Infection Control Surveillance - Pharmacy

• 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 Hand Hygiene

• 1.1 Alcohol hand rubs are well stocked?

  Yes

  No

  N/A

• 1.2 Sinks for hand hygiene are well stocked?

  Yes

  No

  N/A

• 1.3 Employee knows how to document hand hygiene observations?

  Yes

  No

  N/A

2.0 General Area

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

  Yes

  No

  N/A

• 2.2 There is no evidence of pest present?

  Yes

  No

  N/A

• 2.3 Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 2.4 No signs of mildew or mold present?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.6 No storage from 18" from ceiling?

  Yes

  No

  N/A

• 2.7 Floors are clean?

  Yes

  No

  N/A

• 2.8 Trash basket are not overflowing?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.10 Nothing is stored under the sink and there is no sign of leaks?

  Yes

  No

  N/A

• 2.11 Is this section free of additional findings?

  Yes

  No

  N/A

3.0 Medication storage area

• 3.1 Medication area generally clean (without dust, clutter or debris)?

  Yes

  No

  N/A

• 3.2 Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 3.3 Ceiling tiles are not stained or wet?

  Yes

  No

  N/A

• 3.4 Floors are clean?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.6 Temperature log for warmer complete?

  Yes

  No

  N/A

• 3.7 Refrigerator log complete?

  Yes

  No

  N/A

• 3.8 Medication area free of food and drink?

  Yes

  No

  N/A

• 3.9 Supply cart has solid bottom?

  Yes

  No

  N/A

• 3.10 Medication bins are clean and dust free?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.12 Is this section free of additional findings?

  Yes

  No

  N/A

4.0 Add/Mixture Area

• 4.1 Medication area generally clean (without dust, clutter or debris)?

  Yes

  No

  N/A

• 4.2 Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 4.3 Ceiling tiles are not stained or wet?

  Yes

  No

  N/A

• 4.6 Floors are clean?

  Yes

  No

  N/A

• 4.7 Nothing is stored under the sink and there is no sign of leaks?

  Yes

  No

  N/A

• 4.8 Eye wash log complete?

  Yes

  No

  N/A

• 4.9 Edgegard evaluation date documented?

  Yes

  No

  N/A

• 4.10 Supply cart has solid bottom?

  Yes

  No

  N/A

• 4.11 Is this section free of additional findings?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign