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?

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
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.