1. 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:

2. 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

3. 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

4. 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

5. 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