Back to Standards/Criterion 22.3.4.22
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot applicable
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.

22.3.4.22
Organisation and management

Disinfectant Dilution Protocol 3.4

The Housekeeping and Cleaning Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for disinfectant dilution.

Compliance Criteria

  • 1Approved standard operating procedure for disinfectant dilution reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day disinfectant dilution 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 22 Jan 2026

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

"The department has established comprehensive operational policies for disinfectant dilution. 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 14 Apr 2026

Departmental scope verification confirms that disinfectant dilution is not applicable to the operational services provided by Housekeeping and Cleaning Services at this facility.

None specified.

None specified.