Back to Standards/Criterion 21.3.3.21
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot met
Dr Noraini AhmadRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

21.3.3.21
Policies and procedures

Infectious Linen Segregation Protocol 3.3

The Linen and Laundry Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for infectious linen segregation.

Compliance Criteria

  • 1Approved standard operating procedure for infectious linen segregation reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day infectious linen segregation compliance
  • 3Regular documentation audits and evidence of corrective action implementation
  • 4Staff training records and competency assessments maintained in the department

Hospital Self-Rating

Rated by Pn. Harlina binti Mansor on 21 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for infectious linen segregation. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

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.

HM
Person-in-ChargeMortuary Services Supervisor
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Noraini Ahmad (Allied Health & Clinical Support Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Surveyor assessment revealed complete absence of structured monitoring logs and verified staff competency assessments for infectious linen segregation in Linen and Laundry Services.

Formulate and approve a formal operational framework for infectious linen segregation with designated staff competencies and active surveillance.

Develop mandatory SOP, assign operational indicator oversight, and conduct staff training within 60 days.