Healthcare Infection Control Audit Checklist

OSHA 29 CFR 1910.1030 requires every employer whose employees have occupational exposure to blood or other potentially infectious materials (OPIM) to establish a written Exposure Control Plan, provide engineering and work practice controls, supply appropriate PPE at no cost, offer hepatitis B vaccination, and provide post-exposure evaluation and follow-up. An infection control audit verifies that 1910.1030 controls are in place, current, and effective. Willful violations of 1910.1030 carry OSHA

• Industry: Healthcare
• Frequency: Monthly / Quarterly
• Estimated Time: 45-60 minutes
• Role: Infection Preventionist / Quality Manager
• Total Items: 30
• Compliance: CDC Guidelines, CMS CoP, TJC IC Standards, UK NHS IPC, WHO Core Components

OSHA 1910.1030 Exposure Control Plan (c)(1) -- Written Program

Verify the Exposure Control Plan (ECP) is written, current, and meets all requirements of 29 CFR 1910.1030(c)(1). The ECP is the foundational document of bloodborne pathogen compliance. A facility without a current, accessible written ECP is in direct violation of 1910.1030(c)(1) regardless of the quality of its other controls.

• Is there a written Exposure Control Plan that is accessible to all employees during all work shifts, including night shifts?
• Does the ECP include an exposure determination identifying all job classifications with occupational exposure, and for mixed-duty classifications, the specific tasks that create exposure?
• Has the ECP been reviewed and updated at least annually and whenever there are task or personnel changes that affect occupational exposure, with the review date documented?
• Have employees with occupational exposure been involved in the identification, evaluation, and selection of engineering controls and safer medical devices?
• Is the ECP accessible in a form that accommodates employees with limited English proficiency or disabilities that prevent access to a written plan?

Engineering Controls and Sharps Safety (1910.1030(d)(2)(i)-(xi))

Inspect engineering controls including sharps disposal containers, needleless systems, and sharps with engineered sharps injury protection (SESIP). Engineering controls are the primary line of defense under the bloodborne pathogen hierarchy. PPE is supplemental, not a substitute for engineering controls.

• Are needleless systems used for IV access and medication delivery, and are sharps with engineered injury protection (retractable needles, blunt-tipped sutures, self-sheathing cannulas) used where clinically feasible?
• Are sharps disposal containers located as close as feasible to where sharps are used, maintained upright, not filled above the fill line (typically 2/3 full), and puncture-resistant?
• Are sharps containers closeable, leak-proof on all sides and bottom, and labelled with the biohazard symbol and the word BIOHAZARD?
• Is two-handed needle recapping prohibited by policy and practice, with one-handed scoop technique or a mechanical cap-holding device used in the limited circumstances where recapping is clinically necessary?
• Are all sharps disposal contractors licensed by the state for regulated medical waste transport and disposal, and is chain-of-custody documentation maintained?

PPE for Bloodborne Pathogen Exposure (1910.1030(d)(3)(i)-(ix))

Verify that appropriate PPE is provided at no cost to all employees with occupational exposure, that it is accessible at the point of use, and that it is correctly used for each task with exposure potential. PPE selection must be matched to the specific exposure type and route.

• Are gloves provided at no cost to all employees with occupational exposure, and are they of the appropriate material and size for the task (latex, nitrile, or vinyl matched to exposure risk and individual latex allergy status)?
• Are gowns or fluid-resistant protective clothing provided and worn during procedures or activities with potential for splash or spray of blood or OPIM?
• Are face shields or masks combined with eye protection provided and worn during procedures likely to generate splashes or sprays to the face, eyes, nose, or mouth?
• Is all used PPE removed before leaving the work area, and is contaminated PPE placed in a designated container or labelled bag for washing or disposal?
• Is PPE supplied in sufficient quantities at each point of use so employees are never required to delay a procedure or reuse contaminated items while waiting for PPE?

Hand Hygiene Program (1910.1030(d)(4) / CDC HICPAC 2002)

Verify that handwashing facilities and procedures meet OSHA 1910.1030(d)(4) and CDC HICPAC 2002 Category IA and IB recommendations. Hand hygiene is the single most important measure to prevent the spread of healthcare-associated infections and occupational bloodborne pathogen transmission.

• Are handwashing facilities with running water, soap, and paper towels accessible in or directly adjacent to all areas where employees have occupational exposure?
• Do employees wash hands with soap and running water for at least 20 seconds immediately after removing gloves and immediately after any contact with blood or OPIM?
• Is alcohol-based hand rub with at least 60% alcohol provided at or immediately adjacent to each patient care location for routine hand decontamination when hands are not visibly soiled?
• Is hand hygiene compliance monitored at a frequency that allows trend identification, with results reported to staff and incorporated into quality improvement activities?
• Are employees with exudative lesions or weeping dermatitis on hands restricted from direct patient contact and contact with patient care equipment until the condition resolves?

Environmental Cleaning and Disinfection (CDC/HICPAC 2003 Guidelines)

Inspect environmental cleaning and disinfection practices per CDC/HICPAC 2003 Guidelines for Environmental Infection Control. Environmental surfaces in patient care areas must be cleaned and disinfected at frequencies appropriate to the surface contact level using EPA-registered hospital disinfectants.

• Are EPA-registered hospital disinfectants used for all patient care environmental surfaces, and is the contact time required by the product label met before surfaces are wiped dry?
• Are high-touch surfaces (bed rails, call buttons, IV poles, door handles, light switches, computer keyboards in patient rooms) cleaned and disinfected at a defined minimum frequency within each shift?
• Is terminal cleaning of all surfaces in a patient room performed after each discharge before the room is occupied by the next patient, including under-bed areas, the undersides of furniture, mattress seams, and equipment surfaces?
• Are mops, cloths, and cleaning equipment cleaned and thoroughly dried between rooms, or are single-use items used, to prevent cross-contamination between patient rooms?
• Is a cleaning verification system (fluorescent marker, ATP bioluminescence, or direct observation audits) used to monitor cleaning effectiveness, with results driving corrective action and retraining?

Hepatitis B Vaccination, Post-Exposure, and Training (1910.1030(f)(g))

Verify hepatitis B vaccination is offered within 10 working days of initial assignment, that post-exposure evaluation is available immediately (including outside business hours), and that annual bloodborne pathogen training records are maintained for all employees with occupational exposure.

• Has hepatitis B vaccination been offered to all employees with occupational exposure within 10 working days of initial assignment, at no cost to the employee?
• Are declination statements signed by employees who decline vaccination, using the exact language in 29 CFR 1910.1030 Appendix A?
• Is post-exposure evaluation and follow-up available within 2 hours of a reported exposure incident, including outside normal business hours?
• Are sharps injury incidents recorded in a sharps injury log with the required information (device type and brand, work area, and description of how the incident occurred), and is the log maintained for 5 years?
• Have all employees with occupational exposure received bloodborne pathogen training upon initial assignment, annually thereafter, and when there are task or procedure changes affecting exposure, with training records retained for 3 years?

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Why Use This Healthcare Infection Control Audit Checklist?

This healthcare infection control audit checklist helps healthcare teams maintain compliance and operational excellence. Designed for infection preventionist / quality manager professionals, this checklist covers 30 critical inspection points across 6 sections. Recommended frequency: monthly / quarterly.

Ensures compliance with CDC Guidelines, CMS CoP, TJC IC Standards, UK NHS IPC, WHO Core Components, India NABH. Regulatory-aligned for audit readiness and inspection documentation.

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