General Infection Control Audit Checklist

Information

Hospital Name
Conducted on
Prepared by
Location

Food Safety Pending

Deficiencies

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Does the department have a current state or county license?
Was there a inspection by the state within the last 18 months?
Were all deficiency corrected per last inspection?
Deficiency
Responsible Person for Addressing Deficiency
Date Corrected
Product recall list available
Recall corrected
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Are refrigerators within parameters as indicated on the log sheet (x< 41 degrees Fahrenheit, x< 5 degrees Celsius)?
Is adequate follow-up documentation shown on the log sheet when ranges are outside of parameters?
Are freezers within parameters as indicated on the log sheet (x = 0 degrees Fahrenheit, -18 degrees Celsius)?
Is adequate follow-up documentation shown on the log sheet when ranges are outside of parameters?
Are all foods dated and labled?
Cooked foods stored above raw foods
Raw animal foods separated from raw ready to eat foods
Foods wrapped or covered
Are steam table temperatures within parameters as indicated on the log sheet?
Are dish machine temperatures within parameters as indicated on the log sheet?
Is adequate follow-up documentation shown on the log sheet when ranges are outside of parameters?
Clean utensils and cookware protected from contamination

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Fire Safety Management

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Clearly and correctly marked for EXIT, including when fire doors are closed?
Are lights in exit signs functional?
Clear of any obstructions/equipment?
Are doors in and around the kitchen that can be confused for an exit marked, NOT AN EXIT?
Fire extinguishers clearly marked for identification
Inspection tags current
Safety seals intact and in place?
Egress to fire extinguishers (3 foot clearance)
Within 75ft. in any direction
K-Type fire extinguisher located within 30ft. of grease producing equipment?
Is the kitchen hood system free of grease build-up
Manual pull station for the kitchen hood suppression system conspicuously labeled for staff
Egress to fire alarm (3 foot clearance)
Fire alarm free from tampering and glass bar in place
Electrical covers/plates in place
Free from exposed wiring of any kind
Combustible materials (cardboard, boxes, paper, linen, wastes) stored in proper containers (32 gallons or less)
Kept to a minimum for daily use in the department
Properly labeled and identified?
All doors free from being propped, wedged, or held open in anyway
Fire doors labeled properly and free of paint?
Fire and stairwell doors latch positively to maintain closure?
Stairwells free of storage and penetrations?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Furnishing and decorations fire-rated?

Hand Hygiene

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Handwashing ONLY sink are readily available at nurses station?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Hand towel dispenser available/operable?
Handwashing solution dispenser is available/operable?
Handwashing solution is appropriate for area/unit?
Handwashing solution within beyond-use date?
Alcohol hand rub are readily available between patient rooms?
Alcohol hand rub dispenser is available/operable?
Alcohol hand rub is appropriate for area/unit?
Alcohol hand rub within beyond-use date?
No personal lotion use (facility approved lotion only)?
Placement of alcohol hand rubs is compliant with safety (x > 48 inchs apart, not installed x < 1 inch adjacent to an electrical outlet or switch, between 42 and 48 inches of the ground)?
Take note of walls and counters where hand hygiene products are mounted. Do you see an accumulation of dirt?
Respiratory hygiene available?
Hand hygiene reminder posters present?
1 point for each employee who can identify all 5 Moments of Hand Hygiene (ask a total of 5 employees)?
Nails are natural and kept short, no longer than ¼ inch in length (nail polish, if worn, must be free<br>of cracks or chips and should be an appropriate, neutral color)?
Is this section free of additional findings?
Please describe other findings:

General Cleanliness and Safety

Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
No cardboard boxes on the floor
No corrugated shipping containers present
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Wheels on all equipment free of lint and debris?
Floors are clean (free of trash)?
Slip-resistant finish in place?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
All drain covers in-place?
Visibly looks like a clean storage room with clean supplies and equipment?
There is no evidence of pest present?
Are the Emergency Procedures flip charts easily accessible?
Are all guards on equipment (i.e., slicer, mixer)
Emergency eye wash station
Personal protective equipment readily available
Is this section free of additional findings?
Please describe other findings:

Personal Protective

All patient care equipment is clean?
Medical equipment is inventoried & tagged (inspection should be current)?
Service sink/mop sink shows no signs of mildew or mold?

Food Preparation

Raw unprocessed fruits and vegetables thoroughly washed under running water
Discard food that comes out of broken packages or swollen cans
Discard food that has an abnormal appearance or odor
Color coded cutting boards
Foods are cooked and held at proper temperatures
Individual portions of food once served are discarded
Unwrapped foods are protected with sneeze guards
Single service articles are discarded after one use
Discar

Foods

Steaks and Roast Beef - 130 F or above/customer request
Raw fish, Seafood, and Eggs - 140 F or above
Uncooked Pork - 150 F or above
Raw Ground and tenderized Meat - 155 F or above
Raw Poultry, Stuffing - 165 F or above
Steam tables (x>135 degrees Fahrenheit, x>57 degrees Celsius) - should not be used to warm foods
Cold tables (x< 41 degrees Fahrenheit, x< 5 degrees Celsius) - should not be used to refrigerate foods

Hazard Analysis and Critical Control Point Training

Prepared food is transported to other areas in closed food carts or covered containers
Food is served with clean tongs, scoops, forks, spoons, spatulas, or gloves
Thermometers are cleaned appropriately before and after temperature check

Quiz

How are foods prepared to be served at a later time are cooked, chilled, and reheated
Process for cooling

Cleaned and Properly Maintained Equipment

Clean equipment not in use is covered and protected from contamination
Clean utensils and cookware covered and protected from contamination
Dish machine drained and flushed daily
Dish machine maintains a wash water of x = 150 degrees Fahrenheit, 66 degrees Celsius (20s)
Dish machine maintains a final sanitizing rinse of x = 180 degrees Fahrenheit, 82 degrees Celsius (10s)
Serving carts sanitized

