Infection Control Surveillance - Respiratory Therapy

• 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 Employee knows how to document hand hygiene observations?

  Yes

  No

  N/A

2.0 General Unit

• 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 Patient equipment is clean?

  Yes

  No

  N/A

• 2.9 Trash basket are not overflowing?

  Yes

  No

  N/A

• 2.10 Work area free of food and drink?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.13 Supply packaging intact?

  Yes

  No

  N/A

• 2.14 Supply cart has solid bottom?

  Yes

  No

  N/A

• 2.15 Needles and syringes are disposed of properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.17 Respiratory hygiene available?

  Yes

  No

  N/A

• 2.18 Medication cart locked?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.20 No personal lotion use.

  Yes

  No

  N/A

• 2.21 Is this section free of additional findings?

  Yes

  No

  N/A

3.0 Endoscope cleaning area

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

  Yes

  No

  N/A

• 3.6 Sinks are available in all areas as needed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.9 Sinks for hand hygiene are well stocked?

  Yes

  No

  N/A

• 3.10 Soiled linens are bagged at point of use?

  Yes

  No

  N/A

• 3.11 Infectious waste in red bag or container?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.14 Strips are dated when opened?

  Yes

  No

  N/A

• 3.15 Cidex monitoring Log complete?

  Yes

  No

  N/A

• 3.16 QC check done when Cidex test strips opened?

  Yes

  No

  N/A

• 3.17 Enzymatic cleaner manufacturer's instructions being followed?<br>

  Yes

  No

  N/A

• 3.18 Cidex spill kit in room?

  Yes

  No

  N/A

• 3.19 Is this section free of additional findings?

  Yes

  No

  N/A

4.0 Employee General Knowledge

• 4.1 Employees know the procedure for blood exposure?

  Yes

  No

  N/A

• 4.2 Personnel can locate their Infection Control Policy?

  Yes

  No

  N/A

• 4.3 Personnel can locate spill kit for Cidex?

  Yes

  No

  N/A

• 4.4Is this section free of additional findings?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign