Title Page
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Department audited
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Site audited
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Date audited
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Conducted by
Environment
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Floors/Walls clean, no dust or trash noted
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Ceiling tiles appropriately placed & free from water stains or holes
Staff Area
Clean Utility Room
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Linens covered
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No storage on floor
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No dirty items stored here
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Storage is 18in from sprinkler heads
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No external/shipping boxes
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Room is clutter-free and clean (walls,floor, high dusting)
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Entry door not propped open (kept closed except for entry/exit)
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Only clean equip stored here, if any
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No supplies left in equipment drawers/baskets/cubbies (discarded during cleaning/disinfecting of equip)
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Hand hygiene available upon entering/exiting room
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No porous or unwipe-able items noted (e.g., paper, tape, adhesive residue, torn chairs, peeling tape/labels, etc)
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No food or drinks
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Dirty Utility Room
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No storage on floor
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No clean items, clean equip, or patient care supplies stored here
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Biohazard containers labeled as such; covered, and not overflowing
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Room is clutter-free and clean (walls, floor, high dusting)
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Entry door not propped open (kept closed except for entry/exit)
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Hand hygiene available upon entering/exiting room
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No porous or unwipe-able items noted (e.g., paper, tape, adhesive residue, torn chairs, peeling tape/labels, etc)
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No food & drinks
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