Environment of Care

Inspection Guidelines
Safety Officer’s Hazard Surveillance

Environmental Health & Safety

NYULMC, August 2014
This presentation will explain:
 Key steps to conduct Environment of Care (EOC) inspections of
patient care areas effectively
 Inspection Guidelines using the Environmental Health & Safety
Hazard Surveillance checklist, which covers the following categories:
• Emergency Preparedness • Medications
• Fire Safety • Safety
• Hazardous Materials and Wastes • Security
• Infection Control • Utilities
• Medical Equipment
Key steps to conduct EOC inspections effectively
• Upon arrival, introduce yourself to the Charge Person and give them the
option of accompanying you.
• Complete the appropriate checklist during the inspection, and inspect all
areas, including but not limited to:

• If possible, review findings with the Charge Person person before leaving.
• Report findings to responsible parties as soon as possible.
• Submit completed checklist to the group responsible for data collection.
Inspection Guidelines:

Emergency Preparedness

Presentation Title Goes Here 4

Emergency Preparedness
Phones have current emergency phone # stickers

Example of the correct phone sticker at the Main Campus

Make sure that all phones have

the red sticker with the
emergency phone number for
the specific location
• Main Campus – 33-911
• HJD – 3-911
• Offsite locations vary (most
are 911 or 9-911)
Stickers are available from
Telecom

For emergency, please call 33-911

Inspection Guidelines:

Fire Safety

Presentation Title Goes Here 6

Fire Safety
Fire Alarm pull stations not blocked
Fire extinguishers not blocked
• Make sure that there is nothing in front of fire alarm pull
stations or fire extinguishers, not even mobile objects
• Extinguishers must be readily accessible and not obscured
from view

Not OK
 Fire Safety
Fire extinguishers installed so that the top of the extinguisher is
no more than 5 feet above the ground
• Make sure that there are no extinguishers on the ground!
• All extinguishers must be mounted so that they are readily accessible to
employees without subjecting them to possible injury

Fire extinguishers must be hung with the

top no higher than 5’ from the ground.

5’

Not OK
Not OK OK
 Fire Safety
Current inspection tags on fire extinguishers
 Punched holes indicate
month/year of last annual
inspection
• If the date on the tag is over 1
year ago, the annual inspection
is overdue!
Year inspected
 At the main campus, monthly
inspection dates are maintained
electronically. At other locations,
monthly inspection dates may be
logged on the back of the tag.
• If the last date written on the
back of the tag is not within the
last month, the monthly
inspection may be overdue!
Month inspected
Fire Safety
Exit signs are present, properly maintained, and direct to exit
• Exit signs must not be obstructed
• Exit signs must be visible from every point in the corridor
• Arrows must point to the path of egress/exit door
• Watch out for contradicting signs!

Not OK

Although marked as an exit, sign on Exit sign obscured

door says “do not enter”
Fire Safety
Corridors doors properly maintained
• Corridor doors must:
− Be in good condition
− Close and latch properly
− Not be missing any hardware

Missing lock hardware

Fire Safety
No door in fire or smoke barrier held open with door stop
• No unapproved devices (e.g., doorstops, carts, other objects)
Magnets used to hold
• Approved devices installed by Facilities Operations are OK fire doors open

Approved devices OK for

offices and patient rooms

No jammed door jams or latches Nothing holding door open

Fire Safety
Laundry chute securely latched and locked
• The laundry chute should not be accessible without a key or code
• The chute door or closet door to chute area should not be held open
• Verify that keypad combinations are not written on the wall
 Fire Safety
No penetrations in smoke or fire barriers
• Any hole that goes all the way through a fire barrier
is a penetration
• Approved cabling pathways may be used
Approved cabling pathways

Watch out for these

common penetrations

Gaps around pipes Holes left behind from construction Look closely for cracks in
fire-stopping material
Fire Safety
Evidence of smoking
Smoking and the use of tobacco products* are prohibited:
• At all owned and leased medical center facilities
• On roofs and grounds, including courtyards and gardens of owned and
leased facilities
• In front and on the sidewalks of owned and leased medical center facilities
• Within 15 feet of any entrance to or exit from a medical center facility

Watch out for evidence of smoking:

In bathrooms & stairwells
On grounds, sidewalks and roofs

*This includes cigarettes, cigars, pipe tobacco,

powdered tobacco, chewing tobacco, electronic
cigarettes, and any other tobacco-containing substance.
Fire Safety
Storage at least 18” below sprinkler heads
• No storage is permitted directly below a sprinkler head Must be 18”
within an 18 inch radius. or more

• Sprinklers may be visible or covered

• Watch out for sprinklers in storage closets!

