WELLNESS MONTHLY INSPECTION

• WELLNESS

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Smoke Detectors

  Yes

  No

  N/A

• Heat Sensors

  Yes

  No

  N/A

• Pull Stations

  Yes

  No

  N/A

• Strobes

  Yes

  No

  N/A

• Fire Extinguishers

  Yes

  No

  N/A

• Emergency Lights

  Yes

  No

  N/A

• Exit Lights

  Yes

  No

  N/A

• Carbon Monoxide Detectors (if applicable)

  Yes

  No

  N/A

• Electrical Outlets

  Yes

  No

  N/A

• Electrical Panels Labeled/No missing Breakers/Blocked with in 36 inches?

  Yes

  No

  N/A

• Lighting

  Yes

  No

  N/A

• Facility Exits

  Yes

  No

  N/A

• Facility Exit Plan Posted

  Yes

  No

  N/A

• SDS Binder Accessible/Index Current

  Yes

  No

  N/A

• Chemicals Stored and Labeled Properly

  Yes

  No

  N/A

• Broken Glass

  Yes

  No

  N/A

• Proper Use of Extension Cords/Surge Protectors

  Yes

  No

  N/A

• Trip Hazards

  Yes

  No

  N/A

• Walls – Ceilings – Floors

  Yes

  No

  N/A

• Doors/Door Closers/Hardware

  Yes

  No

  N/A

• Emergency Eye Wash inspected

  Yes

  No

  N/A

• Safety Boards display all required information and up to date

  Yes

  No

  N/A

ENVIROMENTAL SAFETY

• Facility Cleanliness

  Yes

  No

  N/A

• Trash Containers

  Yes

  No

  N/A

• Urinals – Commodes

  Yes

  No

  N/A

• Microwaves

  Yes

  No

  N/A

• Refrigerators

  Yes

  No

  N/A

• Cleaning Supplies / Storage

  Yes

  No

  N/A

• HVAC Vents

  Yes

  No

  N/A

• Floor Coverings

  Yes

  No

  N/A

• Outside Area – cleanliness - safe

  Yes

  No

  N/A

• Examining rooms private, separate from reception area, clean and have adequate space

  Yes

  No

  N/A

• Waiting area and Common area clean and free of clutter

  Yes

  No

  N/A

• Adequate storage space, medical supplies in locked closet or cabinet

  Yes

  No

  N/A

• Medications are labeled, kept in locked storage

  Yes

  No

  N/A

• Isolation rooms present for patients with communicable diseases

  Yes

  No

  N/A

• Medical equipment properly inspected and maintained

  Yes

  No

  N/A

• AED inspected/Epi Pen

  Yes

  No

  N/A

• Warning signs and labels appropriately displayed

  Yes

  No

  N/A

• Hazardous materials, medical waste, and sharps properly labeled, stored and disposed of

  Yes

  No

  N/A

• Yes

  No

  N/A

EQUIPMENT

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