Infection Control Surveillance - Material Management

• Audit Title

• Document No.

• Client / Site

• 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 Supply Storage Areas

• 1.1. Supply bens clean and dust free?

  Yes

  No

  N/A

• 1.2. Storage less than 18 inches from ceiling?

  Yes

  No

  N/A

• 1.3. Storage for supplies are appropriate?

  Yes

  No

  N/A

• 1.4. Boxes are off the floor?

  Yes

  No

  N/A

• 1.5. Package integrity of supplies are intact?

  Yes

  No

  N/A

• 1.6. Supply area is free of food and/or drink?

  Yes

  No

  N/A

2.0. Personal Protective Equipment

• 2.1. PPE cabinets (barrier boxes) are fully stocked?

  Yes

  No

  N/A

• 2.2. PPE removed prior to leaving area?

  Yes

  No

  N/A

3.0 General Unit

• 3.1. Ceiling tiles are not stained or wet?

  Yes

  No

  N/A

• 3.2. Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 3.3. Walls / floors are clean

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.5. Expired supplies are not present?

  Yes

  No

  N/A

• 3.6. Appropriate soap/foam in use?

  Yes

  No

  N/A

4.0. Employee General Knowledge

• 4.1. Employees know where to find infection prevention policies?

  Yes

  No

  N/A

• 4.2. Employees know post-exposure protocol?

  Yes

  No

  N/A

• 4.3. Employees know how to document hand hygiene observations?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign