Housekeeping Environmental Surveillance

• Document No.

• Room/Area Being Evaluated

• Conducted on

  Date

• Prepared by

• Location
  Address

Personal Protective Equipment

• Perform Hand Hygiene?

  Yes

  No

  N/A

• Corrective Action

• Correct glove use?

  Yes

  No

  N/A

• Corrective Action

• Gown and Mask? (If applicable)

  Yes

  No

  N/A

• Corrective Action

High Traffic/ High Touch Areas Areas

• Door Knobs and Handles?

  Yes

  No

  N/A

• Corrective Action

• Door Surface?

  Yes

  No

  N/A

• Corrective Action

• Hand washing station/Sink Area?

  Yes

  No

  N/A

• Corrective Action

• Counter Tops?

  Yes

  No

  N/A

• Corrective Action

• Light Switches?

  Yes

  No

  N/A

• Corrective Action

• Chairs and Furniture?

  Yes

  No

  N/A

• Corrective Action

• Medical Equipment?

  Yes

  No

  N/A

• Corrective Action

• TV, Stands. Remote, Electronics. ?

  Yes

  No

  N/A

• Corrective Action

• Spot Clean Walls? (If Applicable)

  Yes

  No

  N/A

• Corrective Action

• Cabinet Doors and Handles?

  Yes

  No

  N/A

• Corrective Action

• Entire Hospital Bed Frame?

  Yes

  No

  N/A

• Corrective Action

• Supply tray/Mayo Stand?

  Yes

  No

  N/A

• Corrective Action

• Sharps Container?

  Yes

  No

  N/A

• Corrective Action

• Empty Trash and Replace Liner?

  Yes

  No

  N/A

• Corrective Action

Restrooms, IP Bathrooms, and/or Special Bathing (Only one area needs to be observed)

• Door and Door knob/handle?

  Yes

  No

  N/A

• Corrective Action

• Toilet Seat? (Horizontal Surface)

  Yes

  No

  N/A

• Corrective Action

• Toilet Flush Lever?

  Yes

  No

  N/A

• Corrective Action

• Sinks and Faucets?

  Yes

  No

  N/A

• Corrective Action

• Hand rails? (If applicable)

  Yes

  No

  N/A

• Corrective Action

• Tub or Shower? (If applicable)

  Yes

  No

  N/A

• Corrective Action

• Mirrors?

  Yes

  No

  N/A

• Corrective Action

Floors

• Wet mop entire floor?

  Yes

  No

  N/A

• Corrective Action

Post Cleaning

• Change dust/mop pad?

  Yes

  No

  N/A

• Corrective Action

• Properly Remove PPE?

  Yes

  No

  N/A

• Corrective Action

• Perform correct hand hygiene?

  Yes

  No

  N/A

• Corrective Action

• Room(s) appear presentable and clean?

  Yes

  No

  N/A

• Corrective Action

• Please confirm time and date

  Date

• By entering name, this acts as an electronic signature. Auditor please type name.