Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • 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.

  • Return this form to me by:

Employee Hand Hygiene Compliance

  • Hand hygiene observations submitted monthly?

  • Name of observer and/or safety coach?

1.0 Hand Hygiene

  • 1.1. Sinks for hand hygiene are well stocked?

  • 1.2. Hand sanitizers are well stocked?

  • 1.3. Sinks are available in all areas as needed?

  • 1.4. Alcohol hand rubs are available in patient's rooms?

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

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

  • 1.7. Hand soap is available in all hand washing stations / bathrooms?

2.0. Clean Utility / Central Supply / Storage

  • 2.1. Clean linen cart is covered?

  • 2.2. Clean linen cart has solid surface or plastic barrier on bottom shelf?

  • 2.3. Nothing is stored under the sink (except for cleaning supplies) and there is no sign of leaks?

  • 2.4. Trash cans or waste basket are not overfilled or overflowing?

  • 2.5. Ceiling tiles are not stained or wet?

  • 2.6. Floors are clean?

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

  • 2.8. Air intake vents and diffusers are clean/free of dust

  • 2.9 Is this section free of additional findings?

3.0 Patient Rooms

  • 3.1. Horizontal surfaces are clean?

  • 3.2. Trash cans or waste basket are not overfilled or overflowing?

  • 3.3. Bathrooms are clean?

  • 3.4. Hand hygiene products are available?

  • 3.5. Soap and paper towels are available in each bathroom?

  • 3.6. PPE is available as needed?

  • 3.7. Patient equipment is clean?

  • 3.8. Ceiling tiles are not discolored, wet, missing, or damaged?

  • 3.9. Air intake vents and diffusers are clean?

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

  • 3.11. Floors are clean?

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

  • 3.13. Dust not found in high places?

  • 3.14. General area is dust free?

  • 3.15. Foley catheters hanging and secured appropriately?

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

  • 3.17. There is no evidence of pest infestation present?

  • 3.18. Clean linen handled appropriately?

  • 3.19. Dirty linen handled appropriately?

  • 3.20. No needles, syringes, medications within reach of the patient?

  • 3.21. No signs of mildew or mold present?

  • 3.22. Is this section free of additional findings?

4.0 Patient Kitchen / Nutrition Area

  • 4.1. Floors and walls clean?

  • 4.2. Horizontal and vertical surfaces are clean?

  • 4.3. Microwave oven clean?

  • 4.4. Refrigerator clean and thawed of ice?

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

  • 4.6. Patient refrigerator labeled for patient use only?

  • 4.7. Temperature checks are documented with corrective action when temp is out of range?

  • 4.8. Patient food is labeled appropriately with no expired food found (food from home expires in 3 days)?

  • 4.9. Ice machine is clean?

  • 4.10. There is no evidence of pest present?

  • 4.11. Is this section free of additional findings?

5.0. Employee Kitchen / Breakroom

  • 5.1. Floors and walls clean?

  • 5.2. Horizontal and vertical surfaces are clean?

  • 5.3. Microwave oven clean?

  • 5.4. Refrigerator clean and thawed of ice?

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

  • 5.6. No expired or old food found?

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

  • 5.8. Is this section free of additional findings?

6.0 General Unit / Nurses Station / Medication Room

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

  • 6.2. Unused patient equipment/supplies are stored and handled appropriately?

  • 6.3. Medication, specimens, and food are handled appropriately?

  • 6.4. Biohazard trash is segregated from regular trash?

  • 6.5. Clean linen is handled appropriately?

  • 6.6. Dirty linen is handled appropriately?

  • 6.7. All clean linen carts are covered?

  • 6.8. Linen carts have a solid bottom shelf?

  • 6.9. Needles and syringes are disposed of properly?

  • 6.10. Out of date supplies are not present?

  • 6.11. Infectious waste in red bag or container?

  • 6.12. Clean items are not stored in soiled utility room?

  • 6.13. Ceiling tiles are not discolored/ wet/ missing / damaged?

  • 6.14. Lab supplies are not expired?

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

  • 6.16. Respiratory hygiene available?

  • 6.17. Restrooms are clean?

  • 6.18. Trash basket are not overflowing?

  • 6.19. Biohazard symbol on door of biomedical waste storage?

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

  • 6.21. No personal lotion use.

  • 6.22. Medication room refrigerator is clean and without ice?

  • 6.23. There are no expired products found (IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)

  • 6.24. Is this section free of additional findings?

7.0 Logs

  • 7.1. Temperature checked for vaccine / medication storage?

  • 7.2. Daily refrigerators checks with corrective actions as needed?

  • 7.3. Ice machine clean?

  • 7.4. Glucose meter strips dated?

  • 7.5. High-level disinfection documentation

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

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

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

  • 7.5.d. Quality control of test strips performed and documented?

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

  • 7.5.f. Devices are disinfected for the appropriate length of time as specified by manufacturer instructions

8.0. Isolation Rooms

  • 8.1. Appropriate signage in place?

  • 8.2. Supplies and PPE's available?

  • 8.3. Trash and linen handled per policy?

  • 8.4. Door closed as appropriate?

  • 8.5. Negative pressure is being supplied as required?

  • 8.6. Patient with proper attire when being transported?

  • 8.7. Is this section free of additional findings?

9.0. Employee General Knowledge

  • 9.1. Employees know the procedure for blood exposure?

  • 9.2. Personnel can locate their Infection Control Manual?

  • 9.3. Personnel can locate their Exposure Control Plan?

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

  • 9.5. Personnel can locate their Cidex / chemical spill kit?

  • 9.6. Is this section free of additional findings?

10.0. Soiled Linen / Dirty Utility Room

  • 10.1. Biohazard symbol on door of biomedical waste storage?

  • 10.2. Door to soiled linen / dirty utility room locked?

  • 10.3. Soiled materials are stored appropriately?

  • 10.4. Walls / floors are clean and undamaged?

  • 10.5. Ceiling tiles are not discolored/ wet/ missing / damaged?

  • 10.6. Dust not found in high places?

  • 10.7. Is this section free of additional findings?

11.0. Patient Shower Room

  • 11.1. Shower clean?

  • 11.2. Shower room clean and orderly?

  • 11.3. Walls and floor are clean and undamaged?

  • 11.4. Ceiling tiles are not discolored/ wet/ missing / damaged?

  • 11.5. Dust not found in high places?

  • 11.6. Is this section free of additional findings?

Additional Comments

  • Additional Comments

  • Surveyor's Signature

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