed. It will ensure an established clear system
for reporting hazards and close calls.
Is a visitor sign in log being used and Any form of log is acceptable.
emergency evacuation information Auditor to verify all visitors are signing in and out on a log and
reviewed with all visitors? this log is being used. This does not include vendors.
• If client controls access and egress and requires sign
in/out. Compliant
• If not, client controlled, account must have a log in
place to be in compliance.
• Visitors are informed of emergency evacuation
information. (i.e. fire evacuation)
A sample Visitors Log can be found on Sodexo Net in the Form
A6 Center
Key Word: Visitors Log
Example:

Has the District or Regional Safety Auditor to validate by viewing DSC = District Safety Coordinator
Coordinator provided account safety or RSC = Regional Safety Coordinator follow-up report.
support within the last year? Examples of follow up report:
• Copy of on-site review
A7 • Copy of an email follow up on support with
incident/accident, and root cause analysis
• Copy of conference call with account manager
• Documentation of safety program support

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 11 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Must have documentation of how and when this support was


provided.

Key Definitions:
District Safety Coordinator (DSC) - This is a manager within a
Sodexo DM’s area that takes on the roles and responsibility of
being the Subject Matter Expert (SME) for Safety for the District
Manager’s region. The DSC is typically one of the GM’s or
Operational managers for one of the DM’s accounts.

Regional Safety Coordinator (RSC) - This is a manager within a


Sodexo Vice President’s (VP) region that takes on the roles and
responsibility of being the Subject Matter Expert (SME) for
Safety for the VP’s region. The RSC is typically one of the GM’s
or Operational managers for one of the VP’s accounts. The RSC
helps oversee and support the DSC’s within that VP’s region.
Can management access the Sodexo Auditor to verify management can access Sodexo Safety Policy
Safety Policy Manual within a Manual.
reasonable time frame (15 minutes)? Safety Policy Manual can be found on the Safety Landing Page
on Sodexo Net.
In addition: (California Accounts) Key words: Safety Policy Manual
A8
(California accounts must have an California Accounts must have a documented
IIPP (Injury and Illness Prevention IIPP= Injury & Illness Prevention Program on-site.
Plan) on-site. California IIPP can be found on the Safety Landing Page on
Sodexo Net.
Key words: California IIPP
Is management aware of his/her Auditor to verify Managers knows they are responsible for
A9 safety responsibilities as per OSHA providing a safe work environment for all employees per OSHA
3165 and the Safety Policy Manual? 3165 and Safety Policy Manual.
Does account manager have a safety Auditor to verify account has a safety improvement plan
improvement plan documented? documented.
Any form of a safety improvement plan that has action items,
who owns the action items and a timeline for the action items
A10
are acceptable.

Below is an example of a safety improvement plan:

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 12 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Safety Improvement Plan template can be found on SodexoNet


in the Forms Center.
Key words: Safety Improvement Plan
Is a current OSHA 300 recordkeeping Applies to Sodexo Managers and Employees.
log, the privacy case list
(if applicable), OSHA 300A summary, Auditor to verify OSHA 300 log and 300A summary must be
and the First Report of Injury completed, signed, and filed each year, even if no
maintained for 5 years following the accidents. Each injury or illness must be recorded within 7
end of the calendar year that each calendar days of receiving information that a recordable injury
record covers or since account or illness has occurred.
opened, if shorter time? On-site management must retain the OSHA 300 Log, the privacy
case list (if applicable), OSHA 300A Annual Summary, and the
Post: First Reports of Injury for 5 years following the end of the
A11
If audited during February 1 – April calendar year that each record covers or since account opened,
30, OSHA 300A summary is posted if shorter time?
for all employees to view. Posting: Auditor to verify previous year’s 300A summary is
completed, signed and posted February 1 – April 30 if audited
during this time frame.
Note: 300A log must be signed by highest level managers of
account.
The time frame for this document, as with all documentation, is
based upon the General Managers tenure at the account.

NEW: Can a random employee Applies to All Managers and Employees.


explain the 3 Checks for Safety This question is non-scored for FY2019.
process before starting a job?
Auditor to verify by asking 2 random employees what are the 3
Post: Is the 3 Checks for Safety checks For Safety process.
A12
poster displayed for employees to
review? Before Starting a job / Stop and Think
➢ Do I Know How To Do The Job?
This question is non-scored for ➢ Do I Have The Right Equipment?
FY2019. ➢ Is My Environment Safe?

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 13 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

If the answer is “no” to any of the checks you should


speak up and share your concerns with your colleagues and
supervisor.

Posting:
Is the 3 Checks for Safety poster displayed for employees to
review?
Auditor to verify 3 Checks for Safety poster is being displayed in
an employee accessible area.

Can be ordered on SodexoNet from Sodexo Print Management.


Item Numbers:
• 3 Checks For Safety: 719ENG, 719FR, 719SPA
Chemical Hazard Communication and Alignment with the UN's Globally Harmonized System of
B.
Classification and Labeling of Chemicals
Does management maintain an Auditor to verify a hazardous chemical inventory list is
inventory list of hazardous chemicals maintained and dated with in the last 12 months.
that is dated within the last 12 Any type of a Chemical Inventory list is acceptable but must be
B1 months, and is accurate? reviewed and dated within the last 12 months.
Any new hazardous chemical received are to be documented in
the Hazardous Chemical Inventory list before use by any
employee.
Are Safety Data Sheets (SDS) readily Auditor to verify SDS is readily available for review.
available for each hazardous Electronic access to SDS is acceptable, but the manager will
chemical in the workplace? need to demonstrate they can retrieve them within 15 minutes.
• Auditor to randomly select a chemical in the work place
B2
and have the manager present the SDS sheet for the
selected chemical.
• If using Fax-On Demand to download SDS, the account
must demonstrate and retrieve SDS.

13
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 14 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

• If using the internet, go to www.myecolab.com


SDS are available on the Safety Landing Page of SodexoNet
Key words: Ecolab SDS
Are chemical containers Auditor to verify all chemical containers are appropriately
appropriately labeled? labeled. Account uses the label and container supplied by the
chemical manufacturer.
Hazard Communication Standard Labels:
OSHA has updated the requirements for labeling of hazardous
chemicals under its Hazard Communication Standard (HCS). All
labels are required to have pictograms, a signal word, hazard
and precautionary statements, the product identifier, and
supplier identification. Labels must be legible.

B3
NFPA and HMIS labeling is acceptable.

All chemical containers including compressed gas cylinders and


piping that carries hazardous chemicals must be labeled.

14
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 15 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

C. Communicating Safety & Health


Does a safety committee meet Auditor to verify the following:
monthly? • Six months documentation required.
Is there an established Safety • Safety Committee Meeting minutes is not considered
Committee complete with the same as reviewing a safety topic with account staff
documented meeting minutes for for accounts with 10 employees or more.
the last six months? (Applies to Look for a consistent pattern and take holidays and closing
accounts with 10 or more periods (i.e. summer months for Schools and Universities) under
employees) consideration.
Auditor to verify if safety committee minutes are posted on a
bulletin board for all employees to access.
C1

Safety Committee Meeting Minutes form can be found on


SodexoNet in the forms center.
Key words: Safety Committee Meeting Minutes

Is a Safety Moment presented at the Auditor to verify by asking a random employee, supervisor, or
beginning of all account, face-to-face managers what is the last safety moment you heard presented
meetings? in a meeting with management. If one employee, supervisor, or
C2
manager answers correctly then points are awarded.
Safety Moment Link on SodexoNet
Key words: Safety Moment
Are Weekly Safety Messages All accounts are required to conduct a Weekly Safety Message.
communicated to employees? Adding a weekly safety message to Sodexo operations help
bridge the time between in-depth training meetings and help
employees retain what they’ve learned.
• The weekly safety message does not require employee
sign-off documentation.
• A weekly safety message may be as brief as a one line
C3
safety reminder, or last a couple of minutes. Whatever
you decide to do, keep in mind you are trying to
reinforce safe behavior and keep safety in the minds of
employees.
• A good time to have safety message is at the beginning
of a shift. Whether you give the safety message at the
beginning of the shift day or at some other time, it is

15
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 16 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

important to give the safety message while the workers


are away from their regular tasks.
• Present during Huddles
• Auditor to ask employees what safety topic at last
huddle or weekly discussion or you may see it posted.
Predefined Auditor notes:
• Conduct a weekly safety message and reinforce safe
behavior that is needed to do the job safely.
• Create greater safety awareness through specific
focused safety reminders.
• Weekly safety messages are located in the Health &
Safety Calendar and Sodexo Net
Key words: Weekly Safety Messages
Examples of Weekly Safety Messages:
• Keep exits clear
• Drink extra water when working in a hot environment
• Use Handrails on Stairs
• Don’t twist your back while lifting

Does the management team review Auditor to verify training is completed.


a workplace safety topic each month Auditor Observations:
with employees (includes • The sum of employees includes all management, full
management) for the past 12 time, client employees under our management, and
months? Documentation required. part time employees
• Count time cards or employees to determine workforce
NOTE: size
C4 THIS IS NOT FOOD SAFETY The following methods are best practices:
TRAINING • Pre-printed roster – dated and with signatures.
• Internet based tracking – must demonstrate to Auditor
Note: The time frame for this document, as with all
documentation, is based upon the General Managers tenure at
the account. For new managers with:
• 2 months on site > 1 topic is required
• 3 months on site > 2 topics are required
Are employees engaged and Auditor to validate knowledge of safety awareness topics by
understand safety training topics? randomly asking five hourly employees two questions each.
If less than five employees, two employees are asked five
questions each.
C5
In the aggregate, if 80% of the questions are answered
correctly, award points.

