Infection Control Checklist
Make sure to implement initial control measures to prevent healthcare-associated infections.
Location
Please Select
Skillman North
Skillman South
Skillman East
Hannan Ranch
Lohrman
Rebecca
Magnolia
Sonoma Mountain
Penngrove North
Penngrove South
Thompson
Auberry North
Auberry West
Makena South
Bradley
DaVinci
Mary
Petaluma IOP
Fresno IOP
Year
Month
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Hand Hygiene
Rows
Yes
No
Comments
Are the sinks adequately supplied for hand hygiene?
Are sinks readily available in all areas?
Are there sufficient stocks of hand sanitizer?
Is
hand sanitizer
available in the med room?
Are healthcare workers performing hand washing/hand hygiene between clients?
Are there reminders for hand hygiene present in the form of posters?
Is hand soap available in all hand washing stations/bathrooms?
Storage
Rows
Yes
No
Comments
Are client clothes hampers covered?
Does the clean linen cart have a solid surface on the bottom shelf?
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?
Client Rooms
Rows
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?
Client rooms are 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?
Dust not found in high places?
The general area is dust free?
Is there no evidence of pests present?
Is clean/dirty linen handled appropriately?
Are there no signs of mildew or mold present?
Paper towels are available?
Are client rooms free of food and drinks?
Kitchen
Rows
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 there no evidence of pests present?
Staff Office
Rows
Yes
No
Comments
Are the floors and walls clean?
Are horizontal and vertical surfaces 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 refrigerator temperature checks documented with corrective action taken when the temperature is out of range?
Medication Area
Rows
Yes
No
Comments
Is the unit/area generally clean and free of dust, clutter, or debris?
Are unused medical 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?
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?
Is there nothing stored under the sink and no sign of leaks?
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 Room refrigerator clean and without ice?
Any comments
Staff Name
First Name
Last Name
Title
Date
-
Month
-
Day
Year
Date
Signature
Submit
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