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For each of the standards listed below, check "YES" or "NO", as appropriate, to indicate whether or not the standard was achieved. (If a particular standard is not applicable to the facility at which the survey is being conducted, check "N/A.")
Use the "Comments" space after the standard to note details about why a standard has not been achieved or to note other information that may be useful in identifying or resolving inappropriate practices.
Refer to the User's Guide to the Infection Prevention Assessment Survey for a detailed explanation of each standard.
1. Hands should be washed when indicated.
___ Yes
____No
Comments:
2. Hands should be washed with soap and running water.
___ Yes
____No
Comments:
3. Hands should be dried with a clean towel or allowed to air-dry.
___ Yes
____No
Comments:
4. Plans should be made and supplies should be available for times when running water is not available.
___ Yes
____No
____N/A
Comments:
5. Gloves should be worn whenever contact with blood or other body fluids is anticipated.
___ Yes
____No
Comments:
6. Utility gloves should be worn when handling contaminated instruments and other items, handling medical or hazardous chemical waste and linens, performing housekeeping activities, and cleaning contaminated surfaces.
___ Yes
____No
Comments:
7. Antiseptics should be used only on the skin and mucous membranes.
___ Yes
____No
Comments:
8. Disinfectants should be used only for processing instruments and other items for reuse and for housekeeping activities.
___ Yes
___ No
____N/A
Comments:
9. Antiseptics and disinfectants should be handled in a manner that reduces the risk of contamination.
___ Yes
____No
Comments:
10. A surgical handscrub should be performed before all surgical procedures.
___ Yes
____No
____N/A
Comments:
11. Sterile or high-level disinfected surgical gloves should be put on and removed in ways that do not contaminate the gloves or allow the wearer to touch the contaminated outside part of the gloves.
___ Yes
____No
____N/A
Comments:
12. Shaving the surgical site should not be performed routinely and should be performed only when absolutely necessary.
___ Yes
____No
____N/A
Comments:
13. The surgical/procedure site should be prepared properly using an appropriate antiseptic solution.
___ Yes
____No
____N/A
Comments:
14. A sterile field should be established and maintained during all surgical/clinical procedures.
___ Yes
____No
____N/A
Comments:
15. Traffic and activities should be controlled and appropriate attire should be worn in surgical/procedure areas.
___ Yes
____No
____N/A
Comments:
16. Hypodermic needles should not be routinely recapped and should never be bent or broken before disposal. Needles should not removed from syringes before disposal.
___ Yes
____No
Comments:
17. Sharps should be disposed of in puncture-resistant containers.
___ Yes
____No
Comments:
18. Sharps containers should be available wherever sharps are used. Containers should be disposed of when they are three-quarters full.
___ Yes
____No
Comments:
19. Unprotected sharp items should not be passed directly from one person to another during surgical/clinical procedures.
___ Yes
____No
Comments:
20. A new or properly processed needle and syringe should be used every time an injection is given or medication is withdrawn from a multidose vial.
___ Yes
____No
Comments:
21. "Clean" and "dirty" activities should be performed in separate areas. When only one room is available for processing instruments and other items, it should be arranged so that activities and objects flow in an organized fashion from receiving used items to storing sterilized or high-level disinfected items.
___ Yes
____No
Comments:
22. Instruments and other items should be stored dry and should never be left soaking indefinitely in solutions.
___ Yes
____No
Comments:
23. Soiled linen should be handled wearing utility gloves in a way that prevents exposure of the skin and mucous membranes to potentially contaminated material.
___ Yes
____No
Comments:
24. Instruments and other items should be decontaminated by placing them in a 0.5% chlorine solution immediately after use and letting them soak for 10 minutes.
___ Yes
____No
Comments:
25. Instruments and other items should be thoroughly scrubbed using a soft brush and detergent and water and rinsed thoroughly with clean water before sterilization or HLD.
___ Yes
____No
Comments:
26. If gloves are processed, they should be checked carefully for holes or tears after cleaning.
___ Yes
____No
____N/A
Comments:
27. For steam sterilization, instruments and other items should be packed in a way that allows steam to reach all surfaces.
___ Yes
____No
____N/A
Comments:
28. Appropriate parameters (time, temperature, pressure) for steam sterilization should be followed.
___ Yes
____No
____N/A
Comments:
29. Appropriate parameters (temperature, time) for dry-heat sterilization should be followed.
___ Yes
____No
____N/A
Comments:
30. Sterilization equipment should be properly monitored and maintained.
___ Yes
____No
____N/A
Comments:
31. A properly prepared chemical solution, such as a product containing glutaraldehyde, should be used for chemical sterilization.
___ Yes
____No
____N/A
Comments:
32. For chemical sterilization, instruments and other items should be dry, opened or disassembled, and completely submerged in the solution.
___ Yes
____No
____N/A
Comments:
33. Instruments and other items should soak in the chemical solution for the time listed in the manufacturer's instructions and should be rinsed with sterile water.
___ Yes
____No
____N/A
Comments:
34. After any method of sterilization, instruments and other items should be stored in a way that limits the risk of contamination.
___ Yes
____No
____N/A
Comments:
35. For HLD by boiling, instruments and other items should be opened or disassembled, completely submerged in water, and boiled for 20 minutes from the time when the water reaches a rolling boil.
___ Yes
____No
____N/A
Comments:
36. Appropriate and properly prepared disinfectant solutions should be used for chemical HLD.
___ Yes
____No
____N/A
Comments:
37. For chemical HLD, instruments and other items should be dry, opened or disassembled, and completely submerged in the solution.
___ Yes
____No
____N/A
Comments:
38. Instruments and other items should soak in the chemical solution for 20 minutes and be rinsed with boiled water.
___ Yes
____No
____N/A
Comments:
39. If gloves or MVA cannulae are steamed, they should be placed in the steamer so that steam can contact all surfaces and should be steamed for 20 minutes.
___ Yes
____No
____N/A
Comments:
40. After any method of HLD, instruments and other items should be stored in a way that limits the risk of contamination.
___ Yes
____No
____N/A
Comments:
41. Non-client-care areas should be kept free of dust, dirt, and organic debris.
___ Yes
____No
Comments:
42. Client-care areas should be dusted each morning and cleaned with a disinfectant cleaning solution between clients and at the end of each clinic session or day.
___ Yes
____No
Comments:
43. Once a week, the ceilings in operating theaters and procedure rooms should be cleaned with a mop dampened with a disinfectant cleaning solution.
___ Yes
____No
Comments:
44. Housekeeping equipment (mops, buckets, and cloths) should be decontaminated, cleaned in detergent and water, rinsed in clean water, and allowed to dry before reuse.
___ Yes
____No
Comments:
45. Fumigation and ultraviolet (UV) light should not be used to disinfect operating theaters or other areas of the facility.
___ Yes
____No
Comments:
46. General and medical waste should be separated into appropriate containers at the point at which it is generated.
___ Yes
____No
Comments:
47. Solid medical waste should be either burned or buried in a pit.
___ Yes
____No
Comments:
48. The community should be protected from possible exposure to medical waste.
___ Yes
____No
Comments:
49. Liquid medical waste and hazardous chemical waste should be poured down a drain or buried in a pit.
___ Yes
____No
Comments:
50. Medical-waste containers should be cleaned with a disinfectant cleaning solution and rinsed with water daily, or more often, if visibly contaminated.
___ Yes
____No
Comments:
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