Uncovered sprinkler head

Boxes stored too close to sprinkler Covered sprinkler head

Fire Safety
Corridors free from mobile storage

What is mobile storage?

Any item on wheels which can be easily moved, including:
• Crash carts
• Isolation carts
• Food carts
• Garbage carts
• Gurneys
• Clinical Equipment
 Mobile items in corridors are OK in the following situations:

Code allows crash carts in corridors Storage is allowed in alcoves Mobile items are permitted in
corridors when in use or
charging (30 min or less)
Not OK
Fire Safety
Corridors free from non-mobile storage
What is non-mobile storage?
Any item not on wheels:
• Chairs
• Cabinets and lockers
• Other furniture
• Pallets

Not OK
 Fire Safety
No wall computer station left open
• All computer stations must be closed when not in use.
• If patient information is visible, this is a HIPAA violation! (see slide #74)

Not OK
Fire Safety
No storage in exit stairwells
• Nothing is permitted to be stored in exit stairwells!

Not OK
Fire Safety
No ignition source within 1” of an ABHS dispenser, or directly below
its horizontal clearance area
Ignition sources include:
• Outlets and light switches
1”
• Electrical cover plates
• Phones and intercoms
1” 1”
• Electric or electronic thermostats
• Lights of any kind
• Mobile electrical equipment
• Electrical beds (motors, foot controls, nurse call)

No ignition sources allowed

within purple area
Fire Safety
Other fire safety issues
Includes any condition that increases the risk of starting a fire, increases the risk
of injury in the event of a fire, or compromises the effectiveness of fire safety
devices.
Look for the yellow tie!
For example:
• Fire extinguisher missing yellow tie
• Excess storage of flammables/combustibles
• Sprinklers damaged or impaired

Not OK

Excess storage of combustibles Sprinkler damaged by corrosion

Inspection Guidelines:

Hazardous Materials and Wastes

Presentation Title Goes Here 25

Hazardous Materials and Wastes
Appropriate PPE (e.g., gloves, goggles)
Examples of proper use of PPE include:
• Wearing gloves when handling hazardous materials
• Not reusing gloves
• Wearing an apron, long sleeves and/or lab coat when there is potential
for splashing the body when handling hazardous materials
• Wearing goggles or a face shield when there is potential for splashing
the eyes when handling hazardous materials
• Wearing lab coats designated for lab use in the lab, and NOT wearing
them outside the lab
Hazardous Materials and Wastes
Patients/visitors can’t access sharps, chemicals or other
hazardous materials
• Sharps include items that have the potential for
laceration, puncture or cutting of the skin. Some
examples include:
− Needles
− Blades (such as razors or scalpels)
− Broken glassware
• All sharps, chemicals or other hazardous materials
must be stored in locked carts/cabinets or behind
locked doors.
• Any unlocked medications should be marked as
deficient under “Medications” (slides 63 & 64).
Sharps in cabinet without locks
Hazardous Materials and Wastes
Cleaning compounds and other chemicals properly labeled

Check for:
• The name of the product (e.g., hydrogen peroxide)
• Hazard warnings (eg., corrosive, flammable, poison, etc.)
Hazardous Materials and Wastes
Safety Data Sheets (SDSs) readily accessible

• If you do not see the SDS binder, ask staff to point it out

• Check binder for products used in the area!

