Patient Division - Environmental Quality Evaluation (E.Q.E.) Revised

• Conducted on:

  Date

• Division/Location:

• Division Director:

• Division Manager:

• Prepared by EVS Management:

• Overall Summary:

PATIENT ROOM:

• PT. Room #

• 1. Overbed Table Cleaned?

  Yes

  No

  N/A

• Notes from question # (1)

  Over Bed table needs to be cleaned

• Completion date:

  Date

• 2. Night Stand Cleaned?

  Yes

  No

  N/A

• Notes from question # (2)

  Night stand needs to be cleaned

• Completion date:

  Date

• 3. Phone Cleaned?

  Yes

  No

  N/A

• Notes from question # (3)

  Phone needs to be cleaned

• Completion date:

  Date

• 4. T.V Cleaned free of Dust?

  Yes

  No

  N/A

• Notes from question # (4)

  T.V. Ned’s to be cleaned

• Completion date:

  Date

• 5. Picture Frame Clean & free of Dust?

  Yes

  No

  N/A

• Notes from question # (5)

  Picture frame needs to be cleaned

• Completion date:

  Date

• 6. Overbed Light Cleaned free of Dust? (Discharge Only)

  Yes

  No

  N/A

• Notes from question # (6)

  Overbed Light needs to be cleaned

• Completion date:

  Date

• 7. Closet Cleaned?

  Yes

  No

  N/A

• Notes from question # (7)

  Closet needs to be cleaned

• Completion date:

  Date

• 8. Walls Cleaned?

  Yes

  No

  N/A

• Notes from question # (8)

  Select Walls need to be cleaned Walls need painted

  • Walls need to be cleaned
  • Walls need painted

• Completion date:

  Date

• 9. Vents Cleaned free of dust?

  Yes

  No

  N/A

• Notes from question # (9)

  Vent need to be cleaned and dusted

• Completion date:

  Date

• 10. Ceiling Cleaned?

  Yes

  No

  N/A

• Notes from question # (10)

  Select Ceiling needs to be cleaned Tile needs replaced

  • Ceiling needs to be cleaned
  • Tile needs replaced

• Completion date:

  Date

• 11. Door Cleaned?

  Yes

  No

  N/A

• Notes from question # (11)

  Door needs to be cleaned

• Completion date:

  Date

• 12. Door Handle Cleaned?

  Yes

  No

  N/A

• Notes from question # (12)

  Door handle needs to be cleaned

• Completion date:

  Date

• 13. Door Frame Cleaned?

  Yes

  No

  N/A

• Notes from question # (13)

  Door frame needs to be cleaned

• Completion date:

  Date

• 14. Waste Can Cleaned?

  Yes

  No

  N/A

• Notes from question # (14)

  Waste can needs to be cleaned

• Completion date:

  Date

• 15. Is Floors being mopped according to standard cleaning procedure?

  Yes

  No

  N/A

• Notes from question # (15)

  Floor needs to be mopped

• Completion date:

  Date

• a. Is appearance of the floors meet satisfactory condition?

  Yes

  No

  N/A

• Notes from question # (15)

  Select Floor needs deep scrubbing and burnishing Floor needs stripped and waxed Floor needs detail scrubbing of corners, edges and baseboards Floor needs iMopped

  • Floor needs deep scrubbing and burnishing
  • Floor needs stripped and waxed
  • Floor needs detail scrubbing of corners, edges and baseboards
  • Floor needs iMopped

• Completion date:

  Date

• 16. Cubicle Curtain Cleaned & Fully Functional?

  Yes

  No

  N/A

• Notes from question # (16)

  Select Mesh needs replaced Missing/broken hooks need replaced Cubicle Curtains needs changed

  • Mesh needs replaced
  • Missing/broken hooks need replaced
  • Cubicle Curtains needs changed

• Completion date:

  Date

• 17. Room/Furniture Organized?