Food grinders, choppers, and mixers

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Taken apart
Cleaned
Sanitized
Completely dried
Reassembled
After each use

3-Sink Method of Manual Washing and Sanitizing

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Sort, scrape, and pre-rinse
Sink #1: Wash - clean warm water and detergent
Sink #2: Rinse - clean warm water (minimum temperature x = 110 degrees Fahrenheit, 43 degrees Celsius
Sink #3: Sanitize - minimum of 45 seconds
Chemical method?
Active ingredient?
- Chlorine 100 ppm
- Quaternary ammonium compound 200 ppm
- Iodine 25 ppm
- Other
Other:
Air Dry
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Hand towel dispenser available/operable?
Dishwashing solution dispenser is available/operable?
Sanitizer dispenser is available/operable?
Sanitizer solution within beyond-use date?
Is this section free of additional findings?
Please describe other findings:

Multiple

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Location (ED, PreOp/PACU, OR, PSU)
Sinks are readily available at nurses station?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Hand towel dispenser available/operable?
Handwashing solution dispenser is available/operable?
Handwashing solution is appropriate for area/unit?
Handwashing solution within beyond-use date?
Alcohol hand rub are readily available between patient rooms?
Alcohol hand rub dispenser is available/operable?
Alcohol hand rub is appropriate for area/unit?
Alcohol hand rub within beyond-use date?
No personal lotion use (facility approved lotion only)?
Placement of alcohol hand rubs is compliant with safety (x > 48 inchs apart, not installed x < 1 inch adjacent to an electrical outlet or switch, between 42 and 48 inches of the ground)?
Take note of walls and counters where hand hygiene products are mounted. Do you see an accumulation of dirt?
Respiratory hygiene available?
Hand hygiene reminder posters present?
1 point for each employee who can identify all 5 Moments of Hand Hygiene (ask a total of 5 employees)?
Nails are natural and kept short, no longer than ¼ inch in length (nail polish, if worn, must be free<br>of cracks or chips and should be an appropriate, neutral color)?
Is this section free of additional findings?
Please describe other findings:
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Room Number / Bay Number (e.g., PreOp 1, PACU 7)
Occupied
On a scale of 1 to 5, 5 being GREAT, how would you rate our hand hygiene practice?
Foley catheter present?
Foley secured to prevent movement and urethral traction?
Closed drainage system to maintain sterility?
Off the floor to maintain sterility and for unosbstructed urine flow?
Hanging below the bladder for unobstructed urine flow?
Independent loops and no kinks for unobstructed urine flow?
No portable heaters or fans?
Per isolation type, PPE is available as needed?
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Mattress pad is without tears or puncture holes (N/A if patient is occupying the stretcher)?
Patient care equipment (e.g., IV pumps and poles, feeding pumps, wound vacs) are clean?
Medical equipment is inventoried & tagged (inspection should be current)?
No needles, syringes, medications within reach of the patient?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
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Location (ED, PreOp/PACU, OR, PSU)
Appropriate signage in place?
Door closed as appropriate?
Negative pressure is being supplied as required?
Per isolation type, PPE is available as needed?
Appropriate PPE used by staff?
Proper donning and/or doffing of PPE?
Occupied
Patient and family have been educated on isolation precautions?
Patient with proper attire when being transported (e.g., covered infected or colonized area of patient's body, source control mask when medically appropriate)?
Is this section free of additional findings?
Please describe other findings:
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Location
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free
Shower is clean?
No signs of mildew or mold present?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
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Location
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free
Shower is clean?
No signs of mildew or mold present?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
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Location
Biohazard symbol on door of biomedical waste storage?
Hand hygiene products are available (refer to HH section for guidance)?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Hoppers (flushing-rim clinical service sink) are clean and in good condition?
Faucets and/or pipes are not leaking?
Hoppers truck/basket are clean and in good condition?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Floors are clean (free of trash)?
General area is dust free?
Faucets and/or pipes are not leaking?
No outer warehouse or shipping boxes present?
Dirty supplies only?
Is this section free of additional findings?
Please describe other findings:
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Location
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Service sink/mop sink shows no signs of mildew or mold?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Visibly looks like a clean storage room with clean supplies and equipment?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
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Location
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free
Furniture (e.g., chairs, sleepers) are without tears or wear?
Lockers and cubicles are clean, free from dust, dirt, and debris?
Microwave oven clean?
Employee refrigerator labeled for employee use only?
Refrigerator clean?
Freezer ice is thawed?
Patient refrigerator labeled for patient use only?
Refrigerator clean?
Freezer ice is thawed
Patient refrigerator: Temperature checks are documented with corrective action when temp is out of range (Fridge 36-46 degrees Fahrenheit, Freezer 3-5 degrees Celsius)?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Hydration station is clean - free of liquids and debris?
Condiments station is clean - free of debris?
Condiments within beyond-use date?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
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Location (e.g., across from PACU 9 and 11, across from OR 5)
Hand hygiene products are available (refer to HH section for guidance)?
Warming cabinet temperatures monitored daily per IFU (maximum temperature setting of 130 degrees Fahrenheit - 54 degrees Celsius)?
Blankets and fluids are not commingled in warming cabinets?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
RCRA Hazardous Waste Container available?
Hazardous Pharmaceutical Waste Pressurized Aerosols & Inhalers available (N/A in OR)?
RX Destroyer available (N/A in OR)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Sterile supplies 2 inches away from outside walls (adequate air circulation)?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
Open vials dated and timed per policy (Only applicable in PSU)?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Unused patient equipment/supplies are stored and handled appropriately?
Specimens labeled appropriately and zipped in specimen biohazard bag?
Glucose meter strips dated?
Glucose quality control solutions dated?
Medication refrigerator labeled for medication use only (Red plug)?
Refrigerator clean?
Temperature checks are documented with corrective action when temp is out of range (36-46 F)?
Medication freezer labeled for medication use only (Red plug)?
Temperature checks are documented with corrective action when temp is out of range (3-5 F)?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

