No items stored under sinks?

Equipment / Furniture:
* Cleaned - Not visibly soiled

Potential safety hazards: Housekeeping & Laundry buckets are attended or locked up. All fluids are labeled.

* is locked.
* area around it is clear of debris.

Hazardous rooms are locked: EVS closets, & supply closets are locked?
* only appropriate items are contained in closets.

Hazardous chemicals and flammable agents are labeled and stored properly.

What is the "dwell" time when using cleaning supplies?

What is the approximate number of mops used per patient room including bathroom?

No outer shipping carton boxes in patient care areas.

No expired items.
* cleaning supplies

Preventative Maintenance:
* Equipment checked with up to date PM sticker.

Food and drink in designated areas:
* No evidence of it in patient rooms/areas, perches, EVS closets, or on carts.

Hand Hygiene Products:
* No empty alcohol gel bottles
* No empty soap or paper towels
* No unapproved lotions

ID badges are worn appropriate?

* Worn correctly
* Changed between tasks

How do you clean up a blood/body fluid spill - with what?

Biohazard Waste:
* Discard in Red Bags with a biohazard symbol.
* Not overfilled
* Covered when transported

Sharps Waste:
* Discard in a designated sharps container with a biohazard symbol.
* Not overfilled
* Closed and locked when transported


Soiled Linen:
* Properly stored
* Covered at storage
* Covered on transport
* Not overfilled
* Cart has solid bottom

Clean Linen:
* Clearly marked
* Covered on transport
* Covered on unit
* Has solid bottom

Linen handling occurs with minimum agitation to avoid environment contamination.

Soiled linen is held out away from the body to avoid personal contamination.

Soiled linen are bagged and contained at point of collection in leak proof container.

How/Is hand hygiene performed correctly during linen stocking procedures.


Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

No dust on surfaces.

Floors are clean and scrubbed

Stairwells and doors are clean.

Nourishment areas are clean

Med prep areas and Omnicell areas are clean

Patient Rooms - Floor to ceiling clean.

Vents are clean.

Windows and treatments are clean and free of dust.

Do you clean the vitals equipment and how often?

Drinking fountains are clean.


Greet the team with smiles and introductions.

Have a space designated for the team to conduct interviews and file reviews.

Promptly deliver materials required for review to the tracer team.

Any additional comments regarding positive or suboptimal issues observed during the tracer.

Surveyors Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.