Information

  • Document No.

  • Audit Title

  • Conducted on

  • Location
  • Prepared by

Utility and Storage Areas

  • Floors and walls clean?

  • Corrective Action

  • Supplies are 18 inches from ceiling?

  • Corrective Action

  • Clean Linen Adequately Covered?

  • Corrective Action

  • No Supplies on floor?

  • Corrective Action

  • Adequate separation of clean and soiled materials?

  • Corrective Action

  • Curtains Changed out Quarterly?

  • Corrective Action

  • Documentation of Curtain change available?

  • Corrective Action

  • Area free of Miscellaneous Findings?

Soiled Linen/Bio-Hazard Areas

  • HLD- High Level Disinfectant for Ultrasound Probes properly labeled?

  • Corrective Action

  • Documentation of QC and Temperature Log for HDL Complete?

  • Corrective Action

  • No clean supplies stored in area?

  • Corrective Action

  • Floors/Walls/Cabinets/Ceilings clean?

  • Corrective Action

  • Soiled Linen Appropriately bagged?

  • Corrective Action

  • Bio-hazard Materials stored off of floor?

  • Corrective Action

  • Area free of Miscellaneous Findings?

Exam Rooms: ER

  • Floors and walls clean?

  • Corrective Action

  • Furniture Clean and undamaged?

  • Corrective Action

  • Alcohol based foam hand sanitizer available and not expired?

  • Corrective Action

  • Soap and paper towels available at hand washing station?

  • Corrective Action

  • No supplies under sinks?

  • Corrective Action

  • Sharps containers less than 3/4 full?

  • Corrective Action

  • Trash cans less than 3/4 full?

  • Corrective Action

  • Red bio-hazard bins free from regular trash items?

  • Corrective Action

  • Red bio-hazard bins less than 3/4 full?

  • Corrective Action

  • No Items on top of linen hampers?

  • Corrective Action

  • Check manometer on isolation room, Is it operating correctly? (Does the red light come on when the door is held open for an extended amount of time?)

  • Corrective Action

  • Area free of Miscellaneous Finding

Hospital Beds: IP Rooms

  • No Items on top of linen hampers?

  • Corrective Action

  • Check manometer on isolation room, Is it operating correctly? (Does the red light come on when the door is held open for an extended amount of time?)

  • Corrective Action

  • Floors and walls clean?

  • Corrective Action

  • Furniture Clean and undamaged?

  • Corrective Action

  • Alcohol based foam hand sanitizer available and not expired?

  • Corrective Action

  • Soap and paper towels available at hand washing station?

  • Corrective Action

  • No supplies under sinks?

  • Corrective Action

  • Sharps containers less than 3/4 full?

  • Corrective Action

  • Trash cans less than 3/4 full?

  • Corrective Action

  • Red bio-hazard bins free from regular trash items?

  • Corrective Action

  • Red bio-hazard bins less than 3/4 full?

  • Corrective Action

  • No excessive Linens stored in Inpatient Rooms?

  • Area free of Miscellaneous Finding?

Hallways, Walkways, Employee break room and Lobby

  • Floors and walls clean?

  • Corrective Action

  • Hallways and walkways free from obstruction?

  • Corrective Action

  • Ceiling tiles clean and in good condition?

  • Corrective Action

  • Furniture Clean and undamaged?

  • Corrective Action

  • Area free of Miscellaneous Findings?

ER/ IP Nursing, and Physician work stations

  • Computers, Desks and other furniture Items clean and undamaged?

  • Corrective Action

  • No linens in area?

  • Corrective Action

  • No food or drinks in Area?

  • Corrective Action

  • Alcohol based hand sanitizer available and not expired?

  • Corrective Action

  • Floors and walls clean?

  • Corrective Action

  • Area free of miscellaneous findings?

Dietary/Miscellaneous Items

  • Ice Machines Clean?

  • Corrective Action

  • Patient refrigerator has food properly labeled with expiration date?

  • Corrective Action

  • Patient food on wire shelving is properly labeled with expiration date?

  • Corrective Action

  • Is facility free of shipping boxes on floor?

  • Corrective Action

  • Area free of miscellaneous findings?

Conclusions/Recommendations and Corrective Actions

  • Confirm Date and Time

  • By entering name, this acts as an electronic signature. Auditor, please enter name here

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