BC Health Authorities. Housekeeping Cleaning Audit

Transcription

1 Slutins Fr Optimum Facility Cleaning Management 1820 Maple Street Vancuver, B.C., V6J 3S7 Tel: (604) Fax: (604) BC Health Authrities Husekeeping Cleaning Audit Reference Guide Revisin Seven - D - DRAFT Westech Systems, Inc Maple Street; Vancuver, B.C., Canada (604) Last Revised: January 24, 2007 Westech Systems, Inc Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

2 Revisin Seven D - DRAFT Westech Systems, Inc. Auditing Training Manual Page 2 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

3 Revisin Seven D - DRAFT INTRODUCTION TO THE MANUAL:...4 AUDITING GUIDE: NON COMPUTER PROCEDURES AND PROTOCOL...5 BC HEALTH AUTHORITIES CLEANING OUTCOME STANDARDS DEFINED...5 INSPECTION ELEMENTS & CLEANING EXPECTATIONS:...6 IMPORTANT AUDITING CONSIDERATIONS:...8 Maintenance versus Husekeeping Issues:...8 Time f the Day:...8 Decisin Making When Auditing...9 Useful Auditing Tls...9 SPECIFIC INSPECTION ELEMENT AUDITING GUIDELINES:...11 RISK CATEGORIES...37 AUDITING GUIDE: COMPUTERIZED AUDIT TOOL PROCEDURES...39 SENDING DATA FROM THE COMPUTER TO THE PALM PILOT:...39 PERFORMING AN AUDIT:...41 RETRIEVING THE AUDITS TO THE COMPUTER:...53 REVIEWING REPORTS ON THE COMPUTER:...54 IMPORTANT FEATURES IN THE SA AUDIT COMPUTER SOFTWARE:...54 Exprting a Reprt t a Wrd Dcument r Excel Spreadsheet...55 IMPORTANT DATABASE TABLES...57 SORT FIELD ONE: HIGH LEVEL FUNCTIONAL AREAS...57 SORT FIELD TWO: HOSPITAL SPECIFIC FUNCTIONAL AREAS...57 SORT FIELD FOUR: ROOM USE LISTING...58 CLEANING PROMPTS TABLE...60 ROOM TYPES...61 ROOM TYPE INSPECTION SCHEMES...61 IMPORTANT AUDITING COMPUTER PROCEDURES & PROTOCOL...64 UPDATING THE SA AUDIT SOFTWARE ON THE LAPTOP & PALM PILOT...64 BACKING UP & ING DATABASES...65 APPENDIX...67 PHA MANUAL HOUSEKEEPING QUALITY AUDIT FORM...68 HEALTH AUTHORITY SPECIFIC CLEANING REQUIREMENTS...70 Westech Systems, Inc. Auditing Training Manual Page 3 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

4 Revisin Seven D - DRAFT This training manual has been written with the primary gal f prviding infrmatin that will make the prcess f auditing the cleanliness f hspitals as cnsistent as pssible. The dcument will be updated and revised ver time based n input frm the different users. The manual is divided int five main sectins Auditing Guide: Nn Cmputer Auditing Prcedures and Prtcl Auditing Guide: Cmputerized Audit Tl Prcedures & Palm Pilt Auditing Guide Imprtant Database Tables Imprtant Auditing Cmputer Prcedures and Prtcl Appendix Westech Systems, Inc. Auditing Training Manual Page 4 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

5 Revisin Seven D - DRAFT This sectin cvers the necessary backgrund infrmatin required t perfrm an audit! The Prvincial Health Authrities have develped the fllwing cleaning utput specificatins that are referred t here as Cleaning Outcme Standards. It is an expectatin that Cleaning Outcme Standards be met at all times. The Cleaning Outcme Standards are nt an exhaustive list, but reflect many typical utcmes that are expected frm husekeeping prviders. Husekeeping Services invlves meeting numerus standards that are different frm and may be cnfused with Cleaning Standards: Quality Standards Frequency Standards Methds Standards Materials Standards Equipment Standards Respnse Time Standards Cleaning utcme standards are the utcmes which result frm balancing many f the abve ther standards. The cleaning utput specificatins listed belw are the Participating Health Authrity s desired Service Levels and Standards utcme, with respect t Cleaning Standards. The Cleaning Outcme Standards are designed t meet the fllwing needs: The primary fcus must remain the prtectin f the patient and resident. Rutine cleaning is usually all that is needed t achieve a clean envirnment. Hwever, surfaces frequently tuched by health care prviders, and/r patients, such as call bell lights, medical equipment, knbs, handles, light switches and assist rails have a greater ptential as vehicles fr infectius agents. Therefre, these items require frequent cleaning. They must help minimize the utbreak and spread f micrbial infectins. The standards are understandable and attainable The standards t remain a viable tl they must be reviewed as ften as required. Review is necessary t keep abreast f changes in the Health Care envirnment Westech Systems, Inc. Auditing Training Manual Page 5 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

6 Revisin Seven D - DRAFT " # "$ When perfrming an audit, the fllwing interpretatins f the cleaning expectatins shuld help when deciding whether an inspectin element is acceptable r unacceptable. When making that judgment call, we must remember that all f the facilities are being used n a cntinuus basis thrughut the day. Fr this reasn, there will always be a certain amunt f dust, remvable marks, scuffs, finger marks etc. Minimal amunts f these will be cnsidered acceptable. When there is an accumulatin f dust, remvable marks, scuffs, finger marks etc. n a surface, this is where an item will receive a failing scre because f an unacceptable amunt f siling. INTERPRETATIONS FREE OF DUST Minimal dust is acceptable An accumulatin f dust is unacceptable If when passing a hand ver a vertical surface a visible mark remains in the dust this will be cnsidered as a build up f dust and marked as unacceptable If when passing a hand r finger ver a hrizntal surface the amunt f dust allws fr balling r beading this will be cnsidered as unacceptable REMOVABLE SPOTS A mark may be tested with a dampened paper twel, if the mark is remvable it will be cnsidered as unacceptable SCUFFS & BLACK MARKS Minimal scuffing is acceptable Minimal amunts f black marks n flring will be cnsidered t be acceptable Scuffing that detracts frm the appearance f the area will be cnsidered unacceptable An accumulatin f scuff marks frm shes r equipment will be cnsidered unacceptable An accumulatin f black marks n flring that detracts frm the verall appearance f the flr will be cnsidered as unacceptable FINGER MARKS A minimal amunt f finger marks will be cnsidered acceptable A build up f finger marks will be cnsidered unacceptable SOILED Any lse sil that can be remved frm the surface will be cnsidered unacceptable SOIL/FLUID BUILD UP Any build up f sil r fluid that has caused disclratin f a surface will be cnsidered unacceptable Any sil build up that can be remved by scratching the surface will be cnsidered unacceptable Westech Systems, Inc. Auditing Training Manual Page 6 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

7 Revisin Seven D - DRAFT Any build up f sap that causes disclratin r hardening arund the sink, drain, verflw r the area arund where the sink r fixtures attach t the cunter will be cnsidered unacceptable COBWEBS Any accumulatin f dust that frms a webbing affect attached t a surface will be cnsidered unacceptable ADHESIVE RESIDUE A minimal amunt f adhesive r tape residue will be cnsidered acceptable An accumulatin f adhesive r tape residue in mre than ne lcatin will indicate neglect and be cnsidered unacceptable DEBRIS Debris-paper, tissue, needle caps, sand, gravel etc Islated pieces f debris will be cnsidered acceptable An accumulatin f debris in mre than ne lcatin will be cnsidered unacceptable STRINGS OR WIRE Remvable strings r wire that have been attached t walls, ceilings, fixtures that have nt been remved will be cnsidered unacceptable This wuld include strings r wires that have been used t hang seasnal decratins INCONSISTANT APPEARANCE When assessing the many different types f flr surfaces, the main thing that yu need t cnsider is if there is a cnsistent appearance between the traffic and nn traffic areas. When there is a nticeable difference between these tw areas (caused by scratches, scuffing, traffic wear etc.), then this will be cnsidered unacceptable When the flr is nt prperly maintained, sil will accumulate n the surface which will present a dirty surface appearance. This will usually cver the traffic lanes with varying degrees f disclratin DUST BALLS Any accumulatin f dust balls will be cnsidered as unacceptable MINERAL DEPOSITS Any build up f mineral depsits will be cnsidered unacceptable REMOVABLE RESIDUE Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty mps, clths, etc) will be cnsidered unacceptable. Flrs which are nt maintained n a rutine basis will have a gradual build up f dirt accumulate n their surface which will give the flr a dirty surface appearance Nte: Any surface that has an bvius residue after being cleaned using Virx, r any ther cleaning chemical, will be cnsidered unacceptable Westech Systems, Inc. Auditing Training Manual Page 7 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

