Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Managers - Infection Control performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each deficiency.
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Return this form to me by:
Summary of Survey
Employee Hand Hygiene Compliance
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Employees Monitored
1.0 Hand Hygiene
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1.1. Sinks for hand hygiene are well stocked?
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1.2. Alcohol hand rubs are well stocked?
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1.3. Sinks are available in all areas as needed?
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1.4. Alcohol hand rubs are available in patient's rooms?
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1.5. Placement of alcohol hand rubs is compliant with safety?
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1.6. Hand washing / hand hygiene is performed between patients?
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1.7. Hand Hygiene reminder posters present?
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1.8. Hand soap is available in all hand washing stations / bathrooms?
2.0. Clean Utility / Central Supply / Storage
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2.1. Clean linen cart is covered?
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2.2. Clean linen cart has solid surface on bottom shelf?
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2.3. Sink storage area empty and clean?
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2.4. Thrash cans or waste basket are not overfilled or overflowing?
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2.5. Ceiling tiles are not stained or wet?
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2.6. Floors are clean?
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2.7. Supplies are stored at least 6 inches off of the floor?
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2.8. Air intake vents and diffusers are clean?
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2.9 Is this section free of additional findings?
3.0 Patient Rooms
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3.1. Horizontal surfaces are clean?
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3.2 Thrash cans or waste basket are not overfilled or overflowing?
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3.3. Bathrooms are clean?
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3.4. Hand hygiene products are available?
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3.5. Soap and paper towels are available in each bathroom?
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3.6. PPE's are available as needed?
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3.7. Patient equipment is clean?
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3.8. No visible soil on vertical surfaces?
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3.9. Ceiling tiles are not discolored, wet, missing, or damaged?
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3.10. Air intake vents and diffusers are clean?
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3.11. Furniture (chairs, sleepers) are without tears or wear?
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3.12. Mattress pad is without tears or puncture holes?
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3.13. Floors are clean?
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3.14. Sharp containers are no more than 3/4 full?
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3.15. Dust not found in high places?
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3.16. General area is dust free?
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3.17. Foley catheters hanging and secured appropriately?
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3.18. IV pumps and poles, feeding pumps etc. are clean?
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3.19. There is no evidence of pest present?
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3.20. Clean / dirty linen handled appropropriatly?
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3.21. No needles, syringes, medications within reach of the patient?
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3.22. No signs of mildew or mold present?
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3.23 Is this section free of additional findings?
4.0 Patient Kitchen / Breakroom
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4.1. Floors and walls clean?
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4.2. Horizontal and vertical surfaces are clean?
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4.3. Microwave oven clean?
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4.4. Refrigerator clean and thawed of ice?
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4.5. Under sink clean and without storage?
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4.6. Patient refrigerator labeled for patient use only?
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4.7. Temperature checks are documented with corrective action when temp is out of range?
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4.8. Patient food is labeled appropriately with no expired food found?
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4.9. Ice machine is clean?
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4.10 There is no evidence of pest present?
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4.11 Is this section free of additional findings?
5.0. Employee Kitchen / Breakroom
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5.1. Floors and walls clean?
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5.2. Horizontal and vertical surfaces are clean?
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5.3. Microwave oven clean?
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5.4. Refrigerator clean and thawed of ice?
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5.5. Under sink clean and without storage?
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5.6. Employee food labeled and dated?
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5.7. Temperature checks are documented with corrective action when temp is out of range?
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5.8 is this section free of additional findings?
6.0 General Unit / Nurses Station / Medication Room
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6.1 Unit / area generally clean (without dust, clutter or debris)?
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6.2. Unused patient equipment/supplies are stored and handled appropriately?
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6.3. Medication, specimens, and food are handled appropriately?
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6.4. Biohazard trash is segregated from regular trash?
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6.5. Clean linen is handled appropriately?
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6.7. Dirty linen is handled appropriately?
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6.8. All clean linen carts are covered?
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6.7. Linen carts have a solid bottom shelf?
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6.8. Needles and syringes are disposed of properly?
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6.9. Out of date supplies are not present?
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6.10. Infectious waste in red bag or container?
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6.11. Clean items are not stored in soiled utility room?
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6.12 Ceiling tiles are not discolored/ wet/ missing / damaged?
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6.13. Lab supplies are not expired?
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6.14. Nothing is stored under the sink and there is no sign of leaks?
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6.15. Halls are uncluttered?
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6.16. Respiratory hygiene available?
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6.17 Restrooms clean?
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6.18. Trash basket are not overflowing?
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6.19. Biohazard symbol on door of biomedical waste storage?
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6.20. Medication cart locked?
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6.21. No artificial / acrylic nails use. Nails are no more than 1/4 inch above finger?
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6.22. No personal lotion use.
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6.23. Medication Room refrigerator is clean and without ice?
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6.24. There are no expired products found(IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)
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6.25. Is this section free of additional findings?
7.0 Logs
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7.1. Crash cart checked daily?
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7.2. Defibrillator checked daily
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7.3. Narcotic counts documented every shift?
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7.4. Temperature checked BID for vaccine / medication storage?
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7.5. Daily refrigerators checks with corrective actions as needed?
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7.6. Ice machine cleaning date / time stamped?
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7.7. Glucose meter strips dated
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7.8. Cidex monitoring Log complete?
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7.9. Is this section free of additional findings.
8.0. Isolation Rooms
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8.1. Appropriate signage in place?
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8.2. Supplies and PPE's available?
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8.3. Trash and linen handled per policy?
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8.4. Appropriate PPE's used by staff?
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8.5. Door closed as appropriate?
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8.6. Negative pressure is being supplied as required?
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8.7 Patient and family instructed on isolation requirements?
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8.8. Patient with proper attire when being transported?
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8.9. Is this section free of additional findings?
9.0. Employee General Knowledge
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9.1. Employees know the procedure for blood exposure?
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9.2. Personnel can locate their Infection Control Manual?
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9.3. Personnel can locate their Exposure Control Plan?
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9.4. Personnel can locate the blood spill kit?
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9.5. Personnel can locate their spill kit for Cidex?
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9.6. Employees can state the WHO's 5 moments of Hand Hygiene.
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9.7 Dust not found in high places?
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9.8. Is this section free of additional findings?
10.0. Soiled Linen / Dirty Utility Room
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10.1 Biohazard symbol on door of biomedical waste storage?
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10.2 Boxes are stored at least 6 inches off of the floor?
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10.3. Walls / floors are clean
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10.4. Ceiling tiles are not discolored/ wet/ missing / damaged?
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10.5 Dust not found in high places?
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10.6 Is this section free of additional findings?
11.0. Patient Shower Room
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11.1. Shower clean?
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11.2. Shower room clean and orderly?
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11.3. Walls and floor are clean?
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11.4. Ceiling tiles are not discolored/ wet/ missing / damaged?
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11.5 Dust not found in high places?
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11.6 Is this section free of additional findings?
Additional Comments
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Additional Comments
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Surveyor's Signature