• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Summary of Survey

  • Number of deficiencies found during this Inspection:

  • Score - Total Survey Score %

Employee Hand Hygiene Compliance

  • Employees Monitored

1.0 Employee PPE

  • Employee wearing appropriate PPE

  • Employee wearing PPE appropriately

  • Staff remove gloves before moving to the next task or patient

  • Staff wear gloves for procedures that might involve contact with blood or body fluids?

  • Staff wear gloves when handling potentially contaminated patient equipment?

  • Eye wash station checked weekly. Have staff member demonstrate

2.0. Soiled Instruments

  • Instrument carts are being received with the 'Dirty' sign on side of cart

  • Soiled instruments are moist when they are received from other departments

  • Instruments are received unhinged

  • Instruments in the washer are not stacked

3.0 Single use devices, sterilization, HDL

  • 3.5. Items are pre-cleaned according to manufacturer's instructions or evidence based guidelines prior to sterilization?

  • 3.6. Medical devices and instruments are visually inspected for residual soil and re-cleaned as needed before packaging and sterilization.

  • 3.7. a chemical indicator is placed in each load.

  • 3.8. A biological indicator is performed at least weekly and with all implantable loads.

  • 3.9. Each load is monitored with mechanical indicators (e.g. time, temperature, pressure)

  • 3.10. Documentation for each piece of sterilization equipment is maintained and up to date and includes results from each load.

  • 3.11. Items are appropriately contained and handled during the sterilization process to assure sterility is not compromised prior to use.

  • 3.12. After sterilization, medical devices and instruments are stored in a designated clean area so sterility is not compromised.

  • 3.13. Sterile packages are inspected for integrity and compromised packages are reprocessed.

  • 3.14. Semi critical equipment is high-level disinfected or sterilized.

  • 3.15. Items are pre-cleaned according to manufacturer's instructions or evidence-based guidelines to high-level disinfection.

  • 3.16. High-level disinfection equipment is maintained according to manufacturer's instructions.

  • 3.17. Chemicals used for HDL are prepared according to manufacturer's instructions.

  • 3.18. chemicals used for HDL are tested for appropriate concentration according to manufacturer's instructions.

  • 3.19. Chemicals used for HDL are documented to have been prepared and replaced according to manufacturer's instructions.

  • 3.20. Instruments requiring HDL are disinfected for the appropriate length of time as specified by manufacturer's instructions or evidence based guidelines.

  • 3.21. Instruments requiring HDL are disinfected at the appropriate temperature according to manufacturer's instructions or evidence based guidelines.

  • 3.22. Items that undergo HLD are allowed to dry before use.

  • 3.23 Following HDL, items are stored in a designated clean area in a manner to prevent contamination.

4.0 Environmental Infection Control.

  • 4.1. Operating Rooms are cleaned and disinfected after each surgical or invasive procedure with EPA registered disinfectant.

  • 4.2. Operating rooms are terminally cleaned daily.

  • 4.3. High touch surfaces in patient care areas are cleaned and disinfected with an EPA registered disinfectant.

Additional Comments

  • Additional Comments

  • Surveyor's Signature

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