16
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 17 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

1. Where are the Safety Data Sheets or SDS located?


Answer: Employee brings you to the SDS binder.
2. What’s safer - Pushing or pulling a cart? Answer: Pushing
3. Can you tell me two ways to prevent a slip, trip or fall?
Answers: Watch where you walk; do not block your vision;
clean up spills immediately; use a floor cone to keep people
away from the spill; notify my supervisor of a hazard;
maintain a clear walkway; Use ladders, do not climb on
chairs; do not run; Place trash in proper container; wear slip
resistant shoes.
4. Can you tell me two ways to prevent a back injury?
Answers: Exercise; Stretch before lifting; Do not lift heavy
or awkward loads, get help; Use a cart; Do not twist, pivot
your feet; Do not overreach; Use your legs to lift, not your
back; Do not bend your back; Use a mechanical device;
Team lift; Break down the load
5. Can you show me the Personal Protective Equipment you
use on the job? Answer: Employee displays his/her PPE
6. Can you direct me to the emergency exit? Answer: The
employee identifies the exit which must be clearly marked
and unobstructed.
7. Should you always report hazards to your supervisor?
Answer: Yes
8. What would you do if you observe damaged electrical cords
or other unsafe condition? Answer: Report it to your
supervisor
9. Can you tell me what the last employee safety training topic
was and what did you learn? Answer: General answer is
correct except it cannot be about food safety. Please clarify,
if needed.
10. What of the following are safety tips to keep your hands
safe? A. Always know where you are putting your hands; B.
Watch for pinch points, sharp edges, and chemical
exposures; C. Wear gloves if required; D. Treat minor
injuries promptly; or E. All of the above Answer: E.
11. Can you give me two safety tips when driving?
Answer: Wear your seat belt; Do not use your phone; Do
not text message; Do not drink and drive; Do not speed;
other related answers may be ok.
Do all site managers and supervisors Auditor to verify
complete two safety observations Site managers and supervisors are completing two safety
C6
per week or conduct regular observations per week.
conservations about 3 checks for

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 18 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

safety or any other safety related Method of Documenting safety observations:


concerns frontline staff may have?
1. If account is SoSafe Journey (Rounding for Safety)
Trained:
a. Auditor would verify account is completing two
observations per week per manager or
supervisor and this information is documented
in DataPro. Auditor would validate through
DataPro while on site.

2. If account is NOT SoSafe Journey (Rounding for Safety


Trained:
a. Auditor would interview a few employees and
ask about the last one on one conversation they
had with their manager about 3 Checks for
Safety and/or any other safety related concerns
they may have.

Environmental Services accounts that are not trained in


Rounding for Safety and using Trakkar to document their
observations are acceptable.

D. Hazard Identification and Control


SAFETY INSPECTION: Account Auditor to verify Monthly Safety Inspection is completed.
conducts Monthly Safety Inspection Modified variations that are specific to the account are fine;
with corrective action plan Corrective Action must be developed and documented on all
implemented to abate unsafe discrepancies noted on inspections.
conditions or unsafe acts? Completing the Health & Safety Audit form does not constitute
a monthly safety inspection.
Monthly Safety Inspection forms can be found on SodexoNet in
the forms center.
D1 Key words: Monthly Safety Inspection

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 19 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

Was the account’s previous fiscal Auditor to verify by having GM log into Sodexo Net and access
year's Health and Safety Audit the 3rd Party Audit Results to verify previous year’s corrective
D2
corrective action plan completed? action plan was completed.
CTM accounts will be N/A for FY2019
Are all restrooms that Sodexo Auditor to verify restrooms that Sodexo maintains are clean
maintains clean and sanitary? and sanitary.
D3 Toilet rooms enclosed, fixtures good repair, clean, hand soap,
sanitary towels, hand-drying devices provided, proper waste
receptacles.
Compressed gas cylinders stored in Auditor to verify compressed gases are stored correctly and
upright position, chained or secured secured.
and those not in use have protective Definition of a compressed gas – any gas, or mixture of gases,
caps in place? that is pressurized and contained in a cylinder or tank.
Examples of compressed gases: acetylene, anhydrous
ammonia, carbon dioxide, helium, etc.
• Ensure that the storage area is:
• properly labeled
• secure together or individually
D4 • away from ignition sources
• separate from oxidizing gases

Note: Some smaller CO2 cylinder have built in protective ring


which meets cap requirement.
All electrical cords and plugs in good
condition - such as loose parts,
deformed and missing pins, or
damage to outer jacket or
D5 insulation?

Auditor will visually check for damaged electrical cords and


plugs.
Extension cords are not used in
Special to verify extension cords are not used in place of
place of permanently installed fixed
permanently installed fixed wiring.
D6 wiring?
Extension cords may not be used in permanent installations as
specified in (A) through (E) below:

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Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
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(A) As a substitute for the fixed wiring of a structure;


(B) Where run through holes in walls, ceilings, or floors;
(C) Where run through doorways, windows, or similar openings;
(D) Where attached to building surfaces; or
(E) Where concealed behind building walls, ceilings, or floors.

In most cases, the temporary installation is used to supplement


the permanent wiring, because the temporary loads will exceed
the rating of the installed wiring system. Example applications,
for which temporary power is used, are listed below.
• Lighting when primary power equipment is down for
maintenance
• Supplemental power to offices, cafeteria, shops, and as
such, when the primary power sources are down for
maintenance
• Supplemental power to machinery acquired specifically
for the plant outage
• Supplemental power for temporary wiring

Electrical panels have minimum 36” Auditor to visually confirm that electrical panels are
of unobstructed workspace in front unobstructed as required. Barrier tape not required, but a plus.
and are closed?

D7

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Trash compactors, balers, or similar Auditor to verify that safety signage is in place.
mechanical machines are equipped
with adequate guards and safety
switches? Signage on machine
states: ONLY AUTHORIZED
PERSONNEL SHOULD BE ALLOWED
TO OPERATE OR SERVICE THIS
COMPACTOR or similar signage.
D8

Does compactor, balers, or similar Auditor to verify compactor, balers, or similar devices have
devices have controls in place to controls in place to prevent unauthorized Sodexo Managed
prevent unauthorized Sodexo employees from operating.
Managed employees from
D9 operating? Other acceptable controls
• Administrative Controls
• Interlocks
• Access control (Key pads)
• Secured Keys
Post: No Smoking signs posted on Auditor to verify signage is posted.
liquefied petroleum (LP) tanks. No
LP gas cylinders used indoors and LP
D10 gas cylinders are guarded to prevent
damage from vehicles?

