Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Waiting Rooms. Public Bathrooms, and Hallways
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1. All horizontal surfaces are clean
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2. Areas/hallways are not cluttered
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3. Trash is not overflowing
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4. Bathrooms are clean
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5. Handwashing supplies are available
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6. No stained ceiling tiles
Nursing Station
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1. Clean and free of cllutter
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2. No food present, only drinks with a lid
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3. No patient care supplies left open on table
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4. Trash is not overflowing
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5. Refrigerators daily temperature logs checked and documented appropriately.
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6. Refrigerator is clean.
Medication Room
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1. Clean and free of clutter
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2. Trash is not overflowing
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3. Medication prep is done at least 3ft from the sink
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4. Non-medication items stored separately from medications in the biological refrigerator
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5. Light sensitive medications are properly stored
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6. All open vials were appropriately dated and not expired.
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7. No damaged or illegibly labeled medications available for use.
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8. All single use vials are discarded appropriately after use.
Staff
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1. Hand Hygiene is being performed correctly
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2. no fingernail polish or artificial nails. (if providing patient care)
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3. Appropriate fingernail length. (1/4")
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4. Staff understands isolation precaution protocol and needlestick protocol
Precautions
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1. PPE supplies available
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2. Trash and linens handled per policy
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3.Appropriate PPE being used by staff
Patient Care Equipment
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1. Equipment is cleaned according to policy/manufacture's IFUs.
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2. Vital sign machines are cleaned using the disinfectant wipes before being used.
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3. Equipment that has expiration dates have not expired.
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4. Wheelchairs or other assistive devices are disinfected after each patient use.
Hazardous Materials and Medical Waste
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1. Appropriate sharps containers in use
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2. Sharps containers no more than 3/4 full
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3. Sharps containers secured to wall or cabinet
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4. Appropriate biomedical waste manifests maintained
Clinical Exam Room
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1. Exam table, countertops, chairs, and wall mounted diagnostic equipment disinfected after each patient encounter
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2. Trash is not overflowing
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3. Sink is cleaned when visibly soiled and at the end of each shift.
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4. Alcohol hand rub dispensers are located outside the exam room or located inside the exam room.
Floor Care
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1. All carpet is vacuumed and spotted daily
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2. All tile/vinyl floors dust mopped or swept before they are mopped or autoscrubbed
Changing Room
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1. Room is disinfected after each use.
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2. Trash is not overflowing.
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3. Dirty gowns/linens are handled appropriately
Rad Onc Room
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1. "Exam" table is cleaned after each use
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2. equipment is stored appropriately and covered when not in use.
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3. Equipment is stored off the floor.
Clean utility/Storage Room
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1. There is a clear walk way
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2. All equipment is clean and stored off the ground
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3. Equipment/supplies are not out of date.
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4. No supplies stored under sink
Clean Linens
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1. Linens are in good condition
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2. Stored on covered cart or in linen room where shelf is covered
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3. Clean linen covered during transport
Soiled Utility
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1. Door to room is labeled
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2. Biohazard symbol on door if biomedical waste in room
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3. Soiled linen in hamper with impervious liner
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4. Clean supplies not in room
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5. Appropriate PPE available
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6. Soiled linen covered for transport
Infusion Area
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1. Cubical and patient care equipment cleaned and disinfected after each use
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2. PPE available for staff
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3. Clean and free of clutter
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4. trash is not overflowing
EOC
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1. All cylinders (Oxygen, other compressed gas) are secured
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2. Empty oxygen tanks are kept separate from full oxygen tanks
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3. Fire extinguishers not obstructed from easy access
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4. No electrical panels are blocked
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5. Furnishings /equipment are kept in good repair (no torn or soiled furniture, wheelchairs, mattresses)
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6. countertops/doors are in good condition with no chipping to laminate
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7. no supplies stored under sinks
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8. Paper is not present on fire-rated doors
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9. Maintains the integrity of egress throughout the unit
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10. No space heater present in patient care areas
