Village Clinic Inspection

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Building Condition

• Arctic entry - appropriate design and maintained?

  Yes

  No

  N/A

• Sound construction, easily cleanable?

  Yes

  No

  N/A

• Exam rooms -Is there 80 square ft; treatment rooms 120 square ft?

  Yes

  No

  N/A

• ADA compliant?

  Yes

  No

  N/A

• Storage adequate and organized? <br>

  Yes

  No

  N/A

• Boiler and electrical rooms not being used to store combustibles?

  Yes

  No

  N/A

• Exam room doors 3' clearance?

  Yes

  No

  N/A

• All doors function correctly?

  Yes

  No

  N/A

• Bathrooms enclosed and staff able to open?

  Yes

  No

  N/A

• Secure lock for outside doors? Allows egress or sign posted to "Keep unlocked during Normal Business Hours"?

  Yes

  No

  N/A

• Patient privacy maintained through doors, curtains or opaque windows?

  Yes

  No

  N/A

Plumbing

• Installed to UPC by competent personnel?

  Yes

  No

  N/A

• Handwashing sinks in exam rooms?

  Yes

  No

  N/A

• Convenient to toilet?

  Yes

  No

  N/A

• <br>Boiler room enclosed by 1 hour fire resistant barrier or sprinklered?

  Yes

  No

  N/A

• Hot water does not exceed 110 degrees F?

  Yes

  No

  N/A

Heating and Ventilation (mechanical)

• Appliances installed to code by competent personnel?

  Yes

  No

  N/A

• Outside air used for combustion and ventilation?

  Yes

  No

  N/A

• Heating - 68 - 72 degrees F when occupied?

  Yes

  No

  N/A

• 10 ACH in toilet and shower room and Janitor Closets?

  Yes

  No

  N/A

• Boilers thermostatically controlled?

  Yes

  No

  N/A

• Boilers not set over 180 degrees F?

  Yes

  No

  N/A

• Boiler pressure not lower than 10 psig or higher than 20 psig?

  Yes

  No

  N/A

• Portable space heaters not in evidence?

  Yes

  No

  N/A

• Fuel tanks and connections installed to code?

  Yes

  No

  N/A

• Fuel lines supported and protected?

  Yes

  No

  N/A

• Flexible connectors used on fuel lines between fuel tank and building?

  Yes

  No

  N/A

• SPCCP in place if fuel tank exceeds 660 gallons?

  Yes

  No

  N/A

• Chemical toilet or box - and - pail type toilet if no water under pressure?

  Yes

  No

  N/A

• Utility sink with anti-syphon device, if water pressure available?

  Yes

  No

  N/A

• Backflow preventer installed, if equipped?

  Yes

  No

  N/A

• Annual backflow preventer inspection completed?

  Yes

  No

  N/A

• Fuel gas piping installed and maintained to code, if applicable?

  Yes

  No

  N/A

• All fixtures clean and in good repair?

  Yes

  No

  N/A

Electrical

• Wiring installed and maintained according to NEC?

  Yes

  No

  N/A

• Sufficient receptacles available?

  Yes

  No

  N/A

• Each exam and worktable served by at least one duplex receptacle?

  Yes

  No

  N/A

• GFCI installed within 6' of a water source?

  Yes

  No

  N/A

• Tamper resistant outlets in Child Occupied areas?

  Yes

  No

  N/A

• Electrical Panel schedule current and updated?

  Yes

  No

  N/A

• 3' clearance in front of electrical panels?

  Yes

  No

  N/A

• Cords or plugins NOT frayed, damaged, or worn?

  Yes

  No

  N/A

• Extension cords are NOT being used as "permanent" wiring?

  Yes

  No

  N/A

• Extension cords are NOT plugged into a UPS?

  Yes

  No

  N/A

• Multi-plex outlets are NOT "daisy chained"?

  Yes

  No

  N/A

• Appliances are UL Listed or listed by another independent safety lab?

  Yes

  No

  N/A

Lighting

• Minimum light levels for prep/exam/desks 100FC?

  Yes

  No

  N/A

• Janitor's Closets 50FC?

  Yes

  No

  N/A

• General area and Toilets 20FC?

  Yes

  No

  N/A

• External entrance lighting available and sufficient?

  Yes

  No

  N/A

• Emergency lighting available?

  Yes

  No

  N/A

• 30 second monthly and 90 minute annual testing completed?

  Yes

  No

  N/A

• Fixtures without lens, are they shielded with a tube type shield?

  Yes

  No

  N/A

Furnishings

• Furniture and carpet allow for cleaning?

  Yes

  No

  N/A

• Satellite or Landline phone available for emergency communication?

  Yes

  No

  N/A

Water

• Potable water provided - clinic connected to community supply - if available?

  Yes

  No

  N/A

• Water source tested according to Alaska Department of Environmental Conservation (ADEC) standards?

  Yes

  No

  N/A

• Drinking fountains or single service cups available?

  Yes

  No

  N/A

• Hauled water delivered in approved containers and maintains sufficient residual chlorine?

