Infection Control Environmental Surveillance

• Document No.

• Audit Title

• Conducted on

  Date
• Location
  Address

• Prepared by

Utility and Storage Areas

• Floors and walls clean?

  Yes

  No

  N/A

• Corrective Action

• Supplies are 18 inches from ceiling?

  Yes

  No

  N/A

• Corrective Action

• Clean Linen Adequately Covered?

  Yes

  No

  N/A

• Corrective Action

• No Supplies on floor?

  Yes

  No

  N/A

• Corrective Action

• Adequate separation of clean and soiled materials?

  Yes

  No

  N/A

• Corrective Action

• Curtains Changed out Quarterly?

  Yes

  No

  N/A

• Corrective Action

• Documentation of Curtain change available?

  Yes

  No

  N/A

• Corrective Action

• Area free of Miscellaneous Findings?

  Yes

  No

  N/A

Soiled Linen/Bio-Hazard Areas

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

  Yes

  No

  N/A

• Corrective Action

• Documentation of QC and Temperature Log for HDL Complete?

  Yes

  No

  N/A

• Corrective Action

• No clean supplies stored in area?

  Yes

  No

  N/A

• Corrective Action

• Floors/Walls/Cabinets/Ceilings clean?

  Yes

  No

  N/A

• Corrective Action

• Soiled Linen Appropriately bagged?

  Yes

  No

  N/A

• Corrective Action

• Bio-hazard Materials stored off of floor?

  Yes

  No

  N/A

• Corrective Action

• Area free of Miscellaneous Findings?

  Yes

  No

  N/A

Exam Rooms: ER

• Floors and walls clean?

  Yes

  No

  N/A

• Corrective Action

• Furniture Clean and undamaged?

  Yes

  No

  N/A

• Corrective Action

• Alcohol based foam hand sanitizer available and not expired?

  Yes

  No

  N/A

• Corrective Action

• Soap and paper towels available at hand washing station?

  Yes

  No

  N/A

• Corrective Action

• No supplies under sinks?

  Yes

  No

  N/A

• Corrective Action

• Sharps containers less than 3/4 full?

  Yes

  No

  N/A

• Corrective Action

• Trash cans less than 3/4 full?

  Yes

  No

  N/A

• Corrective Action

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

  Yes

  No

  N/A

• Corrective Action

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

  Yes

  No

  N/A

• Corrective Action

• No Items on top of linen hampers?

  Yes

  No

  N/A

• 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?)

  Yes

  No

  N/A

• Corrective Action

• Area free of Miscellaneous Finding

  Yes

  No

  N/A

Hospital Beds: IP Rooms

• No Items on top of linen hampers?

  Yes

  No

  N/A

• 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?)

  Yes

  No

  N/A

• Corrective Action

• Floors and walls clean?

  Yes

  No

  N/A

• Corrective Action

• Furniture Clean and undamaged?

  Yes

  No

  N/A

• Corrective Action

• Alcohol based foam hand sanitizer available and not expired?

  Yes

  No

  N/A

• Corrective Action

• Soap and paper towels available at hand washing station?

  Yes

  No

  N/A

• Corrective Action

• No supplies under sinks?

  Yes

  No

  N/A

• Corrective Action

• Sharps containers less than 3/4 full?

  Yes

  No

  N/A

• Corrective Action

• Trash cans less than 3/4 full?

  Yes

  No

  N/A

• Corrective Action

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

  Yes

  No

  N/A

• Corrective Action

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

  Yes

  No

  N/A

• Corrective Action

• No excessive Linens stored in Inpatient Rooms?

  Yes

  No

  N/A

• Area free of Miscellaneous Finding?

  Yes

  No

  N/A

Hallways, Walkways, Employee break room and Lobby

• Floors and walls clean?

  Yes

  No

  N/A

• Corrective Action

• Hallways and walkways free from obstruction?

  Yes

  No

  N/A

• Corrective Action

• Ceiling tiles clean and in good condition?

  Yes

  No

  N/A

• Corrective Action

• Furniture Clean and undamaged?

  Yes

  No

  N/A

• Corrective Action

• Area free of Miscellaneous Findings?

  Yes

  No

  N/A

ER/ IP Nursing, and Physician work stations

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

  Yes

  No

  N/A

• Corrective Action

• No linens in area?

  Yes

  No

  N/A

• Corrective Action

• No food or drinks in Area?

  Yes

  No

  N/A

• Corrective Action

• Alcohol based hand sanitizer available and not expired?

  Yes

  No

  N/A

• Corrective Action

• Floors and walls clean?

  Yes

  No

  N/A

• Corrective Action

• Area free of miscellaneous findings?

  Yes

  No

  N/A

Dietary/Miscellaneous Items

• Ice Machines Clean?

  Yes

  No

  N/A

• Corrective Action

• Patient refrigerator has food properly labeled with expiration date?

  Yes

  No

  N/A

• Corrective Action

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

  Yes

  No

  N/A

• Corrective Action

• Is facility free of shipping boxes on floor?

  Yes

  No

  N/A

• Corrective Action

• Area free of miscellaneous findings?

  Yes

  No

  N/A

• Confirm Date and Time

  Date

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