Housekeeping Checklist (Precautions/Terminal clean)- Long Form

Service Provider: __________________ Site: ___________ Date: _____________

Housekeeper Name: _________________ Auditor Name/Title: _______________________
Unit / Room: ___________ Cubicle #:___ Room type:  Patient room  Other _________
 Precautions / Precautions Plus  Terminal Clean

Precaution
TASK

Plus 
Complete in the ACTION 
following order 1-15
Assemble microfiber cleaning products, mop handle/heads, mop bucket/wringer, putty knife,
grout brush, scrub pad, toilet bowl brush, and garbage bags for your housekeeping cart.
Collect ladder for wall, ceiling washing and curtain changing.
1 Cart Assembly Fill buckets or squirt bottles with appropriate cleaning /disinfectant solutions e.g. glass
cleaner, cream cleanser, and toilet bowl cleaner on your housekeeping cart at required
concentration.
Position cart just outside the room door.
2 Linen & Garbage Place open laundry receptacle and garbage bag outside the room door.
Personal Protective Follow Infection Control Precautions sign posted outside the room for appropriate PPE to be
3 Equipment (PPE) used. Housekeeper to follow the sequence for “putting on” (donning) Personal Protective
Selection/ Putting On Equipment (PPE).
Ensure all patient belongings, equipment, medical devices and containers of bodily fluids
have been removed from the room following appropriate cleaning.
Report to Nursing Staff any personal belongings, unused medical supplies or patient care
items that are left in the room.
DO NOT start cleaning the room until Nursing has removed and/or appropriately disposed of
the items.
Check bathroom for personal hygiene disposable items e.g. soap, toothpaste and exposed
Room Preparation unused supplies (toilet paper, paper towels, tissues, boxes of gloves etc.) Discard these items
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for Cleaning into garbage bag. Check bedside table, drawers, cabinets, and closet for any disposable
items, and patient care items e.g. bedpans, urinals, and washbasins, toilet brush etc and
handle/dispose of as appropriate.
Check sharps containers, close & remove if ¾ full.
Remove garbage from waste containers, and discard any waste can liners. Place in garbage
bag without compressing bag. Wipe interior, exterior & bottom of waste containers.
Place all towels, washcloths, etc. into laundry receptacle.
Carefully loosen linen from corners of bed. Roll linen into a bundle & place into laundry
receptacle. If a cloth pillow, place in laundry receptacle. If vinyl, disinfect when bed is
cleaned.
5 Linen Removal Remove cubicle curtains and shower curtains and place in laundry receptacle. Use ladder as
appropriate.
Remove window curtains and place in laundry receptacle.
Using the appropriate color microfiber cloth from the bucket, thoroughly clean each surface
below using the “rub and scrub” technique:
* Wash walls from top to bottom & from windows to room entrance door.
6 Walls / Ceilings Included in wall washing are all wall bumpers, light switches, ceiling tracks, vertical and
horizontal pipes/cords. Ensure all tape and adhesive residue is removed.
* Wash ceiling as required.
Report to Housekeeping Supervisor if unable to clean any item due to FMO issues.
Use the appropriate colored microfiber cloth from the bucket, for each item unless the cloth
becomes soiled or dry. Thoroughly clean each surface as described below using the “rub and
Patient scrub” technique:
Wipe call bell cord, medical gas controls, leads, over bed light cord and switch.
Contact Remove any gauze/tape and residue.
7 Wipe entire base and receiver of telephone & cords
Items Wipe entire chair(s) including all arms & patient lifts surfaces.
Unplug television. Wipe TV, remote control devices, support stand/brackets, and cords.
Clean screen with glass cleaner.
Plug TV back in when cleaning is complete.
Wipe entire door including door hardware e.g. knob/handle/door frame.
Ensure all scuff marks, tape and adhesive residue etc. is removed.

