Information
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Document No.
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Conducted on
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Audit Title
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Location
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Prepared by
Utility and Storage Areas
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Floors and walls clean?
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Corrective Action
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Supplies are 18 inches from ceiling?
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Corrective Action
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Clean Linen Adequately Covered?
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Corrective Action
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No Supplies on floor?
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Corrective Action
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Adequate separation of clean and soiled materials?
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Corrective Action
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Curtains Changed out Quarterly?
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Corrective Action
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Documentation of Curtain change available?
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Corrective Action
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Medication prep area is clean and free of clutter?
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Area free of Miscellaneous Findings?
Soiled Linen/Bio-Hazard Areas
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HLD- High Level Disinfectant for Ultrasound Probes properly labeled?
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Corrective Action
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Documentation of QC and Temperature Log for HDL Complete?
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Corrective Action
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No clean supplies stored in area?
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Corrective Action
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Floors/Walls/Cabinets/Ceilings clean?
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Corrective Action
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Soiled Linen Appropriately bagged?
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Corrective Action
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Bio-hazard Materials stored off of floor?
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Corrective Action
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Area free of Miscellaneous Findings?
Exam Rooms: ER
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Floors and walls clean?
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Corrective Action
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Furniture Clean and undamaged?
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Corrective Action
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Alcohol based hand sanitizer available and not expired?
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Corrective Action
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Soap and paper towels available at hand washing station?
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Corrective Action
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No supplies under sinks?
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Corrective Action
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Sharps containers less than 3/4 full?
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Corrective Action
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Trash cans less than 3/4 full?
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Corrective Action
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Red bio-hazard bins free from regular trash items?
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Corrective Action
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Red bio-hazard bins less than 3/4 full?
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Corrective Action
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No Items on top of linen hampers?
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Corrective Action
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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?)
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Corrective Action
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Area free of Miscellaneous Finding
Hospital Beds: IP Rooms
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No Items on top of linen hampers?
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Corrective Action
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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?)
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Corrective Action
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Floors and walls clean?
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Corrective Action
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Furniture Clean and undamaged?
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Corrective Action
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Alcohol based hand sanitizer available and not expired?
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Corrective Action
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Soap and paper towels available at hand washing station?
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Corrective Action
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No supplies under sinks?
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Corrective Action
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Sharps containers less than 3/4 full?
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Corrective Action
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Trash cans less than 3/4 full?
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Corrective Action
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Red bio-hazard bins free from regular trash items?
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Corrective Action
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Red bio-hazard bins less than 3/4 full?
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Corrective Action
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No excessive Linens stored in Inpatient Rooms?
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Area free of Miscellaneous Finding?
Hallways, Walkways, Employee break room and Lobby
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Floors and walls clean?
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Corrective Action
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Hallways and walkways free from obstruction?
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Corrective Action
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Ceiling tiles clean and in good condition?
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Corrective Action
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Furniture Clean and undamaged?
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Corrective Action
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Area free of Miscellaneous Findings?
ER/ IP Nursing, and Physician work stations
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Computers, Desks and other furniture Items clean and undamaged?
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Corrective Action
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No linens in area?
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Corrective Action
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No food in Area?
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Corrective Action
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Alcohol based hand sanitizer available and not expired?
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Corrective Action
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Floors and walls clean?
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Area free of miscellaneous findings?
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Corrective Action
Dietary/Miscellaneous Items
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Ice Machines Clean?
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Corrective Action
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Patient refrigerator has food properly labeled with expiration date?
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Corrective Action
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Patient food on wire shelving is properly labeled with expiration date?
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Corrective Action
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Is facility free of shipping boxes on floor?
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Corrective Action
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Area free of miscellaneous findings?
Conclusions/Recommendations and Corrective Actions
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Confirm Date and Time
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