OVERALL INFECTION PREVENTION SCORECARD DATE SITE MANAGER METRIC POINTS N/A FOR SITE MEETS STANDARD DOES NOT MEET STANDARD INSTRUMENT CLEANING, PROCESSING AND STERILIZATOIN 100/100 N/A HIGH LEVEL DISINFECTION MEDICATION SAFETY =>80/100 ENVIRONMENTAL CLEANING (NON-CRITICAL EQUIPMENT) Hand Hygiene +observation/ opportunities Green in All Metrics COMMENTS:

HIGH LEVEL DISINFECTION PROCEDURES DATE SITE MANAGER METRIC POINTS MEETS STANDARD DOES NOT MEET STANDARD Chemicals used for HLD are prepared according to manufacturer instructions; tested for minimum effective concentration (MEC) 15 Standard Precautions practiced. Supplies available and used appropriately No food or drink in area 10 Equipment (GUS, water filter, eye wash "high-level" in good working order 5 Devices and instruments are stored in a designated clean area so sterility/cleanliness is not compromised 20 HLD logs are in order and up to date. There is a distinct separation to clearly differentiate dirty, patient ready (not-ready-to-use) instruments from clean, ready-to-use instruments. Clean and sterile supplies and equipment are stored appropriately ATP monitor is <10 RLU TOTAL Points ____/100 TOTAL Points to Meet Standard 100 Points

INSTRUMENT CLEANING, PROCESSING & STERILIZATION DATE SITE MANAGER METRIC POINTS MEETS STANDARD DOES NOT MEET STANDARD Storage maintains integrity of pouch, is clean, away from dirty/mixed supplies pouch right size for instrument 20 Logs are maintained and UTD; no indication of over loading chamber Spore Test weekly (Mesa Lab >90%) Instrument handled per training. Fully submerged; not left over night; drying single layer; no evidence of debris/contamination 10 Clean and sterile supplies and equipment are stored appropriately. There is a distinct separation to clearly differentiate dirty, not-ready-to-use instruments from clean, ready-to-use instruments OSHA, Standard Precautions practiced. Supplies available and used appropriately No food or drink in area. TOTAL Points ____/100 TOTAL Points to Meet Standard 100 Points

ENVIRONMENTAL CLEANING (NON-CRITICAL EQUIPMENT) DATE SITE MANAGER METRIC POINTS MEETS STANDARD DOES NOT MEET STANDARD Surfaces are free of dust, dirt & clutter, HTO including medical equipment that involves blood testing is cleaned between every patient 20 Trash and biohazard waste are appropriately separated. Clean linen is stored in a designated are to prevent contamination from traffic, and falling on floor 10 Staff is observed by IP complying with the hand hygiene policy; Staff can explain hand hygiene policy Clean and sterile supplies and equipment are stored appropriately (and within expiration date); drawers & cabinets w/o mixed dirty supplies There is clear separation of clean and dirty activities. Supplies stored in a way prevent contamination; sterile supplies and instruments are not pre-set or left on counter top; ATP monitor <50 RLU for > 85% (6/7) routine HTO 35 Supplies available and used appropriately. Sani-Wipes, personal protective equipment stocked; including respiratory hygiene station; 5 TOTAL Points ____/100 TOTAL Points to Meet Standard 80 Points

MEDICATION SAFETY METRIC DATE SITE MANAGER METRIC POINTS MEETS STANDARD DOES NOT MEET STANDARD Single dose vials are never used as multi-dose vials 10 Multi dose vials are within expiration date 20 Clean and sterile supplies and equipment are stored appropriately Topical mediations are stored in a manner to prevent cross contamination; chemicals are not stored adjacent to medication Medications are prepared safely. ATP of med prep < 50 RLU Vials used for more than one (1) patient are always entered with a sterile needle and syringes are used for only one patient Needles and syringes are discarded intact in an appropriate sharps container after use. OSHA, Standard Precautions practiced. Supplies available and used appropriately including respiratory hygiene station TOTAL Points ____/100 TOTAL Points to Meet Standard 80 Points