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General Facility Information
Facility Name
Facility Type
Address
Date of Inspection
Handwashing and Hand Hygiene
Handwashing sinks available in all patient care areas
Sinks have warm water, soap, and disposable towels or air dryers
Staff perform hand hygiene (handwashing or alcohol-based hand sanitizer) before and after each patient contact
Staff receive training on proper hand hygiene techniques
Personal Protective Equipment (PPE)
Appropriate PPE (gloves, gowns, masks, eye protection) available and accessible for staff
Staff wear appropriate PPE when indicated
Staff receive training on proper donning and doffing of PPE
Cleaning and Disinfection
Facility has written policies and procedures for cleaning and disinfection of patient care equipment and environmental surfaces
Facility uses EPA-registered disinfectants and follows manufacturer instructions for use
Staff perform regular cleaning and disinfection of high-touch surfaces
Facility has a process in place for terminal cleaning of patient rooms
Injection Safety
Single-dose vials are used for one patient only
Multi-dose vials are dated when opened and discarded within 28 days, unless otherwise specified by the manufacturer
Staff use aseptic technique when preparing and administering injections
Staff receive training on safe injection practices
Reprocessing of Reusable Medical Equipment
Reusable medical equipment is properly cleaned and high-level disinfected or sterilized between uses
Staff follow manufacturer instructions for reprocessing of reusable medical equipment
Reprocessing area is physically separated from patient care areas
Staff receive training on reprocessing of reusable medical equipment
Respiratory Hygiene and Cough Etiquette
Facility has tissues, no-touch receptacles, and alcohol-based hand sanitizer available in waiting areas and at patient check-in
Facility posts signs to instruct patients and visitors on respiratory hygiene and cough etiquette
Staff follow respiratory hygiene and cough etiquette when coughing or sneezing
Sharps Safety
Sharps containers are available at the point of use
Sharps containers are not overfilled
Staff receive training on proper sharps disposal
Infection Control Program
Facility has a written infection control program
Facility has an infection control coordinator or committee
Facility conducts infection surveillance and reporting
Facility provides infection control training for staff