8 Revisin Seven D - DRAFT %& When perfrming an audit, the auditr must be able t distinguish between Husekeeping issues and Maintenance issues. Cnditins such as stained r missing ceiling tiles, flaking paint, hles in a wall surface, years f finish build-up n a basebard, tarnished washrm fixtures, etc are Maintenance issues that the Husekeeping staff must nt be held respnsible fr. A gd rule f thumb is if a tl is required t fix r remve the item (in rder t clean it) than it is mst likely a maintenance item (see nte belw). When auditing, we must lk past these deficiencies and assess the surface n the accumulatin f sil nly. Ntes: It shuld be emphasized thugh that in sme instances such as in the case where there are bugs under light lenses these items will be cunted in the audit n matter what it takes t remve the bugs (i.e., with r withut tls) Any dirt fund n a wall, flr, r windw area that is inaccessible unless an item is dismantled shuld be cnsidered a Maintenance issue. The Husekeeping Department must make arrangements with the Maintenance Department s that access can be made pssible fr the necessary cleaning. The frequency f the scheduled cleaning shuld be based n the type f area a situatin like this may be fund in. (i.e. ICU, ffice r lcker rm etc)!' The ideal time in which t audit an area is after it s been cleaned. With the Husekeeping Departments running a 24hr wrk day, it is nt always pssible fr the auditrs t accmmdate the timing f the cleaning being perfrmed. With this in mind, an auditr must lk at the level f siling n a particular surface and make their judgment based n that and that alne. N matter hw frequently a building is being cleaned, there will always be a certain amunt f siling n a surface. We must be able t lk past a days wrth f dirt while deciding t pass r fail an item. Fr example, when running yur hand ver a 6-12 sectin f a bed frame and yu see a very light film f dust n yur fingers, this wuld be an acceptable level f dust n that surface. Hwever, if yur fingers are cvered in what lks like fuzzy dirt then the bed wuld mst likely receive a failing grade. Anther example wuld be a mirrr in a washrm. In a very busy area, this washrm may be used many times a day. If this mirrr is lcated ver the sink, which mst are, then it s ging t receive the splashing f sapy water cuntless times ver the curse f a day. When assessing this item, first lk at the tp half f the glass. This shuld be free f smearing and smudges. If it is, this will demnstrate that the Husekeeper is ding a thrugh jb f cleaning this surface and any amunt f siling n the bttm half f the glass wuld nt justify this item receiving a failing grade. If a tilet is nt flushed and the bathrm has bad dur this item shuld nt fail since it is nt the husekeeper s respnsibility t flush the tilet. With garbage cntainers judgment als has t be used since it des nt take lng fr a garbage can t fill up. If the garbage cntainer has bad dur and dirt n the utside this is usually a gd indicatin that it has nt been emptied in a while. If the garbage can is full and verflwing with paper twels that d nt lk cmpacted then it might have been emptied quite recently and the auditr shuld cnsider ther telltale signs in the rm prir t making a decisin. Westech Systems, Inc. Auditing Training Manual Page 8 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

9 Revisin Seven D - DRAFT When ding audits n patient rms, whenever pssible, lk fr nes that have been discharged cleaned. This is when a patient n lnger ccupies that bed and the Husekeeping staff has thrughly wiped dwn all surfaces befre making the bed back up fr the next patient wh is being transferred in. This is when everything shuld be at its cleanest and it shuld be much easier t make the decisin abut whether the item shuld pass r fail.! &( When making a decisin n whether t pass r fail a particular inspectin element it is imprtant t lk at all items in the categry. Fr instance, if there are six r eight items in the same categry (i.e., six drs in ne rm) yu must lk at all f them. If 85% r mre f the item r items are clean t an acceptable level than a passing scre can be given r cnversely if 15% r mre f the item r items are dirty t an unacceptable level than a failing scre can be given (referred t as the 85/15 rule). Please keep in mind the 85/15 rule is nly a general rule f thumb and cmmn sense and experience must prevail. Fr instance if an item is extremely dirty and/r it pses a danger (spread f infectin) than it verrides the 85/15 rule. A gd example where yu wuld ignre the 85/15 rule is when yu are auditing drs. Fr example, if there are a lt f finger marks r dirt near the dr handle then a pass r fail decisin shuld nt take int cnsideratin the 85/15 rule. This exceptin is based n the fact that this part f the dr is an excellent way t spread infectin and therefre requires mre attentin. Greater emphasis is being place n human cntact pints such as light switches, laundry hamper lids,,cupbard and drawer pulls, underside edges f tables, hand and bed rails, patient equipment, children s tys, underside lip f wall munted bumper guards etc. Sap dispensers (especially the underside) are an area f great cncern if they are nt prperly maintained n a daily basis as these can becme ideal breeding grunds fr Micrbes. When encuntering heavy cncentratins f siling n ne item r a prtin f an item (i.e. ne dr f six r a prtin f ne wall) the auditr shuld disregard the 85/15 rule and fail the item because f the degree f siling fund. Anther imprtant cnsideratin t make when auditing a rm is t nt cunt the same items twice in tw different categries r inspectin elements. Fr instance if the tp f a cabinet is unacceptable yu wuld (and it warrants a fail) then cunt this item in the prper categry which in this case wuld be furnishing/fixtures. D nt cunt the tp f the cabinet again in the high dusting categry since if yu did this it wuld be cnsidered duble dipping. The fllwing listing f the different inspectin elements defines which categry the inventry items in a rm belng t. When encuntering dirty film, spts r marks n a surface, it s imprtant that these are tested (by using a wet wipe r wet paper twel) t insure they are remvable befre failing an item. Use a wet wipe r damp white paper twel cmes int play. When film, spts r marks are nt remvable, the respnsibility may shift away frm the Husekeeping department and becme a maintenance issue. Judgment is needed as t whether a film, spt, r mark can be remved with a chemical and pad e.g. streaky stainless steel, scuff marks n basebards, etc. ) We have fund the fllwing tls extremely useful when auditing: A pwerful pen flash light wrks well fr dark areas under beds and crners. A telescping mechanics mirrr is extremely helpful t access hard t reach areas such as high dusting r under beds. Handy wipes r wet paper twels t see if the dirt is remvable (especially in areas under sinks and dispensers). Westech Systems, Inc. Auditing Training Manual Page 9 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

10 Revisin Seven D - DRAFT Optinal equipment camera and a pad f sticky ntes s that date and lcatin infrmatin can be recrded. Nte: Auditrs shuld nt wear prtective glves when auditing After each audit it is imprtant t wash yur hands in rder t reduce the risk f spreading infectin Inspectin Elements That Have Sub Categries When inspecting certain inspectin elements (walls, carpets/mats, interir windws, patient equipment, furnishings/fixtures, waste cntainers, sinks r tilets), the auditr is required t dcument the specific sub-element within each f these categries that is unacceptable. Specifically, the auditr can pick ne r all f the specific items frm a sub categry list. As an example, when an item such as patient equipment has failed, the auditr has t pick the specific element in the patient equipment categry that has failed such as cmmdes and/r call bells. The fllwing list prvides sme EXAMPLES f sme f the sub categries that appear in the patient equipment categry. Please nte that the subcategries are different fr each inspectin element and sme inspectin elements d nt have any subcategries. Example Subcategries Cmmde IV Ples/Pumps/ Suctin Wall Munted Equipment Lifts/Tractin Bars Over Bed/Bedside Tables Wheel/Geri Chairs/walkers Sharp cntainers Call Bells Once the sub categry item/s have been picked, the auditr then picks frm the fllwing fail prmpt list which will give further infrmatin n why the item/s have failed. Example Fail Prmpts (different fr each inspectin element) Adhesive Residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Feces/Urine Finger Marks - any substance n the hands that will leave finger marks Sharps Over 3/4 Remvable Spts - anything that will transfer nt a wet paper twel Remvable Residue - dirty clths/slutin will leave very nticeable wiping marks n the surface Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Westech Systems, Inc. Auditing Training Manual Page 10 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

11 Revisin Seven D - DRAFT " 1. DOORS Definitin - All types f drs (including dr grilles, verhead drs), sills, surrunding frames, dr glass, dr clsers and hardware, and mldings. Cnditins Expected Clean means: free f dust, remvable marks, sil/fluid build up, cbwebs, and adhesive residue. 1. The dr, sills and tracks appear t be clean as per the cnditins expected. 2. Bth sides f the dr, all the edges, the frame, mldings and dr clser mechanism are clean. 3. There are n remvable marks n the drs, sills, and kick plates. 4. The dr hardware including the handles, knbs, hinges and push bars are clean. The specific fail prmpts fr the abve item are Nte: That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Dr Dr Frame Cntact Pints Adhesive residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Finger Marks - any accumulatin will be cnsidered unacceptable Graffiti Only put this cmment in if husekeeping is able t remve it. If it requires maintenance t remve it then enter a cmment and dn t fail the item. Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty mps/clths) and r inapprpriate cleaning slutin dilutin Remvable Spts - anything that can be remved using a damp paper twel Scuff Marks - caused by shes, prtective bumpers n equipment and patient equipment Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Auditing Nte: As a general rule if the dr pens int the area being audited, such as a rm r hallway, the entire dr (this will include bth sides f the dr, the dr frame and the mlding) will be part f that area. An exceptin t this rule is if a patient rm dr r a washrm dr pens int the hallway it shuld be audited as part f the patient rm r washrm audit since it is Westech Systems, Inc. Auditing Training Manual Page 11 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

