Title Page

  • Conducted on

  • Prepared by

Operational Compliance

  • Are the hours of operation posted on the doors of the office / suite?

  • Is the clinic business license current and viewable from the lobby?

  • Is this clinic location in Florida?

  • Does this clinic have an ACHA binder on site?

  • Is the Medical Director posted in the lobby?

  • Is the Patient's Bill of Rights and Responsibilities posted in the lobby?

  • Is the AHCA Patient Right to Report Complaints or Abuse posted in the lobby?

  • Is the Notice of Insurance Fraud and Reporting posted in the lobby?

  • Is the Report Medicaid Fraud poster posted in the lobby?

  • Does this clinic location generate biomedical waste?

  • Is this clinic located in Alabama?

  • Are physicians licenses viewable in the lobby?


Cabinetry / Counters

  • Are cabinets and counter tops in overall good condition?

  • Are doors, hinges, drawers and handles in good condition?


  • Are all doors in overall good condition?

  • Does door hardware function properly? (Handles, Hinges, Latches)


  • Is flooring in good condition?

  • Is flooring clean and dry?

  • Is flooring free of trip / fall hazards? (no areas uneven by more than 1/2 inch)


  • Are walls in overall good condition?

  • Is paint in overall good condition?

  • Are wall plates present and in good condition?


  • Are ceilings in overall good condition?

  • Are ceiling tiles in place and in good condition?

  • Is ceiling grid / track in good condition?



  • Are shipping boxes present? (Patient care areas only)

  • Is staff food / drink present in patient care areas?

  • Are areas under the sink free of patient contact items?

  • Are all cardboard boxes off the floor?

  • Is personal protective available and in good condition?

  • Are soap and paper towels properly stocked at hand washing sinks?

  • Are hand sanitizer dispensers properly stocked?



  • Are refrigerators labeled properly? ("Meds Only", "Patients Only", "Staff Only", etc.)

  • Do refrigerators have current temperature logs, where applicable?

  • Are temperature alarms set at the proper parameters? (Can be found on temperature logs)

  • Are items properly stored? (No food and meds in same refrigerator)

  • Are refrigerators clean and organized?

Bloodborne Pathogens

  • Are sharps containers free of items being stored on top of containers?

  • Are sharps properly disposed of in sharps containers ONLY?

  • Are sharps containers less than 75% full?

  • Are sharps properly stored and secured?



  • Are corridors kept clear to allow ambulation of patients and visitors?

  • Are corridors kept clear to allow carts, wheelchairs and beds to pass?

  • Are corridors clean and free of obstructions?

Egress / Exit Doors

  • Are doors clearly and correctly marked?

  • Are exit signs working properly?

  • Are doors clear of debris and equipment?

Fire / Smoke / Stairwell Doors

  • Are doors free of being propped / wedged open?

  • Are the doorways clear to close? (Nothing in the path of the door swing)

  • Do fire and stairwell doors latch firmly and maintain closure?

  • Do door closers / interrupters work properly?

Fire Extinguishers

  • Are all fire extinguisher locations clearly marked and unobstructed?

  • Do all fire extinguishers have current inspection tags?

  • Are safety seals present on all extinguishers?

Fire Alarm Pull Stations

  • Are pull stations free from obstructions? (Carts, Furniture, Equipment, etc.)

  • Are pull stations in good condition?


Hazardous Chemicals

  • Are chemicals labeled properly?

  • Are SDS binders available and accessible?

  • Are chemical spill kits available and accessible?

Bio-Hazardous Waste

  • Is bio-hazardous waste in red bags and proper containers?

  • Is bio-hazardous waste properly separated and segregated?

  • Is bio-hazardous waste properly disposed of?

  • Are bio-hazardous waste logs present and accessible?


Biomed & Digital Imaging Equipment

  • Are inspection tags current on all medical equipment?

  • Is medical equipment clean and properly stored?

  • Is broken equipment properly tagged and out of service?


Electrical Safety

  • Are breaker panels kept secured? (Electrical room locked or panels locked)

  • Are electrical cords in good condition?

  • Are electrical boxes, switches and outlets intact and in good condition?


Patient & Staff Safety

  • Are staff, vendors and contractors wearing ID badges in plain view?

  • Are all doors to secured areas free from being propped / wedged open?

Medication Management

  • Are medications / injections properly secured with minimal accessibility?

  • Are injections logs maintained and readily accessible?

  • Are any expired medications present? (Including first aid kit)

  • Is DME properly stored and secured?


Emergency Operations Plan

  • Are the Emergency Response flip charts present?

  • Is the location-specific page completed?

  • Is the facility evacuation map present?


Staff Knowledge

  • Does staff know what number to call in case of an emergency?

  • Can staff explain what R.A.C.E. stands for?

  • Can staff explain the P.A.S.S. technique for extinguisher use?

  • Do staff know where to find Safety Data Sheet (SDS) binder? (physical copy and online)

  • Can staff demonstrate how to look up a Safety Data Sheet (SDS)?

  • Can staff explain if medical equipment inspections are current?

  • Can staff explain how to get help in a security emergency?

  • Can staff locate the Emergency Response flip chart nearest to them?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.