**Non - Patient E.Q.E.**

• Division/Location

• Conducted on

  Date

• Prepared by

RESTROOM:

Public Restroom: 1

• Location:

• 1. Toilet bowl / Plumbing fixtures clean?

  Yes

  No

  N/A

• 2. Sink / Plumbing fixtures clean?

  Yes

  No

  N/A

• 3. Mirriors clean?

  Yes

  No

  N/A

• 4. Walls / Stalls clean?

  Yes

  No

  N/A

• 5. Wastecans clean & freshly lined?

  Yes

  No

  N/A

• 6. Floors clean / mopped?

  Yes

  No

  N/A

• 7. Vents / Cieling clean?

  Yes

  No

  N/A

• 8. Supplies in place?

  Yes

  No

  N/A

Staff Restroom: 2

• Location:

• 1. Toilet bowl / Plumbing fixtures clean?

  Yes

  No

  N/A

• 2. Sink / Plumbing fixtures clean?

  Yes

  No

  N/A

• 3. Mirriors clean?

  Yes

  No

  N/A

• 4. Walls / Stalls clean?

  Yes

  No

  N/A

• 5. Wastecans clean & freshly lined?

  Yes

  No

  N/A

• 6. Floors clean / mopped?

  Yes

  No

  N/A

• 7. Vents / Cieling clean?

  Yes

  No

  N/A

• 8. Supplies in place?

  Yes

  No

  N/A

ANCILLARY AREA:

WAITING/LOBBY ROOM:

• Location:

• 1. Vents Cleaned?

  Yes

  No

  N/A

• 2. Chairs?

  Yes

  No

  N/A

• 3. Walls Cleaned?

  Yes

  No

  N/A

• 4. Ledges Cleaned?

  Yes

  No

  N/A

• 5. Floors Cleaned?

  Yes

  No

  N/A

Ancillary Area: 1

• Location:

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

• 10. Floors Cleaned?

  Yes

  No

  N/A

Ancillary Area: 2

• Location:

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

• 10. Floors Cleaned?

  Yes

  No

  N/A

Ancillary Area: 3

• Location:

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

• 10. Floors Cleaned?

  Yes

  No

  N/A

Ancillary Area: 4

• Location:

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

• 10. Floors Cleaned?

  Yes

  No

  N/A

FLOORCARE:

Floorcare: 1

• Location:

• 1. Baseboard Cleaned?

  Yes

  No

  N/A

• 2. Corners Cleaned?

  Yes

  No

  N/A

• 3. Edges Cleaned?

  Yes

  No

  N/A

• 4. Floors Finished / Carpet Clean?

  Yes

  No

  N/A

Floorcare: 2

• Location:

• 1. Baseboard Cleaned?

  Yes

  No

  N/A

• 2. Corners Cleaned?

  Yes

  No

  N/A

• 3. Edges Cleaned?

  Yes

  No

  N/A

• 4. Floors Finished / Carpet Clean?

  Yes

  No

  N/A

READINESS ROUNDS:

• Disinfection wipe container lids closed and labeled correctly? Chemical Dispensing unit in working condition?

  Yes

  No

  N/A

• Eye Wash sheets properly dated? (Unblocked)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hopper Room locked when not in use?

  Yes

  No

  N/A

• Housekeeping carts clean and free of unnecessary item?

  Yes

  No

  N/A

• Cart Locked and put away when not in use?

  Yes

  No

  N/A

• Equipment clean? (Vacuums, buffers & carts)

  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

• Staff have knowledge of Dwell time for Disinfectant? (Name of Disinfectant)

  Yes

  No

  N/A

• Performex?

  Yes

  No

  N/A

• Clorox Hydrogen Peroxide?

  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?) Hand Hygiene Being Performed? (Observation of Evidence)

  Yes

  No

  N/A

• Staff have knowledge of location of Fire Pull Stations?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hand Hygiene Being Performed? (Observation of Evidence)

  Yes

  No

  N/A

• Signature By:

  Sign