E. Slip and Fall Prevention


All work areas are free of slip Auditor to verify
hazards. - Such as wet/oily surfaces Look in the common and high traffic areas and employee
and spills? entrance areas.
Auditor to verify there is no wet or oily surfaces on work area
E1 floors.
Common causes of slipping hazards:
• Wet, waxed, or oily surfaces
• Occasional spills
• Weather hazards (that is, ice, rain, or snow)

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• Walk-off mats not provided at entrance areas during


rain or winter
• Loose, unanchored rugs or mats
All work areas are free of trip Auditor to verify
hazards. - Such as boxes (or similar Look in the common and high traffic areas and employee
items) on the floor, poor lighting, entrance areas.
wrinkled carpets, mats or clutter? Auditor to verify there are no items that could pose a trip
hazard in work area.
Common causes of tripping are:
E2 • Obstructed view
• Poor lighting
• Clutter
• Wrinkled carpeting or mats
• Cables or cords left in walk way
• Uneven (steps, thresholds) surfaces
Are walkways clear of obstructions Auditor to verify
and free of slipping hazards? Look in the common and high traffic areas and employee
entrance areas.
E3
Auditor to verify that walkways are clear of obstructions that
could pose a slipping hazard.
Standing water on floor with no effort given to clean up?
E4 Are walkways clear of obstructions Auditor to verify
and free of tripping hazards? Look in the common and high traffic areas and employee
entrance areas.
Auditor to verify that walkways are clear of obstructions that
could pose a tripping hazard.
Do you see employees step over clutter rather than cleaning it
up?
E5 Are the correct ladders and step Auditor to verify the ladders and step stools that are being used
stools being used for safe climbing, for safe climbing are rated for the weight of the employee and
rated for the weight of the the load they intend to carry.
employee, and the load they intend Note: (No point awarded if)
to carry? Climbing on chairs, milk crates, equipment, or shelving.
If no employees observed climbing, employees must
demonstrate knowledge of proper ladder usage and safe
climbing.
Sample: Ladder Load Rating:

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Are ladders and step stools in good Auditor to verify ladders are maintained in good condition,
condition and of sufficient height to joints between steps and side rails tight, all hardware and
prevent over-reaching? fittings securely attached, and moveable parts operate freely.
The use of metal ladders must be prohibited in areas where the
ladder of the employee using the ladder could come in contact
with energized parts of equipment, fixtures, or circuit
conductors. The number of onsite ladders is determined by
E6
business need.
Sites that have more than 3 ladders on site, the Auditor will
physically inspect 3 at random to ensure safe/good condition.
Sites with less than 3 ladders on site, the Auditor will physically
inspect all ladders to ensure safe/good condition.
Tag it “Defective” and inform manager during audit if a
damaged ladder is observed.
Employees not observed carrying Auditor to verify
materials that obstruct their vision Employees make use of existing elevators, dumb waiters,
while traveling up or down stairs? loading docks to move materials from one elevation to another.
Employees use hand rail while Employees are not seen carrying items of excess weight, which
traveling up or down stairs? would require two hands, or size, which may obstruct vision
E7
while traversing stairs.
Hand rails are used when going up or down stairs.
If no employee observed, employee must demonstrate
knowledge of safe material handling procedures when using
stairs.
Does every flight of stairs (portable Auditor to verify
or fixed) having 4 or more risers and If no hand rail is in place, then work orders requesting
all winding stairs must be equipped installation of same must be submitted monthly, until
with standard stair railings or completed. If the account has documented work orders for
E8
standard handrail? installation or repair for aforementioned, then points are
awarded. If work orders exceed three months, then the account
must demonstrate that they have addressed the potential
hazard.
Does account management actively The Auditor must verify that the account uses floor warning
use approved floor hazard warning signs or cones at least 30” high.
E9 signs to prevent access to areas that
expose potential dangers (such as Observe floor hazard warning signs in use.
spills, damaged floors)?
Do Sodexo employees wear closed Auditor to verify
toe, closed top, closed heel, and To be awarded points, the Auditor must verify the following:
E10
rubber sole, slip resistant footwear? All Sodexo employees (including management) are wearing slip
resistant shoes.

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If management is not wearing slip resistant shoes, overshoes


(i.e. Crew Guards), or other acceptable substitute, then points
are not awarded.
Are standard guardrails provided Auditor to verify
wherever aisle or walkway surfaces Loading docks require fall protection when they have a fall
are elevated 48 inches or more potential of 48" (4') or more.
above any adjacent floor or the Auditor should measure the fall potential as most docks are
ground? built to a 44" standard.
E11

Employee parking lot and walkway Auditor will need to scan the employee parking area and path
leading into the workplace have leading into the workplace.
E12 adequate lighting and is free from If a slipping or tripping hazard exists, then the audit is scored
slipping or fall hazards (this includes “no”.
walkways free of snow and ice)?
Does account management have an Auditor to verify management has an inclement weather
inclement weather procedure in procedure in place to avoid potential employee slips and falls
place to protect employees from during inclement weather conditions.
exposure? Example: Wind, Rain, Snow and Ice
Example of Procedure:
Written procedure for checking parking lot and walk ways to
verify snow and ice removal.
E13 If client responsibility, manager must still demonstrate how
they are working with their clients to ensure an inclement
weather procedure is in place.
Example of Documentation:
• Copy of a client work program
• Copy of inclement weather schedule
• Copy of inclement weather plan

F. Safe Material Handling


Are carts or other mechanical aids Auditor to verify no employees are observed manually handling
F1 used to transport heavy items or hot items in access of 40 lbs., and carts are in use or available for
liquids? use. No Heavy lifting (>40 lbs.) is observed.
Are carts or other mechanical aids in Auditor to verify carts or other mechanical aids in proper
F2 proper working condition – casters working conditions – casters in good conditions, handles in
place.

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in good condition, handles in place,


etc.?
Employees observed pushing a load Auditor to verify employees are pushing loads instead of pulling
instead of pulling it? them. There are many special situations with light loads that
F3
pulling is unavoidable. I.e.: on and off elevators, doorways,
transport in hallways.
Post: Safe Lifting signage present in Auditor to verify Safe Lifting signage present in areas to
work areas to remind employees promote safe lifting. Any proper safe lifting poster acceptable.
how to lift safely? Example:

F4

Poster can be ordered from Sodexo Print Management


Item Number: Proper Lifting Procedure P-680

Proper body mechanics observed Auditor to verify employees are using proper body mechanics
when any lifting takes place? when lifting.
If no one is observed lifting, then Auditor would ask a random
employee the proper body mechanics to lift a box from point A
to point B.
No twisting, bending, or over reaching and carrying load above
shoulders.

F5

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Employees observed team Auditor to verify


lifting/moving items 40lbs. or more? No employees should be observed manually handling items at
40 lbs. or more.
• Carts are in use or available for use.
• Loads are broken down to reduce weight.
• Lifting teams are utilized for loads 40 lbs. or more.
F6

Storage room safety check - Shelves Auditor to verify shelves and racks are in good condition and
and racks are of adequate strength stable. Products are stored properly and stable on shelves;
and are stable? Products are stored No items over 40 lbs. are stored below knuckles and above
F7
properly, stable and not overhanging shoulders; and not over hanging.
on shelves?

G. Personal Protective Equipment (PPE)


Is a Personal Protective Equipment Auditor to verify Personal Protective Equipment Hazard
Hazard Assessment completed and Assessment is completed and reviewed annually and signed by
reviewed annually and signed by on- on-site management.
G1
site management? Sample PPE Assessments can be found in the Forms Center on
SodexoNet.
Key words: PPE

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Is Personal Protective Equipment Auditor to verify PPE is available and employees are actively
(PPE) provided and actively worn? wearing them.
As referenced in the PPE Assessments.
For example, in food operations: cut resistant gloves, oven
mitts, splash proof goggles, etc.
PPE Type:
Head gear – Protects against falling objects, low hanging objects
Eye & Face gear – Protects against flying or blowing particles
like dust, sparks; splashing liquids; intense heat or light; blood
G2 borne pathogens
Hearing protection-Protects against constant machine noise or
intense bursts of sound energy
Respiratory protection- Protects against dangerous dusts, gases,
vapors, mists, TB, etc.
Arm & hand covering- Protects against cuts, burns, cold, bumps,
electrocution, caustic liquids, blood borne pathogens
Foot & leg protection – Protects against slippery floors, heavy
objects that could roll or flat, objects on wheels, burns from
spills or sparks.
Evidence of properly maintained Auditor to verify PPE properly maintained and No damaged PPE
G3 (clean) PPE in use? allowed to be worn.

H. Ensuring Zero Energy


LOCK, TAG, TRY. Auditor to verify if an account has authorized employees that
Are equipment specific procedures perform maintenance and servicing of equipment. Then
developed and implemented for questions; H1, H2, H3 and H4 apply.
equipment that contains stored If an account does not have authorized employees that perform
hazardous energy? maintenance and servicing of equipment. Then questions; H1,
H3 and H4 are non- applicable.
Servicing and/or maintenance which takes place during normal
production operations is covered by Lock Tag Try only if: An
employee is required to remove or bypass a guard or other
H1 safety device; or an employee is required to place any part of
his or her body into an area on a machine or piece of equipment
where work is actually performed upon the material being
processed (point of operation) or where an associated danger
zone exists during a machine operating cycle. Minor tool
changes and adjustments, and other minor servicing activities,
which take place during normal production operations, are not
covered by lock, tag, try if they are routine, repetitive, and
integral to the use of the equipment for production.