3rd Floor

Preoperative (PreOp) and Post-Anesthesia Care Unit (PACU)

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Location
Respiratory Hygiene Station is available and stocked?
Warming cabinet temperatures monitored daily per IFU (maximum temperature setting of 130 degrees Fahrenheit - 54 degrees Celsius)?
Blankets and fluids are not commingled in warming cabinets?
Wipe warmer temperatures monitored daily per IFU (100-125 degrees Fahrenheit, 38-52 degrees Celsius)?
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
No equipment not in active use is permitted in the hallway (permitted items are staged to one side; path to safety is unobstructed)?
Crash cart checked daily?
Defibrillator checked daily?
Emergency exits clear of any obstruction?
Fire equipment present and clear of any obstructions (fire extinguishers and fire pulls should never be blocked)?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supply cart is staged to one side; path to safety to unobstructed?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Supply cart is covered?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers are not in the hallways, unless in active use or empty?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
No needles, syringes, medications within reach of the patient?
Specimens labeled appropriately and zipped in specimen biohazard bag?
Glucose meter strips dated?
Glucose quality control solutions dated?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
Patient refrigerator labeled for patient use only?
Refrigerator clean?
Temperature checks are documented with corrective action when temp is out of range (Fridge 36-46 F)?
There is no evidence of pest present?
1 point for each employee who knows how to access the Safety Data Sheets (ask a total of 5 employees)?
1 point for each employee who knows the procedure for blood pathogen exposure (ask a total of 5 employees)?
Is this section free of additional findings?
Please describe other findings:

3rd Floor Nourishment (Nurses Station)

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Location
Patient refrigerator labeled for patient use only?
Refrigerator clean?
Freezer ice is thawed?
Patient refrigerator: Temperature checks are documented with corrective action when temp is out of range (Fridge 36-46 degrees Fahrenheit, Freezer 3-5 degrees Celsius)?
Hydration station is clean - free of liquids and debris?
Condiments station is clean - free of debris?
Condiments within beyond-use date?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Clean Linen Utility

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Location
Oxygen symbol on door if O2 E-cylinders are stored?
Hand hygiene products are available (refer to HH section for guidance)?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Clean linen cart is covered?
No items found on top of clean linen cart?
Clean linen cart has a solid surface on the bottom shelf?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
O2 E-cylinders are secured?
O2 E-cylinders are not co-mingled?
O2 E-cylinders stored in a well-protected, well ventilated, dry location, x > 20 ft from highly combustible materials?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage room with clean supplies and equipment?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
Would you like to complete this section?
Location
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage room with clean supplies and equipment?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Completion

