Environment of Care Site Audit

• Conducted on

  Date

• Prepared by

Operational Compliance

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Is this clinic location in Florida?

  Yes

  No

  N/A

• Does this clinic have an ACHA binder on site?

  Yes

  No

  N/A

• Is the Medical Director posted in the lobby?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Does this clinic location generate biomedical waste?

  Yes

  No

  N/A

• Is this clinic located in Alabama?

  Yes

  No

  N/A

• Are physicians licenses viewable in the lobby?

  Yes

  No

  N/A

SAFE ENVIRONMENT

Cabinetry / Counters

• Are cabinets and counter tops in overall good condition?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

Doors

• Are all doors in overall good condition?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

Flooring

• Is flooring in good condition?

  Pass

  Fail

  N/A

• Is flooring clean and dry?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

Walls

• Are walls in overall good condition?

  Pass

  Fail

  N/A

• Is paint in overall good condition?

  Pass

  Fail

  N/A

• Are wall plates present and in good condition?

  Pass

  Fail

  N/A

Ceilings

• Are ceilings in overall good condition?

  Yes

  No

  N/A

• Are ceiling tiles in place and in good condition?

  Yes

  No

  N/A

• Is ceiling grid / track in good condition?

  Yes

  No

  N/A

INFECTION CONTROL

Environmental

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Are all cardboard boxes off the floor?

  Pass

  Fail

  N/A

• Is personal protective available and in good condition?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Are hand sanitizer dispensers properly stocked?

  Pass

  Fail

  N/A

Linens

• Pass

  Fail

  N/A

Refrigerators

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

  Pass

  Fail

  N/A

• Do refrigerators have current temperature logs, where applicable?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Are refrigerators clean and organized?

  Pass

  Fail

  N/A

Bloodborne Pathogens

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

  Pass

  Fail

  N/A

• Are sharps properly disposed of in sharps containers ONLY?

  Pass

  Fail

  N/A

• Are sharps containers less than 75% full?

  Pass

  Fail

  N/A

• Are sharps properly stored and secured?

  Pass

  Fail

  N/A

FIRE / LIFE SAFETY

Corridors

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Are corridors clean and free of obstructions?

  Pass

  Fail

  N/A

Egress / Exit Doors

• Are doors clearly and correctly marked?

  Pass

  Fail

  N/A

• Are exit signs working properly?

  Pass

  Fail

  N/A

• Are doors clear of debris and equipment?

  Pass

  Fail

  N/A

Fire / Smoke / Stairwell Doors

• Are doors free of being propped / wedged open?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Do door closers / interrupters work properly?

  Pass

  Fail

  N/A

Fire Extinguishers

• Are all fire extinguisher locations clearly marked and unobstructed?

  Pass

  Fail

  N/A

• Do all fire extinguishers have current inspection tags?

  Pass

  Fail

  N/A

• Are safety seals present on all extinguishers?

  Pass

  Fail

  N/A

Fire Alarm Pull Stations

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

  Pass

  Fail

  N/A

• Are pull stations in good condition?

  Pass

  Fail

  N/A

HAZARDOUS MATERIALS & WASTE MANAGEMENT

Hazardous Chemicals

• Are chemicals labeled properly?

  Pass

  Fail

  N/A

• Are SDS binders available and accessible?

  Pass

  Fail

  N/A

• Are chemical spill kits available and accessible?

  Pass

  Fail

  N/A

Bio-Hazardous Waste

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

  Pass

  Fail

  N/A

• Is bio-hazardous waste properly separated and segregated?

  Pass

  Fail

  N/A

• Is bio-hazardous waste properly disposed of?

  Pass

  Fail

  N/A

• Are bio-hazardous waste logs present and accessible?

  Pass

  Fail

  N/A

MEDICAL EQUIPMENT

Biomed & Digital Imaging Equipment

• Are inspection tags current on all medical equipment?

  Pass

  Fail

  N/A

• Is medical equipment clean and properly stored?

  Pass

  Fail

  N/A

• Is broken equipment properly tagged and out of service?

  Pass

  Fail

  N/A

UTILITY SYSTEMS

Electrical Safety

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

  Pass

  Fail

  N/A

• Are electrical cords in good condition?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

SECURITY

Patient & Staff Safety

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

Medication Management

• Are medications / injections properly secured with minimal accessibility?

  Pass

  Fail

  N/A

• Are injections logs maintained and readily accessible?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Is DME properly stored and secured?

  Pass

  Fail

  N/A

EMERGENCY MANAGEMENT

Emergency Operations Plan

• Are the Emergency Response flip charts present?

  Pass

  Fail

  N/A

• Is the location-specific page completed?

  Pass

  Fail

  N/A

• Is the facility evacuation map present?

  Pass

  Fail

  N/A

KNOWLEDGE BASED

Staff Knowledge

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Can staff explain if medical equipment inspections are current?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A