EVS - Joint Commission Readiness Rounds - 2018

• Audit Title

• Conducted on

  Date

• Inspected By

• Location
  Address

• Division/Location:

• Supervisor Coverage:

Division Observation:

• Corridor:

  Satisfactory

  Needs Attention

  N/A

• Waiting Room:

  Satisfactory

  Needs Attention

  N/A

• Public restroom:

  Satisfactory

  Needs Attention

  N/A

• Staff restroom:

  Satisfactory

  Needs Attention

  N/A

• Nurse Station:

  Satisfactory

  Needs Attention

  N/A

• Staff lounge:

  Satisfactory

  Needs Attention

  N/A

• Med room:

  Satisfactory

  Needs Attention

  N/A

• ASR/Supply Room:

  Satisfactory

  Needs Attention

  N/A

• Pantry:

  Satisfactory

  Needs Attention

  N/A

• Patient Room:

  Satisfactory

  Needs Attention

  N/A

• PACU/OR/Procedure Room:

  Satisfactory

  Needs Attention

  N/A

• Soiled Utility room:

  Satisfactory

  Needs Attention

  N/A

Chemical Disinfectant:

• Disinfection wipe container lids closed and labeled correctly?

  Yes

  No

  N/A

• Chemical Dispensing unit in working condition?

  Yes

  No

  N/A

• Staff have knowledge of Disinfectant? (Name of Disinfectant)

  Yes

  No

  N/A

• Performex?

  Yes

  No

  N/A

• Clorox Hydrogen Peroxide?

  Yes

  No

  N/A

• Staff have knowledge of what “Dwell/Kill Time” mean? (Item stays wet for the 5 minutes, to disinfectant and kill all germs), If drys re-wet item.

  Yes

  No

  N/A

Equipment/Hopper Closet:

• Housekeeping carts clean and functional, free of unnecessary item?

  Yes

  No

  N/A

• Housekeeping carts put away when not in use?

  Yes

  No

  N/A

• Equipment clean? (Vacuums, buffers & carts)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Eye Wash sheets properly dated? (Unblocked)

  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

• 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

• Hand Hygiene Being Performed? (Observation of Evidence)

  Yes

  No

  N/A