Additional Comments
Surveyor's Name and Signature

Operating Room

General OR

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Location
Propper PPE worn by all personnel: all hair covered, OR personnel wearing long sleeve jackets, buttoned up, shirts tucked in, proper foot wear, no dangling masks
Respiratory Hygiene Station is available and stocked?
Alcohol hand rub are readily available between patient rooms?
Blankets and fluids are not commingled in warming cabinets?
No portable heaters or fans?
Floors are clean (free of trash)?
Wheels on all equipment free of lint and debris?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
No equipment not in active use is permitted in the hallway (permitted items are staged to one side; path to safety is unobstructed)?
Wheels on all equipment free of lint and debris?
Temperature checks are documented with corrective action when temp is out of range?
Humidity checks are documented with corrective action when temp is out of range?
Crash cart checked daily?
Defibrillator checked daily?
Emergency exits clear of any obstruction?
Fire equipment present and clear of any obstructions (fire extinguishers and fire pulls should never be blocked)?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supply cart is staged to one side; path to safety to unobstructed?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers are not in the hallways, unless in active use or empty?
Are there linen hampers in the hallway?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
There is no evidence of pest present?
1 point for each employee who knows how to access the Safety Data Sheets (ask a total of 5 employees)?
1 point for each employee who knows the procedure for blood pathogen exposure (ask a total of 5 employees)?
Is this section free of additional findings?
Please describe other findings:
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Male or Female
Hand hygiene products are available (refer to HH section for guidance)?
Shower is clean?
No signs of mildew or mold present?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Vanity units clean and free from dust, dirt, and debris?
Mirrors are clean and free from water marks?
Lockers and cubicles are clean, free from dust, dirt, and debris?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off the floor?
Floors are clean (free of trash)?
General area is dust free
General area free from rubbish?
Furniture (e.g., chairs, sleepers) are without tears or wear?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
Would you like to complete this section?
Location
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free
Furniture (e.g., chairs, sleepers) are without tears or wear?
Microwave oven clean?
Employee refrigerator labeled for employee use only?
Refrigerator clean?
Freezer ice is thawed?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Hydration station is clean - free of liquids and debris?
Condiments station is clean - free of debris?
Condiments within beyond-use date?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
Would you like to complete this section?
Location (between OR _ and OR _)
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Hand towel dispenser available/operable?
Handwashing solution dispenser is available/operable (hands-free operation)?
Handwashing solution available?
Avagard (waterless hand antiseptic)?
Scrub-Stat 4% Solution?
1% Povidone-Iodine (nail cleaner & sponge)?
4% Chlorhexidine gluconate Scrub (nail cleaner & sponge)?
Handwashing solution within beyond-use date?
Alcohol hand rub dispenser is available/operable?
Alcohol hand rub is appropriate for area/unit?
Alcohol hand rub within beyond-use date?
No personal lotion use (facility approved lotion only)?
Placement of alcohol hand rubs is compliant with safety (x > 48 inchs apart, not installed x < 1 inch adjacent to an electrical outlet or switch, between 42 and 48 inches of the ground)?
Take note of walls and counters where hand hygiene products are mounted. Do you see an accumulation of dirt?
Hand hygiene reminder posters present?
Is this section free of additional findings?
Please describe other findings:
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Location (between OR _ and OR _)
Warming cabinet temperatures monitored daily per IFU (maximum temperature setting of 130 degrees Fahrenheit - 54 degrees Celsius)?
Blankets and fluids are not commingled in warming cabinets?
Clean linen cart is covered?
No items found on top of clean linen cart?
Clean linen cart has a solid surface on the bottom shelf?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
O2 E-cylinders are secured?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage area with clean supplies and equipment?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
Would you like to complete this section?
OR Number (Procedure Room 1 = OR 8)
Hand hygiene products are available prior to entering OR room?
Hand hygiene products are available at anesthesia desk?
Propper PPE worn by all personnel: all hair covered, OR personnel wearing long sleeve jackets, buttoned up, shirts tucked in, proper foot wear, no dangling masks
Occupied
Per procedure type, all personnel donned proper PPE?
Foley catheter present?
Foley secured to prevent movement and urethral traction?
Closed drainage system to maintain sterility?
Off the floor to maintain sterility and for unosbstructed urine flow?
Hanging below the bladder for unobstructed urine flow?
Independent loops and no kinks for unobstructed urine flow?
Is this section free of additional findings?
Please describe other findings:
Witnessed time out?
Time out initiated, surgeon engaged?
Introductions?
All activity ceases?
Circulator: Patient identification (Name and DOB)?
Circulator: Procedural Consent?
Circulator: Verbalizes fire assessment risk/precautions?
Anesthesia: Patient identification (Name and DOB)?
Anesthesia: Allergies?
Anesthesia: Antibiotic Dose/Time?
Anesthesia: Time for antibiotic re-dose?
Anesthesia: Need for blood products?
Scrub Tech: Verification of sterility of instruments?
Scrub Tech: Confirmation of equipment, supplies, and implants?
Radiology: confirmation of correct side, equipment operation and images are on monitor?
Surgical: Procedure?
Surgical: Site, side, and operative level?
Physician: "I SEE the mark"
All Team Members: "I SEE the mark"
Circulator: "Is there ANY reason to STOP the LINE?"
Team engagement: no one became disengaged?
Is this section free of additional findings?
Please describe other findings:
Temperature checks are documented with corrective action when temp is out of range?
Humidity checks are documented with corrective action when temp is out of range?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Specimens labeled appropriately and zipped in specimen biohazard bag?
RCRA Hazardous Waste Container available?
RX Destroyer available?
Renewal Container
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Mattress pad is without tears or puncture holes (N/A if patient is occupying the stretcher)?
Patient care equipment (e.g., IV pumps and poles, feeding pumps, wound vacs) are clean?
Medical equipment is inventoried & tagged (inspection should be current)?
Wheels on all equipment free of lint and debris?
No needles, syringes, medications within reach of the patient?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
Would you like to complete this section?
- Yes
- No
Operating Room (Procedure Room 1 = 8)
Wears dosimeters correctly and in a consistent location.
Wears radiation protective garments (eg, aprons, thyroid shields, gloves) during procedures with a radiation source.
Wears protective garments that cover the body from the area below the chin to the knees.
Stores garments flat or hung vertically and not folded.
Cleans and disinfects shared personal protective devices between use and spot cleans them if soiled.
Cleans protective garments daily if worn by only one individual.
Wears leaded eye protection when unable to distance from the source during activation.
Maintains the greatest distance possible from the radiation source and limits time spent close to the source without leaving the OR.
If scrubbed, stands on the image intensifier side of the fluoroscopy unit when procedural considerations allow.
Uses devices, such as slings, traction devices, and sandbags, to maintain the patient’s position during radiation exposure.
Uses equipment-mounted and mobile shields when required to remain near the patient or the sterile field.
Uses radiation shielding drapes as an alternative or in addition to equipment-mounted and mobile shields when permitted by the requirements of the invasive procedure.
Returns dosimeters to the designated location after use.
Is this section free of additional findings?
Please describe other findings:
Would you like to complete this section?
Operating Room (Procedure Room 1 = 8)

Scrubbed Team Member

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Keeps hands and arms above waist level at all times.
Does not fold arms with hands positioned in the axillary area.
Does not change levels, and sits only when the entire procedure will be performed at that level.
Does not turn his or her back on the sterile field.
Does not leave the sterile field to retrieve items from the sterilizer.
Turns back to back or face to face during position changes, while staying away from other team members, the sterile field, and unsterile areas.

Unscrubbed Team Member

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Faces the sterile field on approach.
Does not walk between sterile fields or scrubbed persons.
Does not reach over an uncovered sterile field.
Stays as far from the sterile field and scrubbed persons as possible.
Keeps doors to the operative or invasive procedure room closed.
Keeps the number and movement of persons in the OR to a minimum
Is this section free of additional findings?
Please describe other findings:
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Operating Room (Procedure Room 1 = 8)
During the procedure, removes gross soil from instrument surfaces with a sterile radiopaque surgical sponge moistened with sterile water.
Uses sterile water to irrigate instruments with lumens at frequent intervals during the procedure.
Separates sharp instruments from other instruments and confines them in a puncture-resistant container before transport to the decontamination area.
Protects delicate instruments from damage during transport by segregating them into different containers or by placing them on top of heavier instruments.
Keeps instruments moist until they are cleaned, by either saturating them with an enzymatic pretreatment product or placing a towel moistened with water over the instruments.
Separates contaminated items from clean and sterile supplies before transporting contaminated items to the processing area.
Transports contaminated instruments to the decontamination area as soon as possible after completion of the procedure.
Witnessed transportation of instrument to the decontamination area.
• closed container or enclosed transport cart
• leak proof
• puncture resistant
• large enough to contain all contents
• labeled with a fluorescent orange or orange-red label containing a biohazard legend
Is this section free of additional findings?
Please describe other findings:

The Core

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Location
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage room with clean supplies and equipment?
Temperature checks are documented with corrective action when temp is out of rang?
Humidity checks are documented with corrective action when humidity is out of range?
Is this section free of additional findings?
Please describe other findings:

Trash Hold

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Location
Biohazard symbol on door of biomedical waste storage?
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Floors are clean (free of trash)?
General area is dust free?
Faucets and/or pipes are not leaking?
No outer warehouse or shipping boxes present?
Dirty supplies only?
Is this section free of additional findings?
Please describe other findings:

Specimen Storage

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Floors are clean (free of trash)?
General area is dust free
Specimen refrigerator labeled for specimen use only?
Refrigerator clean?
Freezer ice is thawed
Patient refrigerator: Temperature checks are documented with corrective action when temp is out of range (Fridge 36-46 degrees Fahrenheit, Freezer 3-5 degrees Celsius)?
Specimen log is readily available?
Specimen log is fully filled per entry?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Equipment Storage and Sterile Supplies

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Location
Oxygen symbol on door if O2 E-cylinders are stored?
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
O2 E-cylinders are secured?
O2 E-cylinders are not co-mingled?
O2 E-cylinders stored in a well-protected, well ventilated, dry location, x > 20 ft from highly combustible materials?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage room with clean supplies and equipment?
Temperature checks are documented with corrective action when temp is out of rang?
Humidity checks are documented with corrective action when humidity is out of range?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Completion

Any immediate concerns?
Please describe immediate concern(s)?
Additional Comments
Surveyor's Name and Signature

Sterile Processing

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Location
Propper PPE worn by all personnel: all hair covered, OR personnel wearing long sleeve jackets, buttoned up, shirts tucked in, proper foot wear, no dangling masks
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Is this section free of additional findings?
Please describe other findings:

Endoscope

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Leak Testing

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Performs leak testing before manual cleaning if indicated.
Removes all port covers and function valves.
Pressurizes the endoscope to the recommended pressure.
Places the endoscope in the sink in a loose configuration.
Manipulates all moving parts; angulates the bending section of the distal end.
Actuates video switches while testing.
Maintains pressure and inspects for a minimum of 30 seconds.

Manual Cleaning

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Manually cleans the flexible endoscope as soon as possible after leak testing.
Uses a freshly prepared cleaning solution and does not add products to the water other than cleaning solution unless recommended by the manufacturer.
Completely submerges the endoscope and accessories.
Cleans exterior surfaces of the endoscope with a soft, lint-free cloth or sponge.
Cleans all accessible channels and the end of the endoscope with a cleaning brush of the length, width, and material recommended by the endoscope manufacturer.
Uses a clean brush for each endoscope cleaning.
If the endoscope has an elevator, raises and lowers the elevator throughout the manual cleaning process and manually actuates the valves.
Brushes the accessible channels until no debris appears on the brush.
Removes debris before retracting the brush.
Flushes the channels of the endoscope with the cleaning solution.
Cleans, brushes, and rinses reusable parts, accessories, and cleaning implements.
Flushes and rinses exterior surfaces and internal channels with utility water until all cleaning solution and residual debris is removed.
Dries exterior surfaces and purges all channels with air.

Inspection - inspects and evaluates endoscopes and accessories for:

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• cleanliness
• missing parts
• clarity of lenses
• integrity of seals and gaskets
• physical or chemical damage
• moisture
• function
Uses additional illumination and magnification for inspection.
Inspects internal channels using a camera or borescope.

High-Level Disinfection or Sterilization

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Manually cleans before mechanical processing.
Uses a test strip and checks the expiration date of the disinfectant.
Positions endoscopes and accessories within the mechanical processor to ensure contact of the processing solutions with all surfaces of the endoscope.
Connects the endoscope to the mechanical processor correctly.
Rinses the endoscope with critical or sterile water after disinfection.
Dries exterior surfaces and removable parts of the endoscope.
Dries the endoscope with pressure-regulated instrument air or HEPA-filtered air for a minimum of 10 minutes or until no visible moisture remains.
Sterilizes endoscopic accessories that enter sterile tissue or the vascular system per the health care facility’s policy and procedure.

Storage

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Places flexible endoscopes in a drying cabinet or a storage cabinet.
Based on the cabinet design, stores flexible endoscopes horizontally or hangs them vertically so they do not coil or touch the floor of the cabinet.
Stores the flexible endoscope with all valves open and removable parts detached but stored with the endoscope.
Wears clean gloves when transporting the endoscope to and from the storage cabinet.
Visually inspects the storage cabinet for cleanliness before hanging the endoscope.
Uses a distinct visual cue for identification of flexible endoscopes ready for use
Follows policy for removing and reprocessing the endoscope before use if the maximum storage time has been exceeded.
Is this section free of additional findings?
Please describe other findings:

