• Audit Title

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • No items stored under sinks?

  • Equipment / Furniture:<br> * Cleaned - Not visibly soiled

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

  • Compactor:<br> * is locked.<br> * area around it is clear of debris.

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

  • 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.<br>* cleaning supplies

  • Preventative Maintenance:<br> * Equipment checked with up to date PM sticker.

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

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

  • ID badges are worn appropriate?

  • PPE:<br> * Worn correctly<br> * Changed between tasks

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

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

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


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

  • Clean Linen:<br> * Clearly marked<br> * Covered on transport<br> * Covered on unit<br> * 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<br>

  • Stairwells and doors are clean.

  • Nourishment areas are clean

  • Med prep areas and Omnicell areas are clean<br>

  • Patient Rooms - Floor to ceiling clean.<br>

  • 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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.