Download Virginia Assisted Living Facilities Walk-Through Survey

Suburban Cook County Assisted Living/Long-Term Care Facilities
Blood Borne Pathogen Walk-Through Survey
2007
Facility Layout
1. Facility configuration
□ One Building
□ Multiple Buildings
□ Connected with other institution(s)
2. Primary room type
□ Private
□ Semi-Private
□ Private and Semi-Private
3. Where do most residents eat?
□ Dining Hall
□ Private room or bedroom
□ Pods
□ Other common area
Nursing/Medical
1. Number of nursing stations _______
2. Are sinks located in accessible places for staff (near med room, treatment rooms)? Yes
No
3. Where are medications stored?
□ Nursing station
□ Medication room
□ With individual patient in their room
□ Other (locked boxes, closets, etc.): ________________________________________
4. Are there separate refrigerators for food and medications?
Yes
No
5. Are there examination/treatment rooms?
If yes, what kinds of procedures are performed in these rooms?
Yes
No
5. Are needle boxes used?
Yes
If yes, where are they located?
□ Hallways
□ Central location on floor/wing (i.e. nursing station)
No
6. Were any needle boxes overfilled (>2/3 full)
No
Yes
□ In patient rooms
Facility Cleaning
1. Where are housekeeping supplies stored?
□ Closet (i.e. janitor’s closet)
□ Mobile carts
□ Other ________________________________
2.
□ Cabinets in bathrooms or kitchens
Is there a written cleaning schedule?
Yes
No
3. How often are rooms cleaned by facility staff?
□ Multiple times per day
□ Once a day
□ At least once a month
□ Multiple times a week □ Once a week
4. Where are bed linens and clothing laundered?
□ At facility
□ Sent to a Laundromat
□ Other
5.
How often is trash collected in resident rooms?
□ Multiple times per day □ Once a day □ Multiple times a week □ Once a week □ At least once a month
6. Please rate overall appearance of common areas within facility
Poor
Fair
Good
Excellent
Personal Hygiene/Handwashing
1. Bathing facility descriptions
□ Individual bathrooms for each resident
□ Shared Bath
□ Other
2. Are handwashing supplies readily available at sinks (e.g., soap and paper towels)?
Yes
3. Does the facility provide an alcohol-based hand sanitizer?
Yes
No
If yes where is sanitizer located?
□ Nursing stations □ Bathrooms □ Resident rooms □ Hallways □ Other
Personal Protective Equipment
1. Is there a central location (e.g. shelf) for PPE such as gloves?
If yes, was the equipment in this central location?
Yes
Yes
No
No
2. Are gloves in medication room and treatment rooms?
Yes
No
Policies and Procedures
1. Does the facility have written policies related to:
□ Cleaning/Disinfection
□ Blood spills
□ Infectious disease illness reporting
□ Needle sticks & related BBP exposures
□ In-service training and orientation
□ Handwashing
□ Blood glucose monitoring
□ Staff hepatitis B vaccination
Record Keeping
1.
Are in-service records available?
Yes
No
2. Are staff Hepatitis B vaccination records available (including declination forms)?
If yes, do they reflect compliance?
Yes
No
Yes
3. Do they keep records of needlestick or occupational exposure injuries?
Yes
No
Observations
1. Was staff seen washing their hands?
If yes, did they wash using soap, a hand sanitizer, or both?
No
Yes
No
2. Was staff seen using gloves?
Yes
No
During what procedures? ______________________________________________________
Did they use gloves properly?
Yes
No
Dispose of gloves properly?
Yes
No
3. Did housekeepers have on gloves while cleaning?
Did they change them (specify when they should change)?
Yes
No
Never Sometimes
Always
4. Did staff wear gloves during glucose monitoring procedures?
How often did they wear gloves during procedures?
How often did they change their gloves?
Yes
No
Never Sometimes
Never Sometimes
Always
Always
Suburban Cook County Assisted Living Facilities
Blood Borne Pathogen Walk-Through Survey, 2007
Page 2 of 3
No
Interviews with Random Staff
1. Did staff know about the Bloodborne Pathogen Standard?
Yes
No
2. Did they receive training in the proper use of PPE?
Yes
No
3. Does staff know where PPE can be found and when to use PPE?
Yes
No
4. Are staff aware of polices (specify) related to blood glucose monitoring, etc.?
Yes
No
Specify Policies:____________________________________________________________
5. What type of training do they receive at the time of hire and annually?
□ Bloodborne pathogen
□ Waste disposal
□ Occupational Injury
□ Other
6. What would they do if they got exposed to body fluids (e.g., needle stick, bite)?
Other Comments/Observations
Suburban Cook County Assisted Living Facilities
Blood Borne Pathogen Walk-Through Survey, 2007
Page 3 of 3
□ PPE