Instrument Care and Cleaning

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Cleaning

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Cleans and decontaminates all instruments that were open in the OR or procedure room.
Cleans and decontaminates surgical instruments and equipment according to the manufacturer’s validated, written IFU.
Before processing, disassembles instruments and devices composed of more than one piece according to the manufacturer’s written IFU.
After disassembly, arranges the instrument or medical device components in a manner that will permit contact of cleaning solutions with all surfaces of the item.
Opens port, valves, stopcocks, ratchets, and joints before cleaning.
Rinses instruments in cool water before manual cleaning.
Submerges the device in a cleaning solution that is compatible and mixed according to the cleaning solution manufacturer’s IFU.
Flushes lumens with cleaning solution and brushes them with a brush of the length, diameter, type, and material specified in the device manufacturer’s IFU.
Performs brushing under the surface of the water during manual cleaning.
After manual cleaning, uses mechanical methods (eg, ultrasonic cleaner, washer-disinfector/decontaminator) for cleaning instruments and medical devices unless otherwise specified in the manufacturers’ IFU for the instrument and the equipment.
Uses the type of water for cleaning that is consistent with the manufacturers’ written IFU and the intended use of the equipment and cleaning product.
Performs the final rinse with critical water.
Is this section free of additional findings?
Please describe other findings:
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• cleanliness
• completeness
• correct alignment
• surface integrity
• sharpness of cutting edges
• integrity of insulation on insulated devices
• integrity of cords and cables
• clarity of lenses
• integrity of instrument labels
• correct functioning
Absence of: corrosion, pitting, burrs, nicks, and cracks; wear and chipping of inserts and plated surfaces; moisture; and any other defects.
Checks power equipment for functionality.
Inspects internal channels for cleanliness.
Removes damaged instruments from service and communicates the instrument dispensation to the surgical team.
Thoroughly dries instruments before they are assembled and packaged for sterilization.
Maintains records of instrument cleaning and disinfection processes.
Is this section free of additional findings?
Please describe other findings:

Sterile Storage

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Location
No receptacles or waste baskets?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Integrity of sterilization wrap?
General area is dust free?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
No outer warehouse or shipping boxes present?
Visibly looks like a sterile storage?
Is this section free of additional findings?
Please describe other findings:

Completion

Any immediate concerns?
Please describe immediate concern(s)?
Additional Comments
Surveyor's Name and Signature

2nd Floor

Conference Room

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Facility approved power strips?
Power strips are not piggybacked?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Respiratory Hygiene Station is available and stocked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
Carpet is free of stains?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Cafeteria

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Respiratory Hygiene Station is available and stocked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Microwave oven clean?
Hydration station is clean - free of liquids and debris?
Condiments station is clean - free of debris?
Condiments within beyond-use date?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Equipment Storage - 2nd Floor

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Location
Oxygen symbol on door if O2 E-cylinders are stored?
Clean linen cart is covered?
No items found on top of clean linen cart?
Clean linen cart has a solid surface on the bottom shelf?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
O2 E-cylinders are secured?
O2 E-cylinders are not co-mingled?
O2 E-cylinders stored in a well-protected, well ventilated, dry location, x > 20 ft from highly combustible materials?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
Freezer labeled for patient use only (gel ice packs)?
Freezer clean?
Freezer ice is thawed?
Temperature checks are documented with corrective action when temp is out of range (Freezer 3-5 degrees Celsius)?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage room with clean supplies and equipment?
Is this section free of additional findings?
Please describe other findings:

Medication Room

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Warming cabinet temperatures monitored daily per IFU (maximum temperature setting of 130 degrees Fahrenheit - 54 degrees Celsius)?
Blankets and fluids are not commingled in warming cabinets?
Wipe warmer temperatures monitored daily per IFU (100-125 degrees Fahrenheit, 38-52 degrees Celsius)?
Medication cart/WOW locked?
Facility approved power strips?
Power strips are not piggybacked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
RCRA Hazardous Waste Container available?
Hazardous Pharmaceutical Waste Pressurized Aerosols & Inhalers available?
RX Destroyer available?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Sterile supplies 2 inches away from outside walls (adequate air circulation)?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
Open vials dated and timed per policy?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Unused patient equipment/supplies are stored and handled appropriately?
Specimens labeled appropriately and zipped in specimen biohazard bag?
Glucose meter strips dated?
Glucose quality control solutions dated?
Medication refrigerator labeled for medication use only (Red plug)?
Refrigerator clean?
Temperature checks are documented with corrective action when temp is out of range (36-46 F)?
Medication freezer labeled for medication use only (Red plug)?
Temperature checks are documented with corrective action when temp is out of range (3-5 F)?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

PSU

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Location
Respiratory Hygiene Station is available and stocked?
Warming cabinet temperatures monitored daily per IFU (maximum temperature setting of 130 degrees Fahrenheit - 54 degrees Celsius)?
Blankets and fluids are not commingled in warming cabinets?
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
No equipment not in active use is permitted in the hallway (permitted items are staged to one side; path to safety is unobstructed)?
Medication cart/WOW locked?
Crash cart checked daily?
Defibrillator checked daily?
Emergency exits clear of any obstruction?
Fire equipment present and clear of any obstructions (fire extinguishers and fire pulls should never be blocked)?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supply cart is staged to one side; path to safety to unobstructed?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Supply cart is covered?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers are not in the hallways, unless in active use or empty?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
No needles, syringes, medications within reach of the patient?
Specimens labeled appropriately and zipped in specimen biohazard bag?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
Patient refrigerator labeled for patient use only x 2?
Refrigerator clean?
Temperature checks are documented with corrective action when temp is out of range (Fridge 36-46 F)?
There is no evidence of pest present?
1 point for each employee who knows how to access the Safety Data Sheets (ask a total of 5 employees)?
1 point for each employee who knows the procedure for blood pathogen exposure (ask a total of 5 employees)?
Is this section free of additional findings?
Please describe other findings:

Central Shower Room

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Location
Shower is clean?
No signs of mildew or mold present?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Faucets and/or pipes are not leaking?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Floors are clean (free of trash)?
General area is dust free?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Is this section free of additional findings?
Please describe other findings:

Closet (across from 215 and 216)

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Location
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Floors are clean (free of trash)?
General area is dust free?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage room with clean supplies and equipment?
Is this section free of additional findings?
Please describe other findings:

2nd Floor Nourishment (across from 216)

