Infection Control Surveillance CIP

• Audit Title

• Document No.

• Conducted on

  Date

• 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.

• Return this form to me by:

  Date

Summary of Survey

• Score - Total Survey Score %

Employee Hand Hygiene Compliance

• Employees Monitored

1.0 Hand Hygiene

• 1.1. Sinks for hand hygiene are well stocked?

  Yes

  No

  N/A

• 1.2. Alcohol hand rubs are well stocked?

  Yes

  No

  N/A

• 1.3. Sinks are available in all areas as needed?

  Yes

  No

  N/A

• 1.4 washing / hand hygiene is performed between patients?

  Yes

  No

  N/A

2.0. Clean Utility / Central Supply / Storage

• 2.1 Ceiling tiles are not stained or wet?

  Yes

  No

  N/A

• 2.2 Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 2.3 Walls/Floors are clean?

  Yes

  No

  N/A

• 2.4. Trash cans or waste basket are not overfilled or overflowing?

  Yes

  No

  N/A

• 2.5 Clean supply storage containers are clean and free of dust?

  Yes

  No

  N/A

• 2.6 Clean linen cart is covered?

  Yes

  No

  N/A

• 2.7 Clean linen cart has solid surface on bottom shelf?

  Yes

  No

  N/A

• 2.8 Supplies are stored at least 6 inches off of the floor?

  Yes

  No

  N/A

• 2.9 Supplies are not expired?

  Yes

  No

  N/A

• 2.10 Is this section free of additional findings?

  Yes

  No

  N/A

3.0 Patient Rooms

• Room evaluated

• 3.1 Sinks for hand hygiene are well stocked?

  Yes

  No

  N/A

• 3.2 General area is dust free?

  Yes

  No

  N/A

• 3.3 Nothing stored under sinks?

  Yes

  No

  N/A

• 3.5 Horizontal surfaces are clean?

  Yes

  No

  N/A

• 3.6 No visible soil on vertical surfaces?

  Yes

  No

  N/A

• 3.7 Ceiling tiles are not discolored, wet, missing, or damaged?

  Yes

  No

  N/A

• 3.8 Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 3.10 Patient equipment is clean?

  Yes

  No

  N/A

• 3.11 Mattress pad is without tears or puncture holes?

  Yes

  No

  N/A

• 3.13 Furniture (chairs, sleepers) are without tears or wear?

  Yes

  No

  N/A

• 3.14 There is no evidence of pest present?

  Yes

  No

  N/A

• 3.15 Trash cans or waste basket are not overfilled or overflowing?

  Yes

  No

  N/A

• 3.16 PPE's are available as needed?

  Yes

  No

  N/A

• 3.17 Sharp containers are no more than 3/4 full?

  Yes

  No

  N/A

• 3.19 Clean / dirty linen handled appropriately?<br>

  Yes

  No

  N/A

• 3.20 Is this section free of additional findings?

  Yes

  No

  N/A

5.0 Patient Nourishment Area

• 5.1 Floors and walls clean?

  Yes

  No

  N/A

• 5.2 Horizontal and vertical surfaces are clean?

  Yes

  No

  N/A

• 5.3 Microwave oven clean?

  Yes

  No

  N/A

• 5.4 Refrigerator clean and thawed of ice?

  Yes

  No

  N/A

• 5.5 Sinks for hand hygiene are well stocked?

  Yes

  No

  N/A

• 5.6 Under sink clean and without storage?

  Yes

  No

  N/A

• 5.7 Patient refrigerator labeled for patient use only?

  Yes

  No

  N/A

• 5.8 Temperature checks are documented with corrective action when temp is out of range?

  Yes

  No

  N/A

• 5.9 Patient food is labeled appropriately with no expired food found?

  Yes

  No

  N/A

• 5.10 Ice machine is clean?

  Yes

  No

  N/A

• 5.12 There is no evidence of pest present?

  Yes

  No

  N/A

• 5.13 Is this section free of additional findings?

  Yes

  No

  N/A

6.0 General Unit / Nurses Station / Medication Room

• 6.1 Unit / area generally clean (without dust, clutter or debris)?

  Yes

  No

  N/A

• 6.2 Ceiling tiles are not discolored/ wet/ missing / damaged?

  Yes

  No

  N/A

• 6.3 General area is dust free?

  Yes

  No

  N/A

• 6.5 Trash basket are not overflowing?

  Yes

  No

  N/A

• 6.6 Food located in designated areas only?

  Yes

  No

  N/A

• 6.7 Sinks for hand hygiene are well stocked?

  Yes

  No

  N/A

• 6.8 Under sink clean and without storage?

  Yes

  No

  N/A

• 6.10 Medication, specimens, and food are handled appropriately?

  Yes

  No

  N/A

• 6.11 Needles and syringes are disposed of properly?

  Yes

  No

  N/A

• 6.12 Infectious waste in red bag or container?

  Yes

  No

  N/A

• 6.14 Halls are uncluttered?

  Yes

  No

  N/A

• 6.18 No artificial / acrylic nails use. Nails are no more than 1/4 inch above finger?

  Yes

  No

  N/A

• 6.19 No personal lotion use.

  Yes

  No

  N/A

• 6.20 Medication Room refrigerator is clean and without ice?

  Yes

  No

  N/A

• 6.21 There are no expired products found(IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)

  Yes

  No

  N/A

• 6.22 Is this section free of additional findings?

  Yes

  No

  N/A

7.0 Soiled Linen / Dirty Utility Room

• 7.1 Biohazard symbol on door of biomedical waste storage?

  Yes

  No

  N/A

• 7.2 Biohazard trash is segregated from regular trash?

  Yes

  No

  N/A

• 7.3 Dirty tray cart clean?

  Yes

  No

  N/A

• 7.4 Boxes are stored at least 6 inches off of the floor?

  Yes

  No

  N/A

• 7.5 Clean items are not stored in soiled utility room?

  Yes

  No

  N/A

• 7.6 Walls / floors are clean

  Yes

  No

  N/A

• 7.7 Ceiling tiles are not discolored/ wet/ missing / damaged?

  Yes

  No

  N/A

• 7.8 Is this section free of additional findings?

  Yes

  No

  N/A

8.0 Employee General Knowledge

• 8.1. Employees know the procedure for blood exposure?

  Yes

  No

  N/A

• 8.2. Personnel can locate their Infection Control Policy?

  Yes

  No

  N/A

• 8.3 Is this section free of additional findings?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign