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Infection Control Monitoring ChecklistDate of assessment contact: Click to enter a date.Entry Time: Click to enter time.Exit Time: Click to enter time. Names of Regulatory Officials: Click to enter text.Service name: Click to enter mission ID: Click to enter text.Name of person in charge of Service: Click to enter text.Number of consumers currently at the service: Click to enter text.Room arrangements: Provide details of room arrangements at the service; example, single rooms, shared rooms, ensuites, shared bathroomsSERVICE RISK ASSESSMENT: COVID-19 STATUS?Questions 1 to 12 to be asked of the person in charge PRIOR to the assessment team entering the serviceYesNo1Is the service in lockdown???2Are any of the consumers at the service COVID-19 positive??*??2aNumber of?consumers who are COVID-19 positive: Click to enter number3Are any of the staff at the service COVID-19 positive??*??3aNumber of?staff?who are COVID-19 positive: Click to enter number3bIf answer to 3 is yes, did any of the COVID-19 positive staff attend or work at the service while infectious/COVID-19 positive???3cIf answer to 3b is yes or unsure, how many days has it been since they were last at the service? Click to enter numberIf answer to 2 or 3 is yes:4Date the Public Health Unit (PHU) was notified of positive cases: Click to enter a date.5Date Commonwealth Department of Health (DOH) notified of positive cases: Click to enter a date.6Are you screening consumers daily for COVID-19 symptoms???7What tool are you using for COVID-19 screening? Click to enter details.(Note: an example of a screening tool developed by Safer Care Victoria is at COVID-19 screening tool for residential aged care service)8Do you have any consumers or staff with flu like symptoms at present????9Are?any?consumers or staff waiting on any tests related to?Covid-19????SERVICE RISK ASSESSMENT: COVID-19 STATUS?Questions 1 to 12 to be asked of the person in charge PRIOR to the assessment team entering the serviceYesNoIf answer to 9 is yes:10Are these tests related to suspected symptoms, suspected flu like symptoms????11Are these tests related to exposure or possible exposure to a Covid-19 positive person????12Are these tests related to voluntary or proactive tests as available to?consumers and/or?health care?workers???Further information: Click to enter any further information, such as details of your discussion with the person in charge when requesting consent; any issues or unexpected entry requirements. Also add any necessary details regarding COVID-19 cases or testing details. SCREENING ON ENTRYQuestion 13 to 14 completed based on observations when entering the service and of all other admission points to the serviceYesNo13The following screening procedures are in place at the service: Sign in register for all visitors, agency staff, transportation staff and other contacts who enter the service??Pre-entry screening questions/measures ??Health status declaration??Temperature check??Vaccination check??Alcohol-based hand sanitiser??Sanitiser wipes available at staff or visitor electronic sign in??Other, Add details??14Are signs located at all entrances to the service instructing visitors and staff not to enter if they have fever or symptoms of a respiratory infection???If no to any of the above, provide details and areas of improvement: Click to enter text; where there were other entry requirements not listed, ensure they are recorded here.OUTBREAK MANAGEMENT PLAN Question 15 to 26 completed during review of the Outbreak Management PlanYesNo15Date last reviewed: Enter dateDate plan last practiced: Enter date 16Name of nominated infection prevention and control lead (required from 1/12/20): Enter nameContact mobile phone number (including out of hours contact number): Enter number17Does plan include a list of people with allocated roles and contact details including alternative staff contacts?? ? 18Is there a current staff list with contact details, including detailed rosters and a record of staff who work across multiple aged care/disability/health care services or multiple sites?? ? 19Is there a list (spreadsheet) of all residents including recent photos, room numbers and emergency contact details?? ? 20Are Medicare numbers for all residents documented in a central spreadsheet?? ? 21Does plan include other key points of contacts such as the PHU; DOH; GPs and other visiting staff; PPE stockists; surge workforce organisations; clinical waste contractor (increase frequency of bin collection)?? ? 22Is there a floor plan with:Identified rooms/zones and PPE donning/doffing station locations? ? ? Individual consumers’ rooms, bathrooms, communal areas and food preparation areas, and how staff are allocated to each area?? ? 23Does the plan outline: The lockdown process including staff assigned to teams to support cohorting?? ? Processes for clinical handover? ? ? Guidelines to determine when to transfer COVID positive consumers to hospital???Communication protocol???Access details to electronic records by all relevant parties, including contingency plan for loss of electronic records???24Are there contingency plans to immediately safely move and isolate COVID-19 positive consumers in a single room/share with another positive resident with ensuite/separate bathroom or if bathrooms are shared, commodes are used to minimise sharing bathrooms???25Is there prepared signage to communicate lockdown/facility closure and to identify areas that are active COVID-19 consumers zone/cohorts?? ? 26Is there a list of staff who actually worked on relevant dates (not just a roster), to determine dates, shifts and areas of work, and the consumers they cared for???If no to any of the above, provide details and areas of improvement: Click to enter text.PERSONAL PROTECTIVE EQUIPMENT (PPE) Responses to question 27 to 43 completed based on PPE observations; leave unchecked for practices not able to be observed and provide detailsYesNoNot Required*PPE supply and storage27Does the service have sufficient PPE to manage the first 24-48 hours of an outbreak???28Has an area been identified for bulk stocks of PPE stock (pallets) to be safely delivered, received and stored???29Is PPE stored securely and always accessible by a designated person???30Is PPE readily available and in easy reach of staff who require them (may include masks, gowns, gloves, face shields, hand sanitiser, waste disposal bins)???PPE usage31Does the service have a process for overseeing and monitoring that staff are using required PPE, and using PPE correctly???32Are there separate areas/stations for PPE donning and doffing that are clearly identified???33Are there posters/instructions on donning/doffing PPE available???34Where PPE is required, are staff donning and doffing PPE correctly? ??? 