12 Revisin Seven D - DRAFT extremely imprtant that this inspectin element is checked. If yu are auditing the hallway as well then d nt audit the drs that yu audited as part f the patient rms r washrms. The tp frame r sill f the dr way shuld be checked n bth sides f the dr that yu are auditing. Thus if a dr pens int a patient rm then yu wuld audit the tp frame f the dr in the hallway and inside the rm. When auditing drs if there are a lt f finger marks r dirt near r n the dr then a pass r fail decisin shuld nt take int cnsideratin the 85/15 rule. This exceptin is based n the fact that this part f the dr is an excellent way t spread infectin and therefre requires mre emphasis. If auditing in a hallway that falls between tw sets f fire drs, and these drs pen in ppsite directins, nly audit the drs which pen int the area yu are in. In the dd case where yu have a sliding r swinging dr audit the dr n matter which side f the rm yu are in. In a main entrance, audit bth sides f a sliding dr. Large & small partitin drs are audited as part f walls. Access drs are audited as part f its lcatin i.e. ceiling r wall. A vent in a dr shuld be cunted in the dr categry. A mirrr n a dr shuld be cunted in the mirrr categry. Blinds are cunted in the windw cverings categry. Westech Systems, Inc. Auditing Training Manual Page 12 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

13 Revisin Seven D - DRAFT 2. WALLS Definitin - All types f walls including hand and chair rails, rm dividers including clumns, lw partitin walls, cubicle walls, chair rails, wall bumper rails, washrm stall partitins (including munting brackets and dr hardware), switch plates, panels & utlets. Any vertical piping ging up the wall (nt cunting plumbing fixtures under the sink r tilet) shuld als be cunted in this categry. Hrizntal piping belw five feet wuld als be cunted in the wall categry. Cnditins Expected - Clean means: free f dust, remvable marks, sil/ fluid build up, cleaning fluid residue, streaking, cbwebs and adhesive residue. 1. The surface f the walls appear t be clean as per the cnditins expected 2. There are n remvable marks 3. Walls requiring plishing are kept in plished state and appear clean, including wall plaques The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Stall Partitins - any type f structure that surrunds a tilet, inclusive f stall dr, r is placed between urinals Walls Rm Dividers Wall bumpers Adhesive residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Feces/Urine Finger Marks - any accumulatin will be cnsidered unacceptable Graffiti Only put this cmment in if husekeeping is able t remve it. If it requires maintenance t remve it then enter a cmment and dn t fail the item. Remvable Spts - anything that can be remved using a damp paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Scuff Marks - caused by prtective bumpers n equipment and patient equipment Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Auditing Nte: When encuntering cbwebs that are attached t the walls and the ceiling, these must nly be failed in ne categry either the walls r the ceiling. An exceptin t this rule is if there are an excessive amunt f cbwebs n bth the walls and ceilings. If the tp prtin f a wall surface has dust n it, this will be cunted as dust n the wall and will nt be including in the high dusting categry. The same will apply fr lw dust. The tp f a bathrm stall partitin is included in this categry and nt high dusting. Westech Systems, Inc. Auditing Training Manual Page 13 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

14 Revisin Seven D - DRAFT The handrails n stairwells and elevatrs are included in this categry. Pictures, bulletin bards, white bards, clcks, fire bells, fixed signage, etc. that are n the wall surface are nt part f the wall, these items will fall under the furnishing r high dusting categry. Shwer walls, walls arund a tub and the wall area directly behind a tilet will be cvered in the sink/tub/shwer r tilet categry. Hrizntal piping abve five feet shuld be cunted in the high dusting categry. Assist bars in the tilet r shwer area will be cunted as part f the tilet r shwer inspectin items. The underside lip f wall munted bumper guards shuld be checked fr bld. On a few ccasins bldy finger prints have been fund in this area This is a cntact pint that is mst ften ver lked. By elevatrs r patient rms it is nt uncmmn fr peple t lean against the wall and put their finger tips right n these areas. Westech Systems, Inc. Auditing Training Manual Page 14 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

15 Revisin Seven D - DRAFT 3. CEILINGS Definitin - All types f ceilings, Cnditins Expected - Clean means: free f dust, remvable marks, sil/fluid build up, cbwebs, adhesive, strings r wire that is nt in use. 1. The ceiling appears t be clean as per the cnditins expected 2. T-Bar/supprt frames are clean The specific fail prmpts fr the abve item are Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Remvable Spts - anything that can be remved using a damp paper twel Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Auditing Nte: When evaluating a ceiling, have a gd lk arund where the ceiling vents are lcated (remember, the vents have their wn categry s dn t include them in with the ceilings). This is usually where the greatest accumulatin f dust will be fund with this item. Mst ceiling tiles used fr suspended ceilings are prus and will stain very easily when any liquid cmes in cntact with them. Once they becme stained, they are almst impssible t clean and will usually need replacing. Remember, this is nw a Maintenance issue. There is a suspended ceiling tile that has a very thin vinyl cating. This prduct can be easily wiped remving any substance that has been splashed nt it. The t-bars hlding the ceiling tiles in place are easy t wipe and shuld be cunted as a husekeeping item in the ceiling categry. Westech Systems, Inc. Auditing Training Manual Page 15 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

16 Revisin Seven D - DRAFT 4. VENTS/REGISTERS/EXHAUST HOODS Definitin - All types f air vents, heat registers, hd exhausts whether n a wall r a ceiling Cnditins Expected - Clean means: free f dust, remvable marks, cbwebs, debris and sil/fluid build up 1. The vents, hds and heat registers appear t be clean as per the cnditins expected The specific fail prmpts fr the abve item are Adhesive residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Remvable Spts - anything that can be remved using a damp paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Auditing Nte: When inspecting vents, registers r exhaust hds cncentrate n the uter surfaces and the area inside the vent if it can be remved by a vacuum. Areas f the vent that are nt accessible by a vacuum r clth that require cleaning will be cnsidered a maintenance item since a tl will be required t access these areas. If the cleaning f the vent is cnsidered a maintenance item a nte shuld still be entered. A vent in the dr shuld be cunted in the dr categry. This categry includes speakers n the ceiling. Westech Systems, Inc. Auditing Training Manual Page 16 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

17 Revisin Seven D - DRAFT 5. HARD FLOORING Definitin - All types f hard flring including stairs, risers, stair treads, stair nse, transitin strips, metal threshlds, elevatr tracks. Cnditins Expected - Clean means: free f dust, dust balls, debris, sil/fluid build up, remvable marks and has the apprpriate glss 1. The flr appears t be clean as per the cnditins expected 2. The flr has a cnsistant appearance frm wall t wall 3. There is n sil build-up including crners and edges 4. The stair risers, stair nse appear t be clean. 5. There is n accumulatin f dust r debris in the tracks f elevatrs and in the grves f threshlds The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Flr Crners & edges Bld Debris accumulatin f paper, tissue, needle caps, sand, gravel etc. Dust anything that can be easily remved by dry dusting Dust Balls ften called dust bunnies, under beds, stairways, hallways etc. Feces/Urine Incnsistent Appearance disclratin frm lack f prper cleaning. Remvable Residue - Any nticeable mpping marks r sticky residue caused by inapprpriate cleaning technique (dirty mps) and r inapprpriate cleaning slutin dilutin Flrs which are nt maintained n a rutine basis will have a gradual build up f dirt accumulate n their surface which will give the flr a dirty surface appearance. Remvable Spts anything that can be remved using a damp paper twel Scuff Marks caused by shes, equipment and furniture wheels Siled accumulatin f wet r dried sil that can t be remved by dry dusting Auditing Nte: Auditing a flr is ne f the tughest inspectin elements t accurately and cnsistently make a decisin n. When assessing whether t pass r fail a flr that isn t excessively siled r extremely clean the first thing t keep in mind is t apply the 85/15 rule. With the 85/15 rule in mind the auditr shuld be lking fr the fllwing issues when determining whether r nt t pass r fail a flr: Surface siling that is easily remvable with a wet wipe r damp paper twel. Use a wet wipe r damp paper twel, and rub the flr surface in a nn traffic area abut 6-8 inches away frm a wall. It is best t d this in tw r three areas if yu are having truble making yur Westech Systems, Inc. Auditing Training Manual Page 17 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

