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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Please return this form to me by:
Hand Hygiene
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Sinks for hand hygiene are available in all areas as needed?
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Specimens and/or infectious waste not disposed of into sinks designated for hand hygiene.
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Soap and hand sanitizer dispensers are well stocked.
Specimen Collection Area
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PPE available to staff and worn during specimen collection (lab coats buttoned, sleeves not pulled up, gloves over sleeves; masks/face shields worn for collection of nasal or oral specimen).
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Sharps containers readily available for disposal of venipuncture needles.
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Sharps containers not overfilled.
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Specimen collection area is regularly cleaned.
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No food or drinks stored in this area.
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Alcohol hand rubs are available in patient draw rooms and well stocked.
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Hand hygiene is performed between patients.
Patient Nutrition
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Refrigerator clean and thawed of ice?
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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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No expired food present?
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Ice and/or water machine is clean?
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Is this section free of additional findings?
Department
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Doors, floors, walls, workbenches, ceiling tiles, etc. clean.
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Proper PPE is available and worn while specimens are handled.
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No food, drinks, application of cosmetics or lip balm in work areas where specimens are present.
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Clean supply shelves have a solid bottom shelf.
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Expired supplies are not present.
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Biohazard trash is segregated from regular trash.
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Needles, syringes, pipette tips, other sharps are disposed of properly.
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Infectious waste in red bag or container.
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Dirty PPE is handled appropriately.
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Nothing is stored under sinks (except for cleaning supplies) and there are no signs of leaks.
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Restrooms are clean.
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Trash baskets are not overflowing.
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Is this section free of additional findings?
Biological Safety Cabinets (BSC)
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BSC is currently certified for use and gauges checked before use.
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Only materials and equipment needed for immediate work are stored in the BSC.
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Appropriate PPE worn while working in the BSC (lab coats worn and buttoned, gloves pulled over the wrists of lab coats).
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Manipulation of materials inside the cabinet delayed for 1 minute after placing hands/arms inside the cabinet to allow the air to stabilize and to "air sweep" arms.
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Arms not resting on front grille unless BSC is specifically equipped with permitting features.
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Front grille not blocked with papers or other materials.
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All operations performed on work surface and at least 4 inches from front grille.
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All equipment brought out of the BSC is surface decontaminated prior to removal.
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Process established for regular cleaning of interior walls and window with 70 percent ethanol or other approved disinfectant.
Eyewash Station
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Eyewash station located in areas that are accessible within 10 seconds (roughly 55 feet).
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Eyewash stations located on the same level as the hazard and the path of travel is free from obstructions.
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Eyewash station activated weekly for a period long enough to verify operation and ensure that flushing fluid is available.
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Eyewash bottles are considered supplemental with main purpose to supply immediate flushing only (Injured individual would then proceed to a plumbed or self contained eyewash and flush for the required 15-minute period).
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Dust caps or dust covers installed to protect the unit from contaminates.
Blood Bank
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Blood product refrigerators and freezers clean.
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No expired blood products present in inventory (red blood cells, platelets, plasma, cryoprecipitate, rhogam, etc.).
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Fresh frozen plasma stored at 1-6 C no more than 24 hours.
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Single units of thawed cryoprecipitate stored at room temperature no more than 6 hours.
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Blood product thawing baths emptied and cleaned regularly.
Logs
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Temperature logs complete for blood product storage (RBCs, Platelets, Plasma, Cryo)?
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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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Sterilization documentation
Clean Utility / Central Supply / Storage
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Walls / floors are clean and undamaged?
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Air intake vents and diffusers are clean/free of dust
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Ceiling tiles are not stained or wet.
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Supplies are stored at least 6 inches off of the floor.
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Clean supply cart has solid surface or plastic barrier on bottom shelf.
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There are no outside cardboard shipping boxes present among clean supplies.
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There are no expired supplies present.
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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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Is this section free of additional findings?
Soiled Linen / Dirty Utility Room
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Door to soiled linen / dirty utility room locked?
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Biohazard symbol on door of biomedical waste storage?
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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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Soiled materials are stored appropriately?
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Is this section free of additional findings?
Employee Kitchen / Breakroom
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Doors, floors, walls, counter tops clean?
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Microwave oven clean?
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Refrigerator clean and thawed of ice?
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Temperature checks are checked/documented daily with corrective action when temperature is out of range?
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No expired or old food found?
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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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Is this section free of additional findings?
Employee General Knowledge and Competency
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Personnel can locate PPE.
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Personnel can locate the Infection Control Manual.
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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 chemical spill kit.
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Personnel can demonstrate knowledge of and compliance with mandatory reporting requirements for reportable diseases.
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Is this section free of additional findings?
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.
Additional Comments
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Additional Comments
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Surveyor's Signature