  Yes

  No

  N/A

• Notes from question # (17)

  Select Room Cluttered Items on top of window seal

  • Room Cluttered
  • Items on top of window seal

• Completion date:

  Date

PATIENT RESTROOM:

• 1. Toilet Bowl Cleaned?

  Yes

  No

  N/A

• Notes from question # (1)

  Toilet bowl needs cleaned

• Completion date:

  Date

• 2. Sink Cleaned?

  Yes

  No

  N/A

• Notes from question # (2)

  Sink needs cleaned

• Completion date:

  Date

• 3. Shower Cleaned?

  Yes

  No

  N/A

• Notes from question # (3)

  Shower needs cleaned

• Completion date:

  Date

• 4. Shower Curtain Cleaned & Fully Functional?

  Yes

  No

  N/A

• Notes from question # (4)

  Select Shower curtain needs cleaned Shower curtain needs replaced Shower curtain needs to be fixed

  • Shower curtain needs cleaned
  • Shower curtain needs replaced
  • Shower curtain needs to be fixed

• Completion date:

  Date

• 5. Supply dispensers cleaned?

  Yes

  No

  N/A

• Notes from question # (5)

  Select Paper towel need filled Toilet paper needs filled Dispenser needs to be cleaned

  • Paper towel need filled
  • Toilet paper needs filled
  • Dispenser needs to be cleaned

• Completion date:

  Date

• 6. Is Floors being mopped according to standard cleaning procedure?

  Yes

  No

  N/A

• Notes from question # (6)

  Select Floor needs to be mopped Floor needs scrubbed

  • Floor needs to be mopped
  • Floor needs scrubbed

• Completion date:

  Date

ANCILLARY AREA:

Ancillary Area 1:

• Location:

  Select ASR/Med Room Nurses Station Pantry Clean Utility Soiled Utility Staff Lounge Workroom Conference Room Office Exam Room Waiting Room

  • ASR/Med Room
  • Nurses Station
  • Pantry
  • Clean Utility
  • Soiled Utility
  • Staff Lounge
  • Workroom
  • Conference Room
  • Office
  • Exam Room
  • Waiting Room

• 1. Outside Cabinets Cleaned?

  Yes

  No

  N/A

• Notes from question # (1)

  Outside cabinet needs to be cleaned

• Completion date:

  Date

• 2. Counters Cleaned?

  Yes

  No

  N/A

• Notes from question # (2)

  Counter needs to be cleaned

• Completion date:

  Date

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• Notes from question # (3)

  Sink needs cleaned

• Completion date:

  Date

• 4. Walls Cleaned?

  Yes

  No

  N/A

• Notes from question # (4)

  Select Walls need to be cleaned Walls need painted

  • Walls need to be cleaned
  • Walls need painted

• Completion date:

  Date

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• Notes from question # (5)

  Select Ceiling needs to be cleaned Tile needs replaced

  • Ceiling needs to be cleaned
  • Tile needs replaced

• Completion date:

  Date

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• Notes from question # (6)

  Ledges need dusted and cleaned

• Completion date:

  Date

• 7. Vents Cleaned?

  Yes

  No

  N/A

• Notes from question # (7)

  Vent need to be cleaned and dusted

• Completion date:

  Date

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• Notes from question # (8)

  Waste can needs to be cleaned

• Completion date:

  Date

• 9. Supply dispensers cleaned?

  Yes

  No

  N/A

• Notes from question # (9)

  Select Paper towel need filled Toilet paper needs filled Dispenser needs to be cleaned

  • Paper towel need filled
  • Toilet paper needs filled
  • Dispenser needs to be cleaned

• Completion date:

  Date

• 10. Is Floors being mopped according to standard cleaning procedure?

  Yes

  No

  N/A

• Notes from question # (15)

  Floor needs to be mopped

• Completion date:

  Date

• a. Is appearance of the floors meet satisfactory condition?

