Here is a sample infection control environmental review form used by Brainerd Lakes Surgery Center in Baxter, Minn., and provided by Sandy Berreth, administrator of the ASC and a AAAHC surveyor.
Different members of the Brainerd Lakes Surgery Center staff perform the review every quarter to increase their recognition of what needs to be done, according to Ms. Berreth.
To download a copy of this form, click here (doc).
Infection Control Environmental Review
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GENERAL: Quarterly review [Month] |
Adequate |
Needs improvement |
Comments |
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Handwashing between patients, after patient contact, after glove removal, after personal breaks |
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Proper handwash technique; wet hands first, 10 second scrub, rinse, turn off faucet with paper towel |
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Soap dispensers are full and functional |
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General appearance of area is clean, uncluttered |
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Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies |
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Open bottles of fluids discarded every 24 hours/7 am (saline for irrigation) |
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Single use medication vials discarded (sterile saline, bacteriostatic water) |
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Multi-use medication vials discarded according to manufacturer outdate (exception: insulin, certain RC products) |
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IV tubing labeled with date |
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Urine drainage bags off floor |
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Linen carts covered - Linen carts in clean utility with other supplies need to be covered or behind closed cabinet |
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No shaking, agitation of linens |
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Refrigerator temperature logs for patient use refrigerators - monitored and recorded daily ( approp. action taken if necessary) |
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Only patient items in patient refrigerators |
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No patient care items under/on sinks (including cups, paper towels, anything that may get wet) |
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No wet areas under ice machines |
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No stuffed animals in toy rooms |
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Hampers used appropriately - ie. No bags on floors, no overflowing of linen |
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Ceiling tiles clean and dry |
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At least 18" clearance below sprinkler heads |
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Check biological monitoring logs for completeness, consistency |
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OSHA BLOODBORNE PATHOGEN STANDARD |
Adequate |
Needs improvement |
Comments |
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Staff following Universal/Standard Precautions |
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No food, beverages in work area |
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No applying cosmetics, lip balm in work area |
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No recapping of needles after use (single handed technique acceptable) |
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Maximum fill level of needle boxes as indicated on container |
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Personal Protective Equipment available (PPE) |
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Proper use of PPE: -gloves when handling body fluids -gowns when anticipated exposure to clothing -masks/face shields when anticipated exposure |
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Removal of PPE prior to leaving patient room |
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Glove boxes filled |
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Proper clean up of blood spills (spray with bleach [Dispatch], allow contact time of 1-2 minutes, then wipe) |
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Pick up broken glass with tongs |
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Proper reporting of exposures (report immediately, complete event report, report to ETD) |
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Utilizes safety devices as available |
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CLEAN UTILITY |
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Clean items only |
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No medical supplies on floor |
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No medical supplies left in original shipping container |
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Nothing stored under sinks |
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Check for outdated supplies |
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Door closed |
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DIRTY UTILITY |
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Dirty items only |
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Door closed on soiled utility room |
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No mini drinking cups, tissues, paper towels, toilet tissue |
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No hoses touching in floor drains |
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PPE available |
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HANDLING OF SPECIMENS |
Adequate |
Needs improvement |
Comments |
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PPE utilized when handling specimens |
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Assure covers are properly secured prior to placement in CTS carrier |
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HANDLING OF INFECTIOUS/ HAZARDOUS WASTE |
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Properly identifies examples of hazardous waste |
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Contaminated waste labeled (red bag) |
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Needles/Sharps disposed properly |
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Utilizes safety devices as available |
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Source: Sandy Berreth, Brainerd Lakes Surgery Center. Adapted and reprinted with permission.