Note: ‘Material Safety Data Sheets (MSDSs)’ are now called ‘Safety Data Sheets (SDSs)'.
Either are acceptable until 2016.
Hazardous Materials and Wastes
No large quantities of injurious chemicals present (unless plumbed
eye wash is available)
A plumbed eye wash is required in areas with:
• Large amounts of undiluted corrosive chemicals, and
• Potential for eye or body exposure

The following items do not require an eye wash:

• Small containers of undiluted drugs <100mL
• IV bags of hazardous drugs (typically dilute solutions)
• Wipes (e.g., bleach) Corrosive
• Alcohol-based hand sanitizer

Large quantities of injurious chemicals

Hazardous Materials and Wastes
No portable eye washes (e.g., saline bottles)
• Portable eye washes are often 32 oz. bottles of sterile saline solution. Since
they do not provide adequate volume and they expire, portable eye washes
should not be present.

Eye wash is tested weekly (documentation available)

• All plumbed eye washes must be tested weekly with documentation readily
available. If the eye wash does not have a tag with the last test date, ask
staff to see the paper log.

Portable eye wash not allowed Plumbed eye wash

Hazardous Materials and Wastes
Porter’s closet locked
• The porter’s closet (in some locations called the janitor’s closet)
contains janitorial supplies, including hazardous cleaning chemicals
• The porter’s closet must be locked at all times when unattended
• Make sure that no keypad code is written on the wall

All porter’s closets must be locked.

Hazardous Materials and Wastes
No improper storage of hazardous materials or wastes
(e.g., red bags on the floors)
• Hazardous materials must be stored properly depending on the
chemical (e.g., collodion must be stored in a flammable storage
cabinet). If uncertain, consult the SDS or contact EH&S. Waste not contained

• Hazardous drug waste must be disposed of in black containers

• Regulated medical waste must be disposed of in red bags or
containers
• Full hazardous waste containers should be stored in the soiled
utility room until pick-up
Red bags on floor
• Make sure that:
− Hazardous materials and waste containers are firmly closed and
stored upright
− Waste is completely contained and not overflowing from bins
− No hazardous waste or red bags are directly on the floor
− No waste was disposed of in inappropriate containers or left outside
of containers (e.g., silver dressing left on counter)
Hazardous waste bin
attached to cart
Hazardous Materials and Wastes
No improper disposal of sharps
• Sharps containers must be tight sealing & hard sided with closeable lids
• All needles, blades and broken glass must be disposed of in sharps containers
• Nothing should be protruding from a sharps container
• Sharps containers must be closed before reaching the fill line, or when no
more than 90% full

Too full!
 Hazardous Materials and Wastes
All waste properly managed and labeled
• Proper waste management includes ensuring that waste is picked up regularly
and necessary equipment is present and in good condition (e.g., biohazard
container closing mechanism works properly)
• All waste must be labeled clearly if hazardous or biohazardous
• Sharps containers and regulated medical waste must have a biohazard label
• Black boxes for hazardous waste must have the following:
1. RCRA label, AND
2. NYU Hospitals Center Hazardous Waste label (yellow)
RCRA label

The date must NOT be filled out!

(Hazardous waste must be disposed of within
3 days of this date. To avoid citation, the label
should not be dated until date of pick up).

NYU Hospitals Center

hazardous waste label

Excess accumulation of waste

Hazardous Materials and Wastes
If soiled utility rooms are not in direct sight of staff, or if unit requires
extra security, doors to soiled utility rooms are locked.

• Areas where there is an increased risk of

patients entering unauthorized spaces or
tampering with unsecured items (e.g.,
pediatrics and psychiatry units) require
extra security precautions for patient
safety
• Verify that combinations for keypad locks
are not written on the wall
Hazardous Materials and Wastes
Other hazardous materials and wastes issues
Includes any condition involving hazardous materials or waste that increases
potential for injury or environmental contamination.
Some examples include:
• Hazardous chemicals stored near open drains
• Waste containers blocked or inaccessible (e.g., boxes on top of container)
• Biohazard bags used to store other items
• In patient care areas, trash containers with over a 32 gallon capacity must
not be unattended (recycling and patient records awaiting destruction OK)

32 gallon bin Over 32 gallons Over 32 gallons

Inspection Guidelines:

Infection Control

Presentation Title Goes Here 38

Infection Control
No missing or broken ceiling tiles
No missing or broken floor tiles
No stained ceiling tiles
• A stained ceiling tile may indicate a leak
• Missing tiles can create infection control problems

