Environmental Services

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

• Staff Name

1.0 Key Rounding Questions

• 1.1 What is working well?

  Yes

  No

  N/A

• 1.2 What staff should I recognize?

  Yes

  No

  N/A

• 1.3 Do you have the tools and equipment you need to do your job?

  Yes

  No

  N/A

• Is there anything I can help you with right now?

  Yes

  No

  N/A

2.0 Outer Building Appearance

• 2.1 Are the hours of operation posted?

  Yes

  No

  N/A

• 2.2 Are hedges neatly trimmed around the building?

  Yes

  No

  N/A

• 2.3 Are the flower beds neat and free of trash and debris?

  Yes

  No

  N/A

• 2.4 Does the building need to be pressure washed?

  Yes

  No

  N/A

• 2.5 Are the tobacco free signs posted for the public to see?

  Yes

  No

  N/A

• 2.6 Are all signs appropriate and in good condition?

  Yes

  No

  N/A

3.0 Patient Waiting Area

• 3.1 Are the Notice of Privacy Practice booklets available for patients?

  Yes

  No

  N/A

• 3.2 Are the CHSI and SGHS pamphlets displayed in a brochure rack?

  Yes

  No

  N/A

• 3.3 Is there a hand sanitizer with drip tray in waiting area?

  Yes

  No

  N/A

• 3.4 Is the patient waiting area clean and free of clutter?

  Yes

  No

  N/A

• 3.5 Is the television turned to an appropriate channel?

  Yes

  No

  N/A

• 3.6 Is the Missed Appointment Policy displayed for patient review?

  Yes

  No

  N/A

• 3.7 The Patient Bill of Rights with the HIPPA contact is posted in plain view for patients?

  Yes

  No

  N/A

• 3.8 Are there drug company pamphlets and/or advertisements in the waiting area?

  Yes

  No

  N/A

• 3.9 Does the practice have a clock in the patient waiting area?

  Yes

  No

  N/A

• 3.10 The "No Cell Phone" or "Silence Your Cell Phone" sign is posted in patient waiting area?

  Yes

  No

  N/A

• 3.11 The "Co-Payment is Due at the Time of Service" sign is posted at patient check-in?

  Yes

  No

  N/A

• 3.12 Are magazine subscriptions out of date?

  Yes

  No

  N/A

• 3.13 Is the furniture in good repair?

  Yes

  No

  N/A

4.0 Reception Area

• 4.1 Are team members wearing identification badges?

  Yes

  No

  N/A

• 4.2 Are signs and notices taped to the glass or walls?

  Yes

  No

  N/A

• 4.3 Is the approved Return Check notice affixed to window?

  Yes

  No

  N/A

• 4.4 Are team members aware of prompt pay discount? Employee discount?

  Yes

  No

  N/A

• 4.5 Are patients greeted promptly and cheerfully?

  Yes

  No

  N/A

• 4.6 Are team members familiar with the Financial Assistance program for self pay patients?

  Yes

  No

  N/A

• 4.7 Are patients notified appropriately of provider delays?

  Yes

  No

  N/A

• 4.8 Is there a patient sign-in sheet available?

  Yes

  No

  N/A

5.0 Patient Exam Rooms

• 5.1 Are there locks on the exam room doors?

  Yes

  No

  N/A

• 5.2 Are the walls / floors scuffed and dirty?

  Yes

  No

  N/A

• 5.3 Are there signs taped to the walls in the exam rooms?

  Yes

  No

  N/A

• 5.4 Are there clocks in the exam rooms?

  Yes

  No

  N/A

• 5.5 Are the equipment and furniture in good repair?

  Yes

  No

  N/A

• 5.6 Are the exam rooms stocked with supplies?

  Yes

  No

  N/A

• 5.7 Do the exam rooms appear to be clean and clutter free?

  Yes

  No

  N/A

• 5.8 Are there Sharps Containers in each exam room?

  Yes

  No

  N/A

• 5.9 Are the Sharps Containers full?

  Yes

  No

  N/A

7.0 Bathrooms

• 7.1 Are bathrooms cleaned and stocked?

  Yes

  No

  N/A