Facility Infection Control Assessment Form
Facility Infection Control Assessment Form
Use this facility infection control checklist template to perform a comprehensive assessment of your health care facility’s compliance with all infection control measures.
Facility Infection Control Assessment Form
Use this facility infection control checklist template to perform a comprehensive assessment of your health care facility’s compliance with all infection control measures.
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Preview of the template
General Information
Name of person responsible for the assessment
Hospital Name
Hospital Address
Assessment Date:
Infection Control/Prevention Program and Resources
The hospital has one or more qualified individual(s) responsible for infection control.
The hospital is periodically assessed by an authority on compliance with recommended infection prevention practices.
The hospital regularly assess, whether staff follow recommended infection prevention practices.
Intake and Triage
Patients with symptoms of respiratory infection and other symptomatic persons (e.g., persons accompanying ill patients) are instructed to wear facemasks and are separated (by at least 1 meter) from others.
Patients and visitors with symptoms of respiratory infection are instructed to inform staff so IC precautions may be implemented.
Sign for patients and visitors on recommended hand hygiene and Respiratory Hygiene/Cough Etiquette practices are provided in patient intake and other inpatient areas.
Dispensers of alcohol-based hand rub and/or sinks, soap, paper towels, and tissues are provided in the intake area for hand hygiene and respiratory hygiene.
Personnel protection equipment (appropriate for MERS-CoV prevention) is readily available in the patient intake area of the hospital.
Healthcare personnel (HCP) wear gown protection upon entry into a MERS-CoV patient care area
HCP wear eye and facemasks protection upon entry into a MERS-CoV patient care area
HCP wear a particulate respirator (N95 or higher) upon entry into the patient care area during aerosol-generating procedures for known or suspected MERS-CoV patients.
Infections Prevention staff or medical directors are notified when a MERS-CoV test is positive and it is noted in medical records.
Policies for reporting a MERS-CoV exposure event, post-exposure evaluation and follow-up, are available.
The hospital has a respiratory protection program that details procedures and elements which required personal protective equipment use.
If respirator fit-testing is required, the hospital infection control system ensures that respiratory fit testing is provided at required intervals to healthcare personnel
The hospital encourages reporting of illness based on contact with confirmed cases of MERS-CoV, without danger of loss of job and benefits
General Infection Control Elements
Hand Hygiene
Soap, water, and a sink are accessible in patient care areas including but not limited to direct care areas (such as food and medication preparation areas).
Alcohol-based hand rubs are readily accessible and placed in appropriate locations.
Healthcare personnel perform hand hygiene:
Before contact with the patient or their immediate care environment
Exiting the patient’s care area after touching the patient or the patient’s immediate environment
Before performing an aseptic task (e.g., insertion of IV or urinary catheter)
After contact with blood, body fluids or contaminated surfaces
Before After removing gloves
Healthcare personnel perform hand hygiene using soap and water when hands are visibly soiled (e.g., blood, body fluids).
Personal Protective Equipment/Standard Precautions
Appropriate PPE (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use.
Healthcare personnel (HCP) wear gloves for procedures/activities where contact with blood, body fluids, mucous membranes, or non-intact skin is anticipated.
HCP change gloves and perform hand hygiene before moving from a contaminated body site to a clean body site.
Gowns are worn to prevent contamination of skin and clothing during procedures/activities where contact with blood, body fluids, secretions, or excretions are anticipated.
Gowns and gloves are removed and hand hygiene is performed before leaving the patient’s environment.
Appropriate mouth, nose, and eye protection is worn for aerosol-generating procedures and/or procedures/activities that are likely to generate splashes or sprays of blood or body fluids.
Isolation
Isolation- Contact Precautions
Signs indicating the patient is on Contact Precautions are clear and visible.
Patients on Contact Precautions are housed in single-patient rooms when available or cohorts based on a clinical risk assessment.
Hand Hygiene is performed and gloves and gowns are available in patient care environment.
Dedicated or disposable noncritical patient-care equipment (e.g., blood pressure cuffs) is used or if not available, equipment is cleaned and disinfected prior to use on another patient according to manufacturer's instructions.
Gloves and gowns are removed and discarded, and hand hygiene is performed before leaving the patient care environment.
Isolation- Droplet Precautions
Facemasks are available and located near points of use.
Signs indicating the patient is on Droplet Precautions are clear and visible.
Patients on Droplet Precautions are housed in single-patient rooms when available or cohorts based on a clinical risk assessment.
HCP perform hand hygiene and don facemasks upon entry into the patient care environment.
Facemask is removed and discarded, and hand hygiene is performed upon leaving the patient care environment.
Facility limits movement of patients on Droplet Precautions outside of their room to medically necessary purposes
Isolation- Airborne Precautions
Particulate respirators (N-95 or higher) are available and located near point of use.
Signs indicating the patient is on Airborne Precautions are clear and visible.
Patients on Airborne Precautions are housed in airborne infection isolation rooms (AIIR).
Hand hygiene is performed upon entry into the patient care environment.
Healthcare personnel wears a particulate respirator (N95 or higher) upon entry into the AIIR for patients with confirmed or suspected infection with pathogens requiring AIIR per facility policy.
Facility limits movement of patients on Airborne Precautions outside of their room to medically-necessary purposes and notifies personnel about it.
Environmental Services
During environmental cleaning procedures, healthcare personnel wears appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection).
Objects and environmental surfaces in patient care areas are cleaned regularly using a disinfectant (e.g., daily), and when spills visibly contaminate surfaces.
After patient discharge, all visibly or potentially contaminated surfaces are cleaned and disinfected and towels and bed linens are replaced with clean towels and bed linens (with cleaners and disinfections at right dilution, contact-time).
Confirmation
Comments
Signature
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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.