Information

  • Clinic Name

  • Conducted on

  • Prepared by

  • Personnel involved

  • Address
  • Lights are free of dust/bugs?

  • Reception areas are neat?

  • The window sills are not cluttered and are dust free?

  • All sinks and toilets are clean, soap and towels are available?

  • Floors are clean, free of trash and boxes on floors?

  • Housekeeping closets/Storage are clean and chemicals are stored properly?

  • Linen has no stains and/or tears?

  • Patient privacy curtains are clean, hung properly, function properly, and free of defects? (Cleaned every 6 months)

  • No items are stored under sink?

  • Bottom shelves have 6" clearance for cleaning?

  • Furniture is clean & in good repair (clinical & visitor areas)?

  • Treatment rooms are clean, organized and neat?

  • Equipment is clean and intact (including mats, bolsters, exercise equipment, etc.)?

  • Staff follow CDC hand hygiene?

  • PPE is clean and orderly?

  • Only approved disinfectants in use?

  • Dirty equipment is not stored in clean utility and clean equipment is not stored in dirty utility room?

  • There is no eating or drinking in patient care or public areas?

  • Staff know the process for reporting a work place exposure or injury?

  • Current infectious disease screening process in place?

  • Multi-use containers are correctly labeled and tongue depressors in use when appropriate?

  • There are no expired supplies, medications, or food items?

  • Refrigerators and freezers are labeled properly as to contents?

  • There is no medication or patient food items stored in staff refrigerator?

  • Pantry is clean and items stored properly (ice machine, drawers, cupboards)

  • Sharp boxes are no more than 3/4 full?

  • Biohazard containers are covered and not overflowing?

  • Staff know where spill kits are located?

  • Additional Comments

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