E-Performance Standard Critical Standard
Title: Room Cleaning (3566/3502)
Description: Rooms will be cleaned in accordance with the EPS Sanitation Procedure Guide and the section titled “Environmental Management Service Operations”, established procedures, and supervisory instructions. Some examples within the guide include:
* Using proper PPE
* Clean from top to bottom
* Clean in a methodical manner
* Clean from cleanest to dirtiest
* The two-step processes
Fully Successful: No more than 1 deficiency per quarter (no more than 4 during the rating period).
Exceptional: No more than 2 deficiencies during the rating period.
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Title Page
Conducted on
Prepared by
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Is the housekeeping cart clean and free of debris?
Authorized products for floor care. Virex Plus for patient care rooms
Authorized products for floor care. Stride for public space areas
Authorized products for surface care. Clorox Peroxide wipes
Authorized products for surface care. Clorox bleach wipes for C-dif, sewage over flow, or feces
Crew bathroom cleaner with a Diversity label spray bottle. Label must include IFU.
Glance glass cleaner with a Diversity label spray bottle. Label must include IFU.
If there is anything on the cart other than these four approved chemicals, select non-compliant and take photos of the products.
Please provide a picture of the housekeeping cart interior for visual inspection.
If left alone, was the cart locked?
Kenneth Hood
Housekeeping cart
E-Performance Standard Critical Standard
Title: Room Cleaning (3566/3502)
Description: Rooms will be cleaned in accordance with the EPS Sanitation Procedure Guide and the section titled “Environmental Management Service Operations”, established procedures, and supervisory instructions. Some examples within the guide include:
* Using proper PPE
* Clean from top to bottom
* Clean in a methodical manner
* Clean from cleanest to dirtiest
* The two-step processes
Fully Successful: No more than 1 deficiency per quarter (no more than 4 during the rating period).
Exceptional: No more than 2 deficiencies during the rating period.
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You should independently determine whether the template is suitable for your circumstances.