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If at any time a guard is removed and or a body part is placed in


a hazardous area of a machine, such as the sprocket and chain
area of a flight dish machine or the blades of a pulper or
disposal, exemption status is eliminated.
Auditors to verify account has written equipment specific
procedure for each type of work performed. This is applicable
to all FM accounts and would include boilers, HVAC units, and
should identify all sources of energy to be locked out when
service is performed. Points should NOT be awarded for a
generic procedure written applicable to all equipment.

Lock Out Procedure form can be found on SodexoNet in the


forms center.
Key words: Lockout
Are authorized employees provided Auditor to verify account has at least one lock and/or one tag
at least one lock and/or one tag? available for authorized employees that are performing
maintenance and service. If account does not have an
authorized employee to perform maintenance or service to
equipment, at a minimum, a tag must be available to identify
H2 any equipment out of service for repair or maintenance.
Food Service accounts that do not have access to the electrical
panel, that controls equipment (dishwasher), may place a tag on
the start switch, identifying it as out of service for repair or
maintenance. Facilities, grounds, and laundry services are
required to have both a lock and tag.
At the time of audit, is account Auditor to verify if an account has authorized employees that
management supporting company perform maintenance and servicing of equipment. Then
LOCK/TAG/TRY procedures? questions; H1, H2, H3 and H4 apply.
If an account does not have authorized employees that perform
H3 maintenance and servicing of equipment. Then questions; H1,
H3 and H4 are non- applicable.
Servicing and/or maintenance which takes place during normal
production operations is covered by Lock Tag Try only if: An
employee is required to remove or bypass a guard or other

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safety device; or an employee is required to place any part of


his or her body into an area on a machine or piece of equipment
where work is actually performed upon the material being
processed (point of operation) or where an associated danger
zone exists during a machine operating cycle. Minor tool
changes and adjustments, and other minor servicing activities,
which take place during normal production operations, are not
covered by lock, tag, try if they are routine, repetitive, and
integral to the use of the equipment for production.
If at any time a guard is removed and or a body part is placed in
a hazardous area of a machine, such as the sprocket and chain
area of a flight dish machine or the blades of a pulper or
disposal, exemption status is eliminated.
If account has an authorized employee that performs
maintenance and service to equipment, auditor to verify
lock/tag/try procedures are being practiced and account has
equipment specific procedures in place.
Note: If machinery or equipment is damaged or missing its
guard, it must be locked out and/or tagged out.
Are periodic inspections completed Auditor to verify if an account has authorized employees that
annually to confirm energy control perform maintenance and servicing of equipment. Then
procedures are in place? questions; H1, H2, H3 and H4 apply.
If an account does not have authorized employees that perform
maintenance and servicing of equipment. Then questions; H1,
H3 and H4 are non- applicable.
Auditor to verify LOCK/TAG/TRY Periodic Inspection has been
completed at least annually for accounts that have authorized
employees that perform maintenance and servicing of
equipment.
Inspection form can be found on SodexoNet in the forms center
H4 Key words: Lock Tag Try Periodic Inspection Form

This requirement is for authorized employees performing


service or maintenance to equipment.

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1910.147(c)(6)
Periodic inspection.

1910.147(c)(6)(i)
The employer shall conduct a periodic inspection of the energy
control procedure at least annually to ensure that the
procedure and the requirements of this standard are being
followed.

1910.147(c)(6)(i)(A)
The periodic inspection shall be performed by an authorized
employee other than the ones(s) utilizing the energy control
procedure being inspected.

1910.147(c)(6)(i)(B)
The periodic inspection shall be conducted to correct any
deviations or inadequacies identified.

1910.147(c)(6)(i)(C)
Where lockout is used for energy control, the periodic
inspection shall include a review, between the inspector and
each authorized employee, of that employee's responsibilities
under the energy control procedure being inspected.

1910.147(c)(6)(i)(D)
Where tagout is used for energy control, the periodic inspection
shall include a review, between the inspector and each
authorized and affected employee, of that employee's
responsibilities under the energy control procedure being
inspected, and the elements set forth in paragraph (c)(7)(ii) of
this section.

1910.147(c)(6)(ii)
The employer shall certify that the periodic inspections have
been performed. The certification shall identify the machine or
equipment on which the energy control procedure was being
utilized, the date of the inspection, the employees included in
the inspection, and the person performing the inspection.

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I. Protecting Sodexo Property / Life Safety/ General Liability


Exits and exit accesses are being Auditor to verify exit signs are visible at all times. Exits must not
I1 located and arranged so that they be obstructed.
are readily accessible at all times?
Portable fire extinguishers are Auditor to verify
maintained, fully charged, operating All fire extinguishers are required by law to be:
properly, and kept in designated 1. Maintained in a fully charged and operable condition.
places at all times except during 2. Kept in their designated places at all times when they are not
use? being used.
3. Conspicuously located where they are readily accessible and
immediately available in the event of fire.
4. Located along normal paths of travel, including exits from
areas.
I2
5. Clear from any obstruction nor obscured from view.
6. Installed so that the top of the fire extinguisher is not more
than 5 ft. above the floor (with a gross weight not exceeding 40
lbs. If over 40 lbs., not more than 3.5 ft. above the floor).
7. In no case shall the clearance between the bottom of the
hand held PFE and the floor be less than 4”.
8. Extinguishers’ operating instructions shall be located on the
front of the extinguisher and shall be clearly visible. All other
labels shall not be located on the front of the extinguisher.
J. Required Annual Safety Training
Is the Accident Prevention Review Auditor to verify documentation showing training video and
Video and Form reviewed with all form was reviewed with all new employees.
J1 new employees? Client provided documented programs are acceptable.
Video and Form can be found on the Safety page.
Key words: Accident Prevention
Is the Accident Prevention Review Auditor to verify documentation showing training video and
Video and Form reviewed with all form was reviewed with all employees annually
J2 employees annually? Client provided documented programs are acceptable.
Video and Form can be found on the Safety page.
Key words: Accident Prevention
Has General Manager or other Auditor to verify training is completed.
account Managers successfully Must substantiate by presenting U.S. Department of Labor
completed 10-Hour OSHA General OSHA Completion Card or Certificate. Managers must be
J3
Industry Training Course? employed a minimum of 6 months for this to apply.
All General Managers or other Account managers must be
certified in the 10-hour OSHA General Industry Course

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Online course can be registered through your Sodexo


Ingenium. The class must be completed in order for manager to
receive points for this question.
If first audit is below standards and completing this course is
listed on their corrective action plan, as long as you are
currently “in progress” with the class you will receive points for
working towards completing your corrective action plan.
CTM accounts are N/A for FY2019
Is Slip, Trip, and Fall Prevention Auditor to verify documentation showing training was reviewed
J4 Training provided? (29 CFR 1910.24- with all new hires and annually for all employees.
.27) Training resources available on Safety page on SodexoNet
Is Back Injury Prevention Training Auditor to verify documentation showing training was reviewed
J5 provided? with all new hires and annually for all employees.
Training resources available on Safety page on SodexoNet
Is Fire Safety, Fire Extinguisher, & Auditor to verify documentation showing training was reviewed
J6 Emergency Evacuation Training with all new hires and annually for all employees.
provided? (29 CFR 1910.38) Training resources available on Safety page on SodexoNet
Is Personal Protective Equipment Auditor to verify documentation showing training was reviewed
J7 Training provided? (29 CFR with all new hires and annually for all employees.
1910.132 & .133) Training resources available on Safety page on SodexoNet
Is Lock/Tag/Try Training provided Auditor to verify documentation showing training was reviewed
for all authorized and affected with all new hires and annually for all employees.
J8 employees? (29 CFR 1910.147) This applies to all accounts. For accounts with affected
employees Lock, Tag, Try awareness training is required.
Training resources available on Safety page on SodexoNet
If applicable, is Power Industrial Auditor to verify documentation showing training was reviewed
Truck Training provided for with all new hires and annually for all authorized operators.
authorized operator(s)? This safety training requirement is for fork trucks, tractors,
(29 CFR 1910.178) platform lift trucks, motorized hand trucks, and other
specialized industrial trucks powered by electric motors or
internal combustion engines.
Examples of PIT (Power Industrial Truck):
J9

Training resources available on Safety page on SodexoNet


Is Chemical Hazard Communication Auditor to verify documentation showing training was reviewed
J10 Training provided at orientation, with all new hires and annually for all employees, or when new
chemicals are introduced.

