Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Patient Care Area

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Furniture is clean and in good condition

  • Curtains are clean and free of tears

  • Bathroom is clean

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • PPE is available

  • No expired supplies

  • No staff food or beverages

  • Additional findings

Isolation Rooms

  • Anteroom is clean

  • Appropriate sign(s) posted (laminated and with no tape)

  • Appropriate PPE is available

  • Door is closed as appropriate

  • Negative pressure is being supplied as required

  • Patient is transported with proper procedure

  • Patient and family are instructed on isolation requirements

  • Additional findings

Clean Utility and Storage Rooms

  • Door is closed and locked if appropriate

  • Area is clean

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Adequate separation of clean and soiled

  • No supplies stored on the floor

  • Bottom shelf barriers are in place and are 6 inches from the floor

  • Items stored are 18 inches from the ceiling

  • Equipment stored is clean

  • No expired supplies

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • Additional findings

Soiled Utility Room

  • Door is closed and locked if appropriate

  • Area is clean and orderly

  • Area is free of clean patient supplies and sterilized trays

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Bedpan flusher is clean

  • Separate sinks are available for handwashing and for cleaning soiled instruments if appropriate

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • Soiled linen is bagged and placed in appropriate receptacle

  • Process flow is dirty to clean (if applicable)

  • Additional findings

Nourishment Room

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Food/beverages are not expired

  • Ice machine, microwave, and refrigerator are clean and in good condition

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • Additional findings

Nurses Stations

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • No expired supplies

  • Specimens are bagged, handled, and labeled per policy (if observed)

  • Accu-Chek machines are closed

  • No staff food/beverages and belongings

  • Additional findings

Staff Lounges

  • Furniture is clean and in good condition

  • Area is clean and items are appropriately stored

  • No patient care items

  • Additional findings

Waiting Areas and Hallways

  • Hallways are clean and not cluttered

  • Furniture is clean and in good condition

  • Area is clean and items are appropriately stored

  • Additional findings

Equipment and Non-Critical Items

  • Computer equipment is clean, in good condition, and with no tape

  • Equipment is clean

  • Additional findings

Linen

  • Clean linen is distributed to units on clean, covered carts (if observed)

  • There is separation of clean and soiled linen

  • Clean linen is stored in required area, on shelves, or on covered carts

  • Soiled linen is not placed on floor, furniture, windowsills, etc. and is not overfilled

  • Linen hampers and carts are clean and in good condition

  • Linen carts have solid surface on the bottom shelf

  • Damaged linen is labeled

  • Additional findings

Waste Management

  • Biohazard bags are used appropriately

  • Waste containers are clean, operational, in good condition, and not overfilled

  • Waste containers are covered and labeled as required

  • Red bag is available in regulated medical waste container

  • Items in regulated medical waste containers are appropriate

  • Sharps container is available, secured appropriately, and not overfilled

  • Additional findings

Hand Hygiene

  • Hand hygiene is performed when appropriate (if observed)

  • Appropriate glove use (if observed)

  • Sinks are available, clean, and in good condition

  • Soap is available and not expired

  • Paper towels are available

  • Alcohol-based hand rub is available and not expired

  • Additional findings

General Environment

  • Floors are clean and in good condition

  • Walls are clean and in good condition

  • Ceiling is clean and in good condition

  • Air vents are clean and in good condition

  • Light fixtures are clean and in good condition

  • High-level dusting is performed

  • Area is free of roaches, flies, mice, and other vermin

  • Additional findings

Miscellaneous

  • Signage is laminated and not taped

  • No inappropriate items on windowsills

  • Cleaning supplies are not stored with patient care items

  • Sterilized items are not expired, free of dust/tears, and not opened

  • Items are labeled/dated appropriately (electrodes, ultrasound gel, etc.)

  • No outside shipping/corrugated cardboard boxes

  • No items/surfaces that cannot be cleaned in patient care areas

  • Eyewash stations are checked weekly and documented on the tag

  • Additional findings

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