Patient Division - E.Q.E.**

• Division/Location

• Conducted on

  Date

• Prepared by

PATIENT VISITATION:

• Have you seen your housekeeper today?

  Yes

  No

• How would you rate the cleanliness of your room?

  Satisfactory

  Unsatisfactory

• Any Housekeeping issues or concerns?

  Yes

  No

PATIENT ROOM:

• PT. Room #

• 1. Overbed Table Cleaned?

  Yes

  No

  N/A

• 2. Night Stand Cleaned?

  Yes

  No

  N/A

• 3. Phone Cleaned?

  Yes

  No

  N/A

• 4. T.V Cleaned free of Dust?

  Yes

  No

  N/A

• 5. Picture Frame free of Dust?

  Yes

  No

  N/A

• 6. Overbed Light Cleaned free of Dust?

  Yes

  No

  N/A

• 7. Closet Cleaned?

  Yes

  No

  N/A

• 8. Walls Cleaned?

  Yes

  No

  N/A

• 9. Vents Cleaned free of Lint?

  Yes

  No

  N/A

• 10. Ceiling Cleaned?

  Yes

  No

  N/A

• 11. Door Cleaned?

  Yes

  No

  N/A

• 12. Door Handle Cleaned?

  Yes

  No

  N/A

• 13. Door Frame Cleaned?

  Yes

  No

  N/A

• 14. Waste Can Cleaned?

  Yes

  No

  N/A

• 15. Floors Cleaned?

  Yes

  No

  N/A

• 16. Cubicle Curtain Cleaned?

  Yes

  No

  N/A

• 17. Cubicle Curtain Functional?

  Yes

  No

  N/A

• 18. Room Organized?

  Yes

  No

  N/A

PATIENT RESTROOM:

• 1. Toilet Bowl Cleaned?

  Yes

  No

  N/A

• 2. Sink Cleaned?

  Yes

  No

  N/A

• 3. Shower Cleaned?

  Yes

  No

  N/A

• 4. Shower Curtain Cleaned?

  Yes

  No

  N/A

• 5. Shower Curtain Functional ?

  Yes

  No

  N/A

• 6. Supplies In Place?

  Yes

  No

  N/A

• 7. Floors Cleaned?

  Yes

  No

  N/A

ANCILLARY AREA:

• Ancillary Area:

• 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

• Corridor:

• Location:

• 1. Walls Cleaned?

  Yes

  No

  N/A

• 2. Ceiling Cleaned?

  Yes

  No

  N/A

• 3. Ledges Cleaned?

  Yes

  No

  N/A

• 4. Vents Cleaned?

  Yes

  No

  N/A

• 5. Floors Cleaned?

  Yes

  No

  N/A

FLOORCARE:

• 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

ENVIRONMENTAL ROUNDS:

• Personal Protective Equipment:

• 1. Gloves?

  Yes

  No

  N/A

• 2. Eye Goggles?<br>

  Yes

  No

  N/A

• 3. Staff performing hand hygiene?

  Yes

  No

  N/A

• Chemical:

• 1. Disinfection wipe container lids closed and labeled correctly?

  Yes

  No

  N/A

• 2. Chemical Dispensing unit in working condition?

  Yes

  No

  N/A

• 3. Disinfectant Wipe/bottle properly Dated?

  Yes

  No

  N/A

• Hopper Closet:

• 1. Closet cleaned & organized?

  Yes

  No

  N/A

• 2. Eye Wash Station Clean & Checked?

  Yes

  No

  N/A

• 3. Work Charts Available?

  Yes

  No

  N/A

• 4. Housekeeping Cart Clean & Orderly?

  Yes

  No

  N/A

• Elevator:

• Location:

• 1. Elevator Tracks / Door Clean?

  Yes

  No

  N/A

• Stairwell:

• Location

• 1. Stairwell Clean free of Dust/Litter?a

  Yes

  No

  N/A

• 2. Stairwell Ledges / Handrails Clean?

  Yes

  No

  N/A