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annually to all employees, or when Training resources available on Safety page on SodexoNet
new chemicals are Introduced?
(29 CFR 1910.1200)
Is Blood Borne Pathogen Auditor to verify documentation showing training was reviewed
Precautions Training provided to with all new hires and annually for all employees.
employees with occupational Training resources available on Safety page on SodexoNet
J11
exposure? (29 CFR 1910.1030) Applies to Healthcare & First Aid Trained Staff
Applies to Healthcare & First Aid
Trained Staff
Is Equipment Training provided on Auditor to verify documentation showing training was reviewed
J12 all equipment employees are with all new hires and annually for all employees.
expected to use? Training resources available on Safety page on SodexoNet
Is Work Place Violence Training Auditor to verify documentation showing training was reviewed
J13 provided? with all new hires and annually for all employees.
Training resources available on Safety page on SodexoNet
Is Heat Stress Prevention Training Auditor to verify documentation showing training was reviewed
J14 provided? with all new hires and annually for all employees.
Training resources available on Safety page on SodexoNet
Contractors Working in Sodexo Auditor to verify documentation showing contractor orientation
Areas (i.e. Temp Labor): For training was reviewed with all contractors working in Sodexo
J15 account with contractors on site, areas.
have pre-job orientations been Training resources available on Safety page on SodexoNet
completed?
K. Fleet/Vehicle Safety
Vehicle Safety - Applies to All Auditor to verify a driver’s responsibility form is reviewed and
Sodexo Drivers who operate client or signed annually by all Sodexo drivers.
Sodexo owned or leased vehicles in Note: Points are automatically deducted if the Auditor observes
the conduct of their business. Is the the failure to wear a seat belt or the manually use of a cell
K1
Driver Responsibilities form phone/texting. Immediately report to the GM.
reviewed and signed by all Sodexo Drivers Responsibility form can be found on Sodexo Net in the
drivers within the last 12 months? forms center.
Key words: Driver’s Responsibility
Vehicle Safety - Does the account Auditor to verify a motor vehicle records check was completed
manager retain a copy of the current for all Sodexo drivers annually and retained on file.
motor vehicle record check for all
K2
Sodexo drivers within the last 12
months?

Vehicle Safety - Does account Auditor to verify monthly vehicle safety inspections are being
K3 complete monthly vehicle completed on all client or Sodexo owned or leased vehicles use
inspections for those client or in daily operations. Account should have at least 4 of the last 6

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Sodexo owned or leased vehicles months. Modified variations that are specific to the account are
used in daily operations? acceptable.

Monthly Vehicle Inspection form can be found on Sodexo Net


in the forms center.
Key words: Vehicle Inspection

Vehicle Safety: All Sodexo drivers Auditor to verify training videos have been reviewed with all
have completed Drivers Safety Sodexo drivers.
Training videos? Training resources are available on SodexoNet on the EHS page.

K4
The following drivers training videos must be reviewed with all
drivers annually.
• Winter Driving Safety
• Backing, Parking and Intersections
• Texting and Driving: The Facts
Drivers Safety Training Signoff Form can be found on the EHS
page in the Vehicle Safety Section.
Key words: Vehicle Safety

Golf Cart Safety: All drivers must Auditor to verify Golf Cart Safety training was completed for all
have a valid Drivers' License and golf cart drivers.
receive the following training:
operator training, golf cart safety Training resource on SodexoNet in the forms center:
K5
procedures, battery recharging, Key words: Golf Cart Safety training
distracted driving, and refueling
safety procedures?

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L. Injury/Illness Reporting, SALUS Root Cause Analysis and Investigation, and First Aid

Does account management Applies to Sodexo Employees.


complete the First Report of Injury Auditor to verify past and recent incidents or accidents have
on all Sodexo employee incidents, been completed and reported no later than 24 hours of
L1 accidents and notifies the Sodexo occurrence.
Reporting Hotline 1-888-872-5676
no later than 24 hours of Access to report claims information on SodexoNet
occurrence? Key words: Report Claim
Does account management Applies to Sodexo Employees.
complete a root cause analysis that The Injury Investigation process must be completed and root
includes: (Investigation tab with cause(s) identified using the 5 Whys.
Safety Nets completed), Cause tab Auditor to verify SALUS is actively used to track account
and Action plan tab) on all incidents incidents and accidents;
and accidents and this information is • Injury investigations (Safety Nets)
L2 completed in Salus? • Cause
• Corrective action plan.
RCA = Root Cause Analysis form can be found on Sodexo Net in
the forms center.
Key words: RCA or Root Cause Analysis
Access to SALUS on Sodexo Net on the EHS page:
Key words: SALUS
Does the account management team Applies to Sodexo Employees.
offer immediate Return To Work to Auditor to verify management is offering immediate Return to
injured Sodexo employees? Work to any injured worker by verifying Modified Duty offer
letter for any injury listed on the OSHA log.
L3 Modified Duty Offer Letter and Medical Treatment Form can be
found on SodexoNet in the Forms Center.
Key words: Medical Treatment Form, Modified Duty Offer
Letter.

Is a First Aid Kit(s) easily accessible Auditor to verify first aid kits are accessible.
to the work area? (29 CFR 1910.151) These supplies need to be stored in an area available for
emergency access.
If available within close proximity (same building), then point is
given.
L4
Client resources are acceptable as long as they are available
during our normal working hours.
Nursing stations, security personnel or client first aid that offer
these supplies and operate during employee’s hours of
operation are acceptable.

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Is a First Aid/CPR trained and Auditor to verify at least one employee must be trained in basic
certified employee(s) available? (29 first aid and CPR techniques.
CFR 1910.151) Training is available through Cintas and local First Aid health
service vendors.
If available with close proximity (same building or 4 minutes
L5 time), then point is given.
Also, acceptable if client nurse station or security personnel
offer immediate first aid / CPR to employees during hours of
operation and are within close proximity (same building and/or
4 minutes).

Is an Emergency eye wash station Auditor to verify an eye wash station is available and operating
available and operating properly properly within the immediate work area where employees are
within the immediate work area exposed to corrosive materials.
where employees are exposed to DOES NOT SATISFY SAFETY REQUIREMENT:
corrosive materials? (29 CFR Bottled Eyewash or other Personal Wash units such as single
1910.151) head Drench Hoses are considered to be supplemental
equipment only.
"A personal wash unit may be kept in the immediate vicinity of
employees working in a potentially hazardous area. The main
purpose of these units is to supply immediate flushing. With this
accomplished, the injured individual should then proceed to a
plumbed or self- contained Eyewash and flush the eyes for the
required 15-minute period."
The Auditor will not test the self-contained portable eye wash
station, but will inspect the fluid level and expiration date.
Points will not be awarded if either is deficient.
L6
Tepid Water:
Range should be 60°-100°F.
If temperature is above 100°F, issue Auditor comment to GM to
address the need to tepid water.
Simultaneous Operation:
In laundries and facilities management, the Drench Shower and
Eye Wash Unit must be fully operable at the same time to
properly flush both the skin, eyes, and face.
All flushing equipment must be located in areas that are
accessible within 10 seconds (roughly 55 feet) of anywhere
where corrosive chemicals are mixed, dispensed, and/or stored.
This is commonly referred to in the industry as the 10 second
rule.
The Safety Showers and or Eyewash Stations must be located on
the same level as the hazard and the path of travel shall be free
from obstructions.

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Items such as trash cans, pallet jacks, boxes, raw materials, or


any other stored items must not block access to the flushing
stations. Also, a door is also considered an obstruction. If the
hazard is non-corrosive, 1 door can be present as long as it
opens in the same direction of travel as the person requiring the
use of the flushing station.

Proper maintenance and weekly testing is necessary to ensure


that Emergency Drench Showers and Eyewash Stations are
functioning safely and properly. Weekly testing helps clear the
supply lines of sediment and bacteria build-up that is caused
from stagnant water. At this time, documentation is not
required
HC. Healthcare Specific Guidelines
Blood-borne Pathogens: Auditor to verify the following:
Healthcare Wide Hazards - Applies Applies to Healthcare Segment.
to Healthcare Segments: • Management should -
Are employees with occupational • Evaluate exposure to determine if all job classifications
exposures to blood-borne pathogens have occupational exposure or reasonably anticipated
or bodily fluids offered Hepatitis B having occupational exposure, and
HC1 vaccinations? (29 CFR 1910.1030) • Ensure Hepatitis B Inoculation is offered and provided
at no cost to the employee (Declination form must be
competed where applicable).
Client programs are acceptable, If documented.
A copy of the program must be presented to Auditor.

