Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Patient Care Area
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Countertops are clean and in good condition
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Shelving/drawers/cabinets are clean and in good condition
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Furniture is clean and in good condition
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Curtains are clean and free of tears
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Bathroom is clean
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Sinks are clean and in good condition
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Nothing inappropriate is stored under the sinks
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PPE is available
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No expired supplies
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No staff food or beverages
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Additional findings
Isolation Rooms
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Anteroom is clean
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Appropriate sign(s) posted (laminated and with no tape)
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Appropriate PPE is available
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Door is closed as appropriate
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Negative pressure is being supplied as required
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Patient is transported with proper procedure
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Patient and family are instructed on isolation requirements
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Additional findings
Clean Utility and Storage Rooms
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Door is closed and locked if appropriate
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Area is clean
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Countertops are clean and in good condition
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Shelving/drawers/cabinets are clean and in good condition
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Adequate separation of clean and soiled
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No supplies stored on the floor
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Bottom shelf barriers are in place and are 6 inches from the floor
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Items stored are 18 inches from the ceiling
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Equipment stored is clean
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No expired supplies
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Sinks are clean and in good condition
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Nothing inappropriate is stored under the sinks
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Additional findings
Soiled Utility Room
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Door is closed and locked if appropriate
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Area is clean and orderly
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Area is free of clean patient supplies and sterilized trays
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Countertops are clean and in good condition
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Shelving/drawers/cabinets are clean and in good condition
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Bedpan flusher is clean
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Separate sinks are available for handwashing and for cleaning soiled instruments if appropriate
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Sinks are clean and in good condition
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Nothing inappropriate is stored under the sinks
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Soiled linen is bagged and placed in appropriate receptacle
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Process flow is dirty to clean (if applicable)
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Additional findings
Nourishment Room
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Countertops are clean and in good condition
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Shelving/drawers/cabinets are clean and in good condition
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Food/beverages are not expired
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Ice machine, microwave, and refrigerator are clean and in good condition
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Sinks are clean and in good condition
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Nothing inappropriate is stored under the sinks
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Additional findings
Nurses Stations
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Countertops are clean and in good condition
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Shelving/drawers/cabinets are clean and in good condition
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No expired supplies
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Specimens are bagged, handled, and labeled per policy (if observed)
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Accu-Chek machines are closed
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No staff food/beverages and belongings
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Additional findings
Staff Lounges
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Furniture is clean and in good condition
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Area is clean and items are appropriately stored
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No patient care items
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Additional findings
Waiting Areas and Hallways
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Hallways are clean and not cluttered
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Furniture is clean and in good condition
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Area is clean and items are appropriately stored
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Additional findings
Equipment and Non-Critical Items
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Computer equipment is clean, in good condition, and with no tape
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Equipment is clean
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Additional findings
Linen
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Clean linen is distributed to units on clean, covered carts (if observed)
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There is separation of clean and soiled linen
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Clean linen is stored in required area, on shelves, or on covered carts
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Soiled linen is not placed on floor, furniture, windowsills, etc. and is not overfilled
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Linen hampers and carts are clean and in good condition
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Linen carts have solid surface on the bottom shelf
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Damaged linen is labeled
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Additional findings
Waste Management
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Biohazard bags are used appropriately
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Waste containers are clean, operational, in good condition, and not overfilled
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Waste containers are covered and labeled as required
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Red bag is available in regulated medical waste container
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Items in regulated medical waste containers are appropriate
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Sharps container is available, secured appropriately, and not overfilled
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Additional findings
Hand Hygiene
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Hand hygiene is performed when appropriate (if observed)
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Appropriate glove use (if observed)
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Sinks are available, clean, and in good condition
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Soap is available and not expired
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Paper towels are available
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Alcohol-based hand rub is available and not expired
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Additional findings
General Environment
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Floors are clean and in good condition
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Walls are clean and in good condition
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Ceiling is clean and in good condition
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Air vents are clean and in good condition
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Light fixtures are clean and in good condition
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High-level dusting is performed
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Area is free of roaches, flies, mice, and other vermin
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Additional findings
Miscellaneous
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Signage is laminated and not taped
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No inappropriate items on windowsills
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Cleaning supplies are not stored with patient care items
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Sterilized items are not expired, free of dust/tears, and not opened
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Items are labeled/dated appropriately (electrodes, ultrasound gel, etc.)
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No outside shipping/corrugated cardboard boxes
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No items/surfaces that cannot be cleaned in patient care areas
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Eyewash stations are checked weekly and documented on the tag
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Additional findings