35Where PPE is required, are staff correctly applying PPE? ??? 36Where required, is appropriate PPE used by staff with different roles (care/non-care staff)???? 37If required, is everyone (except residents) in the facility wearing masks????38If required, are staff wearing face shields or other protective eyewear in addition to masks????39Are staff changing gloves and using hand hygiene product between consumers? ??40Where PPE is required, were staff observed not to be touching their face or mask????PPE disposal41Are there sufficient and appropriate waste bins available which are emptied frequently enough? ??42Are staff disposing of PPE correctly???43Is the waste service sufficient to ensure adequate waste removal from site (large volume)???If no to any of the above, provide details and areas of improvement: Click to enter text.INFECTION CONTROL MEASURESResponses to question 44 to 58 completed based on infection control observations; leave unchecked for practices not able to be observed and provide detailsYesNoHand hygiene44Are hand washing and/or alcohol-based hand sanitiser stations readily available for staff, consumers and visitors in all areas of the facility including in kitchen, laundry areas???45Is there hand wash available at all hand basins and in bathrooms? ??46Are acceptable hand washing frequency and techniques being used by staff, consumers and visitors???Environment/Equipment Cleaning47Adequate supplies are in place for increased frequency of cleaning particularly high touch surfaces, including detergent for cleaning, disinfectant and disinfectant wipes???48Is all shared equipment being cleaned with a disinfectant wipe between consumers? ??49Is shared equipment such as telephones and computers, door handles, rails, chair arms and other high touch items being cleaned with disinfectant wipes after use? ??50Disposable equipment is being used for items that should not be shared? ??51Is appropriate signage and cleaning supplies in place for high risk spaces including areas in isolation, staff meeting spaces, shared and separate bathrooms, kitchen, laundry and medication administration???Other Preventative Strategies52Are staff, consumers and visitors following social distancing protocols and appropriate sneeze and cough etiquette at all times including in consumer rooms and communal areas???53Is there social distancing in communal staff areas such as tea room/nurses station/offices/changerooms???54Are breaks staggered to ensure minimal numbers of staff in communal areas???55Is there signage to identify total number of staff able to be in each communal areas???56Are all staff and consumers using own drink bottles and/or are there appropriate management plans for communal taps or fountains (as high touch points)???57Are all staff and residents screened daily for symptoms (fever and acute respiratory symptoms and change in behaviour in residents)???58Are visitors attending the service as per any visitor access/restriction requirements? ??If no to any of the above, provide details and areas of improvement: Click to enter text.WORKFORCE Responses to questions 59 to 63 completed based on interview with the person in charge during the entry meeting and observations of the workforce; leave unchecked for practices not able to be observed and provide detailsYesNo59A process for orientation, induction and training in PPE and infection control measures is in place, including for surge workforce for each shift? ??60A process is in place to ensure staff competency following PPE and infection control training that is consistent with public health directions and best practice guidance? This includes how the service satisfies itself that all staff are able to adhere to hand hygiene and PPE requirements at all times and across all shifts, such as donning and doffing PPE. This includes ensuring staff competency for any anticipated increase in the use of PPE; for example, through PPE drills. Provide details.??61There is a surge contingency staffing plan if a significant number of staff become sick or require quarantining (may include access details to the temporary surge workforce through the DOH)???62Clear handover arrangements occur for consumers’ individual risks, care needs, social needs and monitoring requirements???63The service has determined how it can resource cleaning staff and supplies, including induction and training at surge periods? ??If no or unchecked to any of the above, provide details and areas of improvement: Click to enter MUNICATIONS AND SIGNAGEResponses to question 64 to 66 completed based on observations of communications and signage; ‘yes’ and ‘no’, leave unchecked for practices not able to be observed and provide detailsYesNo64Service has notice boards, signs and other sources of information throughout the facility for staff, consumers and visitors on infection prevention and control including:Hand hygiene??Cough etiquette??Social distancing/staying 1.5m away from other people ??Advice to stay at home even with the mildest of symptoms or possible exposure/close contact to COVID-19 positive person??Density signage??65Materials are language and reading-level appropriate???66The service has signage and processes in place to monitor staff physical distancing, e.g. during handover, breaks, entry and exit, and including remaining in separated and defined work zones.??If no or unchecked to any of the above, provide details and areas of improvement: Click to enter text.CONSUMERSResponses to question 67 to 70 completed based on observations; ‘yes’ and ‘no’ leave unchecked for practices not able to be observed and provide detailsYesNoNot Required67Are consumers able to move freely outside of their rooms???68Is there adequate spacing at meal times in dining room and during group activities? ??69If no to Q68 are meal times staggered to ensure minimal numbers of staff in communal areas? ???70Are consumers and visitors observed to be participating in visits in line with the service’s policies and procedures and the principles of person-centred care (as outlined in the Partnerships in Care Fact sheet? ??If no to any of the above or are unchecked, provide details and areas of improvement: Click to enter text.General consumer observations: Click to add your observations of consumers within the service.Other relevant information: Click to enter text. ................
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