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

Ventilation

  • 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

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