MMH Isolation

• Unit/Room

• Conducted on

  Date

• Prepared by

Managers - Infection Prevention performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each opportunity.

• Return this form to me by:

  Date

Employee Compliance

• Employees Monitored

8.0. Isolation Rooms

• 8.1. Appropriate signage in place?

  Yes

  No

  N/A

• 8.2. Supplies and PPE's available?

  Yes

  No

  N/A

• 8.3. Trash and linen handled per policy?

  Yes

  No

  N/A

• 8.4. Appropriate PPE's used by staff?

  Yes

  No

  N/A

• 8.5. Door closed as appropriate?

  Yes

  No

  N/A

• 8.6. Negative pressure is being supplied as required?

  Yes

  No

  N/A

• 8.8. Patient with proper attire when being transported?

  Yes

  No

  N/A

• 8.9. Is this section free of additional findings?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign