WCG-Environment of Care- Outpatient

• Site conducted

  Select

• Conducted on

  Date

• Site Name:

• Prepared by

• Conducted by:

• Location
  Address

Entry/Lobby Areas/Hallways

• Entry doors are locked, free from issues, and are in working condition?

  Good

  Fair

  Poor

  N/A

• Entry areas are clean and in a safe condition?

  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

• Any additional safety, security or cleanliness issues with entry or lobby areas?

  Good

  Fair

  Poor

  N/A

Common Areas/ Group Areas- Client Care

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

  Good

  Fair

  Poor

  N/A

• Common areas/ group areas appear clean?

  Good

  Fair

  Poor

  N/A

• Common areas/ group areas are free from safety issues?

  Good

  Fair

  Poor

  N/A

• Common areas/ group 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

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

  Good

  Fair

  Poor

  N/A

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

  Good

  Fair

  Poor

  N/A

Bathroom

• Client bathrooms are clean?

  Good

  Fair

  Poor

  N/A

• Client bathrooms are safe?

  Good

  Fair

  Poor

  N/A

• Client bathrooms are in working condition?

  Good

  Fair

  Poor

  N/A

• Trash in client bathroom areas is contained?

  Good

  Fair

  Poor

  N/A

• Any additional safety, security or cleanliness issues 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

• Laundry machines are safe and in working order?

  Good

  Fair

  Poor

  N/A

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

  Good

  Fair

  Poor

  N/A

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

  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 in kitchen area?

  Good

  Fair

  Poor

  N/A

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

  Good

  Fair

  Poor

  N/A

Additional Areas/Items

Additional Areas

• Storage areas are orderly and free from excessive clutter?

  Good

  Fair

  Poor

  N/A

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

  Yes

  No

  N/A

• Ceiling/Ceiling tiles are in good condition and free from stains, holes, excessive cracks?

  Good

  Fair

  Poor

  N/A

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

  Good

  Fair

  Poor

  N/A

• Doors and door frames throughout the building are safe and in good working condition?

  Good

  Fair

  Poor

  N/A

• Windows are safe and in working condition?

  Good

  Fair

  Poor

  N/A

• Window coverings like blinds are safe (to the program) and in working condition?

  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

• Utility Rooms are labeled with shut-offs?

  Yes

  No

  N/A

• Fire extinguishers are labeled and have monthly inspection?

  Yes

  No

  N/A

• Areas storing hazardous waste is marked?

  Yes

  No

  N/A

• All clean supplies are stored under proper conditions including, keeping them out of reach of clients, not storing items under sinks and cleaning items being labeled?

  Good

  Fair

  Poor

  N/A

• SDS sheets are available for chemicals used for cleaning?

  Yes

  No

  N/A

• The program maintains a safe environment free from Infection Prevention concerns?

  Good

  Fair

  Poor

  N/A

• The program stores potentially dangerous items like scissors and sharp items out of the reach of clients?

  Good

  Fair

  Poor

  N/A

• Any Additional safety, security or cleanliness issues related to the program/site?

  Good

  Fair

  Poor

  N/A

Exterior Client Care Spaces

• Exterior spaces are secure?

  Good

  Fair

  Poor

  N/A

• Exterior client space are in good condition?

  Good

  Fair

  Poor

  N/A

• Client space is free from hives/holes or damage related to pests?

  Good

  Fair

  Poor

  N/A

• The area is free from tripping hazards or fall risks?

  Good

  Fair

  Poor

  N/A

• Furniture in outdoor client spaces are in good condition?

  Good

  Fair

  Poor

  N/A

Building Exterior- Non Client Care

• 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

• Site Summary: