Information
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Clinic Name
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Conducted on
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Prepared by
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Personnel involved
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Address
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Lights are free of dust/bugs?
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Staff can speak to the correct consent signing process?
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Reception areas are neat?
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The window sills are not cluttered and are dust free?
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All sinks and toilets are clean, soap and towels are available?
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Floors are clean, free of trash and boxes on floors?
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Housekeeping closets/Storage are clean and chemicals are stored properly?
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Linen has no stains and/or tears?
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Patient privacy curtains are clean, hung properly, function properly, and free of defects? (Cleaned every 12 months)
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No items are stored under sink?
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Bottom shelves have 6" clearance for cleaning?
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Furniture is clean & in good repair (clinical & visitor areas)?
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Treatment rooms are clean, organized and neat?
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Equipment is clean and intact (including mats, bolsters, exercise equipment, etc.)?
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Staff follow CDC hand hygiene?
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PPE is clean and orderly?
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Only approved disinfectants in use?
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Dirty equipment is not stored in clean utility and clean equipment is not stored in dirty utility room?
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There is no eating or drinking in patient care or public areas?
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Staff know the process for reporting a work place exposure or injury?
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Current infectious disease screening process in place?
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Multi-use containers are correctly labeled and tongue depressors in use when appropriate?
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There are no expired supplies, medications, or food items?
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Refrigerators and freezers are labeled properly as to contents?
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There is no medication or patient food items stored in staff refrigerator?
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Pantry is clean and items stored properly (ice machine, drawers, cupboards)
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Sharp boxes are no more than 3/4 full?
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Biohazard containers are covered and not overflowing?
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Staff know where spill kits are located?
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Staff know the wet times (kill time) for the disinfectant wipes used?
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Additional Comments