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Sample Infection Control Environmental Review Form

Here is a sample infection control environmental review form used by Brainerd Lakes Surgery Center in Baxter, Minn., and provided by Sandy Berreth, administrator of the ASC and a AAAHC surveyor.

Different members of the Brainerd Lakes Surgery Center staff perform the review every quarter to increase their recognition of what needs to be done, according to Ms. Berreth.

To download a copy of this form, click here (doc).

Infection Control Environmental Review

GENERAL: Quarterly review  [Month]


Needs improvement


Handwashing between patients, after patient contact, after glove removal, after personal breaks

Proper handwash technique; wet hands first, 10 second scrub, rinse, turn off faucet with paper towel

Soap dispensers are full and functional

General appearance of area is clean, uncluttered

Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies

Open bottles of fluids discarded every 24 hours/7 am

(saline for irrigation)

Single use medication vials discarded

(sterile saline, bacteriostatic water)

Multi-use medication vials discarded according to manufacturer outdate (exception: insulin, certain RC products)

IV tubing labeled with date

Urine drainage bags off floor

Linen carts covered

- Linen carts in clean utility with other supplies need

to be covered or behind closed cabinet

No shaking, agitation of linens

Refrigerator temperature logs for patient use refrigerators - monitored and recorded daily ( approp. action taken if necessary)

Only patient items in patient refrigerators

No patient care items under/on sinks

(including cups, paper towels, anything that may get wet)

No wet areas under ice machines

No stuffed animals in toy rooms

Hampers used appropriately

- ie. No bags on floors, no overflowing of linen

Ceiling tiles clean and dry

At least 18" clearance below sprinkler heads

Check biological monitoring logs for completeness,





Needs improvement


Staff following Universal/Standard Precautions

No food, beverages in work area

No applying cosmetics, lip balm in work area

No recapping of needles after use

(single handed technique acceptable)

Maximum fill level of needle boxes as indicated on container

Personal Protective Equipment available (PPE)

Proper use of PPE: -gloves when handling body fluids

-gowns when anticipated exposure to clothing

-masks/face shields when anticipated exposure

Removal of PPE prior to leaving patient room

Glove boxes filled

Proper clean up of blood spills

(spray with bleach [Dispatch], allow contact time of

1-2 minutes, then wipe)

Pick up broken glass with tongs

Proper reporting of exposures

(report immediately, complete event report, report to ETD)

Utilizes safety devices as available


Clean items only

No medical supplies on floor

No medical supplies left in original shipping container

Nothing stored under sinks

Check for outdated supplies

Door closed


Dirty items only

Door closed on soiled utility room

No mini drinking cups, tissues, paper towels, toilet tissue

No hoses touching in floor drains

PPE available



Needs improvement


PPE utilized when handling specimens

Assure covers are properly secured prior to placement in CTS carrier


Properly identifies examples of hazardous waste

Contaminated waste labeled

(red bag)

Needles/Sharps disposed properly

Utilizes safety devices as available

Source: Sandy Berreth, Brainerd Lakes Surgery Center. Adapted and reprinted with permission.

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