Sanford Clinic Quality Inspections

• Sanford Clinic/Building to be inspected:

• Contract Company:

• Conducted on

  Date

• Person Conducting Audit:

• Comments:

Public Welcome Areas/Waiting Rooms

• Floors free of debris & soil (corners clean/baseboards clean)

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Windows - Glass free of streaks and finger prints. Sills free of dust and insects

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Furniture free of dust/debris/spots

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Reception area free of finger prints/dust/debris

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

Public restrooms #1

• Floors free of soil and debris (check corners and baseboards)

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Toilet and Sink: free of waste, mineral deposits, outside of bowl clean

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Walls/Doors/Partitions/Mirrors - not soiled or dusty. Mirrors Clean

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garbage cans clean - dust free emptied and relined

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Paper towels, soap dispensers clean refilled

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Comments:

Public Restroom #2

• Floors free of soil and debris (check corners and baseboards)

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Toilet and Sink: free of waste, mineral deposits, outside of bowl clean

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Walls/Doors/Partitions/Mirrors - not soiled or dusty. Mirrors Clean

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garbage cans clean - dust free emptied and relined

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Paper towels, soap dispensers clean refilled

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Comments:

Public Restroom #3

• Floors free of soil and debris (check corners and baseboards)

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Toilet and Sink: free of waste, mineral deposits, outside of bowl clean

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Walls/Doors/Partitions/Mirrors - not soiled or dusty. Mirrors Clean

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garbage cans clean - dust free emptied and relined

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Paper towels, soap dispensers clean refilled

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Comments

EXAM/PROCEDURE ROOMS #1

• Floors free of soil and debris (check corners and baseboards)

  Yes

  No

  N/A

• Garbage cans clean - dust free emptied and relined

  Yes

  No

  N/A

• Work surfaces/cabinets free of fingerprints and dust

  Yes

  No

  N/A

• Exam Tables fre eof dust and foreign matter. Base free of dust.

  Yes

  No

  N/A

• Paper towels, soap dispensers clean refilled

  Yes

  No

  N/A

EXAM/PROCEDURE ROOMS #2

• Floors free of soil and debris (check corners and baseboards)

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garbage cans clean - dust free emptied and relined

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Work surfaces/cabinets free of fingerprints and dust

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Exam Tables fre eof dust and foreign matter. Base free of dust.

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Paper towels, soap dispensers clean refilled

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

EXAM/PROCEDURE ROOMS #3

• Floors free of soil and debris (check corners and baseboards)

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garbage cans clean - dust free emptied and relined

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Work surfaces/cabinets free of fingerprints and dust

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Exam Tables fre eof dust and foreign matter. Base free of dust.

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Paper towels, soap dispensers clean refilled

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

Office #1

• Floors free of debris and soil (corners and baseboards clean). Carpets vacuumed

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Furniture free of dust/debris/spots

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garabge cans clean,emptied and relined.

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Comments

Office #2

• Floors free of debris and soil (corners and baseboards clean). Carpets vacuumed

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Furniture free of dust/debris/spots

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garabge cans clean,emptied and relined.

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Comments

Office #3

• Floors free of debris and soil (corners and baseboards clean). Carpets vacuumed

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Furniture free of dust/debris/spots

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Garabge cans clean,emptied and relined.

  GOOD

  SATISFACTORY

  NEEDS IMPROVEMENT

  N/A

• Comments

• Overall Comments On Facility