General Information

Contacts and Records

Name of Institution

Parent Company (if Applicable)

Address

Email Address

Contact Numbers

Name of Manager/CEO

Number of Shifts Operated

Number of Staff /Shift

Number of Staff reported absent

Number absent due to illness

Number of Residents/Clients/Patients

Average number of clients/patients seen Daily

Residents/Clients/Patients Record Seen:

Inspection Parameters

I. Sanitary and Hygiene Practices

A. Sanitary Conveniences

Adequate

Clean Condition

B. Handwashing Facility

Adequate (at minimum - entrance to the
building; nurse’s station(s); toilet facilities;
kitchen; recreational and dining area)

Equipped

Strategically placed

C. Hand Sanitizers strategically placed (equipped with
sanitizer having at least 62% alcohol base, and
adequate)

D. Water safe and adequate quantity available

E. Water Quality records (if trucked) and trucking
information in place

II. Social Distancing and COVID-19 Risk Reduction Measures

A. Temperature checks on entering the building (related
records updated)

B. Implementation (and documentation) of Stay at Home if sick Policy for staff (they should remain at home and call to notify the HR department and the MOHW)

C. Residents/clients/patients subjected to daily
temperature checks and same recorded

D. Multi-use devices properly cleaned and disinfected
after use on each patient/client/resident and prior to use by staff. (example manual sphygmomanometer (blood pressure monitors), stethoscope, thermometers)

E. Established regulatory provision in place (6 feet
distance between beds observed)

F. Social distancing provisions observed in recreational, common and dining areas.

G. Absence of congregating of staff and
residents/clients/patients throughout the facility or on the compound (evidence of such systems in place to include scheduled dining and recreation)

H. The requisite signs for stair use or two persons per
elevator erected (where applicable)

I. Separate entrance and exits in place or evidence of
controlled entry and assigned routes observed

J. Evidence of staggered dining and recreational
assignment per group

III. General Cleaning and Sanitation

A. Waste Storage and Disposal (Medical and General)

Waste separation using established MOHW coding system in place

Proper waste storage facilities

Document in place regarding disposal of waste

B. Garbage Bins

Frequently Emptied (no more than ¾ full)

Hands Free or foot operated receptacle

Lined

Sufficient and strategically placed throughout the health care facility

C. Furnishing, fixture and equipment designed to allow for easy cleaning

D. Cleaning and disinfection guidelines in place for the
facility, appropriate and accessible

Guidelines posted at appropriate locations

E. Cleaning and Disinfection schedule (posted and updated)

F. Recommended cleaning and disinfection agents
observed and properly stored (MSDS present for
chemicals used)

G. Linen properly cleaned, stored and handled

H. Dirty linen properly handled (segregated and transported)


I. No carpeted floor in building

J. All designated support staff provided with appropriate PPE for cleaning and disinfection (gloves, masks, face shields, water-proof coverall)

K. Compound and facility maintained in a clean and sanitary manner

IV. Handling of Sick Persons

A. Suitable isolation area designated

 Proper handwashing station

 Bed(s) has/have impervious and cleanable covering

B. All applicable MOHW Infection Prevention Control (IPC) measures observed

C. Up-to-date and well-maintained records of all workers
who present with or complain of symptoms

D. Ministry of Health and Wellness contact information on record and posted

E. Personal protective equipment available for use by healthcare personnel, other staff members, residents/clients/patients at the facility

V. Transportation

A. Register of all contracted drivers and their vehicles well maintained and available (to include ambulance service)

B. Log of all staff members transported on staff bus for each trip

C. Log of all residents/clients/patients or staff transported or transferred to a healthcare facility or another healthcare facility (as the case may be)

D. Procedures and guidelines for cleaning and
sanitization of vehicles observed (or described)

VI. Personal Protective Equipment (PPE) Use and Disposal

A.Types of PPE observed in use (list)

B. Appropriateness of the PPE used

C. Guidelines for PPE use and disposal in place and
practiced (appropriate notice/ signs posted, proper use and disposal signs noted)

VII. Communication

A. Evidence of training for staff in place as it relates to COVID-19 based on MOHW guidelines (staff meeting register or training schedule, meeting agenda and attendance register seen)

B. Relevant health education pamphlets/ posters
strategically placed throughout the center

Ventilation

A. Use of natural ventilation observed

B. Preventative maintenance programme in place observed

C. Where applicable, the cleaning and maintenance
schedule for all air handling units available, up-to-date

General Comments

Comments

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.