MMH TJC - EVS - Mock Survey

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

EVS ENVIRONMENT OF CARE

• No items stored under sinks?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Acceptable

  Unacceptable

• No outer shipping carton boxes in patient care areas.

  Yes

  No

  N/A

• No expired items.<br>* cleaning supplies

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• ID badges are worn appropriate?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Acceptable

  Unacceptable

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

LINEN HANDLING

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Acceptable

  Unacceptable

CLEANLINESS

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

  Yes

  No

  N/A

• No dust on surfaces.

  Yes

  No

  N/A

• Floors are clean and scrubbed<br>

  Yes

  No

  N/A

• Stairwells and doors are clean.

  Yes

  No

  N/A

• Nourishment areas are clean

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Vents are clean.

  Yes

  No

  N/A

• Windows and treatments are clean and free of dust.

  Yes

  No

  N/A

• Do you clean the vitals equipment and how often?

  Yes

  No

  N/A

• Drinking fountains are clean.

  Yes

  No

  N/A

DESCRIBE THE DEPARTMENTS RESPONSE TO YOUR ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Surveyors Signature

  Sign