• Audit Title

  • Conducted on

  • Prepared by

  • Location
  • Personnel



  • Team Members know where to access the MMH policy.

  • HH is practiced consistent with "the 5 moments" campaign.

  • Team Members are aware of the monitor and reporting.

  • Team Members are able to recall the MMH HH rate.


  • No food, drink, or cosmetics in patient care, specimen, or med areas.

  • Gloves are worn during vascular access

  • Team Members know what to do if an exposure occurs.

  • Sharps are handled appropriately - no recapping, active vs passive, etc.

  • No unattended sharps noted in area.


  • Team Members know how to access the Isolation policy and appendix.

  • Team Members are familiar with types of isolation, how to institute, and the Infection Control Admission Assessment.

  • Negative and Positive air flow rooms function appropriately.

  • Team Members are knowledgable of AII (negative pressure) room controls and know where and when to document readouts.

  • Team Members are aware of contingency measures in AII rooms lose pressure.

  • Isolation signs posted as appropriate.

  • Team Members can locate appropriate PPE equipment.

  • PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>


  • Goal 07.01.01 Hand Hygiene Monitors?

  • GOAL 07.03.01 MDRO -How do you prevent drug resistant organism spread?

  • GOAL 07.04.01 CLABSI - Who places central lines?<br> * What criteria do you use.

  • GOAL 07.05.01 SSI - Are Team Members educated on SSI?<br> * Are patients provided educations?

  • GOAL 07.06.01 CAUTI - Do Team Members recieve education as to how to prevent CAUTI?<br> * Are patients/families educated?


  • Equipment cleaning.<br> * Do Team Members know to follow equipment manufacturers instructions for cleaning.

  • Disinfectants are used on surfaces in accordance with manufacturers recommendations.

  • Patient care supplies: (including lab supplies)<br> * Not expired, damaged, soiled.

  • Patient care items: (including WOWs, vitals, PT items, etc. )are wiped down after each use in patient room.

  • Linen and Linen Carts: Covered and carts have solid bottoms.

  • General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids.<br> * Survey Team Members in the area for opportunities.

  • Air vents: Clean inside and around.

  • Ice machines clean.

  • Water features are cleaned and maintained appropriately.<br>


  • Contain only those items designed for that refrigerator (specimen, medications or patient food)

  • If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.<br>

  • Patient items are dated and labeled as appropriate.

  • No expired items.


  • Greet the team with smiles and introductions.

  • Have a space designated for the team to conduct interviews and file reviews.

  • Promptly deliver materials required for review to the tracer team.

  • Any additional comments regarding positive or suboptimal issues observed during the tracer.

  • Surveyors Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.