Information
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Document No.
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Audit Title
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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
Patient Rooms
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Floors & walls clean
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Walls free of breaks & penetrations
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Bathrooms clean/free of odor
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Sink(s) clean
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Furniture clean & in good condition
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Windows & windowsills clean
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Window coverings clean/without dust
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No high dust present
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Ceiling tiles free of visible dampness/damage
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PPE, gloves available
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Nothing on top of sharps boxes
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ONLY sharps in sharps boxes
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Sharps box < 3/4 full
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Appropriate use of red bags
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Bed clean, linen free of tears
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Alcohol hand hygiene product stocked
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Soap and paper towels at all sinks
Clean Utility/Storage Rooms
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Clean storage contains clean items only
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Ability to determine if equipment is clean
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Floors and walls clean
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No dust on supplies or equipment
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Bins clean & without dust
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Supplies stored 6" above floor
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Supplies stored 18" away from ceiling/fire sprinkler
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No supplies under the sink
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Counter tops in good condition
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Shelving/drawers & cabinets clean
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Sterilized trays free of dust, unopened, no tears
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No expired supplies or equipment (check for PM tags)
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Linen covered
Soiled Utility Rooms
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Floors & walls clean
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Free of patient supplies (clean) & sterile trays
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Hopper clean
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Counter tops clean/in good condition
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Soiled equipment stored appropriately
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Linen bagged appropriately
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Red bag trash appropriate
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Biohazard trash bins & linen bins clean
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PPE available in soiled utility
General Unit
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No food or drinks at station
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Computers & keyboards free of soil/dust
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Laboratory samples segregated from food
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Station free of clutter
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Trash not overfilled
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Floors & baseboards clean
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Desk surfaces in good condition
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Chairs/furniture clean, operational and in good condition
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Staff restroom clean with hand washing supplies
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Alcohol hand rub accessible, full w/in unit (assess if there need to be more locations)
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Tub/shower room clean
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Ceiling tiles are clean, in good condition
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Sink areas are clean, stocked with soap and paper towels
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Ice machine clean, no leaks
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Walls clean, no holes
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Cleaning products available for use
Patient Kitchen
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General area clean
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Refrigerator & freezer clean, no odor
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Daily temperature log complete
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Refrigerator temp 0-41 degrees, freezer less than 0 (to -30) degrees
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All food is labeled w/name, date
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Food containers are closed
Medications
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No expired IV solutions or medications
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No unattended medications
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Medication prep areas are clean, alcohol prep is present
Safety
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Observed hand hygiene
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Staff know how to access IC policies
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Specimens bagged/labeled/handled appropriately
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Safety devices available
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Safety devices are being used appropriately
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Staff can demonstrate use of safety devices
Other
Action Plan
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Due to Safety by: Actions by Department Director or designee:
Signatures of Inspectors
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Infection Control
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Environmental Services Director
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Engineering
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Security
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Unit Director or their designee