Patient Division - Environmental Quality Evaluation*

• Conducted on:

  Date

• Division/Location:

• Division Director:

• Division Manager:

• Prepared by EVS Management:

• Overall Summary:

PATIENT VISITATION:

• Since your stay have we met your expectations?

  Yes

  No

• Anything we can do to make your stay better?

  Yes

  No

PATIENT ROOM:

• PT. Room #

• 1. Overbed Table Cleaned?

  Yes

  No

  N/A

• 2. Night Stand Cleaned?

  Yes

  No

  N/A

• 3. Phone Cleaned?

  Yes

  No

  N/A

• 4. T.V Cleaned free of Dust?

  Yes

  No

  N/A

• 5. Picture Frame free of Dust?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 7. Closet Cleaned?

  Yes

  No

  N/A

• 8. Walls Cleaned?

  Yes

  No

  N/A

• 9. Vents Cleaned free of dust?

  Yes

  No

  N/A

• 10. Ceiling Cleaned?

  Yes

  No

  N/A

• 11. Door Cleaned?

  Yes

  No

  N/A

• 12. Door Handle Cleaned?

  Yes

  No

  N/A

• 13. Door Frame Cleaned?

  Yes

  No

  N/A

• 14. Waste Can Cleaned?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

• 16. Cubicle Curtain Cleaned & Fully Functional?

  Yes

  No

  N/A

• 17. Room Organized?

  Yes

  No

  N/A

PATIENT RESTROOM:

• 1. Toilet Bowl Cleaned?

  Yes

  No

  N/A

• 2. Sink Cleaned?

  Yes

  No

  N/A

• 3. Shower Cleaned?

  Yes

  No

  N/A

• 4. Shower Curtain Cleaned & Fully Functional?

  Yes

  No

  N/A

• 5. Supplies In Place?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

ANCILLARY AREA:

Ancillary Area 1:

• Location:

  Select ASR/Med Room Nurses Station Pantry Clean Utility Soiled Utility Staff Lounge Workroom Conference Room Office Exam Room Waiting Room

  • ASR/Med Room
  • Nurses Station
  • Pantry
  • Clean Utility
  • Soiled Utility
  • Staff Lounge
  • Workroom
  • Conference Room
  • Office
  • Exam Room
  • Waiting Room

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• a. Is access being granted to perform FloorCare?

  Yes

  No

Ancillary Area 2:

• Location:

  Select ASR/Med Room Nurses Station Pantry Clean Utility Soiled Utility Staff Lounge Workroom Conference Room Office Exam Room Waiting Room

  • ASR/Med Room
  • Nurses Station
  • Pantry
  • Clean Utility
  • Soiled Utility
  • Staff Lounge
  • Workroom
  • Conference Room
  • Office
  • Exam Room
  • Waiting Room

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• a. Is access being granted to perform FloorCare?

  Yes

  No

Corridor:

• 1. Walls Cleaned?

  Yes

  No

  N/A

• 2. Ceiling Cleaned?

  Yes

  No

  N/A

• 3. Ledges Cleaned?

  Yes

  No

  N/A

• 4. Vents Cleaned?

  Yes

  No

  N/A

• 5. Floors Cleaned?

  Yes

  No

  N/A

EVS COMPLIANCE:

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

  Yes

  No

  N/A

• Eye Wash sheets properly dated? (Unblocked)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hopper Room locked when not in use?

  Yes

  No

  N/A

• Housekeeping carts clean and free of unnecessary item?

  Yes

  No

  N/A

• Cart Locked and put away when not in use?

  Yes

  No

  N/A

• Equipment clean? (Vacuums, buffers & carts)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Performex?

  Yes

  No

  N/A

• Clorox Hydrogen Peroxide?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Staff have knowledge of location of Fire Pull Stations?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hand Hygiene Being Performed? (Observation of Evidence)

  Yes

  No

  N/A

• Signature By:

  Sign