• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Patient Rooms

  • Floors & walls clean

  • Walls free of breaks & penetrations

  • Bathrooms clean/free of odor

  • Sink(s) clean

  • Furniture clean & in good condition

  • Windows & windowsills clean

  • Window coverings clean/without dust

  • No high dust present

  • Ceiling tiles free of visible dampness/damage

  • PPE, gloves available

  • Nothing on top of sharps boxes

  • ONLY sharps in sharps boxes

  • Sharps box < 3/4 full

  • Appropriate use of red bags

  • Bed clean, linen free of tears

  • Alcohol hand hygiene product stocked

  • Soap and paper towels at all sinks

Clean Utility/Storage Rooms

  • Clean storage contains clean items only

  • Ability to determine if equipment is clean

  • Floors and walls clean

  • No dust on supplies or equipment

  • Bins clean & without dust

  • Supplies stored 6" above floor

  • Supplies stored 18" away from ceiling/fire sprinkler

  • No supplies under the sink

  • Counter tops in good condition

  • Shelving/drawers & cabinets clean

  • Sterilized trays free of dust, unopened, no tears

  • No expired supplies or equipment (check for PM tags)

  • Linen covered

Soiled Utility Rooms

  • Floors & walls clean

  • Free of patient supplies (clean) & sterile trays

  • Hopper clean

  • Counter tops clean/in good condition

  • Soiled equipment stored appropriately

  • Linen bagged appropriately

  • Red bag trash appropriate

  • Biohazard trash bins & linen bins clean

  • PPE available in soiled utility

General Unit

  • No food or drinks at station

  • Computers & keyboards free of soil/dust

  • Laboratory samples segregated from food

  • Station free of clutter

  • Trash not overfilled

  • Floors & baseboards clean

  • Desk surfaces in good condition

  • Chairs/furniture clean, operational and in good condition

  • Staff restroom clean with hand washing supplies

  • Alcohol hand rub accessible, full w/in unit (assess if there need to be more locations)

  • Tub/shower room clean

  • Ceiling tiles are clean, in good condition

  • Sink areas are clean, stocked with soap and paper towels

  • Ice machine clean, no leaks

  • Walls clean, no holes

  • Cleaning products available for use

Patient Kitchen

  • General area clean

  • Refrigerator & freezer clean, no odor

  • Daily temperature log complete

  • Refrigerator temp 0-41 degrees, freezer less than 0 (to -30) degrees

  • All food is labeled w/name, date

  • Food containers are closed


  • No expired IV solutions or medications

  • No unattended medications

  • Medication prep areas are clean, alcohol prep is present


  • Observed hand hygiene

  • Staff know how to access IC policies

  • Specimens bagged/labeled/handled appropriately

  • Safety devices available

  • Safety devices are being used appropriately

  • Staff can demonstrate use of safety devices


Action Plan

  • Due to Infection Control by: Actions by Department Director or designee:

Signatures of Inspectors

  • Infection Control Director

  • Environmental Services Director

  • Engineering

  • Security

  • Unit Director or their designee

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.