Information

  • Audit Title

  • Conducted on

  • Prepared by

  • Location
  • Personnel

EVS ENVIRONMENT OF CARE

  • No items stored under sinks?

  • Equipment / Furniture:<br> * Cleaned - Not visibly soiled

  • Potential safety hazards: Housekeeping & Laundry buckets are attended or locked up. All fluids are labeled.

  • Compactor:<br> * is locked.<br> * area around it is clear of debris.

  • Hazardous rooms are locked: EVS closets, & supply closets are locked?<br> * only appropriate items are contained in closets.<br>

  • Hazardous chemicals and flammable agents are labeled and stored properly.

  • What is the "dwell" time when using cleaning supplies?

  • What is the approximate number of mops used per patient room including bathroom?

  • No outer shipping carton boxes in patient care areas.

  • No expired items.<br>* cleaning supplies

  • Preventative Maintenance:<br> * Equipment checked with up to date PM sticker.

  • Food and drink in designated areas:<br> * No evidence of it in patient rooms/areas, perches, EVS closets, or on carts.

  • Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * No unapproved lotions

  • ID badges are worn appropriate?

  • PPE:<br> * Worn correctly<br> * Changed between tasks

  • How do you clean up a blood/body fluid spill - with what?

  • Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol.<br> * Not overfilled<br> * Covered when transported

  • Sharps Waste:<br> * Discard in a designated sharps container with a biohazard symbol.<br> * Not overfilled<br> * Closed and locked when transported

LINEN HANDLING

  • Soiled Linen:<br> * Properly stored <br> * Covered at storage<br> * Covered on transport<br> * Not overfilled<br> * Cart has solid bottom

  • Clean Linen:<br> * Clearly marked<br> * Covered on transport<br> * Covered on unit<br> * Has solid bottom

  • Linen handling occurs with minimum agitation to avoid environment contamination.

  • Soiled linen is held out away from the body to avoid personal contamination.

  • Soiled linen are bagged and contained at point of collection in leak proof container.

  • How/Is hand hygiene performed correctly during linen stocking procedures.

CLEANLINESS

  • Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

  • No dust on surfaces.

  • Floors are clean and scrubbed<br>

  • Stairwells and doors are clean.

  • Nourishment areas are clean

  • Med prep areas and Omnicell areas are clean<br>

  • Patient Rooms - Floor to ceiling clean.<br>

  • Vents are clean.

  • Windows and treatments are clean and free of dust.

  • Do you clean the vitals equipment and how often?

  • Drinking fountains are clean.

DESCRIBE THE DEPARTMENTS RESPONSE TO YOUR ARRIVAL

  • Greet the team with smiles and introductions.

  • Have a space designated for the team to conduct interviews and file reviews.

  • Promptly deliver materials required for review to the tracer team.

  • Any additional comments regarding positive or suboptimal issues observed during the tracer.

  • Surveyors Signature

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