EVS Inspection Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

FIRST IMPRESSION AREAS

• 1. Are the entrances clean and free of debris?

  Yes

  No

  N/A

• 2. Are the rugs at entrances clean? Are they positioned appropriately to capture debris?

  Yes

  No

  N/A

• 3. Is the furniture in place? Is the furniture stain free?

  Yes

  No

  N/A

• 4. Are the magazines in order? Any magazines that need to be discarded?

  Yes

  No

  N/A

• 5. Are the Hallways clean and free of dust bunnies; wet spots, and debris?

  Yes

  No

  N/A

• 6. Are the carpets free of stains?

  Yes

  No

  N/A

• 7. Has the carpet been vacuumed?

  Yes

  No

  N/A

• 8. Are the sanitizer dispensers clean?

  Yes

  No

  N/A

• 9. Are the trash cans empty or under 3/4 full? Are they clean on the outside?

  Yes

  No

  N/A

• 10. Is the housekeeping cart properly stored if left unattended?

  Yes

  No

  N/A

• 11. Are the EVS closets; trash rooms; bio hazard rooms locked?

  Yes

  No

  N/A

GENERAL CLEANING

• 1. Are the telephones clean?

  Yes

  No

  N/A

• 2. Is the Bedside Table clean?

  Yes

  No

  N/A

• 3. Is the Call Button clean?

  Yes

  No

  N/A

• 4. Is the Remote Clean?

  Yes

  No

  N/A

• 5. Are the cabinets clean & free of any items?

  Yes

  No

  N/A

• 6. Are the counters and desk tops clean?

  Yes

  No

  N/A

• 7. Are the keyboards clean?

  Yes

  No

  N/A

• 8. Is the bed clean?- including head board; foot board; bed frame; mattress; bed power cables; and side rails free of residue. <br><br>

  Yes

  No

  N/A

• 9. Is the furniture clean? Including couch(inside couch); recliner; chair

  Yes

  No

  N/A

• 10. Are the sinks clean?

  Yes

  No

  N/A

• 11. Are the Over Head Exam lights clean?

  Yes

  No

  N/A

• 12. Are the walls clean? Free of holes, blood spots, spots?

  Yes

  No

  N/A

• 13. Are trash cans clean? Inside and outside of trash can

  Yes

  No

  N/A

• 14. Are the doors clean? Including door handles.

  Yes

  No

  N/A

• 15. Are the door frames & hinges clean and free of dust?

  Yes

  No

  N/A

• 16. Are the windows or glass surfaces clean?

  Yes

  No

  N/A

• 17. Is the curtain in the room clean? Free of blood spots or non soiled.

  Yes

  No

  N/A

• 18. Has the floor been mopped?

  Yes

  No

  N/A

RESTROOM CLEANING

• 1. Are the sinks clean?

  Yes

  No

  N/A

• 2. Are the walls clean?

  Yes

  No

  N/A

• 3. Are the Mirrors clean?

  Yes

  No

  N/A

• 4. Are the dispensers full? Toilet paper, paper towels, soap, shower soap.

  Yes

  No

  N/A

• 5. Are the batteries in the dispensers good?

  Yes

  No

  N/A

• 6. Is the Shower or Bath Tub clean?

  Yes

  No

  N/A

• 7. Is the curtain clean? Free of blood spots or non soiled.

  Yes

  No

  N/A

• 8. Is the toilet clean?

  Yes

  No

  N/A

• 9. Are the Trash Cans clean?

  Yes

  No

  N/A

DUSTING

• 1. Is the low dusting good? This includes everything under 6 1/2 ft.<br>Window ledges, counter tops, computers, dispenser stations, fire doors, chairs, etc.

  Yes

  No

  N/A

• 2. Is the high dusting good? This includes everything over 6 1/2 ft. <br>Vents; tops of TV's; tops of ice machines, window blinds, vanity in patient rooms, tops of lockers; etc.

  Yes

  No

  N/A

FLOOR CARE

• 1. Is the floor care (VCT tile or slate); compliant to floor care standards regarding stripping process?<br><br>Do you notice any yellowing; browning in heavy traffic areas; or low wax levels.

  Yes

  No

  N/A

• 2. Is the floor care(VCT tile or slate); compliant to floor care standards regarding scrubbing & top coating process?<br><br>Do you notice any surface dirt; uneven wax levels; browning; low wax levels; etc.

  Yes

  No

  N/A

• 3. Is the floor care (Carpet); compliant to floor care standards regarding extraction process?<br><br>Do you notice heavy chemical build up; browning; heavy soil build-up; heavy spots; etc.

  Yes

  No

  N/A

• 4. Is the floor care (Carpet); compliant to floor care standards regarding spots, streaks, light spills, or vacuuming?

  Yes

  No

  N/A

FLOOR CARE DETAIL

Tile or Slate

• 1. Dust mopping good

  Yes

  No

  N/A

• 2. Mopping good

  Yes

  No

  N/A

• 3. Corners/Edges good

  Yes

  No

  N/A

• 4. Baseboards good

  Yes

  No

  N/A

• 5. Streaks good

  Yes

  No

  N/A

• 6. Burn marks good

  Yes

  No

  N/A

• 7. Vacuuming good

  Yes

  No

  N/A

Carpet

• 1. Vacuuming is good

  Yes

  No

  N/A

• 2. Corners-Edges are good

  Yes

  No

  N/A

• 3. Baseboards are good

  Yes

  No

  N/A

• 4. Spotting performed is good

  Yes

  No

  N/A

EQUIPMENT CLEANING

• 1. Equipment is clean

  Yes

  No

  N/A

• 2. Reservoir tanks are emptied<br><br><br>T-3 machines, wet vac machines, extractor, slow speeds, etc.

  Yes

  No

  N/A

• 3. No frayed wires

  Yes

  No

  N/A

• 4. Batteries are filled with distiller water to the appropriate level

  Yes

  No

  N/A

• 5. Put back in appropriate area

  Yes

  No

  N/A

• 6. Equipment needing to be charged are plugged in appropriately and covers are propped open for proper ventilation

  Yes

  No

  N/A

• 7. Equipment Brushes are clean. <br><br>Extractor, slow speed, vacuum, etc.

  Yes

  No

  N/A

• 8. Squeegees are clean and rotated appropriately

  Yes

  No

  N/A

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