Information

  • Document No.

  • Conducted on

  • Audit Title

  • 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

  • Medication prep area is clean and free of clutter?

  • Area free of Miscellaneous Findings?

Soiled Linen/Dirty/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?

Pre operative area

  • Floors and walls clean?

  • Corrective Action

  • Furniture Clean and undamaged?

  • Corrective Action

  • Alcohol based 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

  • Area free of Miscellaneous Finding

Post operative area

  • Floors and walls clean?

  • Corrective Action

  • Furniture Clean and undamaged?

  • Corrective Action

  • Alcohol based 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 the area?

  • Area free of Miscellaneous Finding?

Hallways, Walkways, Employee changing room, 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?

Nursing, and Physician work stations

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

  • Corrective Action

  • No linens in area?

  • Corrective Action

  • No food 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 and not expired?

  • Corrective Action

  • Corrective Action

  • Patient food on wire shelving is properly labeled with expiration date and not expired?

  • Corrective Action

  • Is area free of shipping boxes on floor?

  • Corrective Action

  • Area free of miscellaneous findings?

Operating rooms and Sterile areas

  • Alcohol base hand sanitizer available and not expired?

  • Corrective action

  • Soap and paper towels available?<br>

  • Corrective action

  • No supplies under the sink?

  • Corrective action

  • Trash cans less than 3/4 full?

  • Corrective action

  • Red biohazard bins free from regular trash?

  • Corrective action

  • Red biohazard bins less than 3/4 full?

  • Corrective action

  • Sharps containers are less than 3/4 full?

  • Corrective action

  • No food or drinks in the area?

  • Corrective action

  • Floors, ceilings and walls clean?

  • Corrective action

  • No exterior shipping containers present in the area?

  • Corrective action

  • Air pressure for all rooms are appropriate ( ORs and clean SPD are positive, dirty areas are negative.)

  • Corrective action

  • Area free of miscellaneous findings?

  • Corrective action

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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