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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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 Employee knows how to document hand hygiene observations?

2.0 General Unit

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 Patient equipment is clean?

2.9 Trash basket are not overflowing?

2.10 Work area free of food and drink?

2.11 Unused patient equipment/supplies are stored and handled appropriately?

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

2.13 Supply packaging intact?

2.14 Supply cart has solid bottom?

2.15 Needles and syringes are disposed of properly?

2.16 Sharp containers are no more than 3/4 full?

2.17 Respiratory hygiene available?

2.18 Medication cart locked?

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

2.20 No personal lotion use.

2.21 Is this section free of additional findings?

3.0 Endoscope cleaning area

3.1 Endoscope cleaning 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 Clean Linen is stored in cabinet in scope cleaning room?

3.6 Sinks are available in all areas as needed?

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

3.8 Hand soap is available in all hand washing stations / bathrooms?

3.9 Sinks for hand hygiene are well stocked?

3.10 Soiled linens are bagged at point of use?

3.11 Infectious waste in red bag or container?

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

3.13 Strips from Steris high level disinfector have name, serial number, and pass/fail results?

3.14 Strips are dated when opened?

3.15 Cidex monitoring Log complete?

3.16 QC check done when Cidex test strips opened?

3.17 Enzymatic cleaner manufacturer's instructions being followed?

3.18 Cidex spill kit in room?

3.19 Is this section free of additional findings?

4.0 Employee General Knowledge

4.1 Employees know the procedure for blood exposure?

4.2 Personnel can locate their Infection Control Policy?

4.3 Personnel can locate spill kit for Cidex?

4.4Is 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.