Run Treatment Mat and Plinth Cleaning Verification — Free

Inspection Details

Area inspected is identified and matches the therapy treatment zone

Record the room, bay, or treatment area inspected.

Inspection date and time recorded

Document when the verification was completed.

Inspector name and role recorded

Enter the inspector's name and job title or role.

Cleaning log or patient turnover record available for review critical (required)

Confirm a log, checklist, or turnover record is present for the inspected area.

Yes No N/A

Between-Patient Disinfection

Treatment mat or plinth disinfected between patients critical (required)

Verify the patient-contact surface was cleaned and disinfected after the prior patient and before the next patient.

Yes No N/A

Visible soil or body fluid contamination addressed before disinfection critical (required)

Confirm gross contamination is removed before disinfectant application, per facility procedure.

Yes No N/A

Approved EPA-registered disinfectant used per label instructions critical (required)

Verify the product used is approved for the surface and applied according to the manufacturer's label and facility SOP.

Yes No N/A

Required wet contact time observed critical (required)

Record the observed or documented contact time for the disinfectant application.

Surface Condition and High-Touch Areas

Treatment surface visibly clean and free of residue

Check for dust, lint, stains, film, or disinfectant residue on the mat or plinth surface.

Yes No N/A

Edges, seams, straps, and adjustment points cleaned

Verify all accessible contact points and crevices were included in the cleaning process.

Yes No N/A

Pillows, bolsters, gait belts, or reusable accessories disinfected if used

Confirm any reusable patient-contact accessories used during treatment were cleaned and disinfected before reuse.

Yes No N/A

No damaged upholstery or torn surface that could prevent effective cleaning

Identify any cracks, tears, peeling, or other defects that compromise cleanability.

Yes No N/A

Infection Control Practices

Staff used appropriate PPE for the cleaning task critical (required)

Verify gloves and any additional PPE required by the disinfectant label or exposure risk were used.

Yes No N/A

Cleaning supplies stored and handled to prevent cross-contamination

Confirm clean and dirty supplies are separated and reusable cloths or wipes are not used in a way that spreads contamination.

Yes No N/A

Hand hygiene performed after cleaning task critical (required)

Verify hand hygiene was completed after removing gloves and finishing the cleaning process.

Yes No N/A

Cleaning procedure aligns with facility SOP and applicable infection prevention guidance

Confirm the observed process matches the department procedure for environmental cleaning in patient-care areas.

Yes No N/A

Documentation and Follow-Up

Cleaning completion documented for the inspected patient turnover critical (required)

Verify the log shows the cleaning event was recorded for the relevant patient encounter or turnover.

Yes No N/A

Deficiencies or non-conformances documented with corrective action

Record whether any issues were identified and whether follow-up action was assigned.

Yes No N/A

Inspector signature completed

Signature confirming the inspection review is complete.

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Run: Treatment Mat and Plinth Cleaning Verification

Inspection Details

Between-Patient Disinfection

Surface Condition and High-Touch Areas

Infection Control Practices

Documentation and Follow-Up

Get your results