Infectious TB: Auditor to verify the following:


Healthcare Wide Hazards - Applies • Account must identify all employees potentially
to Healthcare Segments: exposed to infectious TB and must offer the purified
Are employees working in potential derivative Mantoux skin test.
HC2 close contact of infectious TB • Annual respiratory fit testing must take place.
offered the purified protein A copy of the program must be presented to Auditor.
derivative (PPD) Mantoux Skin Test?

Healthcare Wide Hazards - Applies Auditor to verify documentation showing training was reviewed
to Healthcare Segments: with all new hires and annually for all employees.
HC3 Is Tuberculosis Precautions Training Training resources available on Environment, Health and
provided to employees with Safety page on SodexoNet.
occupational exposure?

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FS. Food Service Specific Guidelines


Is the slicer unplugged and set to Auditor to verify slicer unplugged, set to zero / closed position
FS1 zero / closed position when not in when not in use.
use?
Is hot oil handled safely? Auditor to verify the following:
▪ By observing or asking employee responsible “What is the
process for this task”.
FS2 ▪ Oil, used in deep fat fryers, is cooled down to below 110
degrees F before handling for disposal or straining.
To reduce slip hazard, fats-oils- grease containers are covered to
prevent spillage.
Are safe knife handling procedures Auditor to visually verify that safe storage of knives, carrying
FS3 in place and used? knives, sharpening of knives, cutting on stable surface, carrying
knives with blade downwards, and cut-resistant glove worn.
Are walk-in freezer/cooler floors free Auditor to verify walk-in freezers/coolers floors are free of any
FS4 of ice? ice. If ice is present on the floor walkways then no points will be
awarded.
Do accounts that perform kitchen Auditor to verify cleanliness of grout; soil load on floor, greasy,
floor cleaning use Wash' n Walk as slippery floor; “clean as you go” not practiced.
its daily floor cleaner complete with • Auditor should ask the employees that mop
deck brushing or Dual Tool? “How they use walk n wash.”
If they do not say that they deck brush or use dual tool. No
points awarded.
FS5
Scrape a quarter in the grout area to help determine soil load.
If water supply is “hot” – no points awarded.
Exception for floors requiring use of other Sodexo approved
floor cleaner at the request of client or facility manager due to
the nature of the flooring material?

The floor surface area around the fat Auditor to verify area around the oil disposal container is kept in
disposal container(s) (i.e. drum) is clean condition.
FS6
kept in clean condition?

Is safe access and egress provided in Auditor to determine if the traffic flow from kitchen to server
kitchens and frequently traveled area is safe and defined by the operation.
corridors? For instance, the risk of collision is reduced through a window in
FS7
the door, the doors are marked as “IN and OUT”, staff is trained,
warning signs on cooler/freezer doors, etc.

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Is the automatic fire protection Auditor to verify fire extinguishing systems in the Kitchen Hoods
system for the commercial kitchen has been inspected annually.
hood(s) inspected and serviced by If ventilation hood does not work, check to see if the manager
FS8
qualified person(s) and service submitted work order or scheduled work with in the last
inspection tag current within the last month.
12 months?
Are commercial kitchen hood(s) and Auditor to verify the hood systems are clean and there is no
filter(s) clean and free of grease excessive grease accumulation. If not, then work orders are
FS9
accumulation? submitted at least monthly until addressed.

Does the dish room and commercial Auditor to visually check to ensure ventilation performance and
kitchen hoods ventilation system lighting is working properly.
work and operate efficiently? There are several things to look for when determining whether
a commercial kitchen ventilation system is getting enough
replacement make up air. Signs that a kitchen is not properly
ventilated should cause Sodexo managers to immediately
rectify the situation to prevent the development of dangerous
health or fire hazards.
Here is a list of some of the most common signs that a
commercial hood, exhaust fan, filter, ductwork or replacement
make up air system is not functioning properly:
Doors do not open and close properly: If outward opening doors
are difficult to open or are slamming shut, this is a sign that
adequate replacement air is not returning to the commercial
kitchen. Check filters and fans and ensure they are clean and in
good working order.
FS10
Smoke lingering in the kitchen: A smoky commercial kitchen is
not properly ventilated. Smoke should be effectively drawn out
by the commercial hood, and directed out through the
ductwork with the fans.
Pilot lights go out: When pilot lights are extinguishing
intermittently, it is likely due to drafting and improper air
circulation from the commercial kitchen ventilation system.
Extinguished pilot lights can cause a buildup of gas fumes and
lead to high carbon monoxide levels. Also, the potential for
dangerous explosion of the fumes is present.
Problems with the motors of exhaust fans: When a
commercial hood exhausts fan breaks, it is usually because the
motor is overworked. The motor will have to work harder when
replacement make up air systems are not working in
conjunction with the commercial vent hood.

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If applicable, does account Auditor to verify the following:


management ensure alcohol • Completed Alcohol Responsibility Training
responsibility training and liquor • Liquor License
FS11
license checks when serving and/or Training available on Ingenium
selling alcohol? Key words: Responsible Alcohol Service Training

In wet or damp locations, are outlets Auditor to verify wet or damp locations have GFCI (ground fault
protected by GFCI (ground fault circuit interrupter) installed on outlets.
FS12
circuit interrupter)?

Is Knife Safety Training provided to Auditor to verify documentation showing training was reviewed
those employees using knives? with all new hires and annually for all employees.
FS13
(OSHA's General Duty Clause) Training resources available on Safety page on SodexoNet

Is Burn Prevention Training Auditor to verify documentation showing training was reviewed
FS14 provided? with all new hires and annually for all employees.
Training resources available on Safety page on SodexoNet
FM Facilities Management Specific Guidelines
In wet or damp locations, are Auditor to verify the following:
portable electrical tools and In wet or damp locations are portable electrical tools and
equipment UL rated and protected equipment UL rated and protected by GFCI. Look for test re-set
by GFCI? switch on electrical plug or wall socket.
FM1
*Not applicable to Patient
Transport

Do employees wash hands after Auditor to verify employees are washing hands.
eating, drinking, smoking, using the • Auditor to observe employees over a period of time. If
restroom, when visibly soiled, before hands are not washed between tasks then no points
FM2
and after patient transport, handling awarded.
linen, emptying trash, using
chemicals, etc.?
ASBESTOS: Auditor to verify
If asbestos or presumed asbestos This audit requirement applies to Asbestos containing Materials
containing materials (ACM) are (ACM) or Presumed ACM that exists in buildings built before
FM3 present, does Sodexo management 1981.
maintain a copy of client ACM • The account must have accessibility to Asbestos
management plan and are locations Management Plan. A copy of the program must be
identified with signage? presented to the Auditor.

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*Not applicable to Patient • In the event of that asbestos is suspected, the Asbestos
Transport. Discovery Checklist must be followed by on-site
management to ensure all necessary and appropriate
action is taken.
• Sodexo employees are NOT asbestos abatement
contractors and must NOT perform Class I or Class II
asbestos work.
• Locations are identified with signage, example:

Asbestos Discovery Checklist can be found on SodexoNet


Key words: Asbestos Discovery Checklist
ASBESTOS: Auditor to verify training is completed.
Are Sodexo personnel or Sodexo At accounts where Sodexo personnel or Sodexo managed
managed personnel that may be personnel may be required to conduct work on asbestos
required to conduct work on containing material ACM/PACM. At least one
Asbestos Containing Materials (Class manager/supervisor on site meets the qualifications as
FM4 III and/or IV Asbestos Work) trained Competent Person (16-hour EPA approved course).
and certified in an EPA Approved 16-
Hour asbestos operations and
maintenance course?
*Not applicable to Patient
Transport, and Laundry services.
ASBESTOS: Auditor to verify that the two-hour asbestos awareness training
Is Asbestos Awareness Training is completed annually for all Sodexo personnel or Sodexo
provided? (29CFR1910.1001) managed personnel that have a possibility of coming into
contact/disturbing ACM/PACM. This training must be provided
*Not applicable to Patient by a qualified competent person.
FM5
Transport and Laundry services. Training must include hazard awareness, location of ACM, and
action if encountered in the workplace?
Training can be found on SodexoNet on the Safety Page in the
training section.
Key words: Asbestos Safety
Is Electrical Safety Training Auditor to verify all training is completed by Sodexo personnel
provided? (29 CFR 1910.303) or Sodexo Managed personnel that are classified a qualified
employee.
FM6
Training resources available on Environment, Health and
Safety page on SodexoNet
Key word: Electrical Safety

