EVS Compliance Rounds

• Audit Title

• Conducted on

  Date

• Inspected By

• Location
  Address

Division Appearance: (Overall First Impression of area/unit)

• Entrance to Area/Division Clean and Free of Debris/Dust?<br>

  Yes

  No

  N/A

Housekeeping Cart/Equipment:

• 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

• Disinfection wipe container lids closed and properly labeled?

  Yes

  No

  N/A

• Chemical Spray Bottles properly labeled?

  Yes

  No

  N/A

• Equipment clean? (Vacuums, buffers & carts)

  Yes

  No

  N/A

Housekeeping/Hopper Closet:

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

  Yes

  No

  N/A

• Chemical Dispensing unit in working condition?

  Yes

  No

  N/A

• Chemicals not stored above dry supplies, an below shoulder height? (Paper Products, Waste Bags.)

  Yes

  No

  N/A

• Eye Wash sheets properly dated/Signed-Initialed? (Unblocked)

  Yes

  No

  N/A

• Hopper Room locked when not in use?

  Yes

  No

  N/A

Safety Education:

• 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

• 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?)

  Yes

  No

  N/A

• Staff have knowledge of location of Fire Pull Stations?

  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 Wipes? (OR Only)

  Yes

  No

  N/A

• Clorox Bleach Wipes? (North Only)

  Yes

  No

  N/A

Soiled Utility Room:

• Soiled Utility rooms cleaned & organized?

  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) Foam In, Foam Out

  Yes

  No

  N/A