Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Admitting

  • Horizontal and vertical surfaces are clean.

  • Trash cans not over filled.

  • Hand hygiene products available.

  • PPE available. Appropriate PPE used by staff.

  • Sharps containers less than 3/4 full.

  • Sharps containers are on IV trays.

  • IV start trays clean.

  • Medication preparation area clean, organized and ready for use.

ENDO

  • Horizontal and vertical surfaces are clean.

  • Trash cans and linen hampers not over filled. Trash and linen handled per policy. Suction canisters are handled per policy.

  • Hand hygiene products available.

  • PPE available. Appropriate PPE used by staff

  • Sharps containers less than 3/4 full.

  • Sharps containers secured properly.

  • Scope cleaning is done according to manufacturer's instructions.

  • Scopes are labeled and stored according to policy.

  • Bathroom is clean.

  • No paper supplies or patient care items stored under sinks.

  • Procedure room, including Anesthesia Carts, are cleaned and disinfected between patients.

  • Safe medication preparation and administration practices are followed. IV bags are not spiked more than 1 hour prior to use.

  • DSD's are maintained and operated according to manufacturer's instructions. Logs are maintained.

  • Procedure rooms are terminally cleaned at the end of the day.

OR

  • Horizontal and vertical surfaces are clean.

  • Trash cans and linen hampers are emptied between each case (PE tubes exempt). Trash and linen handled per policy.

  • Hand hygiene products available.

  • PPE available. Appropriate PPE used by staff

  • Sharps containers less than 3/4 full.

  • Sharps containers secured properly.

  • No paper supplies or patient care items stored under the sink.

  • Safe medication preparation and administration practices are followed.

  • Operating room, including Anesthesia Carts, are cleaned and disinfected between patients.

  • Containers are securely closed for transport.

  • All OR's are terminally cleaned at the end of the day.

  • Sterilizers are tested daily according to manufacturer's instructions.

  • Sterile processing and storage is done according to policy.

  • Cidex trays have expiration date and are not expired.

  • Log books are complete and up to date. Cidex test strips, biological indicators, immediate use, chemical indicators, mechanical indicators

  • Sterilization equipment is in good working condition

  • Preventive maintainance program is in place for sterilizers.

  • Employee protection measures are implemented during sterile processing.

  • Event related sterilization packaging is used.

  • Surgical teams are observed during procedure and masks are securely in place prior to entering the OR.

  • All head and facial hair is covered.

  • Doors are completely closed.

  • Time out process completed according to policy.

PACU

  • Horizontal and vertical surfaces are clean.

  • Trash cans and linen hampers not over filled. Trash and linen handled per policy.

  • Hand hygiene products available.

  • PPE available. Appropriate PPE used by staff

  • Sharps containers less than 3/4 full.

  • Sharps containers secured properly.

  • Glucose monitor clean and only one time use lancets are available.

  • Bathrooms are clean.

  • No paper supplies or patient care items stored under the sink.

  • Crash Cart checked.

  • Medication preparation area clean, organized and ready for use.

  • Safe medication preparation and administration practices are followed.

  • Patient bays and carts are cleaned and disinfected according to procedure between each patient.

DWA

  • Horizontal and vertical surfaces are clean.

  • Trash cans not over filled.

  • Hand hygiene products available.

  • PPE available. Appropriate PPE used by staff.

  • Food stored and distributed according to policy. Food area clean.

  • Preventing SSI included in patient discharge instructions.

  • No paper supplies or patient care items stored under the sink.

Nurses stations

  • Horizontal and vertical surfaces are clean and free of clutter.

  • No food present, only drinks with lids.

  • Hand hygiene products available.

Linen

  • Clean linens are in good condition.

  • Clean linen is stored in a covered cart.

  • Soiled linen bagged for transport.

  • Soiled linen hampers have impervious liner or are emptied regularly.

  • Soiled linen is removed from building on a regular schedule.

  • Clean and dirty linen are kept separate.

Hazardous/biological waste

  • Door is labeled. Biohazard symbol on door. Emergency call button operational.

  • Waste containers have correct emblem, are dated and bags are correctly tied and closed.

  • Room is clean and uncluttered.

  • OSHA compliant storage containers are used. Including sharps containers.

  • Pick up for transfer is on a specified schedule.

  • Containers are not overfilled.

  • Appropriate waste manifests are maintained.

  • Red bags are available in each regulated medical waste container.

  • Eye wash station is available.

Trash

  • Door is labeled. Room is clean and uncluttered. Trash is in appropriate bag.

  • Pick up for transfer is on a specified schedule.

Clean Storage areas - clean utility, equipment, sterile items, supplies, receiving,

  • Horizontal and vertical surfaces are clean. Area is clean and uncluttered.

  • Items are clean and ready to use.

  • Supplies are at least 18 inches from the ceiling and 6 inches from the floor.

  • No patient care items or paper products are stored under sinks.

Refrigerators

  • Daily temperature is checked and recorded appropriately on medication refrigerators. Correct temp range 36-46F

  • Refrigerators have single uses. Medication, Staff Food, Patient Supplies. No batteries should be stored in the refrigerator.

  • Items are appropriately labeled.

  • Refrigerators are routinely cleaned and cleaning is documented.

Halls

  • Uncluttered

  • Floors and walls are clean.

  • No stained ceiling tiles.

  • Unobstructed access to exits.

Offices/reception

  • Horizontal and vertical surfaces and floors are clean.

  • Trash / recycle is not overflowing.

  • Area in uncluttered.

Waiting room

  • Horizontal, vertical surfaces and floors are clean.

  • Trash is not overflowing.

  • Coffee area is clean.

  • Area is uncluttered.

Bathrooms

  • All surfaces are clean.

  • Hand washing supplies are available.

  • Trash not overflowing.

Hand Hygiene

  • Sinks for handwashing are appropriately stocked with soap, paper towels and waste can.

  • Sinks are available in all areas. If not available, Alcohol hand rubs are available.

  • Alcohol hand rubs are availalbe near patient care areas and other areas as needed.

  • Placement of alcohol hand rubs comply with regulations.

  • Hand hygiene is monitored for staff compliance.

  • HCW do not wear artificial nails. Nail polish is less than 4 days old.

  • Only hospital approved hand lotion is available, so glove protection is not compromised.

Staff Knowledge

  • Staff know how to access policies and procedures.

  • Staff demonstrate proper hand hygiene technique.

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