Audit

Managers - Infection Prevention performed an inspection of your unit/facility. Please review your survey and document your Plan of Correction next to each deficiency.
Return this form to me by:
Employee Hand Hygiene Compliance

Hand hygiene observations submitted monthly?

Name of observer and/or safety coach?

I. Waiting Area

Signs posted at entrances with instructions to patients with symptoms of respiratory infection to cover their cough.

Notice of universal precautions posted in waiting area or at check-in desk?

Tissues and/or masks available to patients for respiratory hygiene

Network-approved hand sanitizer available for patients to perform hand hygiene

II. Hand Hygiene

Sinks for hand hygiene and hand sanitizer dispensers are well stocked?

Sinks are available in all areas as needed?

Alcohol hand rubs are available in patient's rooms?

Placement of alcohol hand rubs is compliant with safety (not directly over an electrical outlet)?

Hand washing / hand hygiene is performed between patients? (Wash In / Wash Out)

III. Clean Utility / Central Supply / Storage

Clean linen is covered.

Clean linen/supply cart has solid surface or plastic barrier on bottom shelf.

Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks.

Ceiling tiles are not stained or wet.

Floors are clean.

Supplies are stored at least 6 inches off of the floor.

There are no expired supplies present.

Air intake vents and diffusers are clean/free of dust

Walls / floors are clean and undamaged?

There are no outside cardboard shipping boxes present among clean supplies.

Is this section free of additional findings?

IV. Soiled Linen / Dirty Utility Room

Biohazard symbol on door of biomedical waste storage?

Door to soiled linen / dirty utility room locked?

Soiled materials are stored appropriately?

Ceiling tiles are not discolored/ wet/ missing / damaged?

Dust not found in high places?

Is this section free of additional findings?

V. Patient Rooms

Horizontal surfaces are clean?

Trash cans or waste basket are not overfilled or overflowing?

Bathrooms are clean?

PPE is available as needed?

Patient equipment is clean?

Ceiling tiles are not discolored, wet, missing, or damaged?

Air intake vents and diffusers are clean?

Furniture (chairs, sleepers) are without tears or wear?

Floors are clean?

Sharp containers are no more than 3/4 full?

General area is dust free?

Foley catheters hanging and secured appropriately?

There is no evidence of pest infestation present?

IV pumps and poles, feeding pumps etc. are clean?

Clean linen handled appropriately?

Dirty linen handled appropriately?

No needles, syringes, medications within reach of the patient?

No signs of mildew or mold present?

Is this section free of additional findings?

VI. Patient Kitchen / Nutrition Area

Floors and walls clean?

Microwave oven clean?

Refrigerator clean and thawed of ice?

Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks?

Patient refrigerator labeled for patient use only or patient food clearly separated from employee food if shared?

Temperature checks are documented daily with corrective action when temperature is out of range?

Horizontal and vertical surfaces are clean?

No expired food present (food from home expires in 3 days)?

Ice and/or water machine is clean?

There is no evidence of pest present?

Is this section free of additional findings?

VII. Employee Kitchen / Breakroom

Floors and walls clean?

Horizontal and vertical surfaces are clean?

Microwave oven clean?

Refrigerator clean and thawed of ice?

There is nothing stored under the sink (except for cleaning supplies) and there are no signs of leaks?

No expired or old food found?

Temperature checks are checked/documented daily with corrective action when temperature is out of range?

Is this section free of additional findings?

VIII. Nurses Station / Medication Room

Unit / area generally clean (without dust, clutter or debris)?

Unused patient equipment/supplies are stored and handled appropriately?

Medication, specimens, and food are handled appropriately?

Biohazard trash is segregated from regular trash?

Clean linen is handled appropriately?

Dirty linen is handled appropriately?

All clean linen is covered?

Linen/supply carts have a solid bottom shelf?

Needles and syringes are disposed of properly?

Expired supplies are not present?

Infectious waste in red bag or container?

Ceiling tiles are not discolored / wet / missing / damaged?

Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks?

Respiratory hygiene available?

Restrooms are clean?

Trash baskets are not overflowing?

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

No personal lotion use.

Medication room refrigerator is clean and without ice?

Is this section free of additional findings?

IX. Logs

Temperature logs complete checked for vaccine / medication storage?

Equipment cleaning logs complete with corrective actions as needed?

High-level disinfection documentation

Items are thoroughly pre-cleaned according to manufacturer instructions and visually inspected for residual soil prior to high-level disinfection.

Enzymatic cleaner is used and discarded according to manufacturer instructions (typically after each use).

Manufacturer instructions for chemical disinfectants are followed for preparation, testing for appropriate concentration, and replacement prior to expiration or loss of efficacy.

Quality control of test strips performed and documented?

Documentation of proper temperature (ex: OPA disinfectants reaches 68F; Gluteraldehyde/Cidex reaches 77F)

Devices are disinfected for the appropriate length of time as specified by manufacturer instructions

X. Isolation Rooms

Appropriate signage in place?

Supplies and PPE's available?

Trash and linen handled per policy?

Door closed as appropriate?

Negative pressure is being supplied as required?

Patient with proper attire when being transported?

Is this section free of additional findings?

XI. Patient Shower Room

Shower clean?

Shower room clean and orderly?

Walls and floor are clean and undamaged?

Ceiling tiles are not discolored/ wet/ missing / damaged?

Dust not found in high places?

Is this section free of additional findings?

XII. Environmental Services

Facility has written policies and procedures for routine cleaning and disinfection of environmental surfaces, including identification of responsible personnel.

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.

Facility has a policy/procedure for decontamination of spills of blood or other body fluids.

XIII. Employee General Knowledge and Competency

Personnel can locate the Infection Control Manual?

Personnel have an updated list of diseases reportable to public health authority.

Personnel can demonstrate knowledge of and compliance with mandatory reporting requirements for reportable diseases.

Personnel can locate PPE.

Employees know the procedure for blood exposure?

Personnel know procedure and have PPE available for cleaning up a body fluid spill?

Personnel can locate their Cidex / chemical spill kit?

Is this section free of additional findings?

XIV. 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.