Application Date

Facility Name

Mailing Address

Website

Application Contact

Title

Phone

Email

CEO or Medical Director Name

Title

Phone

Email

Facility Size

Total Staff

Full Time

Part Time

Full Time Equivalents - FTEs

Has your facility, organization or institution received any formal accreditation?
YesNo

If YES, please indicate accreditation agency:

Date of acceptance:

If accepted, please indicate the facility, organization or institution’s name you would like to use on the Certificate of Professional Acceptance

By checking the following statements in “B” and “C”, I agree and attest to each item.

B. Specific to Pathogen and Infection Control Training:

All hygiene policy and procedures are documented / updated.

Date

all staff and practitioners have received training on cleaning and sanitation / disinfection methods.

reception area, bathroom and all communal areas have appropriate signage specific to personal hygiene in public and patient / patron areas.

reception area, bathroom and all communal areas have ‘personal use’ disinfectant solutions for killing germs & bacteria.

practitioner and/or care provider spaces have appropriate ‘personal use’ disinfectant solutions for killing germs & bacteria.

practitioner and/or care provider spaces have appropriate equipment cleaning and disinfectant solutions for killing germs & bacteria readily available.

all practitioner and/or care providers use ‘personal protective equipment’ (PPE) – gowns, gloves, and, masks / eye protection as appropriate.

all practitioner and/or care providers change disposable gloves with every patient / patron encounter and place disposable gloves on in front of patient / patron.

all practitioner and/or care providers wash hands thoroughly in front of patient / patron.

all practitioner and/or care providers do not cough in front of on patient / patron.

evidence of ‘SHARPS” injury prevention and disposal is routinely practiced.

contaminated laundry is appropriately bagged and labeled.

hygiene standards are posted in staff lavatories and other communal gathering areas.

a written exposure control plan has been developed & taught to all practitioner and/or care providers.

breach of protocols or related hygiene incidents are recorded, with follow-up actions noted.

breach of protocols or related hygiene incidents are recorded, with follow-up actions noted.

C. Proper Cleaning and Disinfecting for Facility, Equipment & Product:

all staff are required to complete maintenance, cleaning and disinfection solutions & procedure training.

documented evidence of proper cleaning for facility and equipment to include:

scheduled floor cleaning (and disinfecting, where appropriate)

wide spectrum disinfection agents are used after cleaning

there is a separation of cloths and applicators used for cleaning vs. disinfection

cloths and applicators used for cleaning vs. disinfection are changed frequently

cloths and applicators used for cleaning vs. disinfection are laundered or disposed of appropriately and are NOT kept in a closed, combustible location.

products / solutions used for cleaning and disinfection should be suited for the elimination of disease-causing agents to include:

MRSA - Methicillin-Resistant Staphylococcus Aureus

Candida

Streptococcal bacteria

Staphylococcus bacteria

Escherichia Coli

HPV – Human Papillomavirus

D. Attestations:

Agree to provide Medical Wellness Association (MWA) all information as requested and necessary for MWA to perform the services to be rendered under this certification agreement. The parties agree and acknowledge that MWA shall be able to rely on such information as provided by the Client’s signed representative(s) and that all information shared between both parties in connection with this document shall remain confidential, to be used only for the purposes herein intended.

Agreed Expectations:

MWA will:
1. Respect the confidentiality of the process and outcomes and not share outside of {client} except where permission is granted by {client's} designated representative to use agreed information or outcomes as 'distinguished examples' in other presentations or projects,
2. Involve {client} in the process, showing respect for and responding to questions and calls, providing feedback on whether or not suggestions offered by staff would work in specific situations, and, evaluating to determine if the established process outcomes where truly met by the changes implemented,
3. Understand and follow {client’s} chain of command, with the designated representative serving as primary contact and his/her receiving sensitive materials in advance for review prior to distribution to other parties, if needed.
CLIENT will:
1. Provide MWA with requested materials to start application process and keep to desired time frames,
2. Collaborate on developments, needs and assignments,
3. Respect the confidentiality of all the materials that are considered "MWA proprietary" and do not use for purposes other than the internal benefit of {client}.
BOTH PARTIES will:
1. Provide open and honest communication and dialogue.

I attest that myself, all practitioner and/or care providers, and our facility, will follow the accepted standards on hygiene and infection control; and, I further attest to the validity and reliability of the protocols and processes as well as the evaluative, cleaning & disinfection products used in conjunction with our hygiene standards and infection controls used at the facility named above.