If this is also a leak, it should be

marked as a plumbing deficiency
Infection Control
No visible mold growth
• Watch for mold behind peeling wallpaper, bumpers and other surfaces

No pest control issues

• Watch for evidence of rodents or pests (e.g., droppings, chewed wires)
Infection Control
No storage of clean supplies in dirty areas (e.g., soiled utility rooms)
Infection Control
Adequate cleaning (e.g., medical equipment) and housekeeping
• Medical equipment should be clean and ready for use
• Soiled equipment must be stored in the soiled utility room until picked up
• Counters and cabinets should be free of soiled materials
• Used hospital supplies and gloves must be discarded properly
• Vents and surfaces should be clean from dust

Not OK
Infection Control
Temporary construction barriers properly maintained.
• Zipper barriers and doors must be closed at all times
• All barriers (e.g., plastic, plywood) must be intact and properly sealed
• Entrances to construction sites must be locked when no construction
workers are on site.

Not OK OK
Infection Control
Appropriate PPE (e.g., gloves) used for work with patients
Examples of proper use of PPE used for work with patients include:
• Wearing gloves to perform medical exams and handle patient
samples
• Wearing hair caps, shoe coverings and disposable coveralls in
ORs and other clean areas
Infection Control
Linen stacks (on shelves or carts) covered
• Linens must:
• Be covered at all times, unless in a designated closet/cabinet
• Not be stored on top of the cart
• Not be stored directly with patient supplies or other items

Not OK

45
Infection Control
Paper towels and soap in dispensers
• Automatic hand dryers cannot be substituted for paper towels in
patient care areas

46
Infection Control
No improper use of N95s
• N95s must only be used by personnel who have been fit-tested and
approved in the past year for that specific size and model
• N95s are not protective against chemical vapors and gases, and
should not be used when handling such materials
• Watch for incorrectly donned N95s (e.g., straps twisted, mask not
fitted to face, staff with facial hair wearing N95s)

N95 models commonly used at the Medical Center:

Orange side up!

For more information, refer to Policy No. 136: Respirator Program for N95s on the
Environmental Health & Safety website. 47
Infection Control
No patient supplies under sink
• Nothing is permitted under the sink, not even cleaning supplies
No patient supplies on floor
• Patient supplies, even when in cardboard boxes, may not be stored
directly on the floor. Storage on pallets is OK.

Not OK
Infection Control
Supply cart covered
• Supplies on carts must be covered or stored in closed drawers

Not OK
Infection Control
All IV solutions on supply cart have intact wrappers
• IV solution bags should be wrapped to prevent evaporation and
contamination
• For IV bags that come 2 per wrapper: once one bag is removed, the
second can be stored in the wrapper in the clean utility room for up to
30 days
• Hard plastic (non-PVC) IV bags do not need wrappers
 Look for the
hourglass symbol
Infection Control
No expired supplies
• Mark this category if supplies are expired (if medications are expired, mark
under ‘Medications: No expired medications’)
• Check items such as sterile syringes, dressing gowns, alcohol wipes,
vacutainers, etc.
• Spot check several items for expiration date, and make sure to check some
items from the back of drawers, cabinets and closets
Infection Control
No employee food storage/consumption in patient care areas
• No coffee or water bottles, not even at nursing stations or in
cupboards
• No employee food storage in patient care refrigerators
• No eating or drinking except in designated areas

Not OK
Infection Control
ORs have positive pressure and isolation rooms have negative
pressure
• Check that ORs and clean utility rooms are under positive
pressure, and isolation rooms are under negative pressure
• To check pressure, stand outside the room and hold a handheld
smoke device or tissue up to the crack below the door.
• If the smoke or tissue is pulled inward, the pressure is negative.
• If the smoke or tissue is pushed outward, the pressure is positive.
Infection Control
Other infection control issues
Includes any condition that increases the potential for transmission of disease,
increases the risk of infection, or compromises the effectiveness of infection
prevention measures.
• All food packages in refrigerator sealed?
• Ice machines clean?
• Isolation rooms well marked?
• No sticky residues on walls painted surfaces?
• All wall fixtures (e.g., bumpers) in place?
• Properly cleaned toys in children’s play area? (ask about protocol)
• No employee personal items stored with patient care supplies?
Inspection Guidelines:

Medical Equipment

Presentation Title Goes Here 55

Medical Equipment
Current inspection stickers on life support ("high-risk") equipment
(i.e., ventilators, heart lung machines, anesthesia machines and
defibrillators) (check at least 3 items)
Current inspection stickers on non-life support equipment

• Check the sticker and make sure the item is not past its Inspection Due
date.
• If the equipment is overdue for inspection, write down the Clinical
Engineering ID # and location and notify Clinical Engineering the same
day.

