Structural

Facility Overview- Review of Previous Inspection

Identified issues still effective and not recurring

Exterior review

Entrance/Surrounding area clean free of debris

Windows clean and free of spots

Windows tint not discolored or peeling

Entrance carpet intact, no discoloration

Flags are not fringed,damaged or weathered

Surrounding landscaping maintained

Sidewalks require cleaning

Interior Review

Lobby organized no unwanted advertising

Front desk area organized and free of clutter

No miscellaneous papers taped to the walls

Televisions functioning properly

Is the TV free of static

Is the required pricing visible

Is the volume functioning properly

Is there a picture visible

Lobby refrigerator functioning properly

Is the door closing properly

Is the refrigerator cooling

Carpet and Flooring free of stains

Does the carpet need to be professionally cleaned

Are there specific carpet tiles needing replaced

Are there specific laminate tiles needing replaced

Furniture in office does not require repair

Medical- beds, stools, carts

Other - lobby tables, chairs, patient room chairs

Air Conditioning vents and ducts free of dust

Ceiling tiles in intact,free of damage in place

Staff lounge clean and sanitary

Are there boxes stacked on cabinets

Are there items that obstruct exits

Is the refrigerator clean and running properly

Garbage accumulating needing to be taken out

Restrooms Clean and sanitary

Dispensers stocked with paper and soap

Baseboards free and clear of dust

Toilet bowl and seat disinfected inside/outside

Light fittings dusted and wiped inside and out

Cleaning products not stored in restroom

Plungers/cleaning brushes not stored in restroom

Trash cans wiped cleaned; no visible marks or damage

Emergency Preparedness

Evacuation Plan

Disaster paperwork printed, organized; employees aware of placement

Walkways free of obstruction

Exits signs illuminated and free of damage

All Employees knowledgeable of meeting location during an emergency

Fire Prevention

Are all staff members aware of fire extinguisher location

Are all fire extinguishers easily accessible free from obstruction

Are fire extinguishers current with date of recent inspection

Are fire extinguishers free of damage,corrosion, no leaky nozzles

Are there any objects obstructing fire sprinklers

Security

Cameras in good working condition

Authorized Personnel entry secure and key cards working properly

Doors and locks in good working order

Employees wearing company issued name badge

Employees verifying visitors prior to allowing access into the building

Administrative

Automated Reports Completed

Petty Cash & Door locking log completed nightly, if no please notate dates missed

Deposit/Balance Sheets completed

Address Verification log completed

Review of print screens

Pamphlets Displayed

Patient Portal

Ultrasound Pamphlets

Rack Cards

License/Signage

MD Now required signage posted

UCAOA/NUCCA Certification

Non Discrimination Notice

Patient Rights & Responsibilities Notices

Notice of Privacy Practices

Mission Statement

Lounge Signage

Workers compensation Posted

Information current not expired

How to report an injury listed

Minimum Wage posted

Drug free workplace signage posted

Clinical

Logs/Checklist

Weekly Checklist

Med Flats UTD

Expired medication removed

Supplies properly stored

BAT Calibration

HIPAA EMR logs current

Biohazard Manual

ER transfers and PT, US, Ortho Referrals

Medication Administration log

Employee Files UTD

ECW Inventory UTD

Inventory UTD

No expired Meds

RX pedigree UTD

Safety Data sheets staff aware of location in internal web

Clinical License/Signage

Radon Safety Program for Radiation

X-ray Notices

X-Ray Manual

X-ray registration posted

Escreen/Alere Sign in ( account information)

CLIA license (Lab)

License current not expired

If expired notate date of expiration

Bio medical waste license current

License posted in area visible to patients

Copy of license posted in biohazard binder

Generic Rx notice posted

Doctor/PA/ARNP medical license listed

Are the licenses listed of current employees

License posted current not expired

If expired notate date of expiration

Medical Director certificate posted

AHCA displayed

Lead MA Logs

Lead MA log book signed

Lab Log completed

Abnormal lab log

DAily MA Assigned Duties Visible

Control Log

Clincial Equipment

EKG Machine working properly

Leads on machine clean

Cart organized and clean

Supplies needed for machine stocked and UTD

Ear Lavage working properly

Nozzle clean free of debris

Hose clean free of mildew

Surgical Lights working properly

AED working properly

02 Tank free of corrosion

All equipment current with calibrations

List which equipment requires calibration

Date of expired equipment

Rooms

Medication Room

Refrigerator maintaining temperature

Medication guide posted

Cabinets clean and stocked

BUD guide

Counter free of clutter

Dispense medication stocked,organized, no expired medication

Medication not currently stocked or missing

If medication expired please list medication/expiration date

Exam Rooms/Procedure Room 1

Are exams fully stocked

if there are any missing items, please notate

Are the cabinets and drawers clean

OB/GYN Room

Properly stocked

Cabinets and drawers organized

Triage Rooms

Triage Flow chart framed and posted

Desk cleaned and organized no clutter

Lab

Counter decluttered and organized

Autoclave clean and working properly ,no present of rust

Procedure Room 2

Room properly stocked

OCL supplies organized

O2 supplies stocked and ready for use

Crash Cart stocked and organized

Inventory sheet UTD

No expired inventory

If inventory expired notate what is expired and quantity

Health lnk reviewed weekly

If non compliant, list last reviewed

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.