Title Page
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Site conducted
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Site conducted
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Conducted on
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Prepared by
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Location
Storage
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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
Meeting Rooms and 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
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
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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Food and beverages are only in designated areas
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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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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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Additional findings
Dietary
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Food is covered and labeled per policy
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No expired food or beverage items
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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)
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Cleaning items are not stored with food or beverages
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Staff food/beverages and belongings are appropriately stored and labeled
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Staff hair is secured
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Additional findings
EVS and Agiliti
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Equipment is clean or has been recently changed out
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No buildup of waste
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Additional findings
Laundry/Linen
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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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Clean linen is properly covered or sealed to prevent contamination during transport
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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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Laundry chutes are maintained
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Additional findings
Lab/Pathology
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No application of cosmetics in the laboratory work area (if observed)
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Staff hair is secured
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Eyewash stations are checked weekly and documented on the tag
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Additional findings
Pharmacy
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No outdated/expired medications
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Open vials are dated and timed as per policy
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Medications are disposed of properly
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Medications are stored appropriately
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Additional findings
