ROS EVE CLEANING STANDARDS OBSERVATION. Template

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

NAME: TIME: FLOOR /ROOM

• DATE /<br>TIME

  Yes

  No

  N/A

• NAME:

  Yes

  No

  N/A

• FLOOR / ROOM

  Yes

  No

  N/A

CLEANING OBSERVATIONS

• 1. Bed / rails / 2 pillows / linen / privacy curtain meet standards? Tape / residue removed?

  Yes

  No

  N/A

• 2. Over bed table / bed side table / nurse call / telephone / cords clean and organized? Tape / residue removed?

  Yes

  No

  N/A

• 3. Dusting: vents / overbred lights / ceiling lights / pictures / ledges cleaned?

  Yes

  No

  N/A

• 4. Television / information board clean?

  Yes

  No

  N/A

• 5. Trash containers / bio-hazardous waste receptacles empty and clean? Receptacles label?

  Yes

  No

  N/A

• 6. Sharps container < 3/4 full?

  Yes

  No

  N/A

• 7. Patient chair and visitor chair clean and in place? Sleep chair cleaned? Isolate / bassinette cleaned?

  Yes

  No

  N/A

• 8. HC CART: keyboard / scanner / mouse. / monitor / cart surface / wheels clean? ( If in room during clean)

  Yes

  No

  N/A

• 9. Linen hamper empty and clean? " Soiled Linen Only" sign present?

  Yes

  No

  N/A

• 10. Isolation room signs removed, and returned? ( Discharge Only)

  Yes

  No

  N/A

BATHROOM

• 11. Toilet bowl / flush handle / seat / bedpan cleaner / grab-bars clean? Chemicals flushed?

  Yes

  No

  N/A

• 12. shower clean and free of mildew? Shower doors / curtain clean?

  Yes

  No

  N/A

• 13. Sink / Murrow / vents / light switch & door handle meet standards?

  Yes

  No

  N/A

• 14. Floor thoroughly clean? No debris? Corners clean? Behind & under toilet clean?

  Yes

  No

  N/A

• 15. Commode cleaned and in shower?

  Yes

  No

  N/A

• 16. Toilet paper, paper towels and soap adequate?

  Yes

  No

  N/A

EQUIPMENT OBSERVATION

• 17. IV pole clean? Cables coiled? Pump plugged into red power?

  Yes

  No

  N/A

• 18. Bed plugged into specified bed power outlet? Communication cable plugged in?

  Yes

  No

  N/A

• 19. Bed pump & cords clean? Cords neatly secured?

  Yes

  No

  N/A

• 20. Compression plumb & cords clean? Cords neatly secured?

  Yes

  No

  N/A

• 21. Employee able to demonstrate high-touch points? (e.g. Light switches, phone, bed rails, handles, etc)

  Yes

  No

  N/A

• 22. Personal items removed? Left over nursing supplies removed? Closet empty & clean?

  Yes

  No

  N/A

• 23. Window blinds clean? Room & overbred lights turned off?

  Yes

  No

  N/A

• 24. " Right Words T The Right Time" observed? Patient knows who their housekeeper for the day is?

  Yes

  No

  N/A

• 25. EVS Service card filled out & on table?

  Yes

  No

  N/A

• 26.

  Yes

  No

  N/A

• 27.

  Yes

  No

  N/A

SAFETY OBSERVATION

• 28. Employee utilizing proper linen handling procedures.

  Yes

  No

  N/A

• 29. Employee can articulate what to do if full linen hamper is found? ( i.e. ash for help, break down load)

  Yes

  No

  N/A

• 30. Employee states they have stretched at the beginning of shift?

  Yes

  No

  N/A

• 31. Employee utilizing proper PPE?

  Yes

  No

  N/A