Information
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Audit Title
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Document No.
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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
Managers - Infection Prevention performed an inspection of your unit/facility. Please review your survey and document your Plan of Correction next to each deficiency.
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Return this form to me by:
Employee Hand Hygiene Compliance
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Hand hygiene observations submitted monthly?
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Name of observer and/or safety coach?
I. Waiting Area
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Signs posted at entrances with instructions to patients with symptoms of respiratory infection to cover their cough.
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Notice of universal precautions posted in waiting area or at check-in desk?
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Tissues and/or masks available to patients for respiratory hygiene
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Network-approved hand sanitizer available for patients to perform hand hygiene
II. Hand Hygiene
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Sinks for hand hygiene and hand sanitizer dispensers are well stocked?
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Sinks are available in all areas as needed?
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Alcohol hand rubs are available in patient's rooms?
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Placement of alcohol hand rubs is compliant with safety (not directly over an electrical outlet)?
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Hand washing / hand hygiene is performed between patients? (Wash In / Wash Out)
III. Clean Utility / Central Supply / Storage
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Clean linen is covered.
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Clean linen/supply cart has solid surface or plastic barrier on bottom shelf.
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Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks.
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Ceiling tiles are not stained or wet.
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Floors are clean.
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Supplies are stored at least 6 inches off of the floor.
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There are no expired supplies present.
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Air intake vents and diffusers are clean/free of dust
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Walls / floors are clean and undamaged?
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There are no outside cardboard shipping boxes present among clean supplies.
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Is this section free of additional findings?
IV. Soiled Linen / Dirty Utility Room
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Biohazard symbol on door of biomedical waste storage?
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Door to soiled linen / dirty utility room locked?
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Soiled materials are stored appropriately?
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Ceiling tiles are not discolored/ wet/ missing / damaged?
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Dust not found in high places?
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Is this section free of additional findings?
V. Patient Rooms
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Horizontal surfaces are clean?
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Trash cans or waste basket are not overfilled or overflowing?
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Bathrooms are clean?
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PPE is available as needed?
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Patient equipment is clean?
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Ceiling tiles are not discolored, wet, missing, or damaged?
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Air intake vents and diffusers are clean?
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Furniture (chairs, sleepers) are without tears or wear?
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Floors are clean?
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Sharp containers are no more than 3/4 full?
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General area is dust free?
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Foley catheters hanging and secured appropriately?
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There is no evidence of pest infestation present?
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IV pumps and poles, feeding pumps etc. are clean?
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Clean linen handled appropriately?
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Dirty linen handled appropriately?
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No needles, syringes, medications within reach of the patient?
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No signs of mildew or mold present?
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Is this section free of additional findings?
VI. Patient Kitchen / Nutrition Area
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Floors and walls clean?
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Microwave oven clean?
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Refrigerator clean and thawed of ice?
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Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks?
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Patient refrigerator labeled for patient use only or patient food clearly separated from employee food if shared?
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Temperature checks are documented daily with corrective action when temperature is out of range?
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Horizontal and vertical surfaces are clean?
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No expired food present (food from home expires in 3 days)?
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Ice and/or water machine is clean?
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There is no evidence of pest present?
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Is this section free of additional findings?
VII. Employee Kitchen / Breakroom
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Floors and walls clean?
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Horizontal and vertical surfaces are clean?
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Microwave oven clean?
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Refrigerator clean and thawed of ice?
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There is nothing stored under the sink (except for cleaning supplies) and there are no signs of leaks?
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No expired or old food found?
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Temperature checks are checked/documented daily with corrective action when temperature is out of range?
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Is this section free of additional findings?
VIII. Nurses Station / Medication Room
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Unit / area generally clean (without dust, clutter or debris)?
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Unused patient equipment/supplies are stored and handled appropriately?
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Medication, specimens, and food are handled appropriately?
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Biohazard trash is segregated from regular trash?
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Clean linen is handled appropriately?
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Dirty linen is handled appropriately?
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All clean linen is covered?
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Linen/supply carts have a solid bottom shelf?
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Needles and syringes are disposed of properly?
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Expired supplies are not present?
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Infectious waste in red bag or container?
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Ceiling tiles are not discolored / wet / missing / damaged?
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Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks?
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Respiratory hygiene available?
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Restrooms are clean?
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Trash baskets are not overflowing?
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No artificial / acrylic nails use. Nails are no more than 1/4 inch above finger?
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No personal lotion use.
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Medication room refrigerator is clean and without ice?
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Is this section free of additional findings?
IX. Logs
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Temperature logs complete checked for vaccine / medication storage?
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Equipment cleaning logs complete with corrective actions as needed?
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High-level disinfection documentation
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Items are thoroughly pre-cleaned according to manufacturer instructions and visually inspected for residual soil prior to high-level disinfection.
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Enzymatic cleaner is used and discarded according to manufacturer instructions (typically after each use).
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Manufacturer instructions for chemical disinfectants are followed for preparation, testing for appropriate concentration, and replacement prior to expiration or loss of efficacy.
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Quality control of test strips performed and documented?
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Documentation of proper temperature (ex: OPA disinfectants reaches 68F; Gluteraldehyde/Cidex reaches 77F)
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Devices are disinfected for the appropriate length of time as specified by manufacturer instructions
X. Isolation Rooms
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Appropriate signage in place?
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Supplies and PPE's available?
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Trash and linen handled per policy?
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Door closed as appropriate?
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Negative pressure is being supplied as required?
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Patient with proper attire when being transported?
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Is this section free of additional findings?
XI. Patient Shower Room
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Shower clean?
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Shower room clean and orderly?
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Walls and floor are clean and undamaged?
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Ceiling tiles are not discolored/ wet/ missing / damaged?
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Dust not found in high places?
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Is this section free of additional findings?
XII. Environmental Services
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Facility has written policies and procedures for routine cleaning and disinfection of environmental surfaces, including identification of responsible personnel.
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Personnel who clean and disinfect patient care areas (e.g., environmental services, technicians, nurses) receive training on cleaning procedures: upon hire, annually, when new equipment or protocols are introduced.
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Facility has a policy/procedure for decontamination of spills of blood or other body fluids.
XIII. Employee General Knowledge and Competency
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Personnel can locate the Infection Control Manual?
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Personnel have an updated list of diseases reportable to public health authority.
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Personnel can demonstrate knowledge of and compliance with mandatory reporting requirements for reportable diseases.
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Personnel can locate PPE.
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Employees know the procedure for blood exposure?
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Personnel know procedure and have PPE available for cleaning up a body fluid spill?
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Personnel can locate their Cidex / chemical spill kit?
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Is this section free of additional findings?
XIV. Additional Comments
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Additional Comments
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Surveyor's Signature
