Audit

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:
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?

1.2 Sinks for hand hygiene are well stocked?

1.3 Employee knows how to document hand hygiene observations?

2.0 General Area

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

2.2 There is no evidence of pest present?

2.3 Air intake vents and diffusers are clean?

2.4 No signs of mildew or mold present?

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

2.6 No storage from 18" from ceiling?

2.7 Floors are clean?

2.8 Trash basket are not overflowing?

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

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

2.11 Is this section free of additional findings?

3.0 Medication storage area

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

3.2 Air intake vents and diffusers are clean?

3.3 Ceiling tiles are not stained or wet?

3.4 Floors are clean?

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

3.6 Temperature log for warmer complete?

3.7 Refrigerator log complete?

3.8 Medication area free of food and drink?

3.9 Supply cart has solid bottom?

3.10 Medication bins are clean and dust free?

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

3.12 Is this section free of additional findings?

4.0 Add/Mixture Area

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

4.2 Air intake vents and diffusers are clean?

4.3 Ceiling tiles are not stained or wet?

4.6 Floors are clean?

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

4.8 Eye wash log complete?

4.9 Edgegard evaluation date documented?

4.10 Supply cart has solid bottom?

4.11 Is this section free of additional findings?

Additional Comments

Additional Comments

Surveyor's Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.