ROS EVS CLEANING STANDARDS OBSERVATION. TEMPLATE

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

CLEANING OBSERVATIONS

• Bed / Rails / 2 Pillows / Linen / Privacy Curtain meet standards? Tape Residue removed?

  Yes

  No

  N/A

• 2. Over bed table / bedside Table / nurse call / Telephone / Cords clean and Organized? Tape / Residue removed?

  Yes

  No

  N/A

• 3. Dusting: Vents / Over Bed Lights / Ceiling Lights / Pictures / Ledges Clean?

  Yes

  No

  N/A

• 4. Television / Information Board clean?

  Yes

  No

  N/A

• 5. Trash Cans / Bio-Hazardous Waste Receptacles Labeled?

  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 Cleaned? (If In The Room During Cleaning)

  Yes

  No

  N/A

• 9. Linen Hamper Empty and Cleaned? " Soiled Linen Only " Sign Present?

  Yes

  No

  N/A

• 10. Isolation Room Signs Removed, and Returned? (Discharged 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 / Mirror / 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

EQUIPMENR OBSERVATION

• 17. I'VE Pole clean? Cables Clean? <br>Cables Clean? Cords Neatly Secured?

  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?<br>Cords Neatly Secured?

  Yes

  No

  N/A

• 20. Compression Pump & Cords Clean? <br> 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

• 23. Personal Items Removed? Left Over Nursing Supplies Removed? Closet Empty & Clean?

  Yes

  No

  N/A

• 24. Window Blinds Clean? Room & Overbed lights Turned Off?

  Yes

  No

  N/A

• 25. "RIGHT WORDS AT THE RIGHT TIME" Observed? <br> Patient knows who their housekeeper for the day is?

  Yes

  No

  N/A

• 26. EVS Service Placard on Table?

  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 is Found? <br>(I.e. ask for help, break down load)

  Yes

  No

  N/A

• 30. Employee States they have Stretched at the beginning and During their shift.

  Yes

  No

  N/A

• 31. Employee Utilizing Proper PPE.

  Yes

  No

  N/A

(# yes & NA / 27) x 100 / = % (Acceptable cleaning is > 90%)

FOLLOW UP ACTION

• Individual teaching provided to employee, DATE__________________________________________<br>In service needed for department DATE__________________________________________<br>Share at upcoming huddle. DATE__________________________________________<br>Revive or revise policy & procedure. DATE__________________________________________

  Yes

  No

  N/A