*Environmental Quality Evaluation - E.Q.E.*

• Division/Location

• Conducted on

  Date

• Prepared by

PATIENT ROOMS

Patient Room 1

• 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?

  Yes

  No

  N/A

• 7. Closet Cleaned?

  Yes

  No

  N/A

• 8. Walls Cleaned?

  Yes

  No

  N/A

• 9. Vents Cleaned free of Lint?

  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?

  Yes

  No

  N/A

• 16. Cubicle Curtain Cleaned?

  Yes

  No

  N/A

• 17. Cubicle Curtain Functional?

  Yes

  No

  N/A

• 18. Room Organized?

  Yes

  No

  N/A

Patient Restroom 1

• 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?

  Yes

  No

  N/A

• 5. Shower Curtain Functional ?

  Yes

  No

  N/A

• 6. Supplies In Place?

  Yes

  No

  N/A

• 7. Floors Cleaned?

  Yes

  No

  N/A

Patient Room 2

• 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?

  Yes

  No

  N/A

• 7. Closet Cleaned?

  Yes

  No

  N/A

• 8. Walls Cleaned?

  Yes

  No

  N/A

• 9. Vents Cleaned free of Lint?

  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?

  Yes

  No

  N/A

• 16. Cubicle Curtain Cleaned?

  Yes

  No

  N/A

• 17. Cubicle Curtain Functional?

  Yes

  No

  N/A

• 18. Room Organized?

  Yes

  No

  N/A

Patient Restroom 2

• 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?

  Yes

  No

  N/A

• 5. Shower Curtain Functional ?

  Yes

  No

  N/A

• 6. Supplies In Place?

  Yes

  No

  N/A

• 7. Floors Cleaned?

  Yes

  No

  N/A

WAITING ROOM / Public Restroom

• Location:

• Overall condition of the waiting room cleaned?

  Yes

  No

  N/A

• Location:

• Overall condition of the public restroom cleaned?

  Yes

  No

  N/A

ANCILLARY AREA

Ancillary Area 1

• Location:

• 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?

  Yes

  No

  N/A

Ancillary Area 2

• Location:

• 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?

  Yes

  No

  N/A

FLOORCARE

Floorcare 1

• Location:

• 1. Baseboard Cleaned?

  Yes

  No

  N/A

• 2. Corners Cleaned?

  Yes

  No

  N/A

• 3. Edges Cleaned?

  Yes

  No

  N/A

• 4. Floors Finished / Carpet Clean?

  Yes

  No

  N/A

Floorcare 2

• Location:

• 1. Baseboard Cleaned?

  Yes

  No

  N/A

• 2. Corners Cleaned?

  Yes

  No

  N/A

• 3. Edges Cleaned?

  Yes

  No

  N/A

• 4. Floors Finished / Carpet Clean?

  Yes

  No

  N/A

ENVIRONMENTAL ROUNDS

Personal Protective Equipment

• 1. Gloves?

  Yes

  No

  N/A

• 2. Eye Goggles?<br>

  Yes

  No

  N/A

Chemical

• 1. Disinfection wipe container lids closed and labeled correctly?

  Yes

  No

  N/A

• 2. Chemical Dispensing unit in working condition?

  Yes

  No

  N/A

• 3. Disinfectant Wipe/bottle properly Dated?

  Yes

  No

  N/A

Hopper Closet

• 1. Closet cleaned & organized?

  Yes

  No

  N/A

• 2. Eye Wash Station Clean & Checked?

  Yes

  No

  N/A

• 3. Work Charts Available?

  Yes

  No

  N/A

• 4. Housekeeping Cart Clean & Orderly?

  Yes

  No

  N/A

Stairwell/Elevator

• Location:

• 1. Elevator Tracks / Door Clean?

  Yes

  No

  N/A

• Location

• 2. Stairwell Clean free of Dust/Litter?

  Yes

  No

  N/A

• 3. Stairwell Ledges / Handrails Clean?

  Yes

  No

  N/A