IPAC Environmental Audit

• Audit Date

  Date

• Clinical Area

  Select NICU PICU 4 East 4 West 5 East 6 East Amb Care

  • NICU
  • PICU
  • 4 East
  • 4 West
  • 5 East
  • 6 East
  • Amb Care

• Auditor

Physical Environment

• No food/drinks in preparation work areas, specimen areas or WOWs

  Yes

  No

  N/A

• No multi serving food items in patient care/preparation areas

  Yes

  No

  N/A

• No personal/food items 12" near Hand Hygiene sink

  Yes

  No

  N/A

• No patient care supplies/equipment 12" near Hand Hygiene sink

  Yes

  No

  N/A

• Soap dispensers filled, not expired, and functioning properly

  Yes

  No

  N/A

• Alcohol hand rinse dispensers available, filled, not expired and functioning properly

  Yes

  No

  N/A

• Paper towel dispensers filled and functioning

  Yes

  No

  N/A

• No high dust and area dust free

  Yes

  No

  N/A

• Floors are clean

  Yes

  No

  N/A

• Surfaces and furnishings are clean

  Yes

  No

  N/A

• Bathrooms are clean

  Yes

  No

  N/A

• No missing or stained ceiling tiles

  Yes

  No

  N/A

• Area under sink is free from stored items

  Yes

  No

  N/A

• Computer keyboards/WOWs are clean without dust

  Yes

  No

  N/A

• Employee refrigerator free of unlabeled and expired food

  Yes

  No

  N/A

• Breastmilk refrigerator clean and free of unlabeled or expired milk

  Yes

  No

  N/A

• Other:

Standard Precautions and Transmissions Based Precautions

• Current precautions signage available on unit

  Yes

  No

  N/A

• Appropriate PPE available on unit

  Yes

  No

  N/A

• Sharps containers secured & not overfilled

  Yes

  No

  N/A

• Other:

Equipment and Supplies

• Storage so supplies dust free, 6" off floor, on solid bottom & 18" from ceiling

  Yes

  No

  N/A

• No expired supplies noted

  Yes

  No

  N/A

• No cardboard shipping boxes in supply storage

  Yes

  No

  N/A

• No dirty items in clean supply/designated area

  Yes

  No

  N/A

• No clean supplies in dirty utility/designated area

  Yes

  No

  N/A

• Equipment is clean

  Yes

  No

  N/A

• Equipment with biomedical or engineering tags are clean

  Yes

  No

  N/A

• Clean linen is covered and properly stored

  Yes

  No

  N/A

• Dirty linen is bagged in blue bag and covered

  Yes

  No

  N/A

• Other:

Department Specific