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
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 washing / hand hygiene is performed between patients?
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1.5 Employee knows how to document hand hygiene observations?
2.0. Clean Utility / Central Supply / Storage
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2.1 Ceiling tiles are not stained or wet?
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2.2 Air intake vents and diffusers are clean?
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2.3 Walls/Floors are clean?
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2.4. Trash cans or waste basket are not overfilled or overflowing?
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2.5 Clean supply storage containers are clean and free of dust?
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2.6 Clean linen cart is covered?
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2.7 Clean linen cart has solid surface on bottom shelf?
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2.8 Supplies are stored at least 6 inches off of the floor?
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2.9 Supplies are not expired?
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2.10 Is this section free of additional findings?
3.0 Patient Rooms
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Room evaluated
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3.1 Sinks for hand hygiene are well stocked?
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3.2 General area is dust free?
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3.3 Nothing stored under sinks?
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3.4 Dust not found in high places?
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3.5 Horizontal surfaces are clean?
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3.6 No visible soil on vertical surfaces?
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3.7 Ceiling tiles are not discolored, wet, missing, or damaged?
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3.8 Air intake vents and diffusers are clean?
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3.9 No signs of mildew or mold present?
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3.10 Patient equipment is clean?
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3.11 Mattress pad is without tears or puncture holes?
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3.12 Walls/ Floors are clean?
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3.13 Furniture (chairs, sleepers) are without tears or wear?
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3.14 There is no evidence of pest present?
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3.15 Trash cans or waste basket are not overfilled or overflowing?
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3.16 PPE's are available as needed?
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3.17 Sharp containers are no more than 3/4 full?
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3.18 Foley catheters hanging and secured appropriately?
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3.19 Clean / dirty linen handled appropriately?<br>
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3.20 Is this section free of additional findings?
4.0 Patient Shower Room
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4.1 Shower room clean and orderly?
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4.2 Shower curtain clean?
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4.3 Sinks for hand hygiene are well stocked?
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4.4 Walls/floor are clean?
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4.5 Ceiling tiles are not discolored/ wet/ missing / damaged?
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4.6 Dust not found in high places?
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4.7 Soap and paper towels are available in each bathroom?
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4.8 Is this section free of additional findings?
5.0 Patient Nourishment Area
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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 Sinks for hand hygiene are well stocked?
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5.6 Under sink clean and without storage?
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5.7 Patient refrigerator labeled for patient use only?
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5.8 Temperature checks are documented with corrective action when temp is out of range?
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5.9 Patient food is labeled appropriately with no expired food found?
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5.10 Ice machine is clean?
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5.11 Ice machine cleaning date / time stamped?
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5.12 There is no evidence of pest present?
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5.13 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 Ceiling tiles are not discolored/ wet/ missing / damaged?
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6.3 General area is dust free?
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6.4 General area is dust free?
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6.5 Trash basket are not overflowing?
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6.6 Food located in designated areas only?
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6.7 Sinks for hand hygiene are well stocked?
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6.8 Under sink clean and without storage?
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6.9 Unused patient equipment/supplies are stored and handled appropriately?
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6.10 Medication, specimens, and food are handled appropriately?
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6.11 Needles and syringes are disposed of properly?
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6.12 Infectious waste in red bag or container?
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6.13 Nothing is stored under the sink and there is no sign of leaks?
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6.14 Halls are uncluttered?
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6.15 Respiratory hygiene available?
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6.16 Biohazard symbol on door of biomedical waste storage?
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6.17 Medication cart locked?
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6.18 No artificial / acrylic nails use. Nails are no more than 1/4 inch above finger?
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6.19 No personal lotion use.
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6.20 Medication Room refrigerator is clean and without ice?
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6.21 There are no expired products found(IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)
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6.22 Is this section free of additional findings?
7.0 Soiled Linen / Dirty Utility Room
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7.1 Biohazard symbol on door of biomedical waste storage?
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7.2 Biohazard trash is segregated from regular trash?
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7.3 Dirty tray cart clean?
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7.4 Boxes are stored at least 6 inches off of the floor?
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7.5 Clean items are not stored in soiled utility room?
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7.6 Walls / floors are clean
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7.7 Ceiling tiles are not discolored/ wet/ missing / damaged?
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7.8 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 Policy?
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9.3 Is this section free of additional findings?
Additional Comments
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Additional Comments
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Surveyor's Signature