  Yes

  No

  N/A

• Notes from question # (16)

  Select Floor needs deep scrubbing and burnishing Floor needs stripped and waxed Floor needs detail scrubbing of corners, edges and baseboards Floor needs iMopped

  • Floor needs deep scrubbing and burnishing
  • Floor needs stripped and waxed
  • Floor needs detail scrubbing of corners, edges and baseboards
  • Floor needs iMopped

• Completion date:

  Date

Ancillary Area 2:

• Location:

  Select ASR/Med Room Nurses Station Pantry Clean Utility Soiled Utility Staff Lounge Workroom Conference Room Office Exam Room Waiting Room

  • ASR/Med Room
  • Nurses Station
  • Pantry
  • Clean Utility
  • Soiled Utility
  • Staff Lounge
  • Workroom
  • Conference Room
  • Office
  • Exam Room
  • Waiting Room

• 1. Outside Cabinets Cleaned?

  Yes

  No

  N/A

• Notes from question # (1)

  Outside cabinet needs to be cleaned

• Completion date:

  Date

• 2. Counters Cleaned?

  Yes

  No

  N/A

• Notes from question # (2)

  Counter needs to be cleaned

• Completion date:

  Date

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• Notes from question # (3)

  Sink needs cleaned

• Completion date:

  Date

• 4. Walls Cleaned?

  Yes

  No

  N/A

• Notes from question # (4)

  Select Walls need to be cleaned Walls need painted

  • Walls need to be cleaned
  • Walls need painted

• Completion date:

  Date

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• Notes from question # (5)

  Select Ceiling needs to be cleaned Tile needs replaced

  • Ceiling needs to be cleaned
  • Tile needs replaced

• Completion date:

  Date

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• Notes from question # (6)

  Ledges need dusted and cleaned

• Completion date:

  Date

• 7. Vents Cleaned?

  Yes

  No

  N/A

• Notes from question # (7)

  Vent need to be cleaned and dusted

• Completion date:

  Date

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• Notes from question # (8)

  Waste can needs to be cleaned

• Completion date:

  Date

• 9. Supply dispensers cleaned?

  Yes

  No

  N/A

• Notes from question # (9)

  Select Paper towel need filled Toilet paper needs filled Dispenser needs to be cleaned

  • Paper towel need filled
  • Toilet paper needs filled
  • Dispenser needs to be cleaned

• Completion date:

  Date

• 10. Is Floors being mopped according to standard cleaning procedure?

  Yes

  No

  N/A

• Notes from question # (15)

  Floor needs to be mopped

• Completion date:

  Date

• a. Is appearance of the floors meet satisfactory condition?

  Yes

  No

  N/A

• Notes from question # (16)

  Select Floor needs deep scrubbing and burnishing Floor needs stripped and waxed Floor needs detail scrubbing of corners, edges and baseboards Floor needs iMopped

  • Floor needs deep scrubbing and burnishing
  • Floor needs stripped and waxed
  • Floor needs detail scrubbing of corners, edges and baseboards
  • Floor needs iMopped

• Completion date:

  Date

Corridor:

• 1. Walls Cleaned?

  Yes

  No

  N/A

• Notes from question # (1)

  Select Walls need to be cleaned Walls need painted

  • Walls need to be cleaned
  • Walls need painted

• Completion date:

  Date

• 2. Ceiling Cleaned?

  Yes

  No

  N/A

• Notes from question # (2)

  Select Ceiling needs to be cleaned Tile needs replaced

  • Ceiling needs to be cleaned
  • Tile needs replaced

• Completion date:

  Date

• 3. Ledges Cleaned?

  Yes

  No

  N/A

• Notes from question # (3)

  Select Ledges need dusted and cleaned

  • Ledges need dusted and cleaned

• Completion date:

  Date

• 4. Vents Cleaned?

  Yes

  No

  N/A

• Notes from question # (4)

  Vent need to be cleaned and dusted

• Completion date:

  Date

• 5. Floors Cleaned?

