Title Page

  • Conducted on

  • Prepared by

  • Location
  • Person(s) conducting inspection

  • Status of Institution

  • Action Taken

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 <br>building; nurse’s station(s); toilet facilities; <br>kitchen; recreational and dining area)

  • Equipped

  • Strategically placed

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

  • D. Water safe and adequate quantity available

  • E. Water Quality records (if trucked) and trucking <br>information in place

II. Social Distancing and COVID-19 Risk Reduction Measures

  • A. Temperature checks on entering the building (related <br>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 <br>temperature checks and same recorded

  • D. Multi-use devices properly cleaned and disinfected <br>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 <br>distance between beds observed)

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

  • G. Absence of congregating of staff and <br>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 <br>elevator erected (where applicable)

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

  • J. Evidence of staggered dining and recreational <br>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 <br>facility, appropriate and accessible<br>

  • Guidelines posted at appropriate locations

  • E. Cleaning and Disinfection schedule (posted and updated)

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

  • G. Linen properly cleaned, stored and handled

  • H. Dirty linen properly handled (segregated and transported)

  • <br>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 <br>who present with or complain of symptoms<br>

  • 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 <br>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 <br>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 <br>strategically placed throughout the center


  • A. Use of natural ventilation observed

  • B. Preventative maintenance programme in place observed

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

General Comments

  • Comments

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.