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*Not applicable to Patient


Transport and Environmental Training must include content that covers NFPA 70E.
Services. Training resources available on SodexoNet in Ingenium.
Key word: NFPA 70E
Does account conduct a Auditor to verify risk assessment has been completed prior to:
documented risk assessment and Performing any high-risk, non-routine and foreseeable
review with employees prior to emergency tasks or activities, before the introduction of new or
performing all high-risk, non-routine revised activities or procedures and where hazards are
and foreseeable emergency tasks or identified in existing work activities or following an incident.
activities? Any form of risk assessment is acceptable.
Risk assessments must be carried A sample Risk Assessment Template is available on Sodexo Net
out proactively for all routine, non- Take 5 Dynamic Risk Assessment can be found on SodexoNet
routine and emergency conditions Key words: Take 5 Dynamic Risk Assessment
FM7 and activities, before the
introduction of new or revised
activities or procedures and where
hazards are identified in existing
work activities or following an
incident?
*Not applicable to Environmental
Services, Patient Transport and
Laundry Services.
Is a Permit to Work form used and Auditor to verify permit to work form is used and issued to the
issued to the General Manager General Manager before work can proceed on any of the
before work can proceed on any of situations set out below:
the situations that requiring a permit • live working on electricity supply systems, complex electrical
to work? equipment or other work on electrical equipment;
• hot work;
*Not applicable to Patient • work at height, including work on or from scaffolding,
Transport and Environmental suspended working platform, or access to roofs without secure
Services. edge protection;
• entry and work within confined spaces;
FM8
• non-routine lifting operations;
• work involving interaction with asbestos;
• work involving the use of radioactive materials and explosives;
• work involving the isolation of, or modification to, fire safety
systems;
• work which may involve breaking containment of a flammable
or hazardous material;
• working on or near unguarded moving machinery;
• work on pressure systems, including pressure testing of
vessels;

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• any other activity which has been identified through a risk


assessment as being potentially hazardous.
Auditor to review recently completed permit to work form.

Forms can be found on SodexoNet in the Form Center and the


Revised EH&S Safety Policies and Procedures Manual
Key words: Permit to Work
Confined Space: Are all permit- Auditor to verify by asking:
required and non-permit required Do you conduct services in confined spaces such as boilers,
confined spaces identified, tunnel washers (laundry plants only), or manholes?
inventoried and properly classified Spaces that can be partially or bodily entered and are not
(i.e. tunnel washer)? designed for continuous habitation must be labeled Confined
Space.
*Not applicable to Environmental All confined spaces must be identified
Services and Patient Transport.

FM9

NOTE: A sign reading


DANGER -- PERMIT-REQUIRED CONFINED SPACE, DO NOT
ENTER or using other similar language would satisfy the
requirement for a sign.
A Confined Space above that has an exposure that is
Immediately Dangerous to Life or Health must be labeled a
Permit Required Confined Space.
An inventory (list) of Permit Required Confined Space, which
our employees have the likelihood of entering is presented to
Auditor.
Confined Space: If applicable, are Auditor to verify
affected Permit Required Confined Employers must train affected employees before initial
FM10 Space entrants and attendants assignment, before a change in duties, whenever there is a
trained upon initial job assignment change in permit space operations that presents a hazard about
and prior to entry? (29 CFR which an employee has not previously been trained, or

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1910.146). *Not applicable to whenever the employer has reason to believe either that there
Environmental Services and Patient are deviations from the permit space entry procedures required
Transport. or that the employee’s knowledge of these procedures is
inadequate. Employee rescue service personnel must make
practice rescues at least once every 12 months.
If applicable, are all energized parts Auditor should not enter energized parts (exposed wiring). This
of electrical circuits and equipment is a distance visual check only.
FM11
guarded against accidental contact
by approved cabinets or enclosures?
If applicable, are all disconnecting Auditor to verify circuit breakers are all labeled.
switches and circuit breakers labeled
to indicate their use or equipment
FM12 served?

Are the working/shop areas clean Auditor to verify work/shop areas are clean and orderly with
and orderly with sufficient lighting? sufficient lighting to easily read newsprint at arm’s length.
FM13
*Not applicable to Patient
Transport.
Are fall protection requirements Auditor to verify fall protection requirements are met when
implemented when working at working at heights of 48” of higher above a lower level.
heights of 48” or higher above a
FM14
lower level? Note: to include but limited to roof work, powered platforms,
*Not applicable to Patient aerial lifts, and vehicle mounted work platforms.
Transport and Laundry Services.
If aerial lifts or cranes are used, then Auditor to verify
equipment must be inspected prior These inspection records should include:
to use and only operated by a • Date of inspection
FM15
trained employee. Are inspections • Signature of the person who performed the inspection
documented and is there evidence • Serial number or other identifier.
that operators are trained? • Manufacturer's maintenance and inspection records
*Not applicable to Patient • Forms/checklist, or equivalent should be used.
Transport and Laundry Services.
Power Industrial Trucks: Auditor to verify a pre- inspection is performed on all powered
Is a pre-inspection performed on all industrial trucks.
powered industrial trucks (forklifts)? Commonly used types include:
*Not applicable to Patient High lift trucks, counterbalanced trucks, cantilever trucks, rider
FM16 Transport. trucks, forklift trucks, high lift trucks, high lift platform trucks,
low lift trucks, motorized hand trucks, pallet trucks, straddle
trucks, reach rider trucks, high lift order picker trucks,
motorized hand/rider trucks, and counterbalanced front/side
loader lift trucks.

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Observe dumping trash? Auditor to verify the following practices are followed:
• Are protective gloves worn?
• Roll barrels and other equipment containing trash
bags as close as possible to the dumpster.
• If the bag is too heavy, get help.
• With feet and body facing the dumpster, step closer
and toss the bag forward into the dumpster.
FM17 • Avoid twisting. Do not toss sideways.
• Use a step-up platform next to the dumpster to
empty trash bags. It will reduce lifting above
shoulder height.
• Place the dumpster next to the loading dock, if one
is available.
• Mechanized trash dumpster is a plus – trained
operator?
Machine Guarding & Hand Tools: Auditor must visually verify that guarding methods are in place,
Are correct safety guards in place such as, barrier guards, two-handed tripping devices, electronic
and properly installed for equipment safety devices, etc.
with rotating or moving parts (belts, Machine guarding must be provided to protect the operator and
fans, saw blades)? other employees in the area from such hazards as point of
For grinders, do side guards cover operation, ingoing nip points, rotating parts, flying chips and
FM18 the spindle, nut, flange and 75 sparks.
percent of the wheel diameter?
Is a work rest used and kept
adjusted within 1/8 inch of the
grinding wheel? *Not applicable to
Environmental Services, Patient
Transport and Laundry Services.
Machine Guarding: Are emergency Auditor to verify stop controls are in place and clearly
stop controls provided, or are circuit accessible.
breakers controlling machines
FM19 clearly marked and accessible?
*Not applicable to Environmental
Services and Patient Transport.

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Tools and equipment used by Auditor to verify tools and equipment are in safe working
employees are in safe working condition
condition and used for their One way to get injured on the job is using the wrong tool for the
intended use? job. Two important points to remember when using hand tools
is the selection of the tool for the job and the use of the tool for
the job.
Auditor’s will verify these general points:
• Keep your tools clean and in good condition.
• Choose the right tool for a specific job.
• Never use a tool not designed for the job you are doing.
• Never carry tools in your pockets.
• When chipping or cutting, wear eye protection.
FM20 • Be wary of the effect of your actions on other nearby
workers.
• Use a pulling motion to operate hand tools rather than
a pushing method.
• Never leave hand tools in areas where they may be
kicked off onto lower levels or where they may be a
tripping hazard.
• Never improvise.
• Don’t adapt or use “cheaters.”
• Never remove an electrical cord by jerking it; pull it
away from power by the plug.
• Always be sure that power tools are electrically safe.

Employees do not wear loose fitting Auditor to verify no employee is wearing loose clothing (open
clothing and jewelry and tie back cuffs, long un-tucked shirt tails) and un-restrained hair (hair
long hair while operating equipment falling beyond shoulder length) are entanglement hazards with
FM21 or when near moving equipment? equipment.
*Not applicable to Environmental
Services and Patient Transport.