If overdue, make sure to write

down the Clinical Engineering
ID number, not any other
number!

Inspection due
Medical Equipment
Airway cart log maintained

• Look for the binder atop the airway cart

• Verify that all shifts were checked:
• In 24-hour inpatient units, verify that
all shifts were checked.
• In other locations, make sure that all
shifts worked have been checked.

The PM shift for

December 22 is
missing.
Medical Equipment
Other medical equipment issues
Includes any condition that compromises the effectiveness of
medical equipment.
For example:
• Illegible inspection stickers
• Visibly damaged medical equipment
Inspection Guidelines:

Medications

Presentation Title Goes Here 59

Medications
No expired medications
• Mark this category if medications are expired
• Spot check several items for expiration date, and make sure to check
some items from the back of drawers, cabinets and refrigerators
• Notify the Charge Person for immediate disposal of expired meds
Medications
No insulin vials opened more than 28 days

No opened vials of insulin without expiration date

• Check for expiration date
• Check that it is not past expiration date
• Notify the Charge Person for immediate
disposal of expired insulin
Medications
No unlabeled medications

• Check that all containers are labeled with the contents

 Medications
No unlocked supply rooms with medications
No medications on counter, or in open bins on medication cart
No unlocked medication refrigerators or carts
• Check that all medication rooms are locked and not propped open
• All medications must be secured in locked cabinets, Omnicells or
Code posted on door
rooms
• Check that keypad combinations are not displayed or written on
the wall

Medication refrigerator
keypad

Omnicell automated medication

dispensing system
Medication unsecured Door propped open
Medications
Other medication issues (describe)
Includes any condition that compromises patient safety due to improper
medication management.
Inspection Guidelines:

Safety

Presentation Title Goes Here 65

Safety
Less than 300 ft3 of oxygen in storage
• No more than 12 small E cylinders of oxygen are allowed on a unit,
unless in an approved oxygen storage room.
Oxygen storage rooms
• Special oxygen storage rooms must:
• Be locked
• Separate flammables or combustibles by at least 5’ (for sprinklered rooms)
or 20’ (for non-sprinklered)

Not OK
• Have proper signage on the door

(unless in O2 storage room)

OK
Safety
Gas cylinders properly secured
• All cylinders must be secured in a rack, holder, or chained to the wall to
avoid falling over.

Not OK

OK
Safety
Full, unused oxygen cylinders are separated from partial and empty
• Once a cylinder is opened, it may not be grouped with the full cylinders.

Proper signage
Correct separation
Safety
No slip, trip or fall hazards
• If you find a spill or slip, trip or fall hazard, do not leave the area
unattended. Immediately notify staff (e.g., Building Services or
Environmental Services).
Watch out for:
• Cords, janitorial supplies, loose articles in the path of foot traffic
• Blind corners and uneven walking surfaces
• Puddles or ice near sinks and on restroom floors
• Potential for spills

Not OK Not OK
Safety
Other safety issues (describe)
Includes any condition that compromises patient, staff or visitor safety or
creates the potential for an unsafe situation.
For example:
• Unsecured items which may be dangerous (e.g., unattended maintenance
equipment or tools)
• Gas cylinders not clearly marked as full, in-use or empty
• In areas requiring extra security (e.g., pediatrics, psychiatry), all closets,
large cabinets and spaces where patients can hide must be locked

Should not be left unattended

Inspection Guidelines:

Security

Presentation Title Goes Here 72

Security
All employees wear ID badges
• ID badges must be visible above the waist
Security
Charts, papers with patient names/info, and electronic data are
protected/secured
• All patient information must be inaccessible and secured, in compliance
with HIPPA
• This includes:
• Computers logged in and unattended
• Charts (electronic or paper)
• Medication labels with patient information
• Items in the trash with patient information

Logged off is OK Logged in is NOT OK!