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 Housekeeping Checklist (Precautions/Terminal clean)- Long Form
Wipe over bed/ bedside table inside and out.
Pay particular attention to the inside corners of the drawers & all horizontal and HT contact
surfaces. Ensure all pen marks, tape and adhesive residue is removed. Thoroughly clean
Patient the bed as described below using the “rub and scrub” technique:
* Raise bed up to a comfortable level for cleaning.
* Unplug bed and move away from wall.
Contact
* Wipe pillow. Wipe mattress top, side and bottom. Allow to dry.
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* Raise head and foot sections of the beds to clean bed frame.
Items
* Wipe h top of bed frames before putting mattress down.
* Remove and wash headboard and footboard (if removable) and clean underneath.
continued
Replace headboard and footboard if removable.
* Wipe handrails including bed controls & remove all residue (e.g. tape)

Report to Housekeeping Supervisor if unable to clean any item due to FMO issues.
Use the appropriate colored microfiber cloth from the bucket, for each item unless the
cloth becomes soiled or dry. Thoroughly clean each surface as described below using the
“rub and scrub” technique:
* Wipe curtain rods, picture frames, bulletin boards, all shelves and vents
Miscellaneous * Wipe windows. Wipe down window sills, ledges and hardware.
surfaces, ledges, * Non-removable window blinds must be fully cleaned (roll down) both side with
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sills, furnishings, a damp cloth. Allow to dry and then roll back up.
lights etc * Wipe alcohol based hand dispensers , sinks , counters, all shelves and wall behind and
under common sink in patient room
* Wipe medical equipment e.g. suction apparatus holders, sharps containers, hand hygiene
products, over bed lights & any other permanently attached item.
Wipe heating devices, radiators, ducts and vents
Clean all patient equipment left in room and place outside the room, e.g. commodes,
9 Patient Equipment
wheelchairs, geri-chairs, lifting devices, and IV poles, etc.
Using the appropriate colored microfiber cloth from the bucket, thoroughly clean each
surface below using the “rub and scrub” technique:
* Clean from top to bottom and cleanest to dirtiest area.
* Clean all walls (top to bottom), light switches, assist rails and shelves.
10 Bathroom * Clean shower/tub
* Wipe down handrails, call bell cord, door knob and dispensers e.g. soap/ toilet
paper and paper towel inside and out.
* Clean sink /faucet, counter and mirror.
* Clean toilet, toilet seat (top and underside), flush handle (clean last),
followed by the floor area around the toilet.
Place “Wet Floor” sign at room entrance. Using the appropriate colored microfiber product, wet
mop floors using the “rub and scrub” technique. Pay particular attention to corners and edges,
Floors behind doors, under furniture and around the toilet remembering to use 1 mop per room.
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DO NOT DUST MOP FLOORS. Wet mop bathroom floor last.
Place soiled mop heads & cleaning cloths in appropriate bags for laundering.
Follow Infection Control Precautions Sign posted outside the room for appropriate sequence for
12 PPE removal “removing” (doffing) Personal Protective Equipment (PPE). Place PPE in garbage bag and tie off
without compressing bag.
Retrieve clean linen from linen cart.
Make bed(s)
Room Preparation Re-hang window curtains (if necessary), bedside curtain & shower curtain.
13 and Restocking Replenish paper products e.g. toilet paper, toilet bowl brush, paper towels, tissues, soap, hand hygiene
after Cleaning products, etc.
Replace any patient care items e.g. bedpans, urinals, and washbasins etc.
Ensure all furniture is returned to proper location(s)
Check the room before leaving, ensuring a complete clean has been performed
and the room is ready for patient occupancy.
Wash hands and forearms before leaving room.

14 Final Check Report to Housekeeping Supervisor any damage, repairs required or any other FMO issues.
Housekeeping checklist is complete, signed off and given to Housekeeping Supervisor/ or Manager.
Remove and clean the Infection Control Precaution sign. Flip over and replace in Plexiglas holder (if
appropriate). Otherwise remove and clean sign & return to the Nursing Station.
Discard cleaner/disinfectant from bucket(s).
Wash hands and forearms and put on new gloves.
Thoroughly clean and sanitize bucket(s), wringer and mop handle.

15 Equipment Cleanup Remove gloves and wash hands and forearms.

Fill bucket with cleaner/disinfectant for next task.
TERMINAL CLEAN: Notify “Tele tracking” or Unit that the room is cleaned and ready for patient
occupancy.

Revised October 2012 (VIHA ESS Contract Admin/Infection Prevention and Control) Page 2 of 2