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Floors are clean (free of trash)?
General area is dust free
Microwave oven clean?
Patient refrigerator labeled for patient use only?
Refrigerator clean?
Freezer ice is thawed?
Patient refrigerator: Temperature checks are documented with corrective action when temp is out of range (Fridge 36-46 degrees Fahrenheit, Freezer 3-5 degrees Celsius)?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Hydration station is clean - free of liquids and debris?
Condiments station is clean - free of debris?
Condiments within beyond-use date?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Elevators

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Floors are clean (free of trash)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Inspected and tested at least twice a year (take pictures of certificate of inspection)
Is this section free of additional findings?
Please describe other findings:

2nd Floor Waiting Room

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Respiratory Hygiene Station is available and stocked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Completion

Additional Comments
Surveyor's Name and Signature

1st Floor

Lobby Area

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Respiratory Hygiene Station is available and stocked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Emergency Waiting

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Respiratory Hygiene Station is available and stocked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Emergency Room

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Location
Respiratory Hygiene Station is available and stocked?
Warming cabinet temperatures monitored daily per IFU (maximum temperature setting of 130 degrees Fahrenheit - 54 degrees Celsius)?
Blankets and fluids are not commingled in warming cabinets?
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
No equipment not in active use is permitted in the hallway (permitted items are staged to one side; path to safety is unobstructed)?
Crash cart checked daily?
Defibrillator checked daily?
Emergency exits clear of any obstruction?
Fire equipment present and clear of any obstructions (fire extinguishers and fire pulls should never be blocked)?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supply cart is staged to one side; path to safety to unobstructed?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Supply cart is covered?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers are not in the hallways, unless in active use or empty?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
No needles, syringes, medications within reach of the patient?
Specimens labeled appropriately and zipped in specimen biohazard bag?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
Patient refrigerator labeled for patient use only?
Refrigerator clean?
Temperature checks are documented with corrective action when temp is out of range (Fridge 36-46 F)?
There is no evidence of pest present?
Employee knows how to access the Safety Data Sheets (ask a total of 2 employees)?
Employee who knows the procedure for blood pathogen exposure (ask a total of 2 employees)?
Is this section free of additional findings?
Please describe other findings:

Emergency Bay

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Respiratory Hygiene Station is available and stocked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Equipment Storage - Triage

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Location
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Glucose meter strips dated?
Glucose quality control solutions dated?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Supplies are stored 8 to 10 inches off of the floor?
All patient care equipment is clean?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
Medical equipment is inventoried & tagged (inspection should be current)?
Facility approved power strips?
Power strips are not piggybacked?
No outer warehouse or shipping boxes present?
Visibly looks like a clean storage room with clean supplies and equipment?
Is this section free of additional findings?
Please describe other findings:
Would you like to complete this section?
Treatment Room
Occupied
On a scale of 1 to 5, 5 being GREAT, how would you rate our hand hygiene practice?
Foley catheter present?
Foley secured to prevent movement and urethral traction?
Closed drainage system to maintain sterility?
Off the floor to maintain sterility and for unosbstructed urine flow?
Hanging below the bladder for unobstructed urine flow?
Independent loops and no kinks for unobstructed urine flow?
No portable heaters or fans?
Per isolation type, PPE is available as needed?
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Mattress pad is without tears or puncture holes (N/A if patient is occupying the stretcher)?
Patient care equipment (e.g., IV pumps and poles, feeding pumps, wound vacs) are clean?
Medical equipment is inventoried & tagged (inspection should be current)?
No needles, syringes, medications within reach of the patient?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Medication Room/Clean Utility

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Medication cart/WOW locked?
Facility approved power strips?
Power strips are not piggybacked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
RX Destroyer available?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Sterile supplies 2 inches away from outside walls (adequate air circulation)?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Floors are clean (free of trash)?
General area is dust free?
Supplies are stored 8 to 10 inches off of the floor?
Open vials dated and timed per policy?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Unused patient equipment/supplies are stored and handled appropriately?
Specimens labeled appropriately and zipped in specimen biohazard bag?
Medication refrigerator labeled for medication use only (Red plug)?
Refrigerator clean?
Temperature checks are documented with corrective action when temp is out of range (36-46 F)?
Medication freezer labeled for medication use only (Red plug)?
Temperature checks are documented with corrective action when temp is out of range (3-5 F)?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Clean Utility Closet

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Floors are clean (free of trash)?
General area is dust free?
Items/supplies are not stored directly on the floor (items approved for storage should be on a pallet or shelving)?
No outer warehouse or shipping boxes present?
Service sink/mop sink shows no signs of mildew or mold?
Splash zone is free from equipment/supplies?
Faucets and/or pipes are not leaking?
Visibly looks like a clean storage room with clean supplies and equipment?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Radiology and Bay

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Location
Respiratory Hygiene Station is available and stocked?
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
No equipment not in active use is permitted in the hallway (permitted items are staged to one side; path to safety is unobstructed)?
Emergency exits clear of any obstruction?
Fire equipment present and clear of any obstructions (fire extinguishers and fire pulls should never be blocked)?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers are not in the hallways, unless in active use or empty?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
No needles, syringes, medications within reach of the patient?
Specimens labeled appropriately and zipped in specimen biohazard bag?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Employee knows how to access the Safety Data Sheets (ask a total of 1 employees)?
Employee knows the procedure for blood pathogen exposure (ask a total of 1 employees)?
Is this section free of additional findings?
Please describe other findings:

Patient Changing Room

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Lockers and cubicles are clean, free from dust, dirt, and debris?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free
General area free from rubbish?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Radiology Waiting Room

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Location
Hand hygiene products are available (refer to HH section for guidance)?
Respiratory Hygiene Station is available and stocked?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (dust free)?
Dust not found in high places?
Floors are clean (free of trash)?
General area is dust free?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Hydration station is clean - free of liquids and debris?
Condiments station is clean - free of debris?
Condiments within beyond-use date?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

