Infection Prevention and Control Online Assessment

This is being offered to your facility at no charge and will be assessed by Phenelle Segal, RN, CIC, certified infection prevention and control consultant as a “first step” in assisting you with identifying gaps in practice.

The purpose of this initial assessment is to provide you with an outline of your infection prevention and control program and the basics needed to ensure you are on the right path for A) compliance with accreditation agencies (e.g., The Joint Commission, AAAHC), federal regulations (e.g., CMS, OSHA, CDC/NHSN), state regulations (title, senate bill and others), and B) appear to have basic strategies in place to for patient and employee safety.

In order for your program to be adequately assessed, it is important to have a staff member who is well versed in your infection prevention and control program fill this out as accurately and thoroughly as possible.

Upon completion of this form, it will be assessed and results provided to you via e-mail within five (5) business days.

All information submitted will be kept strictly confidential. Answer questions to the best of your ability.

General Information

Briggs Customer #

Briggs Representative

Facility Name

City and State

Contact Person Name

First Name

Last Name

Type of Facility

Is your facility surveyed by an agency or accreditation organization?

Yes

If YES, which agency or organization has conducted the survey?

Centers for Medicare and Medicaid Services (CMS)

The Joint Commission (TJC)

Accreditation Association for Ambulatory Health Care (AAAHC)

American Osteopathic Association (AOS)

Healthcare Facilities Accreditation Program (HFAP)

DNV

Other

If Other, please specify.

What is your average daily census? (leave blank if not applicable)

How many operating rooms does your facility have? (leave blank if not applicable)

Infection Prevention and Control Program

Does the facility have a written infection prevention and control program that includes the components necessary to ensure best practices?

Does the facility have a designated clinical licensed staff member directing the program?

If YES, is this person

Does the facility monitor and track patients for healthcare-associated infections (HAIs)?

Does the facility have a written policy addressing reporting of communicable diseases to the Department of Health?

Does the facility conduct staff education in infection control?

Does the facility have a written hand-hygiene policy and procedure?

Does the facility monitor hand-hygiene compliance?

Does the facility have a written policy addressing isolation practices?

Does the facility have a written policy and procedure for use of personal protective equipment (PPE)?

Does the facility have a written policy addressing safe injection practices?

Does the facility have a written policy addressing environmental cleaning?

Does the facility have a written policy addressing disinfection/sterilization?

Does your facility have a written policy addressing cleaning of glucose monitoring devices?

Does your facility have an updated, comprehensive Bloodborne Pathogen Exposure Control Plan (BBP-ECP)?

Do you feel confident that your facility is in compliance with infection prevention and control standards, requirements and practices?