Title Page
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Conducted on
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Prepared by
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Location
Structural
Facility Overview- Review of Previous Inspection
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Identified issues still effective and not recurring
Exterior review
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Entrance/Surrounding area clean free of debris
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Windows clean and free of spots
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Windows tint not discolored or peeling
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Entrance carpet intact, no discoloration
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Flags are not fringed,damaged or weathered
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Surrounding landscaping maintained
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Sidewalks require cleaning
Interior Review
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Lobby organized no unwanted advertising
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Front desk area organized and free of clutter
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No miscellaneous papers taped to the walls
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Televisions functioning properly
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Is the TV free of static
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Is the required pricing visible
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Is the volume functioning properly
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Is there a picture visible
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Lobby refrigerator functioning properly
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Is the door closing properly
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Is the refrigerator cooling
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Carpet and Flooring free of stains
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Does the carpet need to be professionally cleaned
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Are there specific carpet tiles needing replaced
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Are there specific laminate tiles needing replaced
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Furniture in office does not require repair
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Medical- beds, stools, carts
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Other - lobby tables, chairs, patient room chairs
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Air Conditioning vents and ducts free of dust
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Ceiling tiles in intact,free of damage in place
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Staff lounge clean and sanitary
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Are there boxes stacked on cabinets
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Are there items that obstruct exits
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Is the refrigerator clean and running properly
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Garbage accumulating needing to be taken out
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Restrooms Clean and sanitary
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Dispensers stocked with paper and soap
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Baseboards free and clear of dust
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Toilet bowl and seat disinfected inside/outside
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Light fittings dusted and wiped inside and out
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Cleaning products not stored in restroom
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Plungers/cleaning brushes not stored in restroom
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Trash cans wiped cleaned; no visible marks or damage
Emergency Preparedness
Evacuation Plan
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Disaster paperwork printed, organized; employees aware of placement
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Walkways free of obstruction
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Exits signs illuminated and free of damage
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All Employees knowledgeable of meeting location during an emergency
Fire Prevention
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Are all staff members aware of fire extinguisher location
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Are all fire extinguishers easily accessible free from obstruction
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Are fire extinguishers current with date of recent inspection
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Are fire extinguishers free of damage,corrosion, no leaky nozzles
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Are there any objects obstructing fire sprinklers
Security
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Cameras in good working condition
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Authorized Personnel entry secure and key cards working properly
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Doors and locks in good working order
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Employees wearing company issued name badge
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Employees verifying visitors prior to allowing access into the building
Administrative
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Automated Reports Completed
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Petty Cash & Door locking log completed nightly, if no please notate dates missed
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Deposit/Balance Sheets completed
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Address Verification log completed
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Review of print screens
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Pamphlets Displayed
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Patient Portal
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Ultrasound Pamphlets
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Rack Cards
License/Signage
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MD Now required signage posted
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UCAOA/NUCCA Certification
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Non Discrimination Notice
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Patient Rights & Responsibilities Notices
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Notice of Privacy Practices
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Mission Statement
Lounge Signage
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Workers compensation Posted
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Information current not expired
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How to report an injury listed
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Minimum Wage posted
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Drug free workplace signage posted
Clinical
Logs/Checklist
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Weekly Checklist
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Med Flats UTD
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Expired medication removed
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Supplies properly stored
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BAT Calibration
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HIPAA EMR logs current
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Biohazard Manual
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ER transfers and PT, US, Ortho Referrals
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Medication Administration log
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Employee Files UTD
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ECW Inventory UTD
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Inventory UTD
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No expired Meds
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RX pedigree UTD
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Safety Data sheets staff aware of location in internal web
Clinical License/Signage
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Radon Safety Program for Radiation
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X-ray Notices
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X-Ray Manual
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X-ray registration posted
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Escreen/Alere Sign in ( account information)
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CLIA license (Lab)
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License current not expired
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If expired notate date of expiration
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Bio medical waste license current
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License posted in area visible to patients
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Copy of license posted in biohazard binder
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Generic Rx notice posted
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Doctor/PA/ARNP medical license listed
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Are the licenses listed of current employees
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License posted current not expired
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If expired notate date of expiration
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Medical Director certificate posted
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AHCA displayed
Lead MA Logs
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Lead MA log book signed
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Lab Log completed
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Abnormal lab log
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DAily MA Assigned Duties Visible
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Control Log
Clincial Equipment
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EKG Machine working properly
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Leads on machine clean
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Cart organized and clean
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Supplies needed for machine stocked and UTD
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Ear Lavage working properly
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Nozzle clean free of debris
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Hose clean free of mildew
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Surgical Lights working properly
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AED working properly
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02 Tank free of corrosion
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All equipment current with calibrations
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List which equipment requires calibration
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Date of expired equipment
Rooms
Medication Room
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Refrigerator maintaining temperature
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Medication guide posted
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Cabinets clean and stocked
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BUD guide
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Counter free of clutter
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Dispense medication stocked,organized, no expired medication
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Medication not currently stocked or missing
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If medication expired please list medication/expiration date
Exam Rooms/Procedure Room 1
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Are exams fully stocked
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if there are any missing items, please notate
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Are the cabinets and drawers clean
OB/GYN Room
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Properly stocked
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Cabinets and drawers organized
Triage Rooms
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Triage Flow chart framed and posted
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Desk cleaned and organized no clutter
Lab
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Counter decluttered and organized
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Autoclave clean and working properly ,no present of rust
Procedure Room 2
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Room properly stocked
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OCL supplies organized
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O2 supplies stocked and ready for use
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Crash Cart stocked and organized
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Inventory sheet UTD
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No expired inventory
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If inventory expired notate what is expired and quantity
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Health lnk reviewed weekly
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If non compliant, list last reviewed
