Information
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Document No.
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Unit/Area
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Client / Site
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Surveyor
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Employee Name
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Badge ID#
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Role of Person Interviewed: (Support Associate, Environmental Services, Nurse, Technician, Technologist, CMA, CNA, Others)
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Prepared By:
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1. Cleaning carts are not left unattended in hallways.
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2. Cleaning carts are free of food and/or drinks.
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3. Secondary containers (e.g. Wet Task buckets) for cleaning or disinfectant agents are appropriate.
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4. Secondary containers (e.g., Wet Task buckets) are labeled appropriately with chemical name.
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5. Wet Task bucket lids are kept closed when not in use.
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6. Hand hygiene practices are correctly followed.
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7. Patient care areas are free of visible dirt, dust, or stains.
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8. Evidence of completion of terminal cleaning log daily.
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9. Verbalizes the use of appropriate cleaning solutions.
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10. Verbalizes contact time for all cleaning solutions used.
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11. Verbalizes how often mop bucket solutions are changed.
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12. Verbalizes how often mop heads are changed.
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13. Verbalizes 8-step cleaning process for non-isolation rooms.
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14. Verbalizes all 5 processes that are different for isolation rooms.
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15. Verbalizes what to do when patient furniture is damaged, such as permanent stains or rips in mattresses or pillows.
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16.Verbalizes what to do in the case of eye splash.
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17. Verbalizes training received to perform cleaning/ disinfection duties.