  Yes

  No

  N/A

• Water storage containers appropriate and sanitized daily?

  Yes

  No

  N/A

• Non-tested water, if used, receives appropriate treatment?

  Yes

  No

  N/A

• Any emergency water receives disinfection provided by chlorination or boiling?

  Yes

  No

  N/A

Sewage Disposal

• Liquid waste systems operate as designed and dispose of waste in accordance with State of Alaska regulations?

  Yes

  No

  N/A

• Clinic connected to community sewer system if available?

  Yes

  No

  N/A

• Septic tanks, if used, appropriately placed, identified, and functioning correctly?

  Yes

  No

  N/A

• Sludge or "honey bucket" waste disposed of in permitted sites?

  Yes

  No

  N/A

• "Honey Buckets" emptied on a daily basis?

  Yes

  No

  N/A

Refuse Sanitation

• Solid waste appropriately disposed to limit injuries and spread of infection?

  Yes

  No

  N/A

• Solid waste containers not to exceed 32 gallons?

  Yes

  No

  N/A

• Exterior containers have lids to prevent spillage from wind and animals?

  Yes

  No

  N/A

Regulated Medical Waste

• Policy available on definition and procedures for handling?

  Yes

  No

  N/A

• Staff has been trained on "Red Bag" material?

  Yes

  No

  N/A

• Material in "Red Bag" containers is appropriate?

  Yes

  No

  N/A

Sharps

• Needles are the automatic retractable type?

  Yes

  No

  N/A

• Containers of an approve design?

  Yes

  No

  N/A

• Containers are not more than 75% full?

  Yes

  No

  N/A

Waste Collection Frequency

• Waste collected on a daily basis?

  Yes

  No

  N/A

• Collection and storage des not create a health hazard or pollute water run-off?

  Yes

  No

  N/A

Infection Control

• Hand washing means provided and used for hand antisepsis; alcohol-based agent or antimicrobial soap?

  Yes

  No

  N/A

• ABHR available and accessible?

  Yes

  No

  N/A

• Clinics with running water, hand washing sinks available with soap, warm water, and paper towels located in toilet and exam rooms?

  Yes

  No

  N/A

• Clinics with no running water have appropriate containers with spigots in toilet and exam rooms?

  Yes

  No

  N/A

Disinfection and Sterilization - Medical Equipment

• Staff is appropriately trained?

  Yes

  No

  N/A

• Staff wears appropriate PPE during the process?

  Yes

  No

  N/A

• Process flows from "dirty" to "clean"?

  Yes

  No

  N/A

• Level of disinfection/sterilization based on use of equipment?

  Yes

  No

  N/A

• Chemical, mechanical, and or biological monitoring conducted?

  Yes

  No

  N/A

• Disinfected/sterilized packages rotated, intact, and not stored on the floor or under a sink?

  Yes

  No

  N/A

• A Recall Policy developed and "in force" for all disinfected/sterilized items?

  Yes

  No

  N/A

Disinfection and Sterilization - General

• All Surfaces disinfected with approved NSHC disinfection agents?

  Yes

  No

  N/A

• Any and all toys within the clinic are washed and disinfected when visibly contaminated and after each use?

  Yes

  No

  N/A

• Blood Borne Pathogens (BBP) spills are disinfected with approved NSHC disinfectant agents.

  Yes

  No

  N/A

• Proper Personal Protective Equipment (PPE) is worn when cleaning and BBP spills?

  Yes

  No

  N/A

• A written BBP Plan is in place and enforced?

  Yes

  No

  N/A

• Provisions of the Needle Stick Safety and Prevention Act are included?

  Yes

  No

  N/A

• Any broken contaminated glassware collected with a broom and dustpan and the area disinfected with appropriate agents?

  Yes

  No

  N/A

Housekeeping

• Staff have been trained on proper cleaning procedures?

  Yes

  No

  N/A

• Clinic cleaned according to posted schedule or on a daily basis?

  Yes

  No

  N/A

• Cleaning supplies kept locked within the Janitor's Closet?

  Yes

  No

  N/A

Occupational Health and Safety

• Drugs and NARCS stored in a locked room and/or PickPoint unit?

  Yes

  No

  N/A

• Outdated or expired medication removed from patient medication storage area and properly disposed of or shipped back to the Pharmacy for disposal?

  Yes

  No

  N/A

• Lab specimens and other contaminants are separated from prescription medications?

  Yes

  No

  N/A

• Any toxic or hazardous materials stored separately from any food or medicines?

  Yes

  No

  N/A

• Incompatible chemicals separated from one another?

  Yes

  No

  N/A

• Poison Control phone number is posted within the clinic?

  Yes

  No

  N/A

• Refrigerator/freezer temperatures are being recorded and monitored either manually or remotely?

  Yes

  No

  N/A

Fire Safety

• Smoke detectors are online and operational?

  Yes

  No

  N/A

• Sleeping quarters have an operational smoke detector?

  Yes

  No

  N/A

• Fire extinguishers appropriately placed, readily visible, and not blocked?

