Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded finding during tracer inspectionAwaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
16.1.1Core StandardSafety Standard
Facilities and equipmentCSSD Zoning and Unidirectional Workflow
The CSSD physical layout enforces strict separation of Decontamination, Assembly/Packaging and Sterile Storage zones with unidirectional workflow.
Compliance Criteria
- 1Physical partition between dirty decontamination area and clean assembly zone
- 2Unidirectional pass-through double-door washer-disinfectors and autoclaves
- 3Negative pressure in decontamination area and positive pressure in clean packing room
- 4Dedicated air filtration and controlled humidity / temperature monitoring logs
Hospital Self-Rating
Rated by Pn. Zainab binti Sulaiman on 15 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"CSSD maintains strict zoning separation with pass-through washer-disinfectors and negative/positive pressure airflow controls."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Physical partition between dirty decontamination area and clean assembly zone
- Unidirectional pass-through double-door washer-disinfectors and autoclaves
- Negative pressure in decontamination area and positive pressure in clean packing room
- Dedicated air filtration and controlled humidity / temperature monitoring logs
Derived from AccrediSense Evidence Engine · 0 documents attached against 4 compliance criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (0)
A criterion with no document reads as unevidenced to the survey team.
Attach relevant hospital policies, registers, audit reports, or training records.
ZS
Person-in-ChargeCSSD Supervisor
Head of DepartmentHead of Anaesthesia & Operating Theatres
LK
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)