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Facility Overview
Facility Name
Date of Inspection
Surveyor Name
Facility Policies and Procedures
Facility has written infection control policies and procedures
Policies and procedures are readily available to staff
Policies and procedures are reviewed and updated annually
Staff Education and Training
All staff receive initial infection control training
Staff receive annual refresher infection control training
Training attendance is documented
Hand Hygiene
Hand hygiene facilities are available in patient care areas
Supplies (soap, paper towels, ABHR) are consistently available
Staff perform hand hygiene before and after each patient contact
Personal Protective Equipment (PPE)
Appropriate PPE is available for staff use
Staff wear PPE appropriately for the task
PPE is removed and discarded before leaving patient care area
Injection Safety
Single-dose vials are used for one patient only
Multi-dose vials are dated when first opened and discarded within 28 days
Needles and syringes are used for one patient only
Environmental Cleaning
Dialysis stations are cleaned and disinfected between patients
Reusable equipment is properly cleaned and disinfected
Environmental surfaces are cleaned and disinfected daily
