| Agency/Facility Name | |
| Date | |
| Surveyor/Assessor Name |
| Checklist Item | Yes | No | N/A | Comments |
|---|---|---|---|---|
| Hand hygiene supplies (soap, sanitizer) are available and accessible | ||||
| Staff perform hand hygiene before and after patient contact |
| Checklist Item | Yes | No | N/A | Comments |
|---|---|---|---|---|
| PPE (gloves, gowns, masks) is available and used appropriately | ||||
| PPE is disposed of properly after use |
| Checklist Item | Yes | No | N/A | Comments |
|---|---|---|---|---|
| Frequently touched surfaces are cleaned/disinfected regularly | ||||
| Reusable equipment is cleaned after each use |
| Checklist Item | Yes | No | N/A | Comments |
|---|---|---|---|---|
| Aseptic technique is used during wound care and invasive procedures | ||||
| Sharps are disposed of in puncture-resistant containers |
| Checklist Item | Yes | No | N/A | Comments |
|---|---|---|---|---|
| Staff receive regular infection control training | ||||
| Patients/families are educated on infection prevention measures |