Exception: Some large screens with patient information are necessary for
nursing to monitor patient safety. If you are uncertain, ask the Charge Person.
Security
Other security issues
Includes any condition that compromises
patient security or creates the potential for
an unsafe situation.
• Pay special attention to security in areas
that require extra protection, such as
psychiatry and pediatric units
• Watch out for unauthorized people
following staff through doors or
entrances to secured areas without
proper screening (“piggy-backing”)

“Piggy-backing”
Inspection Guidelines:

Utilities

Presentation Title Goes Here 76

Utilities
No obvious air quality problems
Pay attention to:
• Smells. Note the way it smells – gas, chemical, burning or rotten?
• Excessive dust
• Too hot or too cold

Not OK
 Utilities
No medical gas deficiencies

Oxygen valves properly labeled

• All gas valves must be labeled
and distinguishable by color
codes below

OXYGEN (NFPA)
MEDICAL VAC (NFPA)
MEDICAL AIR (NFPA)
NITROUS OXIDE
WASTE ANESTHETIC GAS DISPOSAL (NFPA)
NITROGEN (NFPA)
CARBON DIOXIDE (NFPA)
INSTRUMENT AIR (NFPA)
Utilities
No plumbing deficiencies
Watch out for:
• Leaks (or buckets collecting water)
• No hot water
• Clogged drains
• Inadequate water
pressure
Utilities
MER and EC locked
IT closets locked
• If unlocked or open, write down room number or describe location
MER = Mechanical Equipment Room
EC = Electrical Closet

Check lock
Utilities
Electrical panels closed; locked in public areas Check lock
Junction boxes covered
• If unlocked or open, write down the full number on the panel
and describe its location (e.g., next to room TH204)

Open junction box Open electrical panels

Utilities
No exposed electrical wires
Utilities
No extension cords
In patient-care areas:
• Extension cords are not permitted (except for approved cords for use
only in emergency)
• Power strips are not permitted for use with medical equipment
• Hospital approved power strips may be used for surge suppression
for computers, printers, and copiers
In non-patient care areas:
• Extension cords are only allowed for temporary use, and must not run
through doorways, holes in walls, or other openings
Utilities
No lighting deficiencies (e.g., dirty fixtures, temporary lighting)
• No temporary light fixtures, such as lamps or construction lighting,
are allowed where permanent lighting is needed.
• Burnt out or missing light bulbs
• Inadequate lighting

Not allowed in patient care areas Dirty light panels

Utilities
No other electrical deficiencies
• No over-packed outlets or power strips
• No damaged/defective electrical equipment (e.g., outlets,
light switches)
• No broken or compromised outlets
Utilities
Other utilities issues
Includes any condition involving a utility that deviates from normal
function or has the potential to compromise patient care.
• Make sure to note the issue details
For example:
• Broken keypad locks

If keypad is broken,
mark this category
Inspection Guidelines:

Other

Presentation Title Goes Here 87

Other
Adequate space
Adequate cleaning and housekeeping
• Equipment and supplies should be orderly and not cluttered
Other
No expired or unlabeled food
• Check food for expiration date
• Notify Charge Person if food is expired so it is discarded
immediately
• Patient food from outside the medical center is acceptable in pantry
refrigerators if it has the patient’s name
Other
Refrigerator temperature properly monitored
• Verify that temperature range is posted
• Medication: 36-46oF
• Food: 33-40oF
• Specimens: 33-44oF
• Read temperature on external digital monitor if present, not built-in monitor
• Verify that monitor is not blocked
• If display is outside safe range, check for alarm

Read me (external digital monitor)

Don’t read me
Other
Other issues (describe)
Includes any conditions not listed that may negatively impact the
environment of care
For more information:

• Contact Environmental Health & Safety

545 First Avenue, Room C-117
New York, NY 10016
(212) 263-5159
zinovia.abatzis@nyumc.org

• Safety Policies are available on the Environmental Health & Safety website:
http://redaf.med.nyu.edu/safety/environmental-health-safety

Presentation Title Goes Here 92