Rural Health Clinic

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Which clinic is being surveyed

Environmental Conditions/Infection Control

• Are staff able to speak to the disinfectant dry time that is required before using the equipment or applying the table paper?

  Yes

  No

  N/A

• If a negative response to the above question, what was the issue identified.

• Are sharps containers mounted/secured in clinic areas?

  Yes

  No

  N/A

• The sharps containers are not overfilled.

  Yes

  No

  N/A

• Are electrical pugs at floor level covered with child safety covers?

  Yes

  No

  N/A

• Are rooms with biohazard materials labeled and locked?

  Yes

  No

  N/A

• Does the procedure room have a dirty and clean side?

  Yes

  No

  N/A

Medications

• Are medications stored in a safe and secure location?

  Yes

  No

  N/A

• All medication is not expired.

  Yes

  No

  N/A

• Is the sample medication log kept up to date and completed per policy?

  Yes

  No

  N/A

• All single dose vials are discarded after use.

  Yes

  No

  N/A

• There are no opened multi-dose vials open without a BUD? (Note BUD 28 days after opened.)

  Yes

  No

  N/A

• There are no medications/hazardous liquids stored in bottom cupboards or drawers.

  Yes

  No

  N/A

Emergency Response

• O2 Tank full and in holder?

  Yes

  No

  N/A

• Is the appropriate ambu bag available based on population served in clinic?

  Yes

  No

  N/A

• Is the medication Box for common emergencies in clinic available?

  Yes

  No

  N/A

Misc. Section

• Are the OSHA/State Hiring Laws posted in the clinic?

  Yes

  No

  N/A

• Are PMs for equipment current per the MIFU?

  Yes

  No

  N/A

• Is the process for management of complaints posted in the clinic?

  Yes

  No

  N/A

• Are the PA/NP staff able to speak to the guidelines for management of health problems?

  Yes

  No

  N/A

• Is there a process to ensure the required number of NP/PA charts are reviewed per the organizations policy?

  Yes

  No

  N/A

Sterilization

• Is sterilization done in this clinic?

  Yes

  No

  N/A

• Are MIFU guidelines followed for proper cleaning of instruments?

  Yes

  No

  N/A