Title Page

  • Conducted on

  • Prepared by

  • Location


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


  • 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


  • 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


  • 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



  • 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


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


  • Properly stocked

  • Cabinets and drawers organized

Triage Rooms

  • Triage Flow chart framed and posted

  • Desk cleaned and organized no clutter


  • 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

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.