Title Page
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Site
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Conducted on
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Prepared by
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Nurses on Duty
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Medical Providers on Duty
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Dental Providers on Duty
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Dental Assistants on Duty
General Appearance
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Building Exterior Clean
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Entryway Clean and Neat
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Lawn Cut and Presentable, Landscaping Not Overgrown
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Parking Clean and Well Maintained
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External Lighting Functional
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Interior Areas Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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Additional failure areas? Use notes area to document.
Waiting Rooms
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Furniture Clean
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Windows Clean
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Educational and Promotional Materials Available
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Restrooms Clean and Stocked
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Ceiling tiles stained
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Patient bill of rights, FQHC, workplace violence, weapons free zone, and wait times signage posted
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Additional failure areas? Use notes area to document.
Front Desk
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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Ceiling Tiles Stained
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PHI in View of Patients or Visitors
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Phone Ringers Muted
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Privacy practices brochure readily available
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Additional failure areas? Use notes area to document.
Medical Exam Rooms. Click "Add Medical Exam Room" to add rooms. Place the actual room number in the room number field.
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Medical Exam Rooms
Medical Exam Room
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Room Number
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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All surfaces clean and free of debris
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Workplace violence and cell phone signage posted
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Wall mounted scopes functional
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Adequate supply of exam gloves in room
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Cavicide disinfectant available in the room
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Exam table clean and free of tears or damage
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Walls free of scratches, gouges, and excessive hand prints
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Sharps overfilled
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Biohazard trash not overflowing or putrid
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Excess supplies stored in room
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Expired supplies stored in room
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Waste basket overflowing
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Sink functional, hot and cold, no leaks
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Hand sanitizer, soap, paper towels filled
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Ceiling Tiles Stained
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Additional failure areas? Use notes area to document.
Nurses Station
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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Food Present
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AED present, tested, and supplies not expired
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Ceiling Tiles Stained
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PHI in View of Patients or Visitors
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Phone Ringers Muted
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Additional failure areas? Use notes area to document.
Medication Closet
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Door locked and not propped open. Required staff members have access.
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All medications labeled with expiration date
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Expired medications on shelves
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Narcotic log review. Does pad number match log? Any irregularities on log?
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Additional failure areas? Use notes area to document.
Lab Area
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CLIA waiver posted
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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All surfaces clean and free of debris
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Cavicide disinfectant available in the room
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Biohazard items clearly separate from clean
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Walls free of scratches, gouges, and excessive hand prints
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Sharps overfilled
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Biohazard trash not overflowing or putrid
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Excess supplies stored in room
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Expired supplies stored in room
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Sink functional, hot and cold, no leaks
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Waste basket overflowing
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O2 tank available, stored properly, and above 500 psi left on guage
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Hand sanitizer, soap, paper towels filled
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Ceiling Tiles Stained
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Vaccine Temperature Log Audit
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All Equipment Functional
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All equipment daily/weekly/monthly checks logged
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Additional failure areas? Use notes area to document.
Dental
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Is there dental in this office?
Dental Lab
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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All surfaces clean and free of debris
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O2 tank available, stored properly, and above 500 psi left on guage
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Cavicide disinfectant available in the room
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Walls free of scratches, gouges, and excessive hand prints
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Sharps overfilled
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Biohazard items clearly separate from clean
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Biohazard trash not overflowing or putrid
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Excess supplies stored in room
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Expired supplies stored in room
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Sink functional, hot and cold, no leaks
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Eyewash Present and Functional
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Waste basket overflowing
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Hand sanitizer, soap, paper towels filled
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Ceiling Tiles Stained
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All Equipment Functional
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All equipment checks logged. Autoclave cleaning, trap cleaning, eyewash testing
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Dental assistant certificates and radiology licenses posted for a DA's present
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Site radiology license current
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Spore testing logged every Monday. (check back four weeks in the log)
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Additional failure areas? Use notes area to document.
Dental Exam Rooms
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Click "Add Dental Exam Room" to add rooms. Place the actual room number in the room number field.
Dental Exam Room
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Exam Room Number
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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All surfaces clean and free of debris
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Workplace violence and cell phone signage posted
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Cavicide disinfectant available in the room
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Adequate supply of exam gloves in room
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Exam chair clean, free of tears, and functional
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All equipment functional and free of leaks
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Walls free of scratches, gouges, and excessive hand prints
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Sharps overfilled
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Biohazard trash not overflowing or putrid
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Excess supplies stored in room
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Expired supplies stored in room
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Waste basket overflowing
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Sink functional, hot and cold, no leaks
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Hand sanitizer, soap, paper towels filled
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Ceiling Tiles Stained
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Lead apron available, hung properly, not folded or creased
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Additional failure areas? Use notes area to document.
X-Ray Development Area
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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Ceiling Tiles Stained
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Disinfectant available in room
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Is pano X-ray apron available, hung properly, not folded or creased
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Additional failure areas? Use notes area to document.
Fire, Life, and General Safety
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Medical staff questioned on room and instrument disinfection
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Dental staff questioned on room and instrument disinfection
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All exit lights tested and functional
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Items stored in hallways
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Items stored within 18" of ceiling
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Items stored within 36" of breaker panel
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Extension cords in use (power strips ok)
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Fire extinguishers inspected in last year
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Space heaters in use
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All secure area doors locked and not propped open
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All staff members wearing ID Badges
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Additional failure areas? Use notes area to document.
Staff Break Area
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Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry
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Sink clean with no dishes present
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Microwave clean
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Trash overflowing
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Refrigerator and freezer clean
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Staff restrooms clean and stocked
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Additional failure areas? Use notes area to document.
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Signature
