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Healthcare Facility Compliance 17 items

Infection Prevention & Control Program Audit

Audit of a facility infection prevention and control program covering surveillance, hand hygiene, isolation precautions, and reprocessing across acute and long-term care.

CMS 42 CFR 482.42CMS 42 CFR 483.80CDC GuidelinesTJC IC Chapter

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Program Structure & Surveillance

  • Is there a facility-wide infection prevention and control program led by a qualified infection preventionist? *
  • Is the IPC program based on nationally recognized guidelines (e.g., CDC/HICPAC)? *
  • Is there an active surveillance system to identify, track, and report healthcare-associated infections? *
  • Are reportable diseases and outbreaks reported to state/local public health authorities? *

Hand Hygiene & Standard Precautions

  • Does the facility follow current CDC/WHO hand hygiene guidelines and monitor compliance? *
  • Are alcohol-based hand rub dispensers and sinks with soap available at points of care? *
  • Is personal protective equipment (PPE) available and used appropriately for the level of exposure? *
  • Current observed hand hygiene compliance rate (%)?

Transmission-Based Precautions & Isolation

  • Are patients on transmission-based precautions identified with appropriate signage and PPE at entry? *
  • Are airborne infection isolation rooms (negative pressure) monitored and functioning? *
  • Are multidrug-resistant organisms (MDROs) and C. difficile managed with enhanced precautions? *

Sterilization, Disinfection & Reprocessing

  • Are reusable medical/surgical devices cleaned and reprocessed per manufacturer instructions (IFU)? *
  • Are sterilizers monitored with biological indicators and mechanical/chemical indicators, with logs? *
  • Are high-level disinfection processes for endoscopes documented and periodically audited? *
  • Are single-use devices not reused unless reprocessed by an FDA-cleared reprocessor? *

Immunization & Antibiotic Stewardship

  • Are residents/patients and staff offered influenza and pneumococcal immunizations per policy? *
  • Is there an antibiotic stewardship program with protocols and a system to monitor antibiotic use? *

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