Title Page

  • Conducted on:

  • Division/Location:

  • Division Director:

  • Division Manager:

  • Prepared by EVS Management:

  • Overall Summary:

PATIENT VISITATION:

  • Since your stay have we met your expectations?

  • Anything we can do to make your stay better?

PATIENT ROOM:

  • PT. Room #

  • 1. Overbed Table Cleaned?

  • 2. Night Stand Cleaned?

  • 3. Phone Cleaned?

  • 4. T.V Cleaned free of Dust?

  • 5. Picture Frame free of Dust?

  • 6. Overbed Light Cleaned free of Dust? (Discharge Only)

  • 7. Closet Cleaned?

  • 8. Walls Cleaned?

  • 9. Vents Cleaned free of dust?

  • 10. Ceiling Cleaned?

  • 11. Door Cleaned?

  • 12. Door Handle Cleaned?

  • 13. Door Frame Cleaned?

  • 14. Waste Can Cleaned?

  • 15. Floors Cleaned? (Per Daily Cleaning Procedure)

  • a. Is access being granted to perform FloorCare in Patient Room?

  • 16. Cubicle Curtain Cleaned & Fully Functional?

  • 17. Room Organized?

PATIENT RESTROOM:

  • 1. Toilet Bowl Cleaned?

  • 2. Sink Cleaned?

  • 3. Shower Cleaned?

  • 4. Shower Curtain Cleaned & Fully Functional?

  • 5. Supplies In Place?

  • 6. Floors Cleaned? (Per Daily Cleaning Procedure)

ANCILLARY AREA:

Ancillary Area 1:

  • Location:

  • 1. Cabinets Cleaned?

  • 2. Counters Cleaned?

  • 3. Sinks Cleaned?

  • 4. Walls Cleaned?

  • 5. Ceiling Cleaned?

  • 6. Ledges Cleaned?

  • 7. Vents Cleaned?

  • 8. Wastecans Cleaned & Freshly Lined?

  • 9. Supplies in Place?

  • 10. Floors Cleaned? (Per Daily Cleaning Procedure)

  • a. Is access being granted to perform FloorCare?

Ancillary Area 2:

  • Location:

  • 1. Cabinets Cleaned?

  • 2. Counters Cleaned?

  • 3. Sinks Cleaned?

  • 4. Walls Cleaned?

  • 5. Ceiling Cleaned?

  • 6. Ledges Cleaned?

  • 7. Vents Cleaned?

  • 8. Wastecans Cleaned & Freshly Lined?

  • 9. Supplies in Place?

  • 10. Floors Cleaned? (Per Daily Cleaning Procedure)

  • a. Is access being granted to perform FloorCare?

Corridor:

  • 1. Walls Cleaned?

  • 2. Ceiling Cleaned?

  • 3. Ledges Cleaned?

  • 4. Vents Cleaned?

  • 5. Floors Cleaned?

EVS COMPLIANCE:

  • Disinfection wipe container lids closed and labeled correctly? Chemical Dispensing unit in working condition?

  • Eye Wash sheets properly dated? (Unblocked)

  • Hopper rooms clean and in order? (No unnecessary items)

  • Hopper Room locked when not in use?

  • Housekeeping carts clean and free of unnecessary item?

  • Cart Locked and put away when not in use?

  • Equipment clean? (Vacuums, buffers & carts)

  • Staff have knowledge of R.A.C.E. (Rescue Alarm Contain Extinguish) and P.A.S.S. (Pull Aim Squeeze Sweep.)?

  • Staff have knowledge of Dwell time for Disinfectant? (Name of Disinfectant)

  • Performex?

  • Clorox Hydrogen Peroxide?

  • Does staff have knowledge of SDS? What is SDS? (Safety Data Sheets) Where is the SDS information located?

  • P.P.E. Available? (Gloves, Goggles is there evidence of use?) Hand Hygiene Being Performed? (Observation of Evidence)

  • Staff have knowledge of location of Fire Pull Stations?

  • Green Trash & Red Bio Hazard carts cleaned & lined? (McClure Carts)

  • Hand Hygiene Being Performed? (Observation of Evidence)

  • Signature By:

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