18 Revisin Seven D - DRAFT decisin. The traffic lane shuld als be tested and there shuld nt be a huge visual difference between these tw areas. Incnsistent Appearance caused by surface siling (nt able t determine using a wet wipe). When a flr is nt prject cleaned n a regular basis, the surface will gradually becme siled and present a dirty appearance. This cnditin usually des nt cver 100% f the flr and may be heaviest in the traffic lanes. A dead give away as t hw dirty the flr really is happens when aggressive spt cleaning has taken place, usually in the remval f black scuff marks using a pad. This actin causes very nticeable cleaned lines in the surface siling. Incnsistent Appearance caused by traffic wear is the respnsibility f the husekeeping department. A flr shuld have a cnsistent appearance frm wall t wall whether it has a flr finish applied r nt. When traffic wear is nt repaired n a regular basis, the gradual accumulatin f scratches, scuff and black heel marks etc. cause a definite visual difference between the traffic and nn traffic areas. Incnsistent Appearance caused by staining f the flr which will nt be the respnsibility f the Husekeeping Department. A stain n a flr surface is always irregular in shape and will nt cver 100% f the surface. There will be nticeable patches f damage which can be lighter but are usually darker than the riginal clr f the flr. Unlike the surface siling and traffic wear, these stains are impssible t remve. Incnsistent Appearance due t traffic damage which will nt be the respnsibility f the Husekeeping Department. Sme resilient flr surfaces have had severe traffic damage t the pint that the actual pattern f the flr in the traffic lane has been wrn ut. When lking at this type f damage it is very bvius that the flr is ruined and the nly way t fix it is by replacing it. The flr area right behind flr munted tilets is cunted in the tilet categry as well as 6 inches immediately surrunding it. Metal transitin strips fund in certain areas f flring shuld be included in this categry If there is a dirty line n the flr arund the perimeter f the rm and the flr is clean everywhere else, fail the basebard and nt the flr. The reasn fr this is when using the 85/15 rule the dirty line arund the perimeter f the rm is nt enugh t fail the flr s t be fair the item gets cunted in a lwer weighted categry which in this case is the basebard. If the flr is dirty and there is a dirty line n the flr arund the perimeter f the rm and the basebard is clean then nly fail the flr. Westech Systems, Inc. Auditing Training Manual Page 18 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

19 Revisin Seven D - DRAFT 6. CARPETED FLOORING/MATS Definitin All types f carpet, including matting (n matter what material the mat is made f) Cnditins Expected Clean means: free f dust, debris and sil/fluid build up 1. The carpet appears t be clean as per the cnditins expected 2. There is n gum r tar, all spts are remved 3. Edges, crners and arund furniture legs are free f dust, lint and sil/fluid build up 4. If the flr under the mat is hard flr than it shuld be cunted in the hard flr categry and nt this categry. If the flr under the mat is carpet then bth the mat and carpet are cunted in this categry. The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Mats Carpets Bld Cbwebs any accumulatin f dust that frms a webbing effect t a surface Debris accumulatin f paper, tissue, needle caps, sand, gravel etc. Dust anything that can be easily remved by dry dusting Dust Balls ften called dust bunnies, under beds, stairways, hallways etc. Feces/Urine Remvable Spts anything that will transfer nt a wet paper twel Siled accumulatin f wet r dried sil that can t be remved by dry dusting Auditing Nte: When trying t determine if the clr disclratin n the surface f a carpet is a spt r a stain, use a wet wipe r damp paper twel. Blt r gently rub the area. If it transfers nt the wet wipe r damp paper twel, then this wuld be classified as a remvable spt. Westech Systems, Inc. Auditing Training Manual Page 19 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

20 Revisin Seven D - DRAFT 7. INTERIOR WINDOWS/GLASS/MIRRORS Definitin All types f windws, glass, mirrrs, including frames, sashes, hardware, sills, interir screens and mldings. Cnditins Expected Clean means: free f dust, remvable marks, cbwebs and sil/fluid build up 1. The interir surfaces appear clean as per the cnditins expected 2. The interir frames, sills, screens and hardware appears clean and are free f dust, spts, smudges, adhesives and sil/fluid build up 3. Audit bth sides f the glass in high prfile main entrance areas The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Windws Mirrrs Frames/sills Adhesive residue Bld Auditing Nte: Cbwebs any accumulatin f dust that frms a webbing effect t a surface Debris wide windw sills can accumulate paper, tissue, cffee cups, dead bugs etc. Dust anything that can be easily remved by dry dusting Finger Marks - any accumulatin will be cnsidered unacceptable Remvable Spts anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Siled accumulatin f wet r dried sil that can t be remved by dry dusting Make sure yu determine if the dirt n the glass is n the side f the rm yu are auditing. If the dirt is n the ther side f the rm (utside in the elements r utside f the rm) then dn t cunt it in the current audit f the rm yu are in. The glass n a dr is cunted in the dr categry if the glass is nly a small insert r the whle dr. Mirrrs inside a dresser and ver bed table are included in the furnishing and patient equipment categries respectively and nt the mirrr categry. Glass walls are cunted as glass and nt walls. Smked r paque windws are cunted in this categry. Westech Systems, Inc. Auditing Training Manual Page 20 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

21 Revisin Seven D - DRAFT 8. WINDOW COVERINGS Definitin All types f windw cverings (curtains, vertical and hrizntal blinds, wd luvers etc.) Cnditins Expected Clean means: free f dust (n appearance and by tuch), cbwebs, remvable marks and sil/fluid build up 1. The windw cverings appear t be clean as per the cnditins expected 2. The windw cverings are apprpriate and prperly hung 3. The windw cverings, ie drapes\curtains, d nt have a musty r dusty smell The specific fail prmpts fr the abve item are Auditing Nte: Adhesive residue Cbwebs any accumulatin f dust that frms a webbing effect t a surface Dust anything that can be easily remved by dry dusting Finger Marks - any accumulatin will be cnsidered unacceptable Remvable Spts anything that will transfer nt a wet paper twel Siled accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Nt Prperly hung Lk at the tp edge f the pleats, this is an area where the dust will build-up mre quickly and a gentle tap r shake f the curtain will allw yu t see hw much dust is released. The tp f the windw curtains is nt high-dusting and falls under this categry. If the windw cvering des nt have a clean feel, test it with a wet wipe. Westech Systems, Inc. Auditing Training Manual Page 21 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

22 Revisin Seven D - DRAFT 9. CUBICLE CURTAINS Definitin All types f cubicle curtains. Cnditins Expected Clean means: free f dust, cbwebs, remvable marks and sil/fluid build up 1. The curtains appear t be clean as per the cnditins expected 2. The curtains are prperly hung and in gd repair 3. Curtains are unifrm in length and clr The specific fail prmpts fr the abve item are Bld Dust anything that can be easily remved by dry dusting Feces/Urine Remvable Spts anything that will transfer nt a wet paper twel Siled accumulatin f wet r dried sil that can t be remved by dry dusting Nt Prperly hung Auditing Nte: There will be a greater pssibility f finding bdy fluids splashed n cubical curtains because f their prximity t the patient bed. D nt fail the curtains if yu find pen marks. The tp f the cubicle curtain track is cunted in high dusting. Use a wet wipe r damp paper twel t determine whether a spt r mark is remvable. Westech Systems, Inc. Auditing Training Manual Page 22 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

23 Revisin Seven D - DRAFT 10. BEDS/EXAM TABLES/STRETCHERS Definitin All types f patient beds, perating rm tables, examinatin tables, exam chairs (chem, renal, etc), dental chairs, cts, cribs, bassinettes, islettes and stretchers Cnditins Expected Clean means: free f dust, cbwebs, remvable marks, adhesive r tape residue and sil/fluid build up 1. The bed, tables, cts, cribs and stretchers appear t be clean as per the cnditins expected, fr example but nt limited t frame, hand rails, head and ft bards, cntrl panel, wheels, remte cntrls strage space under, pedestal bases, wheels are lcked and in prper psitin The specific fail prmpts fr the abve item are Adhesive residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Debris - accumulatin f paper, tissue, needle caps etc. Dust - anything that can be easily remved by dry dusting Dust Balls Feces/Urine Finger Marks - any accumulatin will be cnsidered unacceptable Remvable Spts - anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - mp strand r wire that can get ldged in the wheels Auditing Nte: When lking under these items, a flashlight will help accent any unacceptable cnditins that may be present. Check the wheels fr mp strands/wire and the underside f the bed and bed frame fr any remvable spts r residue Items attached t beds and nt physically part f the beds shuld be cunted in the patient equipment categry. If a Geri chair is being used as an exam chair then audit it in the bed categry and nt the patient equipment categry. When a chair has drp dwn arms such as ne fund in a bld cllectin r chem areas etc, check the underside f these fr remvable spts and accumulatin f finger marks. Westech Systems, Inc. Auditing Training Manual Page 23 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

24 Revisin Seven D - DRAFT 11. PATIENT EQUIPMENT Definitin - All types f patient equipment including wall munted equipment Cnditins Expected - Clean means: free f dust, cbwebs, debris, adhesive/tape and sil/fluid build up 1. The patient equipment appears t be clean as per the cnditins expected, fr example but nt limited t Wall munted equipment-including bld pressure cuffs, suctin cntainers, patient equipment (diagnstic) mnitrs, cables Cmmdes- inside and utside, seat, bwl and frame, wheels Night/Over bed tables-tp, sides, legs, mirrrs, shelves, drawers, wheels, (ther tables will captured under furnishings) Wheelchairs-seat/Geri chairs, back, arms, wheels, attachments, (ther chairs will be captured under furnishings) Mnkey Bar/Tractin Bars, assist bars. Patient scales IV Ples/Pumps-stand, exterir casing f pumps, wheels Sharps Cntainers-clean exterir, nt filled t abve the fill line Specialty equipment such as Tys, and patient lifts. Equipment attached t the beds but nt physically part f the bed. Remvable bumper pads are cunted as patient equipment Call bell buttns and crds The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Cmmde IV Ples/Pumps/ Suctin Wall Munted Equipment Lifts/Tractin Bars Over Bed/Bedside Tables Wheel/Geri Chairs/walkers/Patient Scales Sharp cntainers Call Bells Tys Underside Cntact Pints Adhesive Residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Feces/Urine Westech Systems, Inc. Auditing Training Manual Page 24 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

25 Revisin Seven D - DRAFT Finger Marks - any substance n the hands that will leave finger marks Sharps Over 3/4 Auditing Nte: Remvable Spts - anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Geri chairs (high back wheel chair) that are fund in residential care facilities are part f patient equipment and must nt be cnfused with ther high backed styled chairs that wuld be part f furnishing and fixtures. Be careful t nt tuch the sharps cntainer fr safety reasns. When auditing ver bed tables remember t check inside and underneath fr spilled cffee, fd, juice etc. If auditing ver bed tables in ffices these shuld be cunted in the furnishing categry, therwise they are t be cunted in the patient equipment categry. The main pint is t nt cunt them in tw categries r t duble dip. If auditing furniture utside a patient area that is nrmally cnsidered patient equipment audit it as furnishing. Ceiling Lifts (the ceiling lift track and mtr (cassette) is cunted as high dusting and the handle and cntrl unit that cme dwn is treated as patient equipment. Westech Systems, Inc. Auditing Training Manual Page 25 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

26 Revisin Seven D - DRAFT 12. FURNISHING/FIXTURES Definitin - All types f furnishings and fixtures Cnditins Expected - Clean means: free f dust, cbwebs, debris and sil/fluid build up. 1. The furniture and fixtures appears t be clean as per the cnditins expected, fr example but nt limited t Chairs Stls Cmputer Mnitrs Artificial Plants Cabinets Lckers Diaper Decks Desks/Wrk statins Cunters/Vanity Cuches/Lve Seats Filing Cabinets Patient Clsets (including mirrrs) Medicatin Carts Linen Hampers Appliances/Ceiling, wall, flr and desk fans Cffee/End Tables Meeting Rm Tables Dining Rm Tables Cupbards Televisins/Stands/Brackets Black/white bards/pictures/wall hanging, bulletin bards Shelving Units Fixed signage n walls The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Carts/Hampers/Med Carts/Diaper Decks Desk/Tables/Cunters/Vanities Cmputer Mnitrs/Televisins/Appliances Pictures/Bulletin Bards/Signage Seating Shelving/Cabinet/Lcker/Cupbards/Clsets Auditing Nte: Cntact Pints Adhesive residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Dust Balls - ften called dust bunnies, under beds, stairways, hallways etc. Feces/Urine Finger Marks - any accumulatin will be cnsidered unacceptable Remvable Spts - anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Scuff Marks - caused by prtective bumpers n equipment and patient equipment Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Remember include the tps f cabinets, lckers, cupbards, shelving units, bk cases etc. in this categry and nt the high dusting categry Rm dividers that are part f wrkstatins and are included in the wall categry. Dn t audit persnal items r decratins, use judgment. Westech Systems, Inc. Auditing Training Manual Page 26 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

27 Revisin Seven D - DRAFT Mirrrs inside a dresser are in furnishing categry and mirrrs inside an ver bed table are included in the patient equipment categry. Use discretin when auditing painting and pictures in residential care in that sme paintings can nt be cleaned since the cleaning culd ruin the art. Westech Systems, Inc. Auditing Training Manual Page 27 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

28 Revisin Seven D - DRAFT 13. LIGHT FIXTURES Definitin - All types f light fixtures including pull crds Cnditins Expected - Clean means: free f dust, cbwebs, debris and sil/fluid build up 1. The light fixtures appear t be clean as per the cnditins expected, fr example but nt limited t OR Lights/arms Exam Lights/arms X-Ray view bxes Wall munted Flr Lamp Desk Lamp Ceiling Light Shades and cvers Emergency & Exit lighting 2. Pull crds are clean. 3. N adhesive tape r strings are n the fixture. The specific fail prmpts fr the abve item are Debris\bugs Adhesive residue Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Remvable Spts - anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Auditing Nte: Switch plates and utlet cvers are included in the wall categry The call bell lights that are munted abve a dr in a hallway are included in this sectin Please be careful when auditing the tp f lights abve patient beds. In sme cases patient s hide needles up there (use yur mirrr). Westech Systems, Inc. Auditing Training Manual Page 28 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

29 Revisin Seven D - DRAFT 14. PHONES Definitin - All types f telephnes, cradle and stalls. Cnditins Expected - Clean means: free f dust, remvable marks and sil/fluid build up 1. The bdy, muth, cradle, ear piece and dial system f the telephne are clean as per the cnditins expected 2. The crds are clean and free f sil, adhesive. 3. The back f the telephne hlder is free f dust 4. The telephne stall appears t be clean The specific fail prmpts fr the abve item are Adhesive residue Bld Dust - anything that can be easily remved by dry dusting Finger Marks - any accumulatin will be cnsidered unacceptable Remvable Spts - anything that will transfer nt a wet paper twel Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Make up Westech Systems, Inc. Auditing Training Manual Page 29 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

30 Revisin Seven D - DRAFT 15. HIGH DUSTING Definitin - Hrizntal surfaces abve five feet Cnditins Expected - Clean means: free f dust 1. All f the fllwing hrizntal surfaces (certain hrizntal surfaces abve five feet nt cunted in previus categries) are free f dust as per the cnditins expected, fr example but nt limited t Cubicle Curtain Tracks (regular curtain tracks are cunted in windw cverings ). Ceiling Lifts (the ceiling lift track and mtr (cassette) is cunted as high dusting and the handle and cntrl unit that cme dwn is treated as patient equipment. Fire Bells Clcks Free hanging Signage: Defined as any signage that is hanging frm the ceiling r prtruding frm the wall at a 90 degree angle (yu can see bth sides f the sign). Fixed signage is part f furnishing/fixtures and can be defined as signage that culd be fixed r hanging frm a wall like a painting where yu can nly see ne side f the sign. Electrical and plumbing piping Emergency shwers in labs. Shwer curtain rds Munted exit signs (nly if nt lighted. If lighted it falls under the light categry) The specific fail prmpts fr the abve item are Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Strings r Wire - used t hang decratins/signs and are CLEARLY nt in use anymre Auditing Nte: Be careful nt t cunt any f the items in previus categries under high dusting. It s very imprtant that duble dipping is eliminated. The items listed in this categry are nes that have nt been included in any ther sectin. Fr example, the tp ledge f a picture and all ther elements f that picture are listed in the Furnishing/Fixtures categry. As mentined abve hanging signage is cunted as high dusting where as signage fixed t a wall is cunted in the furnishing/fixtures categry. Any vertical plumbing ging up a wall r hrizntal piping belw five feet are cunted in the wall categry. Cubicle curtain tracks are cunted in the high dusting categry but regular curtain tracks are cunted in windw cverings. Westech Systems, Inc. Auditing Training Manual Page 30 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

31 Revisin Seven D - DRAFT 16. BASEBOARDS Definitin - All types f basebards. In areas where the flr material curves up the wall and becmes vertical the vertical prtin (n higher than apprximately a ft) will be cunted as basebard and nt the flr. Cnditins Expected - Clean means: free f dust, remvable marks, cbwebs and sil/fluid build up 1. Basebards appear t be clean as per the cnditin expected 2. The crners and tp edges are clean. The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Bld Basebards, crners & edges Crners & edges Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Remvable Spts - anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Scuff Marks - caused by shes and equipment Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Auditing Nte: When encuntering cbwebs that are attached t the walls and basebards, these must nly be failed in ne categry A bumper guard higher than 1 ft abve the flr belngs in the wall categry and nt the basebard categry. If there is buildup in the crner right beside the basebard and it cntinues up the basebard then fail the basebard and nt the flr. If there is a dirty line n the flr arund the perimeter f the rm and the flr is clean everywhere else, fail the basebard and nt the flr. Westech Systems, Inc. Auditing Training Manual Page 31 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

32 Revisin Seven D - DRAFT 17. WASTE CONTAINERS Definitin - All types f waste r recycle cntainers including ashtrays and used sanitary napkin cntainers fund in bathrms. Cnditins Expected - Clean means: free f dust and sil/fluid build up and emptied as apprpriate 1. All cntainers and ashtrays appear t be clean inside and ut as per the cnditins expected 2. Plastic liners, where required are clean and in place 3. Emptied as apprpriate t the lcatin The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Recycling Cntainer Waste Cntainer Adhesive residue Bad Odur - inside the cntainers where the bags have leaked Bld Dust - anything that can be easily remved by dry dusting Graffiti Only put this cmment in if husekeeping is able t remve it. If it requires maintenance t remve it then enter a cmment and dn t fail the item. Overflwing - garbage that is full past the tp rim f the cntainer Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Remvable Spts - anything that will transfer nt a wet paper twel Siled - accumulatin f wet r dried sil that can t be remved by dry dusting Auditing Nte: Whenever pssible, check inside the cntainer (the plastic bags can leak) and als have a lk at the bttm. These are areas that are smetimes missed. If the garbage inside the cntainer is full t the pint that it s ver the tp f the rim, this will be categrized as verflwing, and wuld be unacceptable If a waste cntainer is empty and the liner was nt changed r it s visibly siled by fd, debris, gum and\r liquids this item shuld fail Westech Systems, Inc. Auditing Training Manual Page 32 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

33 Revisin Seven D - DRAFT 18. SINK/TUB/SHOWER Definitin - All types f sinks, tubs, shwers, assist bars (in the shwer area nly) and sap, paper and sanitary napkin dispensers. Cnditins Expected - Clean means: free f dust, debris, mineral depsits, sap r sil/fluid build up 1. The sink, tub, r shwer, shwerhead, pipes and fixtures appear t be clean as per the cnditins expected Fixtures and shwer heads are free f mineral depsits. All surfaces appear t be clean. Walls in the shwer r tub area appear t be clean and are free f sap r mineral build-up. The flrs in the shwer area appear t be clean and are free f sap r mineral build-up. There is n sil/fluid build up under r arund the uter edges f the sink N sil/mineral depsits in the drain catch and the drain catch is clean. The verflw trap appears t be clean. There is n evidence f muld r mildew. Bright metal surfaces taps, handles and fixtures, dispensers and hld bars appear t be clean. Shwer curtain (n matter what the material type) appears t be clean and hung crrectly. Glass shwer drs are clean and free f remvable residue, streaks and finger marks Dispensers are clean and stcked apprpriately. The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Sink Tub Shwer Walls behind tilet Assist rails Underside Inadequate Supplies Bad Odur Pssibly cming frm mildew. A certain amunt f dur is acceptable since dedrants are nt allwed t be used in mst health care facilities. Bld Cbwebs any accumulatin f dust that frms a webbing effect t a surface Dust anything that can be easily remved by dry dusting Mineral Depsits leaking water taps, r the walls in shwer/tub areas will present a blue/green disclratin n the surface Remvable Spts anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Siled accumulatin f wet r dried sil that can t be remved by dry dusting Siled/ Fluid Build-up heavy accumulatin f sil n tp f dried sil Westech Systems, Inc. Auditing Training Manual Page 33 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

34 Revisin Seven D - DRAFT Auditing Nte: Check the piping under a sink fr dust and cbwebs. The walls directly arund the shwer and tub will be part f this categry. Usually a three r fur ft surrunding area shuld be sufficient (use cmmn sense). Check the underside f all dispensers t make sure they are being cleaned n a daily basis. The area arund the sink (cunter space) is cunted in the furnishing/fixtures categry. Waterless alchl based disinfectant dispensers fund thrughut the hspital shuld be audited in this categry. The auditr shuld be lking fr bth cleanliness and whether the dispenser is adequately filled. The hand sap used in dispensers can be a variety f clrs with red r green being the mst ppular. When dispensed nt the hand, it has a white famy appearance irregardless f what clr it is. When inspecting the underside f a dispenser and yu encunter a red r green clred build up, a sticky white fam r crusty white prus substance, this will clearly demnstrate that this area has nt been cleaned fr smetime. Micrsan dispensers that are lcated in crridrs r ther areas where a Sink/Tub/Shwer are nt present, will still be audited in this categry. When these dispensers are fund in a clean r dirty cnditin, the area will either receive a pass r fail fr a Sink Westech Systems, Inc. Auditing Training Manual Page 34 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

35 Revisin Seven D - DRAFT 19. TOILETS/URINALS/HOPPERS/FLOOR DRAINS Definitin All types f tilets (including raised seats), urinals, hppers/bed pan flushers and assist bars (in the tilet area nly). Tilet paper and any ther dispensers in the stall area are included in this categry. Cnditins Expected Clean means: free f dust, mineral depsits and sil/fluid build up 1. The frnt, back, sides, seat and bwl interir appear t be clean as per the cnditins expected 2. The flush handle appears t be clean 3. Mineral depsits are nt visible in the bwl, the flush rim and arund the jets 4. Blt caps and hinges are free f dirt. 5. Fastenings t the wall r flr shw n sil depsit 6. Flr drains are free f mineral depsits, bdy hair, fluff etc. 7. Dispensers are clean and stcked apprpriately. 8. Flr area right behind the tilet is clean. The specific fail prmpts fr the abve item are Nte - That in this categry the first fail prmpt (square bullet) is actually sub equipment that helps yu t further define what is wrng in this categry: Tilets Urinals Hpper Flr Drain Flr Behind Tilet Wall Behind Tilet Flush Rims Assist Rails Inadequate Supplies Bad Odur - usually cming frm dried urine. A certain amunt f dur is acceptable since dedrants are nt allwed t be used in mst health care facilities. Bld Cbwebs - any accumulatin f dust that frms a webbing effect t a surface Dust - anything that can be easily remved by dry dusting Feces/Urine Mineral Depsits - can be a water line r streaks inside the bwl cming frm the jets, depsits under the flush rims r blue/green disclratin f the flr drains Remvable Spts - anything that will transfer nt a wet paper twel Remvable Residue - Any nticeable wiping marks caused by inapprpriate cleaning technique (dirty clths) and r inapprpriate cleaning slutin dilutin Siled/ Fluid Build-up - accumulatin f wet r dried sil that can t be remved by dry dusting Siled Buildup - heavy accumulatin f sil n tp f dried sil Auditing Nte: The stall partitins are audited in the wall categry. When checking tilets and urinals, an inspectin mirrr will be needed t inspect the flush rim and jet areas. Westech Systems, Inc. Auditing Training Manual Page 35 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

36 Revisin Seven D - DRAFT A certain amunt f dur is acceptable in washrms since mst sites in BC abide by a nn scent plicy and are nt permitted t use dedrizers and urinal pucks. Check fr streaks f urine n the underside f wall munted urinals and the frnts f tilets The flr area directly behind a flr munted tilet and a 6 inch area arund it will be audited as part f the tilet The wall area behind the tilet (that is the same width as the tilet) will be included in this categry The assist rails arund the tilet will be included in the tilet categry. When auditing a bathrm in a patient rm r ffice include the bathrm as part f the patient rm r ffice audit. If yu have a separate rm in yur database fr a bathrm within a patient rm please ignre it r remve it frm the database (r assign it a n duty rm type). A bathrm ff a hallway is treated as a separate rm and as such will be audited as its wn entity. If the bathrm is shared between tw rms then nly audit the bathrm nce. Westech Systems, Inc. Auditing Training Manual Page 36 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

37 Revisin Seven D - DRAFT *& All the functinal areas in a hspital will be assigned ne f fur Risk Areas as defined belw. All the rms within these functinal areas will be assigned the same Risk Categry. In additin every rm in these functinal areas will als be assigned a rm type. All areas adjining the different functinal areas defined belw will receive the same level f cleaning in the specific area. Fr instance an ffice lcated beside an perating rm will receive the same high level f cleaning as the perating rm and will als be defined as a risk categry ne rm. Mrever, an ffice in an administratin area wuld receive a lwer level f cleaning. Thus depending where an ffice is lcated it culd be assigned any f the fur risk categries defined belw. Washrms as well culd be defined as any ne f the risk level s belw. It shuld be emphasized thugh that elements specific t a washrm such as tilets, urinals, & sinks will als have a high weight assciated with them since they are expected t be cleaned at a high level n matter what area they are in. 1. Very High Risk Functinal Areas: (RED) Operating Rms (OR), OR Sterile Cre, Pst Anesthetic Recvery (PAR), Intensive Care Units (ICU), Burn Units, Nenatal ICU, Cardiac ICU, Angi Suites, Labur & Delivery Rms (LDR), Special Care Nurseries (SCN), Emergency Rms (ER), Minr OR\prcedures 2. High Risk Functinal Areas: (YELLOW) Ambulatry Care & Clinics, Medical Day care, Inpatient Units (Inpatient Units include medical, surgical, pediatric, maternity/nursery, neurlgy, and palliative wards), Sterile Prcessing (SPD), Radiatin Treatment Areas. Cardiac Care Units (CCU), Chemtherapy, Renal Dialysis, Surgical day Care All washrms (all washrms shuld be risk 2 unless they are part f a patient rm that is in a lwer r higher risk grup r in an area that is risk 1), main lbbies, public entrances (Include up t twenty feet radius extending frm exterir drways), cafeterias\retail, elevatrs, main stairwells, kitchen, waiting areas, children s play areas, 3. Mderate Risk Functinal (GREEN) Rehabilitatin Areas, Residential Care Units/Facilities, Psychiatric Units, Transitinal Care Units, Labratries, Mrgues Diagnstic Imaging, Pharmacies, Outpatient Clinics, Siled Utility Rms, Special Treatment Areas (cast rms, etc), On call rms 4. Lw Risk Functinal Areas (BLUE) Laundry\Linen areas, Offices, Staff Lcker Areas, Central Stres, Receiving & Distributin Areas, Libraries, Meeting Rms, Seldm used Stairwells, Lading Dcks, External Surrunds, Health Recrds, Physical Plant Rms. 5. Very Lw Risk (GREY) Interstitial space, parkade deck, telephne rms, electrical, biler, mechanical, restricted areas Westech Systems, Inc. Auditing Training Manual Page 37 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

