Title Page

  • Site conducted

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Storage

  • 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

Meeting Rooms and Staff Lounges

  • Furniture is clean and in good condition

  • Area is clean and items are appropriately stored

  • No patient care items

  • Additional findings

Equipment and Non-Critical Items

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

  • Equipment is clean

  • 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

  • Food and beverages are only in designated areas

  • No inappropriate items on windowsills

  • Cleaning supplies are not stored with patient care items

  • No outside shipping/corrugated cardboard boxes

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

  • Additional findings

Dietary

  • Food is covered and labeled per policy

  • No expired food or beverage items

  • Food is stored at appropriate temperatures (41°F and below for cold food storage; 0°F and below for frozen food storage; 140°F and above for hot food storage)

  • Cleaning items are not stored with food or beverages

  • Staff food/beverages and belongings are appropriately stored and labeled

  • Staff hair is secured

  • Additional findings

EVS and Agiliti

  • Equipment is clean or has been recently changed out

  • No buildup of waste

  • Additional findings

Laundry/Linen

  • There is separation of clean and soiled linen

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

  • Clean linen is properly covered or sealed to prevent contamination during transport

  • Linen hampers and carts are clean and in good condition

  • Linen carts have solid surface on the bottom shelf

  • Laundry chutes are maintained

  • Additional findings

Lab/Pathology

  • No application of cosmetics in the laboratory work area (if observed)

  • Staff hair is secured

  • Eyewash stations are checked weekly and documented on the tag

  • Additional findings

Pharmacy

  • No outdated/expired medications

  • Open vials are dated and timed as per policy

  • Medications are disposed of properly

  • Medications are stored appropriately

  • Additional findings

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