HAZARD ENVIRONMENT: Auditor to verify if there is a job task that requires a respiratory
Is there a job task that requires a protection program. If yes, then the following must be
respiratory protection program or completed.
do employees voluntarily wear • A roster showing a list of all affected employees
respirators? Is a respiratory • Annual fit testing is conducted.
FM22
protection program established and • Annual training is conducted
fit testing conducted where • Respirators are being maintained and inspected
employees are exposed to air
contaminants and required to wear
respirators?

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NOISE: Are high noise work areas Auditor to verify


identified and controls taken? There Hearing conservation required for areas where noise exposure
must be a Hearing Conservation exceeds action level of 85 dBA @ 8-hour time weighted
Program for areas where noise average.
exposure exceeds action level of 85 Indicators of high noise levels:
dBA @ 8-hour time weighted • Noise interferes with speech communication and
average? (29 CFR 1910.95) warning signals.
• When tool or machine operating instructions
recommend the use of hearing protection equipment.
• High noise level task includes grounds keeping (i.e.
FM23
mowing, chipping, leaf blower, etc.), wood working (i.e.
using a planner), welding (i.e. plasma arc welding).
• Employee comments about high noise levels.
If the above indicate high noise, ask for monitoring results and
controls taken.
Examples:
• Hearing protection required;
• Limit the time on noise producing equipment or task to
reduce exposure; etc.
A copy of the program must be presented to auditor.
NOISE: If applicable, are employees Auditor to verify
in high noise areas involved in the If noise exposure is equal or exceeds the action level (85 dBA
FM24 Hearing Conservation Program, TWA), then the account must provide free audiometric testing
including annual audiometric (audiograms must be performed annually).
testing?
NOISE: If applicable, is approved Auditor to verify hearing protection equipment is available to
hearing protective equipment (noise every employee working noisy areas.
attenuating devices) available to
every employee working in noisy
FM25
areas (e.g. boiler room, wood planer,
lawn mowing, plasma arc welding,
and laundry facility)? (29 CFR
1910.95)
Are oily rags and combustible wastes Auditor to verify oily rags are to be disposed of in metal
kept in metal containers with lids? containers with lid. Body Material Galvanized Steel; Lid Type
*Not applicable to Environmental Foot Operated Self Closing.
Services, Patient Transport and
FM26 Laundry Services.

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Are flammable liquids (e.g. gasoline) Auditor to verify flammable liquids are stored properly.
stored in safety cans or inflammable
cabinets? *Not applicable to
Environmental Services, Patient
FM27 Transport and Laundry Services.

If applicable, no evidence of smoking Auditor to verify


in same room as oxygen systems, Sample Label – every compressed gas cylinder must be labeled.
and no open flames (gas stoves,
heat, candles, etc.) within 6 feet of
FM28 oxygen system?

Are all gas cylinders clearly labeled Auditor to verify


and protective caps in place over the All compressed gas cylinders not in use are required to have a
valves of all gas cylinders which are protective cap or collar.
not in use?
FM29 *Not applicable to Environmental
Services, Patient Transport and
Laundry Services.

Where applicable, are sharp/needle Auditor to verify


container(s) available and in close Sharp containers must be located in the immediate vicinity of
proximity to areas where needles the soiled linen sort.
may be found (i.e. Soil sort area,
healthcare facilities, and restrooms)?

FM30

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Issue Date: 08/01/2018 Approved By: VP HSE

PT. Patient Transport Specific Guidelines


Hallway mirrors are used during Auditor to verify hallway mirrors are used during transport of
transport of patients? In the patents. If no mirrors, is a process in place to ensure safety is
absence of hallway mirrors, is a maintained during transport.
PT1
process in place to ensure safety is
maintained during transport?
*Applies to Patient Transport only
Aisles and passageways are wide Auditor to verify aisles and passageways are wide enough for
enough for easy movement and kept easy movement and kept clear at all times.
PT2
clear at all times.
*Applies to Patient Transport only.
Are stretchers/wheelchairs pushed, Auditor to verify employees not observed pulling stretchers or
not pulled, and maintained in good wheelchairs and equipment is in good condition.
PT3 condition? Exception: exiting a patient room – pulling is acceptable so
*Applies to Patient Transport only. transporter can see if anyone is passing by the room.
When lifting equipment is not being Auditor to verify
used, are safe lifting practices For the conscious, mobile patient a minimum of two personnel
PT4 followed for patient transfers? is required. For the semi-conscious or unconscious, non-mobile
*Applies to Patient Transport only. patient, a minimum of four personnel is required.
Are two patient identifiers checked Auditor to verify documentation is completed for transporting
before transport of every patient patients.
and a handoff communication
PT5 document completed and (Ticket to Ride, Hall Pass, SBAR, etc.)
transferred with every patient who
is transported?
*Applies to Patient Transport only.
Are brakes locked on transport Auditor to verify brakes are locked on transport equipment in
equipment in storage and prior to storage and prior to transferring a patient?
PT6
transferring a patient?
*Applies to Patient Transport only.
Is the following training provided to Auditor to verify training records
all patient transporters: Diagnostic Diagnostic Imaging Safety Training, Equipment Safety, Care and
Imaging Safety Training, Equipment Cleaning Training, Hand Hygiene & Infection Control Training.
PT7 Safety, Care and Cleaning Training, (Client based program acceptable).
and Hand Hygiene & Infection
Control Training?
*Applies to Patient Transport only.
Are emergency scenarios during Auditor to verify training records
transport reviewed: various codes, Various codes, combative patients, etc.
PT8
combative patients, etc.? (Client based program acceptable).
*Applies to Patient Transport only.

49
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 50 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

CTM. Clinical Technology Management Specific Guidelines


NEW: New employee’s complete Auditor to verify the following training subjects are completed
mandatory safety training as for all new hires and annually for all employees.
outlined in CEM.021 within 30 days List of required training:
of employment and annually for all
CTM employees.
*Applies to CTM Accounts only.

CTM1

Additional information on this topic can be found in the CEM


Procedures Manual.
NEW: All Imaging Service Engineers Auditor to verify ALL (ISEs) have completed radiation safety
(ISEs) on-site have completed training with in the past 12 months.
CTM2 radiation safety training with the If there are no ISEs, the answer is N/A.
past 12 months. Additional information on this topic can be found in the CEM
*Applies to CTM Accounts only. Procedures Manual.
NEW: All Imaging Service Engineers Auditor to verify personally assigned dosimetry badges are worn
(ISEs) on-site have a personally while servicing radiation producing equipment.
assigned dosimetry badge that they If there are no ISEs, the answer is N/A.
CTM3
wear while servicing radiation Additional information on this topic can be found in the CEM
producing equipment. Procedures Manual.
*Applies to CTM Accounts only.
NEW: All Imaging Service Engineers Auditor to verify ALL (ISEs) have registration on file.
(ISEs) on-site have been registered If there are no ISEs or if the state does not require registration,
CTM4 with the state to service radiation the answer is N/A.
producing equipment. Additional information on this topic can be found in the CEM
*Applies to CTM Accounts only. Procedures Manual.

50
Document #: 1.1
Health and Safety Audit Guidelines – FY 2019 Rev. #: 11
Director of H&S
Document Location: Health & Safety Policy Manual Document Owner: Rev. Date: 06/29/2018
Programs
Page 51 of 51
Issue Date: 08/01/2018 Approved By: VP HSE

NEW: Verify through personal Auditor to verify by asking manager if there are any lost time
interview and documented evidence accidents for the current FY. Can be verified by reviewing the
that there have been no lost work OSHA log for the current year.
CTM5 days due to a job-related injury this If any lost time accidents, no points are awarded.
fiscal year.
*Applies to CTM Accounts only. Additional information on this topic can be found in the CEM
Procedures Manual.
NEW: Verify through personal Auditor to verify by interviewing a CTM staff on their roles and
interview that Sodexo CTM staff is responsibilities during a facility emergency code situation.
aware of roles and responsibilities
CTM6
during facility emergency code Additional information on this topic can be found in the CEM
situations. Procedures Manual.
*Applies to CTM Accounts only.
NEW: No food or beverages are Auditor to verify NO food or beverages are being consumed in
being consumed in designated work designated work areas.
CTM7
areas. Additional information on this topic can be found in the CEM
*Applies to CTM Accounts only. Procedures Manual.

51

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