38 Revisin Seven D - DRAFT Still Fr Discussin: Ophthalmlgy OR are they Very High under Minr OR/prcedures. Ophthalmlgy treatment clinics (ut patient clinic area) are they Very High r High r are they Mderate under ut patient clinics? Cardiac Shrt Stay are they Very High as this unit is like PAR Shuld the Nursery n maternity wards be added t impatient units in High Risk? Shuld Renal Dialysis (RDU) remain in very high? Shuld Surgical Day Care remain in Very High Risk? What risk categry wuld a Research Wing at a Cancer Clinic be put int? There shuld be a cmprehensive list fr each risk categry instead f a synpsis i.e. Minr OR/prcedures there shuld be specific areas identified this wuld stp any cnfusin. Each Health Authrity culd send a list f specific names used fr this area. There culd als be the same dne fr Special Treatment areas, Diagnstic Imaging and Outpatient clinics etc. VIHA wants Renal Unit, Surgical Day Care and Cardiac Shrt Stay t remain in the Very High Risk categry. VIHA wants cafeteria retail & dining rms t be in High Risk. Westech Systems, Inc. Auditing Training Manual Page 38 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

39 Revisin Seven D - DRAFT + The fllwing sectin is brken int tasks that are either cmpleted n the cmputer r the palm pilt.!, Plug the palm USB cable int the cmputer and int the palm pilt. Press the pwer buttn n the tp right t turn the palm pilt n. Check the palm battery indicatr t make sure the palm is fully charged (if it is nt charged it takes just ver tw full hurs t fully charge it when it is almst ut f pwer). Duble check that the time and date n bth the palm pilt and cmputer is crrect. T d this n the cmputer click n the date time icn n the desktp. On the palm pilt click n the pref icn and then the time and date buttn (this setting shuld be set crrectly hwever it is imprtant t duble check every nw and then). Turn n the laptp and click n the SA AUDIT icn n the desktp. Lk at the tp f the screen and make sure that the crrect facility database is laded, i.e., SA Audit ~ Burnaby Hspital Fraser Health Authrity. If it is nt g t the Database menu and chse the apprpriate facility. After yu d this make sure the crrect name is nw at the tp f the screen. T send the database t the palm pilt s that yu can begin auditing click n the palm pilt tab. The SECOND THING YOU NEED TO DO IS CLICK THE CORRECT PALM USER ID which is n the left hand side f the screen. Each palm pilt has a user ID stuck n the back. Fr instance, the user ID fr a palm in the example belw is Westech Palm -25. This step is extremely imprtant. Westech Systems, Inc. Auditing Training Manual Page 39 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

40 Revisin Seven D - DRAFT Click n Send Database t Palm When this ptin cmes up make sure that yu click n the database that yu want t send t the palm pilt (yu can send mre than ne database t the palm pilt. See example belw. Verify that the Palm User id is crrect and then click n.k. Yu will then be asked t Overwrite any data in the palm (in ther wrds this step assumes that yu have previusly retrieved audits since yu are abut t verwrite what is ever in the palm pilt); if this is the case click yes fr the secnd time. The please htsync the palm nw screen will cme up at which time yu shuld press the htsync buttn n the palm pilt. Yu shuld then hear a nise indicating that the cnnectin has been made. The htsync will be cmplete nce yu hear this nise again. Westech Systems, Inc. Auditing Training Manual Page 40 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

41 Revisin Seven D - DRAFT The fllwing pages will display a step by step guide that will help yu get setup t perfrm an audit. By fllwing this guide, yu will learn the preladed rm specific database prcedure as well as the Edit Rm prcedure. When using the Edit Rm feature, a detailed table explaining the functinal areas and rm listings will be lcated in a separate part f the manual Figure 1: Buttn A: Hme- when this is used, it will always bring yu back t the Main Menu. Remember, when perfrming an audit, if this icn is used it will erase the current audit yu are ding Buttn B: Menu Buttn C: HtSync-when sending data frm the laptp t the palm pilt r when retrieving data frm the palm and sending it t the laptp, this buttn will be used Buttn D: On/Off Buttn E: Scrll up & Dwn Figure 2 SA Audit When the On/Off (Figure 1 Buttn D) r the Hme (Figure 1 Buttn A) n the palm pilt is used, this is the first menu that will be seen. Tap the SA Audit icn t start the audit prcess Westech Systems, Inc. Auditing Training Manual Page 41 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

42 Revisin Seven D - DRAFT Figure 3 Select a Building Select a building site by tapping the dwn arrw under Select a building Scrll thrugh listings and highlight the prper site The highlighted site will nw appear in this area Figure 4 Select an Auditr Select an auditr by tapping n the dwn arrw under Select an auditr Scrll thrugh the names r auditr numbers and highlight yurs Yur name r auditr number will nw appear in this area Tapping the Clse bx will take yu back t the main Menu When yu tap the Begin bx it will take yu t the fllwing screen Figure 5 Select a Rm t Audit This screen will nly appear when a rm specific data based is being used, therwise it will be blank r it will have a list f Templates The first clumn is the rm number which will be the same as the rm number listed n the flr plans being used The secnd clumn will display the rm use and/r rm name pssibly with the physical rm number that is n the dr depending n hw the database is set up. This will display all the rms cntained in the selected database, which culd be thusands. T narrw rm listing dwn t a manageable number, tap the Menu buttn (Figure 1 Buttn B) and select Narrw rm list and the next screen will appear Westech Systems, Inc. Auditing Training Manual Page 42 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

43 Revisin Seven D - DRAFT Figure 6 Narrw Rm List This will eliminate the need t scrll thrugh a huge list f rms in rder t find the ne yu wish t audit The Narrw rm list is nly used if the preladed rm specific data base cntains numerus rms This Narrw rm list will nly cme up when yu are in the first screen that shws all f the rms The rm use will shw all the different types f rms the building has If yu were t tap n the up arrw beside Lcatin (all) and then highlight the flr where yu are lcated and then tap the Select bx the fllwing screen will appear Figure 7 Narrw the Rm/Area List With the Burrard bldg 4 Flr being selected, yu can nw narrw the search even further, (if needed) by chsing a selectin frm the Functinal Area by tapping n the up arrw beside it and then selecting Intensive Care Unit. Tap Select and the next screen will appear. Figure 8 Narrw the Rm/Area List When the Cntinue bx is tapped n this screen, it will give yu an example f all f the rms in the Intensive Care Unit n the 4 Flr f the Burrard Building. See the next screen. A rm t audit can nw be selected frm this list. When a mistake has been made r yu want t make changes t the set parameters, tap the Reset bx, and it will erase all the setting and let yu start again. Westech Systems, Inc. Auditing Training Manual Page 43 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

44 Revisin Seven D - DRAFT Figure 9 A Rm t Audit An ICU rm n the 4 th Flr Burrard Building can nw be selected (d nt select a rm with a star beside it) Tap the Audit buttn and it will take yu t yur first inspectin element which is Drs If yu tap the back buttn, it will send yu t the main menu frm here yu must fllw the infrmatin in Figures 3 8 t get back t where yu were When yu have cmpleted the desired number f rm in this area tap the Menu buttn and Narrw Rm List fr yur next set f rms Figure 10 Give the Elements a Pass r Fail The first audit inspectin element that will appear is Drs By tapping ne f the bxes yu will either Pass r Fail the item If the area passes it will g t the next inspectin element n the list If the area des nt have drs, then tap the Skip bx and it will g t the next inspectin element n the list which is Walls Figure 11 Select a Prmpt Cmment Selecting the Fail bx will bring up a list f Fail Prmpts One r multiple items can be selected These items will be placed int a hlding basket just abve the Remve bx Westech Systems, Inc. Auditing Training Manual Page 44 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

