Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Summary of Survey
Employee Hand Hygiene Compliance
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Employees Monitored
1.0 Hand Hygiene
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1.3. Soap and water is available in all patient care areas?
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1.4. Alcohol hand rubs are available in all patient care areas?
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1.5. alcohol hand rub is installed as required?
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1.6. Hand hygiene is performed after removing gloves ?
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1.8. Hand hygiene is performed before direct patient contact?
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1.7 Hand hygiene is performed after direct patient contact?
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Hand hygiene performed after contact with blood, body fluids, or contaminated surfaces (even if gloves were worn)?
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Hand hygiene performed before performing invasive procedures e.g. IV placement?
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Staff remove gloves before moving to the next task or patient
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Staff wear gloves for procedures that might involve contact with blood or body fluids?
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Staff wear gloves when handling potentially contaminated patient equipment?
2.0. Injection Practices
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2.1. Needles are used for only one patient?
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2.2. Syringes are used for only one patient?
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2.3. The rubber septum on medication vial is disinfected with alcohol prior to piercing?
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2.4. Medication vials are always entered with a new needle?
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2.5. Medications that are pre-drawn are labeled with the date and time of draw, initials of the person drawing, medication name, strength and discard date and time?
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2.6. Single dose (single use) medication vials are used for only one patient?
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2.7. Manufactured prefilled syringes are used for only one patient?
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2.8. Bags of IV solution are used for only one patient?
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2.9 Medication administration tubing and connectors are used for only one patient?
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Multi-dose injectable medications are used for only one patient?
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Multi-dose vials are dated when they are first opened and discarded within 28 days?
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Multi-dose medication used for more than one patient are stored and accessed away from the immediate area where direct patient contact occurs?
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All sharps are disposed of in puncture resistant sharps container?
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Sharps containers are replaced when the fill line is reached?
3.0 Single use devices, sterilization, HDL
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3.1. if single use devices are reprocessed, they are devices approved by the FDA for reprocessing?
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3.2 If single use devices are reprocessed, they are reprocessed by an FDA approved reprocessor?
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3.3. Critical equipment is sterilized?
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3.4. Are sterilization procedures performed on site?
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3.5. Items are pre-cleaned according to manufacturer's instructions or evidence based guidelines prior to sterilization?
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3.6. Medical devices and instruments are visually inspected for residual soil and re-cleaned as needed before packaging and sterilization.
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3.7. a chemical indicator is placed in each load.
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3.8. A biological indicator is performed at least weekly and with all implantable loads.
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3.9. Each load is monitored with mechanical indicators (e.g. time, temperature, pressure)
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3.10. Documentation for each piece of sterilization equipment is maintained and up to date and includes results from each load.
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3.11. Items are appropriately contained and handled during the sterilization process to assure sterility is not compromised prior to use.
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3.12. After sterilization, medical devices and instruments are stored in a designated clean area so sterility is not compromised.
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3.13. Sterile packages are inspected for integrity and compromised packages are reprocessed.
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3.14. Semi critical equipment is high-level disinfected or sterilized.
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3.15. Items are pre-cleaned according to manufacturer's instructions or evidence-based guidelines to high-level disinfection.
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3.16. High-level disinfection equipment is maintained according to manufacturer's instructions.
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3.17. Chemicals used for HDL are prepared according to manufacturer's instructions.
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3.18. chemicals used for HDL are tested for appropriate concentration according to manufacturer's instructions.
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3.19. Chemicals used for HDL are documented to have been prepared and replaced according to manufacturer's instructions.
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3.20. Instruments requiring HDL are disinfected for the appropriate length of time as specified by manufacturer's instructions or evidence based guidelines.
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3.21. Instruments requiring HDL are disinfected at the appropriate temperature according to manufacturer's instructions or evidence based guidelines.
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3.22. Items that undergo HLD are allowed to dry before use.
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3.23 Following HDL, items are stored in a designated clean area in a manner to prevent contamination.
4.0 Environmental Infection Control.
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4.1. Operating Rooms are cleaned and disinfected after each surgical or invasive procedure with EPA registered disinfectant.
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4.2. Operating rooms are terminally cleaned daily.
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4.3. High touch surfaces in patient care areas are cleaned and disinfected with an EPA registered disinfectant.
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4.4. The ASC has a procedure in place to decontaminate gross spills of blood.
5.0. Point of care devices (e.g. blood glucose monitor)
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5.1. A new single-use, auto disabling lancing device is used for each patient.
Additional Comments
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Additional Comments
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Surveyor's Signature
