MMH Environmental Services Inspection Checklist

• Conducted on

  Date

• Prepared by

DIRECTIONS

• Check all that apply and note if followup is needed. Complete this audit for each area weekly or for random audits as needed.

• Audit Location

FLOORS

• Floors are clean/vacuumed/free of dust

  Met

  Not Met

  N/A

• Floor under bed/furniture is clean and free from dust

  Met

  Not Met

  N/A

• There is no wax buildup in corners or on baseboards

  Met

  Not Met

  N/A

• There are no stains on the floors?

  Met

  Not Met

  N/A

LIGHTS/CEILING SPACES

• Light fixtures are clean

  Met

  Not Met

  N/A

• Vents are clear from dust

  Met

  Not Met

  N/A

• Ceilings are clean and free from cobwebs

  Met

  Not Met

  N/A

WINDOWS/WALLS

• Walls are clean

  Met

  Not Met

  N/A

• Windows, window ledges, and screens are clean<br>

  Met

  Not Met

  N/A

• Window coverings are clean

  Met

  Not Met

  N/A

• Stainless steel is clean

  Met

  Not Met

  N/A

• Cubical curtains are clean

  Met

  Not Met

  N/A

• Doors and handles/knobs are clean

  Met

  Not Met

  N/A

PATIENT SPACES HIGH TOUCH

• Bed rails and under mattress are clean

  Met

  Not Met

  N/A

• Tray Table

  Met

  Not Met

  N/A

• Tray Table Handles

  Met

  Not Met

  N/A

• IV Pole<br><br>

  Met

  Not Met

  N/A

• IV Pump Controls<br><br>

  Met

  Not Met

  N/A

• Call Button

  Met

  Not Met

  N/A

• Telephone

  Met

  Not Met

  N/A

• Chair/Couch

  Met

  Not Met

  N/A

• Room Light Switch

  Met

  Not Met

  N/A

• Room Inner Door Knob

  Met

  Not Met

  N/A

• Sharps Container and Area

  Met

  Not Met

  N/A

• Area is free from insects and pests

  Met

  Not Met

  N/A

• Waste baskets are empty

  Met

  Not Met

  N/A

• Furniture in room is clean and free of defects

  Met

  Not Met

  N/A

BATHROOMS

• Bathroom sink is clean

  Met

  Not Met

  N/A

• Bathroom handrails

  Met

  Not Met

  N/A

• Bathroom mirror is clean

  Met

  Not Met

  N/A

• Bathroom door knob

  Met

  Not Met

  N/A

• Bathroom light switch

  Met

  Not Met

  N/A

• Shower is clean

  Met

  Not Met

  N/A

• Top of dispensers are clean

  Met

  Not Met

  N/A

• Toilet and plumbing/pipes are clean

  Met

  Not Met

  N/A

• Floor is clean

  Met

  Not Met

  N/A

ALL OTHER QUESTIONS

• Supplies are replenished

  Met

  Not Met

  N/A

• Card is placed

  Met

  Not Met

  N/A

HOUSEKEEPING CLOSETS

• Closet is clean and orderly

  Met

  Not Met

  N/A

• Closet is stocked appropriately

  Met

  Not Met

  N/A

ADDITIONAL COMMENTS

• Please enter any additional comments about this audit.

• Date and Time of Audit

  Date

• Please sign your name here to certify this audit as complete

  Sign

• Please email this audit to: Rachel White - rachel.white@mmch.org