Infection Control Surveillance

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Previous Inspection

• Has the last inspection been reviewed?

• Details

Managers - Infection Control performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each deficiency.

1.0 Hand Hygiene

• 1.1. Hand sanitizer is available and accessible for the patients and visitors in all waiting areas?

  Yes

  No

  N/A

• 1.2. Available liquid soap within all treatment rooms?

  Yes

  No

  N/A

• 1.3. Wall mounted paper towels available near each sink?

  Yes

  No

  N/A

• 1.4. Free from bar soaps?

  Yes

  No

  N/A

• 1.5. Posters in appropriate locations demonstrating good handwashing techniques?

  Yes

  No

  N/A

• 1.6. Clinical staff able to demonstrate good handwashing techniques?

  Yes

  No

  N/A

• 1.7. Staff able to apply 5 moments of hand hygiene?

  Yes

  No

  N/A

2.0 Patient Exam Rooms

• 2.1. Floor and walls clean?

  Yes

  No

  N/A

• 2.2. Cubicle curtains unsoiled and free of tears?

  Yes

  No

  N/A

• 2.3. Furniture is clean and in good condition?

  Yes

  No

  N/A

• 2.4. Sink is clean and storage area empty and clean?

  Yes

  No

  N/A

• 2.5. Liquid soap and paper towel dispenser are stocked and working?

  Yes

  No

  N/A

• 2.6. Alcohol hand sanitizers are available?

  Yes

  No

  N/A

• 2.7. Gloves, PPE available?

  Yes

  No

  N/A

• 2.8. No food or drink in patient care areas?

  Yes

  No

  N/A

• 2.9. Vent grill is dirt free?

  Yes

  No

  N/A

• 2.10. Couch covers or couch rolls changed after every patient used?<br>

  Yes

  No

  N/A

• 2.11. Drawers well organized and clean?

  Yes

  No

  N/A

• 2.12. Working surfaces are clean?

  Yes

  No

  N/A

• 2.13. Mattress pad and couch is without tears or puncture holes?

  Yes

  No

  N/A

• 2.14. Plants not present in clinical areas?

  Yes

  No

  N/A

3.0 Waste Management

• 3.1. Waste containers clean, operational and in good condition?

  Yes

  No

  N/A

• 3.2 Waste containers covered and with labels?

  Yes

  No

  N/A

• 3.3. Contaminated instruments or disposables placed on designated area not mixed with clean items?

  Yes

  No

  N/A

• 3.4. Regulated medical waste discarded appropriately?

  Yes

  No

  N/A

• 3.5. Waste clearly segregated?

  Yes

  No

  N/A

• 3.6. Sharp containers secured and labeled appropriately?

  Safe

  At Risk

  N/A

• 3.7. Sharp bins not mixed with any general/biomedical waste?

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

• 3.9. Staffs are aware not to bend, recap ore remove contaminated needle or sharps unless it is absolutely necessary?

  Yes

  No

  N/A

4.0 Medications/ Items

• 4.1. No outdated IV solutions, items and medicines?

  Yes

  No

  N/A

• 4.2. Open vials dated and times as per policy?

  Yes

  No

  N/A

• 4.3. Safe injection practices followed as per policy?

  Safe

  At Risk

  N/A

• 4.4. Out of date sterile supplies are not present?

  Yes

  No

  N/A

• 4.5. Reagents stored appropriately with daily checklist completed for temperatures?

  Yes

  No

  N/A

• 4.6. Correct temperature observed: <br> Medications: 36-46 F<br> Frozen Meds/Vaccine: <3-5 F<br> Specimens: 36-46 F

  Yes

  No

  N/A

5.0. Utility and Storage Room

• 5.1. Floors and walls clean?

  Yes

  No

  N/A

• 5.2. Horizontal and vertical surfaces are clean?

  Yes

  No

  N/A

• 5.3. Adequate separation of clean and soiled?

  Yes

  No

  N/A

• 5.4. Bottom shelf is solid?

  Yes

  No

  N/A

• 5.5. No supplies stored 6" from the floor?

  Yes

  No

  N/A

• 5.6. No supplies stored touching the 18" from the ceiling?

  Yes

  No

  N/A

• 5.7. No supplies stored in the dirty utility room?

  Yes

  No

  N/A

• 5.8 Soiled linen is bagged accordingly?

  Yes

  No

  N/A

• 5.9. Is equipment properly cleaned and stored?

  Yes

  No

  N/A

6.0. Chemical Safety

• 6.1. Material Safety Data Sheets available for all chemicals?

  Yes

  No

  N/A

• 6.2. Risk assessments completed for hazardous substance?

  Yes

  No

  N/A

• 6.3. All containers labelled correctly?

  Yes

  No

  N/A

• 6.4. Unused substances disposed of?

  Yes

  No

  N/A

• 6.5. Do special storage conditions apply?

  Yes

  No

  N/A

• 6.6. Workers trained in the use of hazardous substance?

  Yes

  No

  N/A

• 6.7. If required is PPE available?

  Yes

  No

  N/A

• 6.8. Are eye washes and showers easily accessed?

  Yes

  No

  N/A

7.0. Corridors/ Hallways/ Environment

• 7.1. Furniture is clean and in a good state?

  Yes

  No

  N/A

• 7.2. The wall is clean and dust free?

  Yes

  No

  N/A

• 7.3. Free of obstruction and equipment?

  Yes

  No

  N/A

• 7.4. Reception area is clean and work surface clean and free from clutter?

  Yes

  No

  N/A

• 7.5. OTC and compressor room is clean and maintained and dust free?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

Recommendations

• Inspector's signature

  Sign

• Received by:

  Sign