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Sample report

Four pages from a readiness report.

Facility, people and numbers are fictional. The structure, citations and plan format are exactly what you receive.

Sample — fictional facility
FIND, Forensic Inspection, Navigation & Design

Sterile processing readiness assessment

Lakeside Surgery Center

Ambulatory surgery center · 4 ORs · orthopedics, ophthalmology

71

Overall score

58

Flagged items

3

Open severity 4

Score 71% is below 75%, with 3 open severity-4 items.

ReadinessHigh risk

Top three actions

  1. 1Install a plumbed or self-contained eyewash within 10 seconds of the sinks before survey. TJC EC.02.05.01 · DECON-032
  2. 2Add a dedicated hand-hygiene sink at the exit from the decontamination room. TJC IC.02.01.01 · DECON-004
  3. 3Route every loaner tray through the full decontamination cycle on receipt. TJC IC.02.02.01 EP 2 · DECON-051
Walk-through 3–4 Nov 2025 · Report issued 11 Nov 2025Page 1 of 14

Readiness dashboard

Lakeside Surgery Center · 3 Nov 2025
Compliant71
Needs improvement31
Non-compliant27
N/A18

Score by area · 7 of 15, lowest first

High-level disinfection
0
Process management
13
Opening
50
Training
50
Decontamination
62
Design
63
Distribution
64
Sample — fictional facilityPage 2 of 14

Findings · Decontamination

Area score 62 · 3 open
keyDECON-032Non-compliant4Severity 4: Critical

No eyewash station in decontamination

Install a plumbed or self-contained eyewash within 10 seconds of the sinks before survey.

TJC EC.02.05.01
keyDECON-004Non-compliant4Severity 4: Critical

No hand sink in decontamination

Add a dedicated hand-hygiene sink at the exit from the decontamination room.

TJC IC.02.01.01
Sample — fictional facilityPage 5 of 14

30/60/90-day corrective action plan

58 actions · 3 shown
30 daysdue 11 Dec 2025
DECON-032

Install plumbed eyewash station at decontamination sink wall

Owner Facilities directorVerify Weekly test log, photoIn progress
60 daysdue 10 Jan 2026
DECON-051

Route every loaner tray through full decontamination; update receiving policy

Owner SPD managerVerify Policy revision, 30 consecutive loaner recordsPlanned
90 daysdue 9 Feb 2026
DECON-004

Add a dedicated hand-hygiene sink at the decontamination exit

Owner Perioperative directorVerify Installation sign-off, photoPlanned
Sample — fictional facilityPage 11 of 14
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