WCG-Environment of Care- Inpatient

• Site conducted

  Select

• Conducted on

  Date

• Site name

• Prepared by

• Inspected by

• Location
  Address

Entry

• Entry doors are locked and in working condition?

  Good

  Fair

  Poor

  N/A

• Entry areas are clean and in a safe condition?

  Good

  Fair

  Poor

  N/A

• Entry call buttons are in working order at time of inspection?

  Good

  Fair

  Poor

  N/A

• Lobby areas are clean and free from safety concerns or issues?

  Good

  Fair

  Poor

  N/A

• Hallways leading to client areas are clean and free from safety concerns or issues?

  Good

  Fair

  Poor

  N/A

• Postings related to client rights, accreditation, required notices, and license are present in common areas?

  Good

  Fair

  Poor

  N/A

• Any additional safety, security or cleanliness issues related to entry and lobby areas?

  Good

  Fair

  Poor

  N/A

Exam Room

• Furniture in the exam room is clean, safe and in good condition?

  Good

  Fair

  Poor

  N/A

• Items stored in the exam room are stored under safe conditions preventing risks to patients?

  Good

  Fair

  Poor

  N/A

• Medical equipment has been inspected, is properly tagged with inspection date, and date is not expired?

  Good

  Fair

  Poor

  N/A

• Any additional safety, security or cleanliness issues related to the exam room?

  Good

  Fair

  Poor

  N/A

Common Areas- Client Care

• Furniture in client common areas is clean, safe and in good condition?

  Good

  Fair

  Poor

  N/A

• Common areas appear clean?

  Good

  Fair

  Poor

  N/A

• Common area is free from safety issues?

  Good

  Fair

  Poor

  N/A

• Common areas vents are free from dust and/or dust build-up?

  Good

  Fair

  Poor

  N/A

• Trash in common areas is contained?

  Good

  Fair

  Poor

  N/A

• Posting in common areas are present, including client rights and unit schedule? There are cues to alert clients of date and time?

  Good

  Fair

  Poor

  N/A

• Group areas are clean, safe and in good condition?

  Good

  Fair

  Poor

  N/A

• Areas deemed as "secure" are locked upon inspection? (Examples: Medication closets, bathrooms, utility closets, janitor closets, etc.

  Good

  Fair

  Poor

  N/A

• Temperature in client care areas is comfortable to season?

  Good

  Fair

  Poor

  N/A

• Any additional issues related to safety, security or cleanliness in common and group areas?

  Good

  Fair

  Poor

  N/A

Unit Bathroom

• Client bathrooms are clean?

  Good

  Fair

  Poor

  N/A

• Client bathrooms are safe?

  Good

  Fair

  Poor

  N/A

• Trash in client bathroom areas is contained?

  Good

  Fair

  Poor

  N/A

• Any additional safety, security or cleanliness concerns related to client bathroom areas?

  Good

  Fair

  Poor

  N/A

Laundry

• Laundry Room is locked at time of inspection?

  Yes

  No

  N/A

• Lint is not present in the lint trap?

  Good

  Fair

  Poor

  N/A

• Clothes and client items are not stored on the floor?

  Good

  Fair

  Poor

  N/A

• Items are not stored within 18 inches of the ceiling?

  Good

  Fair

  Poor

  N/A

• Any additional safety, security of cleanliness concerns related to laundry room?

  Good

  Fair

  Poor

  N/A

Kitchen Areas

• Kitchen areas are locked?

  Yes

  No

  N/A

• Kitchen areas are clean?

  Good

  Fair

  Poor

  N/A

• Refrigerator logs are present and completed to date?

  Yes

  No

  N/A

• On inspection, refrigerator is holding proper temperature?

  Yes

  No

  N/A

• Refrigerator is free from expired items?

  Good

  Fair

  Poor

  N/A

• Food stored in kitchen is being stored at proper temperature and condition?

