Monthly Clinic Quality Checks

• Site conducted

  Select

• Inspection date

  Date

• Conducted by

MEDICAL RECORD/PHI

• PHI is secure

  Yes

  No

• Computers/Laptops are locked when employee walks away

  Yes

  No

ENVIRONMENT

• Complete safety check of all equipment and verify equipment has been inspected in past year *Medical Equipment has current PM stickers

  Yes

  No

• Bolsters, tables, edges, balance pads, equipment, etc. are in good condition. There are no tears, frays, cracks, etc

  Yes

  No

• Chemical and cleaning supplies are properly stored

  Yes

  No

• Single use bottles (ultrasound gel, sanitizer, etc.) are not expired

  Yes

  No

• Inspect for and remove any hazardous materials (Remove paint, carpet glue, etc. Cannot be stored in clinic)

  Yes

  No

ENVIRONMENTAL CLEANING ASSESSMENT (CA Hospital sites ONLY)

• Environmental Cleaning Assessment CA Hospital sites ONLY

• Cleaning and Disinfecting of Treatment Tables (Procedure: Assemble gloves and hospital approved disinfectant, Strip all linen from table and pillows, Handle line carefully so that clothing or other surfaces are not contaminated. Place in laundry bag, Scrub top of pad with hospital approved disinfectant, air dry, Wipe off pillows with hospital approved disinfectant, air dry, Dress table with fresh linen. )

  Yes

  No

• Routine Cleaning Therapy Equipment (Procedure – after patient use, Assemble gloves and hospital approved disinfectant. Clean therapy equipment used by patient (high touch surfaces), air dry. Return to proper storage place

  Yes

  No

• Scheduled Cleaning Therapy Equipment (Procedure – Monthly or more frequently as needed Assemble gloves and hospital approved disinfectant. Clean all surfaces of large therapy equipment used by patient, air dry. Return to proper storage place)

  Yes

  No

• Disinfectant wipes are stored according to manufacturer’s instructions.

  Yes

  No

• Disinfectant remains in wet contact with surfaces according to manufacturer’s instructions.

  Yes

  No

• Hand hygiene is performed throughout the cleaning process as needed, including before & after glove use.

  Yes

  No

• There are no visible tears or damage on environmental surfaces or equipment.

  Yes

  No

MEDICATIONS & SUPPLIES

• Supplies are within date and not expired

  Yes

  No

• Check Dry Needles, STIM Pads, Sanitizer, LeukoTape, PDI Wipes, and all other supplies with expirations dates

• There are no medications in the first aid box and the first aid box is well stocked

  Yes

  No

• Is there Iontophoresis in the clinic? *Per PTS guidelines there should not be

  Yes

  No

• Sharps Containers are not overflowed. Shipped back to vendor once 3/4 full

  Yes

  No

SAFETY

• Fire extinguishers are not blocked and easy to get to

  Yes

  No

• Check Fire Extinguisher for proper charge, secure pin, mounted securely to wall, & verify it is not expired. Initial & date card attached to extinguisher in “MMDDYYYY” format

  Yes

  No

• Doors and stairwells are not blocked

  Yes

  No

• Electrical panels are not blocked and there is >36" clearance

  Yes

  No

• Staff can verbalize where to locate the clinic specific emergency action plan

  Yes

  No

• Staff knows the procedure if a device/ equipment is not working properly

  Yes

  No

• Can staff speak to PPE available in the clinic and know how to use it?

  Yes

  No

ADDITIONAL NOTES

• Add additional notes if needed in regards to the clinic monthly quality checks.