High Level Disinfection Survey

• Conducted on

  Date

• Prepared by

• Location
  Address

• Competency checklists with documentation training for each person eligible to perform High Level Disinfection is on file and available in the room?

  Safe

  At Risk

  N/A

• Appropriate High Level Disinfection policies are readily available in the room and signed by Medical Director.

  Safe

  At Risk

  N/A

• Are manufacturer maintenance and instrument manuals are maintained and are available in the room?

  Safe

  At Risk

  N/A

• Are instruments pre-cleaned per manufacturers guide<br>lines and allowed to fully dry prior to disinfecting?

  Safe

  At Risk

  N/A

• Appropriate PPE and Spill Kits are available?

  Safe

  At Risk

  N/A

• Daily High Level Disinfection Probe<br>Instrument Log is filled out <br>and up to date.

  Safe

  At Risk

  N/A

• High Level Disinfection Solution Log <br>is filled out and up to date.

  Safe

  At Risk

  N/A

• Is eye wash available and checked<br> weekly with documentation?

  Safe

  At Risk

  N/A

• Are there any expired solutions?

  Safe

  At Risk

  N/A

• Is a timer available and utilized?

  Safe

  At Risk

  N/A

• Is a thermometer available and temperature checked prior to each use?

  Safe

  At Risk

  N/A

• All Instrument processing containers<br>have a lid that is secure and labeled <br>with a BIOHAZARD and DIAMOND Label.

  Safe

  At Risk

  N/A

• Only manufacturer recommended brushes are utilized. Brushes are disinfected following manufacturer guidelines. They should not be lying on the sink.

  Safe

  At Risk

  N/A

• Are chemical and or biohazard materials disposed of properly?

  Safe

  At Risk

  N/A

• Equipment has PM stickers current within<br>the last 12 months and appropriately <br>calibrated?

  Safe

  At Risk

  N/A

• No Food, Drinks, or Make up are stored or applied in or around the designated HLD area.

  Safe

  At Risk

  N/A

• Room Temperature is maintained between 59-86F for proper storage CidexOPA, Revital-Ox Solutions and/or Trophon Cartridges.

  Safe

  At Risk

  N/A

GUS

• Only approved solutions are being utilized in the GUS System. <br>(Cidex OPA or Revital-Ox)

  Safe

  At Risk

  N/A

• Enzol Instructions for use <br>with GUS are posted.

  Safe

  At Risk

  N/A

Cidex OPA

• HLD with Cidex OPA <br>Understanding the Process<br>Educational Slides are available

  Safe

  At Risk

  N/A

• Are quality Control test performed with each new bottle?

  Safe

  At Risk

  N/A

• Concentration test of MEC performed prior to each use with Cidex OPA test strips? (pass/Fail)

  Safe

  At Risk

  N/A

• Cidex- OPA Test Strips are discarded 90 days from opening date?

  Safe

  At Risk

  N/A

• Cidex OPA solutions is labeled with date opened and 75 day expiration date.

  Safe

  At Risk

  N/A

• Soaking container is labeled with date solution was poured and 14 day expiration date.

  Safe

  At Risk

  N/A

• Soak time of 12 minutes is observed for each instrument.

  Safe

  At Risk

  N/A

• Are three (3) 1 minute separate rinses performed with sterile or potable (drinking) water?

  Safe

  At Risk

  N/A

• Quality Control Instructions <br>are posted.

  Safe

  At Risk

  N/A

• Cidex OPA High Level Disinfection <br> Instructions are posted.

  Safe

  At Risk

  N/A

Revital-Ox

• HLD with Revital-ox Process <br>Educational Slides are available<br>for reference in the room.

  Safe

  At Risk

  N/A

• Are quality Control test performed with each new bottle?

  Safe

  At Risk

  N/A

• Concentration test of MEC performed prior to each use with Revital-Ox R60 test strips? (pass/Fail)

  Safe

  At Risk

  N/A

• Revital-Ox Resert R60 solution test strips are discarded 90 days from opening date?

  Safe

  At Risk

  N/A

• Revital-Ox solution is labeled with the date opened and the 90 day expiration date.

  Safe

  At Risk

  N/A

• Soaking container is labeled with date solution was poured and 21 day expiration date.

  Safe

  At Risk

  N/A

• Soak time of 8 minutes is observed for each instrument.

  Safe

  At Risk

  N/A

• Is a single rinse with sterile or potable (drinking) water performed with each instrument?

  Safe

  At Risk

  N/A

• Quality Control Instructions are posted.

  Safe

  At Risk

  N/A

• Revital- Ox High Level Disinfection <br>Instructions are posted.

  Safe

  At Risk

  N/A

Trophon

• Trophon HLD Process <br>Educational Slides are available <br>for reference in the room.

  Safe

  At Risk

  N/A

• Trophon EPR left connected to power and switched on at all times?

  Safe

  At Risk

  N/A

• Chemical Indicator available and unexpired? Stored away from direct UV light?

  Safe

  At Risk

  N/A

• Cartridges changed every 30 days

  Safe

  At Risk

  N/A

• Single use cleaning clothes available for cleaning before disinfecting?

  Safe

  At Risk

  N/A

• Quality Control is interpreted at end of each cycle and documented.

  Safe

  At Risk

  N/A

• Quality Control Instructions are posted.

  Safe

  At Risk

  N/A