Facility Infection Control Assessment Form
Name of person responsible for assessment: ________________________
Hospital Name: ________________________________________________
Hospital Address: ______________________________________________
Assessment Date: ______________________________________________
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Topic/Question Result Comments
Infection Control/Prevention Program and Resources
1. The hospital has one or more qualified individual(s) responsible for infection control. Y N N/A
2. The hospital is periodically assessed by an authority on compliance with recommended Y N N/A
infection prevention practices.
3. The hospital regularly assess, whether staff follow recommended infection prevention Y N N/A
practices.
Infection Control/Prevention Program and Resources
Intake and Triage
1. Patients with symptoms of respiratory infection and other symptomatic persons (e.g., Y N N/A
persons accompanying ill patients) are instructed to wear facemasks and are separated
(by at least 1 meter) from others.
2. Patients and visitors with symptoms of respiratory infection are instructed to inform Y N N/A
staff so IC precautions may be implemented.
3. Sign for patients and visitors on recommended hand hygiene and Respiratory Y N N/A
Hygiene/Cough Etiquette practices are provided in patient intake and other inpatient
areas.
4. Dispensers of alcohol-based hand rub and/or sinks, soap, paper towels and tissues are Y N N/A
provided in intake area for hand hygiene and respiratory hygiene.
5. Personnel protection equipment (appropriate for MERS-CoV prevention) is readily Y N N/A
available in the patient intake area of the hospital.
6. Healthcare personnel (HCP) wear gown protection upon entry into a MERS-CoV patient Y N N/A
care area
7. HCP wear eye and facemasks protection upon entry into a MERS-CoV patient care area Y N N/A
8. HCP wear a particulate respirator (N95 or higher) upon entry into the patient care area Y N N/A
during aerosol generating procedures for known or suspected MERS-CoV patients.
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9. Infections Prevention staff or medical director are notified when a MERS-CoV test is Y N N/A
positive and it is noted in medical records.
Topic/Question Result Comments
General Infection Control Elements
Hand Hygiene
1. Soap, water, and a sink are accessible in patient care areas including but not limited to Y N N/A
direct care areas (such as food and medication preparation areas).
2. Alcohol-based hand rubs are readily accessible and placed in appropriate locations. Y N N/A
3. Healthcare personnel perform hand hygiene:
a. Before contact with the patient or their immediate care environment Y N N/A
b. exiting the patient’s care area after touching the patient or the patient’s immediate Y N N/A
environment
c. Before performing an aseptic task (e.g., insertion of IV or urinary catheter) Y N N/A
d. After contact with blood, body fluids or contaminated surfaces Y N N/A
e. Before After removing gloves Y N N/A
4. Healthcare personnel perform hand hygiene using soap and water when hands are Y N N/A
visibly soiled (e.g., blood, body fluids).
Infection Control/Prevention Program and Resources
Intake and Triage
1. Policies for reporting a MERS-CoV exposure event, post-exposure evaluation and follow- Y N N/A
up, are available.
2. The hospital has a respiratory protection program that details procedures and elements Y N N/A
which required personal protection equipment use.
3. If respirator fit-testing is required, the hospital infection control system ensures that Y N N/A
respiratory fit testing is provided at required intervals to healthcare personnel
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4. Hospital encourages reporting of illness based on contact with confirmed cases of Y N N/A
MERS-CoV, without danger of loss of job and benefits
Topic/Question Result Comments
Personal Protective Equipment/Standard Precautions
1. Appropriate PPE (e.g., gloves, gowns, mouth, eye, nose, and face protection) are Y N N/A
available and located near point of use.
2. Healthcare personnel (HCP) wear gloves for procedures/activities where contact with Y N N/A
blood, body fluids, mucous membranes, or non-intact skin is anticipated.
3. HCP change gloves and perform hand hygiene before moving from a contaminated body Y N N/A
site to a clean body site.
4. Gowns are worn to prevent contamination of skin and clothing during Y N N/A
procedures/activities where contact with blood, body fluids, secretions, or excretions
are anticipated.
5. Gowns and gloves are removed and hand hygiene is performed before leaving the Y N N/A
patient’s environment.
6. Appropriate mouth, nose, and eye protection is worn for aerosol-generating procedures Y N N/A
and/or procedures/activities that are likely to generate splashes or sprays of blood or
body fluids.
Isolation- Contact Precautions
1. Signs indicating patient is on Contact Precautions are clear and visible. Y N N/A
2. Patients on Contact Precautions are housed in single-patient rooms when available or Y N N/A
cohorted based on a clinical risk assessment.
3. Hand Hygiene is performed and gloves and gowns are available in patient care Y N N/A
environment.
4. Gloves and gowns are removed and discarded, and hand hygiene is performed before Y N N/A
leaving the patient care environment.
5. Dedicated or disposable noncritical patient-care equipment (e.g., blood pressure cuffs) Y N N/A
is used or if not available, equipment is cleaned and disinfected prior to use on another
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patient according to manufacturer's instructions.
6. Facility limits movement of patients on Contact Precautions outside of their room to Y N N/A
medically necessary purposes.
Topic/Question Result Comments
Isolation- Droplet Precautions
1. Facemasks are available and located near point of use. Y N N/A
2. Signs indicating patient is on Droplet Precautions are clear and visible. Y N N/A
3. Patients on Droplet Precautions are housed in single-patient rooms when available or Y N N/A
cohorted based on a clinical risk assessment.
4. HCP perform hand hygiene and don facemasks upon entry into the patient care Y N N/A
environment.
5. Facemask is removed and discarded, and hand hygiene is performed upon leaving the Y N N/A
patient care environment.
6. Facility limits movement of patients on Droplet Precautions outside of their room to Y N N/A
medically necessary purposes
Isolation- Airborne Precautions
1. Particulate respirators (N-95 or higher) are available and located near point of use. Y N N/A
2. Signs indicating patient is on Airborne Precautions are clear and visible. Y N N/A
3. Patients on Airborne Precautions are housed in airborne infection isolation rooms (AIIR). Y N N/A
4. Hand hygiene is performed upon entry into patient care environment. Y N N/A
5. Healthcare personnel wear a particulate respirator (N95 or higher) upon entry into the Y N N/A
AIIR for patients with confirmed or suspected infection with pathogens requiring AIIR
per facility policy.
6. Facility limits movement of patients on Airborne Precautions outside of their room to Y N N/A
medically-necessary purposes and notifies personnel about it.
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Environmental Services
1. During environmental cleaning procedures, healthcare personnel wear appropriate PPE Y N N/A
to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns,
masks, and eye protection).
2. Objects and environmental surfaces in patient care areas are cleaned regulartly using a Y N N/A
disinfectant (e.g., daily), and when spills visibly contaminate surfaces.
3. After patient discharge, all visibly or potentially contaminated surfaces are cleaned and Y N N/A
disinfected and towels and bed linens are replaced with clean towels and bed linens
(with cleaners and desinfections at right dilution, contact-time).
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