  Good

  Fair

  Poor

  N/A

• Ovens and dishwashers are clean?

  Good

  Fair

  Poor

  N/A

• Client care items are not stored under sinks?

  Good

  Fair

  Poor

  N/A

• Any additional safety, security or cleanliness concerns related to kitchen areas?

  Good

  Fair

  Poor

  N/A

Patient Rooms

• Furniture is in good condition and is safe for client use?

  Good

  Fair

  Poor

  N/A

• Overall the room is clean for client?

  Good

  Fair

  Poor

  N/A

• Overall the room is safe for client care?

  Good

  Fair

  Poor

  N/A

• Bathroom in client room is safe and in good condition?

  Good

  Fair

  Poor

  N/A

• Doors and light fixtures are safe and in working order?

  Good

  Fair

  Poor

  N/A

• Temperature in patient rooms is comfortable to season?

  Good

  Fair

  Poor

  N/A

• Any additional safety, security or cleanliness concerns related to kitchen areas?

  Good

  Fair

  Poor

  N/A

Seclusion and Restraint

• Seclusion room doors lock according to design?

  Yes

  No

  N/A

• Doors are in good condition and free from safety issues?

  Yes

  No

  N/A

• Rooms are safe and appropriate for seclusion and/or restraint?

  Yes

  No

  N/A

• Beds stored in S/R room are safe and in good condition?

  Yes

  No

  N/A

• The bathroom in the S/R area is clean?

  Yes

  No

  N/A

• The bathroom in S/R is safe?

  Yes

  No

  N/A

• Lighting in the S/R area is adequate and in working order?

  Yes

  No

  N/A

• Temperature in the S/R is comfortable to season?

  Yes

  No

  N/A

• Any additional safety, security, or cleanliness issues related to S/R area?

  Yes

  No

  N/A

Additional Areas

• Storage areas are orderly and free from excessive clutter?

  Good

  Fair

  Poor

  N/A

• Ceiling tiles are present and free from stains?

  Good

  Fair

  Poor

  N/A

• Flooring is in good condition and free from trip hazards?

  Good

  Fair

  Poor

  N/A

• Overall walls are clean and in good condition?

  Good

  Fair

  Poor

  N/A

• Entry and exits are not blocked at time of inspection?

  Yes

  No

  N/A

• Exit signs are in working order?

  Yes

  No

  N/A

• Items in storage areas are not stored within 18 inches of the ceiling?

  Yes

  No

  N/A

• Utility Rooms are labeled with shut-offs?

  Yes

  No

  N/A

• Fire extinguishers are labeled and have monthly inspection?

  Yes

  No

  N/A

• Exam room is clean, safe and in good condition?

  Good

  Fair

  Poor

  N/A

• Areas storing hazardous waste is marked?

  Yes

  No

  N/A

• Clean utility is separated from dirty utility storage areas?

  Good

  Fair

  Poor

  N/A

• All clean utility areas are stored under proper conditions?

  Yes

  No

  N/A

• Hazardous waste is stored under proper condition?

  Yes

  No

  N/A

• Any additional safety, security, or cleanliness issues related to the general areas?

  Yes

  No

  N/A

• Sidewalks leading to the building are safe and in good condition?

  Yes

  No

  N/A

• Lighting to the building is in good working condition?

  Yes

  No

  N/A

• The exterior if free from holes/hives/ nests or damage related to pests?

  Yes

  No

  N/A

• Entry ways are free from tripping hazards and maintained according to season?

  Yes

  No

  N/A

• Exterior paint, caulking and tuck-pointing is in good condition?

  Yes

  No

  N/A

• Fences/retaining walls are in good condition?

  Yes

  No

  N/A

• Exterior windows are in good condition?

  Yes

  No

  N/A

• Gutters and downspouts are in good condition?

  Yes

  No

  N/A

• Any additional safety, security or cleanliness issues related to exterior spaces?

  Yes

  No

  N/A

• Site Summary