Title Page
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Location/Room #
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Conducted on
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Manager Conducting Audit
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EVS Staff Member Assigned
Door Surfaces
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Frames and Top Edges
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Push Plates/Handles
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Hinges
Walls and Wall Hangings
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Pictures/Frames
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Plastic Chair Rails around the Room
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Dry Erase Board
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Light Switches
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TV/Bracket
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Clocks free of dust
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Medical Equipment and Monitor
Ceilings
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Lights
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No Visible Spots on Ceilings or Tiles
Horizontal Surfaces
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Counters Clean
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Bedding - Clean no stains or tears
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Bed Rails
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Bed Frame
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Over the Bed Tables and Pull Outs clean
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Bedside NIght Stand - Inside and Outside Surfaces Clean. No Patient Belongings.
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TV Remote
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Phone Cords clean and Organized
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Chairs/Sofa clean including Legs
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Garbage cans - Clean, extra bags and Relined
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Tables and Legs Clean
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Mirrors - No Marks
Windows
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Glass Doors
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Windows - No Smears
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Window Sills
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Blinds/Curtains - No Spots
High Dusting
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Vents are clean and free of dust on outsides
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Over the Bed Light is free of dust
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Lift Track and it's Motor free of Dust
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Tops of cabinets are free of dust
Floors
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No build up in corners of floors
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Floors are clean
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Baseboards are clean
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No dust bunnies behind doors or equipment
Patient Bathroom
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Toilet clean on all inside and outside surfaces, under hinges, lid, etc.
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No streaking on shelves, paper towel dispensers or any stainless steel surface
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Shower clean and free of hair and debris in drain and clean shower curtain
Misc.
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Tent Card - Signed, dated and placed on the Over the Bed Table
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Sanitary Strip placed over toilet seat
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Toilet Paper folded in "V"
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Closet and Cabinets empty and clean
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Divider Drapes/Curtains free of spots and oil
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Employee Signature when Available
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Manager Performing Audit
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Comments:
