Title Page
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Department
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Conducted on
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Prepared by:
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Location:
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Personnel
Infection Control
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Are items stored at least 36" from electrical panels?
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Are electric panels properly secured or locked?
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Are electric panel switch labels accurate and are all spares in the off position?
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Are all mechanical and electrical rooms clean and have no storage? Indicate which rooms are not clean in the notes section.
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Are medical gas zone shut-off valves accessible and unobstructed?
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Are medical gas zone shut-off valves properly labeled for area served?
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Do clean utility, sterile storage, medication rooms, and other clean/sterile areas have positive air pressure to the corridor/adjacent areas?
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Do soiled utility, trash, hazardous waste, and other dirty rooms have negative air pressure to the corridor/adjacent areas?
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Clean utility rooms contain only clean/sterile items?
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Soiled utility rooms contain contaminated/soiled items only?
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All clean supplies stored off of the floor?
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Are supplies within expiration dates? (Random checks)
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Is clean linen covered?
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Is clean linen kept separate from the dirty linen disposal?
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Are medication refrigerator logs maintained and up-to-date? Are temperatures within range?
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Are patient food refrigerator logs maintained and up-to-date? Are temperatures within range?
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Are patient food freezer logs maintained and up-to-date?
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Are patient food freezer temperatures within range?
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Are medicines and food stored in separate refrigerators?
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Patient food items have expiration dates and are not expired?
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The only items located under sinks are items allowed by policy?
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Return and supply air diffusers are free from dust?
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Countertops in good repair with no chips or missing laminate?
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Furniture is in good repair and not dirty or soiled?
