Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Hand Hygiene Facilities
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Hand Hygiene dispensers are adequately supplied (not Empty).
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Hand hygiene dispenser is in convenient location that is easily accessible and clean
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hand hygiene sign is prominently displayed in all staff restrooms.
Patient Food Refrigerator/Freezer Acceptable
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Refrigerator and freezer are clean and contain only food items ( no non-food items), contains only food items with current date (no expired items), all food items labeled appropriately with patient name and date.
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Daily temperature log or Temp-Track is current and alarms have been addressed.
Patient Medication Refrigerator/Freezer Acceptable
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Daily temperature log or temp track is current and alarms have been addressed
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Contains patient medication only, no food items or specimens, no sterile items or medications within 3 feet of sink.
Staff Refrigerator/Freezer Acceptable
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Refrigerator/ freezer is clean, contains only food items, food items labeled and dated.
Linen Acceptable
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Dirty linen bagged at point of use and removed. Dirty linen not placed on floor, chairs, on top of trash cans. Linen carts emptied appropriately and not over flowing.
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Clean linen stored appropriately and not touching floor, trash cans, chairs, etc
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Linen is covered, at least 8 inches from floor and solid bottom shelf
Clean Utility Room
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Door closed, no boxes on floor, area is clean. No loose items on floor under storage cabinets.
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Only clean items in room. No expired supplies. Sink and eye wash station (if present) are accessible and not blocked. No items stored under sink in any locations. Clean supplies stored at least 3 feet from sink.
Waste Acceptable
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Waste is placed in appropriate bags and hoppers. Biohazard stickers placed on medical waste containers. No instruments left in sink.
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Soiled utility room is clean. No dirty items, linen bags or trash bags placed directly on floor. Eye wash station (if present), sink, and hopper are accessible.
Sharps Acceptable
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Sharps safety device available and inuse.
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Sharps placed in appropriate containers, sharps containers easily accessible, sharps container not overfilled.
Personal Protective Equipment
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PPE is readily available and utilized appropriately, correct isolation signs on doors, magnet applied to doorway, isolation sticker on chart
Patient Equipment
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Sterile equipment and supplies or high-level disinfected items are stored appropriately in a manner that prevents contamination. Scopes and endocavitary probes are hanging in cabinets. Scopes / probes should not covered with a towel in a drawer. <br>Laryngoscope blades stored in peel-pouch or other bag to prevent contamination, not stored in drawers or carts or left open on trays.
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Cleaned appropriately between use, Mattresses and stretchers in good repair
General Unit Cleanliness
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Staff lounge is clean and in good repair. All food covered and stored appropriately and dated. Food is stored in a manner that does not promote vermin.
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Floors clean, showers clean, walls and ceilings in good repair, furniture in good repair, medication and crash carts clean and free of dust.
Cleaning and Disinfection
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Appropriate cleaning and disinfection supplies are available and utilized appropriately. Staff is able to verbalize appropriate cleaning procedures and contact time for disinfection products.
HIGH LEVEL DISINFECTION
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- Competencies available for all staff members that perform HLD preocedure.<br>- QC logs available and complete<br>- QC logs for QC solution available (testing of new test strips for cidex OPA)<br>- Negative air pressure room (Cidex OPA)<br>- Triple rinse (Cidex OPA)<br>- Approved solution used<br>- Procedure available at the point of use
COMMENTS
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ADDITIONAL COMMENTS
