Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Waiting Room, Public Bathrooms, and Hallways
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1. All horizontal surfaces are clean
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2. Areas/hallways are not cluttered
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3. Trash is not overflowing
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4. Bathrooms are clean
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5. Handwashing supplies are available
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6. No stained ceiling tiles
Nursing Station
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1. Clean and free of clutter
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2. No food present, only drinks with a lid
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3. No patient care supplies left open on tables.
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4.Trash is not overflowing
Staff
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1. Hand hygiene is being performed correctly
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2. No fingernail polish or artificial nails. (if providing patient care)
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3. Appropriated fingernail length. (1/4")
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4. Staff understands isolation precaution protocol and needlestick protocol
Hand Hygiene
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1. Sinks for handwashing are appropriately stocked with soap, paper towel, and trash cans
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2. Alcohol hand-rubs are available near patient rooms/in patient rooms and other areas as needed
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3. Hand hygiene is monitored for staff compliance
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4. Gloves are stocked in patient's room for staff use when needed
Precautions
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1. PPE supplies are available
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2. Appropriate signage in place for isolation rooms.
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3. Trash and linen handled per policy
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4. Patient and family given appropriate education in regards to isolation precautions
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5. If airborne precautions, is the door closed
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6. Appropriate PPE being used by staff
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7. Isolation stations being utilized and are stocked.
Soiled Utility
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1. Door to room is labeled
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2. Biohazard symbol on door if biomedical waste in room
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3. Soiled linen in hamper with impervious liner
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4. Clean supplies not in room
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5. Appropriate PPE available
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6. Soiled linen covered for transport
Clean Utility/ Storage Room
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1. There is a clear walk way
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2. All equipment is clean and stored off the ground
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3. Equipment/supplies are not out of date
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4. Door to room is labeled
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5. No supplies stored under sink
Clean Linen
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1. Linens are in good condition
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2. Stored on covered cart or in linen room where shelf is covered.
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3. Clean linen covered during transport
Refrigerators
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1. Daily temperature checks are documented appropriately
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2. Items are appropriately labeled and nothing out of date
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3. Refrigerator is clean
Patient Care Equipment
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1. Equipment is cleaned according to policy/manufacturer's IFUs
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2. Vital sign machines are cleaned using the disinfectant wipes prior to use.
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3. Equipment that has expiration dates have not expired.
Hazardous Materials and Medical Waste
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1. Appropriate sharps containers in use
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2. Sharps containers no more than 3/4 full
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3. Sharps containers secured for transport
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4. Appropriate biomedical waste manifests maintained
Floor Care
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1. All carpet is vacuumed and spotted daily
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2. All tile/vinyl floors dust mopped or swept before they are mopped or autoscrubbed
Social Area
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1. All horizontal surfaces and clean
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2. Clean and free of clutter
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3. Trash is not overflowing
Medication Room
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1. Clean and free of clutter
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2. Trash is not overflowing
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3. Medication prep is done at least 3ft from the ink
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4. Non-medication items stored separately from medications in the biological refrigerator
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5. Light sensitive medications are properly stored
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6. All open vials were appropriately dated and not expired
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7. No damaged or illegibly labeled medications available for use
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8. All single use vials are discarded appropriately after use.
EOC
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1. All cylinders (oxygen, other compressed gas) are secured
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2. Empty oxygen tanks are kept separate from full oxygen tanks
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3. Fire extinguishers are not obstructed from easy access
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4. No electrical panels are blocked
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5. Furnishings /equipment are kept in good repair (No torn or soiled furniture, wheelchairs, mattresses)
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6. Countertops/doors are in good condition with no chipping to laminate
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7. no supplies stored under sinks
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8. Paper is not present on fire-rated doors
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9. Maintains the integrity of egress throughout the facility
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10. No space heaters present in patient care areas
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There is at least 18" of open space maintained below a sprinkler deflector to the top of storage
