Infection Control Checklist
Make sure to implement initial control measures to prevent healthcare-associated infections.
Hospital Name
Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hand Hygiene
Yes
No
Comments
Are the sinks adequately supplied for hand hygiene?
Are sinks readily available in all areas?
Are there sufficient stocks of alcohol hand rubs?
Are alcohol hand rubs easily accessible in patient rooms?
Is the placement of alcohol hand rubs compliant with safety regulations?
Are healthcare workers performing hand washing/hand hygiene between patients?
Are there reminders for hand hygiene present in the form of posters?
Is hand soap available in all hand washing stations/bathrooms?
Clean Utility / Central Supply / Storage
Yes
No
Comments
Is the clean linen cart covered?
Does the clean linen cart have a solid surface on the bottom shelf?
Is the sink storage area empty and clean?
Are the trash cans or waste baskets not overfilled or overflowing?
Are the ceiling tiles free of stains or wetness?
Are the floors clean?
Are supplies stored at least 6 inches off of the floor?
Are the air intake vents and diffusers clean?
Are there no additional findings in this section?
Patient Rooms
Yes
No
Comments
Horizontal surfaces are clean?
Thrash cans or waste basket are not overfilled or overflowing?
Bathrooms are clean?
Hand hygiene products are available?
Soap and paper towels are available in each bathroom?
PPE's are available as needed?
Patient equipment is clean?
No visible soil on vertical surfaces?
Ceiling tiles are not discolored, wet, missing, or damaged?
Air intake vents and diffusers are clean?
Furniture (chairs, sleepers) are without tears or wear?
The mattress pad is without tears or puncture holes?
Floors are clean?
Sharp containers are no more than 3/4 full.
Dust not found in high places?
The general area is dust free?
Are Foley catheters appropriately hanging and secured?
Are IV pumps, poles, feeding pumps, etc. clean?
Is there no evidence of pests present?
Is clean/dirty linen handled appropriately?
Are there no needles, syringes, or medications within reach of the patient?
Are there no signs of mildew or mold present?
Are there no additional findings in this section?
Patient Kitchen / Breakroom
Yes
No
Comments
Are the floors and walls clean?
Are horizontal and vertical surfaces clean?
Is the microwave oven clean?
Is the refrigerator clean and free of ice buildup?
Is the area under the sink clean and without storage?
Is the patient refrigerator labeled for patient use only?
Are temperature checks documented with corrective action taken when the temperature is out of range?
Is patient food labeled appropriately with no expired items found?
Is the ice machine clean?
Is there no evidence of pests present?
Are there no additional findings in this section?
Employee Kitchen / Breakroom
Yes
No
Comments
Are the floors and walls clean?
Are horizontal and vertical surfaces clean?
Is the microwave oven clean?
Is the refrigerator clean and free of ice buildup?
Is the area under the sink clean and without storage?
Are employee foods labeled and dated?
Are temperature checks documented with corrective action taken when the temperature is out of range?
Are there no additional findings in this section?
General Unit / Nurses Station / Medication Room
Yes
No
Comments
Is the unit/area generally clean and free of dust, clutter, or debris?
Are unused patient equipment/supplies stored and handled appropriately?
Are medication, specimens, and food handled appropriately?
Is biohazard trash segregated from regular trash?
Is clean linen handled appropriately?
Is dirty linen handled appropriately?
Are all clean linen carts covered?
Do linen carts have a solid bottom shelf?
Are needles and syringes disposed of properly?
Are there no out-of-date supplies present?
Is infectious waste stored in a red bag or container?
Are clean items not stored in the soiled utility room?
Are ceiling tiles not discolored, wet, missing, or damaged?
Are lab supplies not expired?
Is there nothing stored under the sink and no sign of leaks?
Are halls uncluttered?
Is respiratory hygiene available?
Are restrooms clean?
Are trash baskets not overflowing?
Is there a biohazard symbol on the door of the biomedical waste storage area?
Is the medication cart locked?
Are artificial/acrylic nails not allowed, and nails no more than 1/4 inch above the finger?
Is personal lotion not allowed?
Is the Medication Room refrigerator clean and without ice?
Are there no expired products found, such as IV solutions, medications, reagents, nutritional supplements, sterile items, etc.?
Are there no additional findings in this section?
Logs
Yes
No
Comments
Is the crash cart checked daily?
Is the defibrillator checked daily?
Are narcotic counts documented every shift?
Is the temperature checked twice a day for vaccine/medication storage?
Are daily refrigerator checks performed with corrective actions taken as needed?
Is the ice machine cleaning date/time stamped?
Are glucose meter strips dated?
Is the Cidex monitoring log complete?
Are there no additional findings in this section?
Isolation Rooms
Yes
No
Comments
Are there signs that are suitable and in place?
Are there sufficient supplies and personal protective equipment (PPEs)?
Are trash and linen being handled according to established policies?
Is the staff using appropriate PPEs?
Is the door being closed as necessary?
Is negative pressure being provided as needed?
Have patients and their families been informed of isolation requirements?
Are patients properly attired during transportation?
Is there no other issue found in this section?
Employee General Knowledge
Yes
No
Comments
Employees know the procedure for blood exposure?
Personnel can locate their Infection Control Manual?
Personnel can locate their Exposure Control Plan?
Personnel can locate the blood spill kit?
Personnel can locate their spill kit for Cidex?
Employees can state the WHO's 5 moments of Hand Hygiene.
Dust not found in high places?
Is this section free of additional findings?
Soiled Linen / Dirty Utility Room
Yes
No
Comments
Is there a biohazard symbol displayed on the door of the biomedical waste storage area?
Are boxes stored at a minimum of 6 inches above the floor?
Are the walls and floors clean?
Are the ceiling tiles not discolored, wet, missing, or damaged?
Is there no dust found in high places?
Are there no additional issues found in this section?
Patient Shower Room
Yes
No
Comments
Is the shower clean?
Is the shower room clean and well-organized?
Are the walls and floor clean?
Are the ceiling tiles not discolored, wet, missing, or damaged?
Is there no dust found in high places?
Are there no additional issues found in this section?
Any comments
Surveyor's Name
First Name
Last Name
Profession
Date
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Month
-
Day
Year
Date
Signature
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