X-Ray

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Location
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
Emergency exits clear of any obstruction?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supply cart is staged to one side; path to safety to unobstructed?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Supply cart is covered?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:
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- No
Location
Wears dosimeters correctly and in a consistent location.
Wears radiation protective garments (eg, aprons, thyroid shields, gloves) during procedures with a radiation source.
Wears protective garments that cover the body from the area below the chin to the knees.
Stores garments flat or hung vertically and not folded.
Cleans and disinfects shared personal protective devices between use and spot cleans them if soiled.
Cleans protective garments daily if worn by only one individual.
Wears leaded eye protection when unable to distance from the source during activation.
Maintains the greatest distance possible from the radiation source and limits time spent close to the source without leaving the OR.
If scrubbed, stands on the image intensifier side of the fluoroscopy unit when procedural considerations allow.
Uses devices, such as slings, traction devices, and sandbags, to maintain the patient’s position during radiation exposure.
Uses equipment-mounted and mobile shields when required to remain near the patient or the sterile field.
Uses radiation shielding drapes as an alternative or in addition to equipment-mounted and mobile shields when permitted by the requirements of the invasive procedure.
Returns dosimeters to the designated location after use.
Is this section free of additional findings?
Please describe other findings:

Computed Tomography (CT)

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Location
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
Emergency exits clear of any obstruction?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supply cart is staged to one side; path to safety to unobstructed?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Supply cart is covered?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
No needles, syringes, medications within reach of the patient?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

Magnetic Resonance Imaging (MRI)

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Location
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
Emergency exits clear of any obstruction?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
MRI non-magnetic O2 cylinders secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Supply cart is staged to one side; path to safety to unobstructed?
Supplies are stored 8 to 10 inches off of the floor?
Supply cart or shelf has a solid surface on bottom shelf?
Supply cart is covered?
There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)?
Linen hampers covered?
Linen hampers clean and in good condition?
Soiled linen not placed on floor, furniture, windowsills, etc.?
Soiled linen contained in bags, not overfilled (no more than 3/4 full)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Sharps containers are not overfilled or overflowing (no more than 3/4 full)?
Medical waste container is free of nonmedical waste items not tainted or contaminated with biohazardous materials?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
No needles, syringes, medications within reach of the patient?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Is this section free of additional findings?
Please describe other findings:

The Core

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Location
Respiratory Hygiene Station is available and stocked?
No portable heaters or fans?
Floors are clean (free of trash)?
Wet-floor signs are used when floor is wet?
Wet-floor signs removed in a timely manner?
General area is dust free?
No equipment not in active use is permitted in the hallway (permitted items are staged to one side; path to safety is unobstructed)?
Emergency exits clear of any obstruction?
Fire equipment present and clear of any obstructions (fire extinguishers and fire pulls should never be blocked)?
Fire equipment appropriate for zone?
Fire evacuation signs are in-place?
Fire equipment inspected (inspected monthly)?
Facility approved power strips?
Power strips are not piggybacked?
O2 E-cylinders are secured?
Items are not stored within 18 inches of the ceiling (sprinkler heads cannot be obstructed)?
Receptacles have covers?
Receptacles are not overfilled or overflowing (no more than 3/4 full)?
Waste baskets are not overfilled or overflowing (no more than 3/4 full)?
Walls are clean, free from chips, scratches, and marks (take note of corners)?
Ceiling tiles are not discolored, wet, missing, or damaged?
Adequate lighting, no burnt-out lights or fixtures/switches?
Air intake vents and diffusers are clean (no dust)?
Dust not found in high places?
Desks and counters are clutter and debris free?
No open food or drinks in patient care areas (marked hydration station)?
Furniture (e.g., chairs, sleepers) are without tears or wear?
Unused patient equipment/supplies are stored and handled appropriately?
Sink storage area empty and clean (secured to prevent items from becoming wet and cause unwanted growth)?
Splash zone is free of equipment/supplies?
Faucets and/or pipes are not leaking?
There is no evidence of pest present?
Employee knows how to access the Safety Data Sheets (ask a total of 2 employees)?
Employee who knows the procedure for blood pathogen exposure (ask a total of 2 employees)?
Is this section free of additional findings?
Please describe other findings:

Completion

Additional Comments
Surveyor's Name and Signature

Completion

Additional Comments
Surveyor's Name and Signature

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Deficiencies

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Fire Safety Management

Hand Hygiene

General Cleanliness and Safety

Personal Protective

Food Preparation

Foods

Hazard Analysis and Critical Control Point Training

Quiz

Cleaned and Properly Maintained Equipment

Food grinders, choppers, and mixers

3-Sink Method of Manual Washing and Sanitizing

Preoperative (PreOp) and Post-Anesthesia Care Unit (PACU)

3rd Floor Nourishment (Nurses Station)

Clean Linen Utility

Completion

General OR

Scrubbed Team Member

Unscrubbed Team Member

The Core

Trash Hold

Specimen Storage

Equipment Storage and Sterile Supplies

Completion

Sterile Processing

Endoscope

Leak Testing

Manual Cleaning

Inspection - inspects and evaluates endoscopes and accessories for:

High-Level Disinfection or Sterilization

Storage

Instrument Care and Cleaning

Cleaning

Sterile Storage

Completion

Conference Room

Cafeteria

Equipment Storage - 2nd Floor

Medication Room

PSU

Central Shower Room

Closet (across from 215 and 216)

2nd Floor Nourishment (across from 216)

Elevators

2nd Floor Waiting Room

Completion

Lobby Area

Emergency Waiting

Emergency Room

Emergency Bay

Equipment Storage - Triage

Medication Room/Clean Utility

Clean Utility Closet

Radiology and Bay

Patient Changing Room

Radiology Waiting Room

X-Ray

Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

The Core

Completion

Completion

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