  Yes

  No

  N/A

• Notes from question # (5)

  Select Floor needs to be mopped Floor needs scrubbed

  • Floor needs to be mopped
  • Floor needs scrubbed

• Completion date:

  Date

EVS COMPLIANCE:

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

  Yes

  No

  N/A

• Notes from question # (1)

  Select Lid needs closed Bucket needs labeled Chemical dispenser needs fixed

  • Lid needs closed
  • Bucket needs labeled
  • Chemical dispenser needs fixed

• Completion date:

  Date

• 2. Eye Wash sheets properly dated? (Unblocked)

  Yes

  No

  N/A

• Notes from question # (2)

  Select Needs unblocked Needs checked

  • Needs unblocked
  • Needs checked

• Completion date:

  Date

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

  Yes

  No

  N/A

• Notes from question # (3)

  Select Needs cleaned Un-necessary equipment needs removed

  • Needs cleaned
  • Un-necessary equipment needs removed

• Completion date:

  Date

• 4. Hopper Room locked when not in use?

  Yes

  No

  N/A

• Notes from question # (4)

  Needs locked

• Completion date:

  Date

• 5. Housekeeping carts clean and free of unnecessary item?

  Yes

  No

  N/A

• Notes from question # (5)

  Select Cart needs cleaned Unnecessary items need removed

  • Cart needs cleaned
  • Unnecessary items need removed

• Completion date:

  Date

• 6. Cart Locked and put away when not in use?

  Yes

  No

  N/A

• Notes from question # (6)

  Select Cart needs locked Left in corridor, needs put away

  • Cart needs locked
  • Left in corridor, needs put away

• Completion date:

  Date

• 7 Equipment clean? (Vacuums, buffers & carts)

  Yes

  No

  N/A

• Notes from question # (7)

  Equipment needs cleaned

• Completion date:

  Date

• 8. 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

• Notes from question # (8)

  Select Staff did not know answer Did not refer to helpcard

  • Staff did not know answer
  • Did not refer to helpcard

• Completion date:

  Date

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

  Yes

  No

  N/A

• Notes from question # (9)

  Select Staff did not know answer Did not refer to helpcard

  • Staff did not know answer
  • Did not refer to helpcard

• Completion date:

  Date

• 10. Performex?

  Yes

  No

  N/A

• Notes from question # (10)

  Select Staff did not know answer Did not refer to helpcard

  • Staff did not know answer
  • Did not refer to helpcard

• Completion date:

  Date

• 11. Clorox Hydrogen Peroxide?

  Yes

  No

  N/A

• Notes from question # (11)

  Select Staff did not know answer Did not refer to helpcard

  • Staff did not know answer
  • Did not refer to helpcard

• Completion date:

  Date

• 12. Does staff have knowledge of SDS? What is SDS? (Safety Data Sheets) Where is the SDS information located?

  Yes

  No

  N/A

• Notes from question # (12)

  Select Staff did not know answer Did not refer to helpcard

  • Staff did not know answer
  • Did not refer to helpcard

• Completion date:

  Date

• 13. P.P.E. Available? (Gloves, Goggles is there evidence of use?) Hand Hygiene Being Performed? (Observation of Evidence)

  Yes

  No

  N/A

• Notes from question # (13)

  Select Needs Eye goggles Hand Hygiene not performed

  • Needs Eye goggles
  • Hand Hygiene not performed

• Completion date:

  Date

• 14. Staff have knowledge of location of Fire Pull Stations?

  Yes

  No

  N/A

• Notes from question # (14)

  Did not know where the fire pull station was located.

• Completion date:

  Date

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

  Yes

  No

  N/A

• Notes from question # (15)

  Select Green trash cart needs cleaned Red bio cart needs cleaned

  • Green trash cart needs cleaned
  • Red bio cart needs cleaned

• Completion date:

  Date

• Signature By:

  Sign