  Yes

  No

  N/A

• Monthly and Annual testing has been completed according to National Fire Protection Association (NFPA) Standards?

  Yes

  No

  N/A

• Staff has received annual training on fire extinguisher use and documented?

  Yes

  No

  N/A

• Clinic has conducted annual fire drill and documented the event?

  Yes

  No

  N/A

• Exit signs placed appropriately?

  Yes

  No

  N/A

• Monthly 30 second testing and annual 90 minute testing completed according to NFPA Standards?

  Yes

  No

  N/A

• Boiler rooms enclosed by 1 hour barrier?

  Yes

  No

  N/A

• Pressure relief valves in place and "blow off" line situated to blow away from people?

  Yes

  No

  N/A

• Smoking is not done in clinic and is prohibited?

  Yes

  No

  N/A

Hazardous Communication Program (HAZCOM)

• Written HAZCOM Program implemented?

  Yes

  No

  N/A

• Do staff know where Safety Data Sheet (SDS) book is located?

  Yes

  No

  N/A

• SDS available in hardcopy and/or electronic format?

  Yes

  No

  N/A

• Departmental HAZCOM completed?

  Yes

  No

  N/A

• SDS book index current?

  Yes

  No

  N/A

• (Have staff search for SDS for 1 item within clinic) - SDS' current?

  Yes

  No

  N/A

Hazardous Materials

Asbestos

• Has an Asbestos Survey been conducted by a certified surveyor?

  Yes

  No

  N/A

• Was the building constructed after to 1980?

  Yes

  No

  N/A

• There is NO Thermal System Insulation(TSI), sprayed on/troweled, asphalt or sheet vinyl flooring in evidence?

  Yes

  No

  N/A

Lead

• Has a Lead Survey been conducted by a certified surveyor?

  Yes

  No

  N/A

• Was the building constructed after 1978?

  Yes

  No

  N/A

Tuberculosis Precautions

• Procedures available describing actions to take in the event of suspected TB?

  Yes

  No

  N/A

• Procedures in place to protect employees from exposure to TB?

  Yes

  No

  N/A

Compressed Gases

• Large cylinders have a valve cap screwed tightly to the cylinder when not in use?

  Yes

  No

  N/A

• Cylinders secured in a stand, cart, or attached to immovable object?

  Yes

  No

  N/A

• Oxygen supply equipment kept free of petroleum products?

  Yes

  No

  N/A

• Cylinders tagged with correct status - New, In Use, Empty?

  Yes

  No

  N/A

• Cylinders retested and stamped every 5 years for steel type and 10 years for aluminum?

  Yes

  No

  N/A

• Cylinders have oxygen manufacturer's label on them?

  Yes

  No

  N/A

• There is NOT more than 12 oxygen cylinders in the clinic?

  Yes

  No

  N/A

• If NO, how many?

Injury Control

• Extension cords not attached to hot or heavy use devices?

  Yes

  No

  N/A

• There are NO poisonous or harmful plants?

  Yes

  No

  N/A

• Window shades with cords/strings NO longer than 6'?

  Yes

  No

  N/A

• There are NO sharp points or corners on any furniture?

  Yes

  No

  N/A

• Are all exits kept free and clear of debris, snow and ice, combustibles, and other hazards?

  Yes

  No

  N/A

• Are hand rails and ant-slip surfaces utilized on steps and ramps?

  Yes

  No

  N/A

Joint Commission

• Medical Records are kept confidential?

  Yes

  No

  N/A

• Hazard Surveillance Surveys conducted on a bi-annual basis?

  Yes

  No

  N/A

• Have all staff completed the Annual Safety Fair with a passing score?

  Yes

  No

  N/A

• Staff utilize there NSHC ID according to policy?

  Yes

  No

  N/A

• Copies of shipping manifests are kept for bio-hazardous and hazardous waste shipments?

  Yes

  No

  N/A

• Staff has been trained in IATA?

  Yes

  No

  N/A

• Annual Emergency Preparedness drills conducted according to standards?

  Yes

  No

  N/A

• Annual fire drill has been conducted and documented according to NFPA standards?

  Yes

  No

  N/A

• Fire suppression system (if equipped) has been tested by a licensed professional on an annual basis?

  Yes

  No

  N/A

• Fire alarm system (if equipped) has been tested by a licensed professional on an annual basis?

  Yes

  No

  N/A

• Medical equipment is on a preventive maintenance schedule?

  Yes

  No

  N/A

• Equipment has a current inspection tag?

  Yes

  No

  N/A

• Staff can show when the equipment has last been tested?

  Yes

  No

  N/A

Lodging

• Is there a room set aside for traveling staff to stay in within the clinic?

  Yes

  No

  N/A

• Single station smoke detectors have been placed in each sleeping room?

  Yes

  No

  N/A

• Smoke detectors are functional?

  Yes

  No

  N/A

• Back up batteries have been replaced within the last year?

  Yes

  No

  N/A

• Is there a secondary means of egress per code?

  Yes

  No

  N/A

Notes

• Notes

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  Date