45 Revisin Seven D - DRAFT Figure 12 Select a Prmpt Cmment In brackets, the (3) indicates that three items frm the list have been selected and ne f thse items is "FINGER MARKS By tapping the dwn arrw a list f all selected items will cme up If yu wish t remve ne r all f these items, first select which ne is t be remved and then tap the Remve bx. Repeat fr each item. When satisfied, tap the finished buttn and it will take t the next inspectin element, walls If yu ntice smething else yu wish t add r delete frm Drs, tap the Prev buttn n the Walls screen, tap the Fail prmpt. This will take yu back t the select a prmpt cmment area fr Drs Use the finish buttn t return t walls Figure 13 Sub Equipment & Fail prmpts Walls, Patient Equipment and Furnishing/Fixtures are the nly inspectin elements that will cntain tw separate categries f fail prmpts. The first prmpts that cme up when yu fail patient equipment are the sub categries f equipment such as cmmdes, I.V Ples, etc and after yu select these items the next elements are the fail prmpts telling why the item failed such as dust, siled, etc. Figure 14 Select a Prmpt Cmment The first sectin cntains the sub categries f equipment within the categry The secnd sectin cntains the pssible fail prmpts One r multiple items can be selected Pick frm the sub categries f equipment first and then pick the reasn the sub equipment failed (i.e. feces-urine, etc). I.e., Cmmde, Wall munted equipment, Lifts-tractin bars, cbwebs, feces/urine, dust. These item will be srted alphabetically Westech Systems, Inc. Auditing Training Manual Page 45 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

46 Revisin Seven D - DRAFT Menu Buttn Optins When yu tap the menu buttn (Figure 1 Buttn B) while perfrming an audit, a drp dwn screen will appear displaying three separate ptins that can be used. Hw d I audit this item? Enter Cmment r Cancel Current Audit. Figure 15 Hw D I Audit This Item? When unsure as t what is invlved with auditing a particular inspectin element, tap the Menu buttn (Figure 1 Buttn B) this will bring up the Hw d I audit this item screen Select Hw d I audit this item? and a screen will cme up giving a brief descriptin f what is cntained in the inspectin element yu are requesting infrmatin n, in this case it s the patient equipment categry Once there is a better understanding f hw t perfrm the audit, tap OK and it will take yu back t where yu were Figure 16 Hw D I Audit This Item? Here is anther example f Hw d I audit this item? This explains the high dusting categry. It will als make reference t items which are nt included in this categry Tap OK and it will send yu back t the high dusting categry Figure 17 Enter Cmment At anytime during the audit, yu can enter a cmment in the verall cmment area by tapping the menu buttn and then tapping Enter Cmment frm the drp dwn menu. The fllwing screen will appear Westech Systems, Inc. Auditing Training Manual Page 46 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

47 Revisin Seven D - DRAFT Figure 18 Overall Audit Cmment Befre all f the inspectin elements have either been Passed, Failed r skipped, this screen will appear This feature allws cmments t be added that were nt cvered in the prmpt specific categry r safety/maintenance issues may be recrded If the rm specific database is nt being used, then rm number and lcatin cmments can be added Tap the centre f the screen and the fllwing bx will appear If there are n inspectin cmments required, tap the OK bx Figure 19 Keybard Using the keybard, type in cmments such as Brken tilet seat When finished, and yu are happy with the cmment, tap the Dne bx. This will save the typed cmments and it will display the same screen pictured abve which will include any cmments that were added. If editing is needed, tap the centre f the screen, make any necessary changes, tap Dne and then OK Figure 20 Want t Cancel Current Audit At anytime during an audit yu can quickly exit the current audit by tapping the OK buttn. This will cancel the current audit withut saving it all ther saved audits will be kay. When ding this, it will take yu back t the rm listings area where yu can make anther rm selectin. If yu wish t cntinue auditing, then tap the Cancel buttn and this will bring yu back t yur current psitin Westech Systems, Inc. Auditing Training Manual Page 47 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

48 Revisin Seven D - DRAFT Figure 21 Press the Hme Buttn by Accident If at anytime during the audit the Hme buttn (Figure 1Buttn A) is activated, this screen will cme up. The nly way ut is t tap the OK bx. Once this is dne, yu will be sent back t the Menu screen (Figure 2) and that audit will be lst. Any cmpleted audits that were previusly saved will be kay. Yu must nw cmplete the steps shwn in figures 3-9 When these steps have been cmpleted yu will see the next screen Figure 22 Give the Elements a Pass r Fail The first audit inspectin element that will appear is Drs By tapping ne f the bxes yu will either Pass r Fail the item If the area passes it will g t the next inspectin element n the list If the area des nt have drs, then tap the Skip bx and it will g t the next inspectin element n the list which is Walls Cmplete an audit by selecting Pass, Fail r Skip fr each f the 19 inspectin elements Figure th Inspectin Element The last inspectin element is Tilet\urinal\hpper Frm here yu are able t g back and check any f the previus inspectin elements by tapping the Prev buttn. Changes can be made alng the way When ging back t tilets, yu MUST tap the Next buttn. If the skip buttn is tapped any Pass Fail cmments will be erased When back t the Tilet screen, tap the Next buttn and it will take yu t the Overall Cmments screen. Any f the typed cmments that were previusly added will be there. Any further cmments can be added by fllwing the instructins in Figures Tap OK when finished Westech Systems, Inc. Auditing Training Manual Page 48 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

49 Revisin Seven D - DRAFT Figure 24 Saving an Audit If yu are still nt satisfied with the audit and yu feel mre changes are needed, tap the N bx and it will take yu back t the Tilet\Urinal\Hpper screen. Frm here yu can g back int each inspectin item by using the Prev/Next bxes and make any necessary changes, r use the menu icn and select the Enter Cmment frm the drp dwn screen t get back t the Overall Audit Cmments area. When yu are satisfied, tap the Yes bx and this will save everything fr the audit that was just cmpleted and the fllwing screen will appear Once the yes buttn has been used, yu will nt be able t make any further changes t this audit until it is upladed t the cmputer Figure 25 Select an Area t Audit The audit that was just cmpleted is shwn n the list with a Star beside it. The Star indicates a cmpleted audit. If by accident, yu chse the rm with the Star beside it again and tap the Audit bx, the prgram will allw this rm t be audited again. This duplicate audit can be remved by using the remve audit feature. The Histry bx allws yu t view the cmpleted audits (editing is n lnger an ptin) Tap the Histry bx and the fllwing screen will appear Figure 26 Histry Screen All f the saved audits will shw up n this screen. They will be listed by Rm number and the date and time it was cmpleted If the same rm number is listed multiple times this indicates that it was audited mre than nce. The date may be the same depending which day it was used again, but the time will definitely be different. There is n way f fixing this except by deleting ne f the duplicated audits after yu retrieve them t the cmputer. If yu want t lk further int the cmpleted audit, highlight the rm yu want t lk at and tap the View bx and then tap the View bx beside Scring The fllwing screen will appear Westech Systems, Inc. Auditing Training Manual Page 49 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

50 Revisin Seven D - DRAFT Figure 27 Histry Screen This will display all f the inspectin elements that were audited. Any items that were previusly skipped, will be mitted frm this list The 9 indicates a passed item and the 1 indicates a failed item Tap the Dne bx and then tap the Dne bx again and it will take yu back t the Select an area t audit screen (Figure 25) Highlight a rm (that des nt have a star beside it) and begin a new audit Figure 28 Edit Rm On the fly editing can be dne with the Edit Rm feature by making changes t the existing infrmatin r fr adding rms that are nt in the database. Tap the Menu buttn and then tap Edit Rm and a screen will appear that allws yu t change r enter a rm number, rm name, the risk categry, the high level functinal area as well as the type f rm. If yu find a rm that is under cnstructin r there is an errr in cad yu can click n SF4 and insert the prper rm type which in this case culd be under cnstructin If a rm is missing frm the database it can be quickly added here by first finding a rm in the rm listings area that is next t the missing rm. Highlight this rm, use Edit Rm, change all f the infrmatin and then tap save. The rm listings screen will nw have this new rm number and related infrmatin added int the palm. This newly added rm can nw be audited. When the audits are retrieved t the PC, this added rm inf will be added t the database. Figure 29 Srt Fields Type and SF 1, SF 2, SF 3 and SF 4 refer t the fllwing: Type: Risk Categry SF1: High Level Functinal Area SF2: Functinal Area SF3: Lcatin SF4: Rm Use. Westech Systems, Inc. Auditing Training Manual Page 50 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

51 Revisin Seven D - DRAFT Figure 30 Edit a Rm After all areas have been filled in, tap the Save bx and a screen will appear telling yu that Rm Number JP 4500 has been added. Tap the OK bx and then tap Cancel (this will nly happen if the Rm Number has been changed) Figure 31 Edit a Rm The fllwing template rm 003 has a default f a template rm type. In rder t be able t audit using this rm number yu will need t assign the rm a specific risk categry. If yu dn t assign the rm a risk categry then the fllwing screen will cme up. Figure 32 N Inspectin Elements Errr Message This is telling yu that all f the necessary infrmatin was nt filled in and until yu d this, Template 003 des nt exist Tap OK and it will take yu back t the previus screen where the necessary infrmatin can be entered When everything has been crrectly added the fllwing screen will be seen Westech Systems, Inc. Auditing Training Manual Page 51 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

52 Revisin Seven D - DRAFT Figure 33 Select a Rm t Audit When using the Edit Rm feature, this is what the screen will lk like nce a new rm has been created. The Template rms in this list refer t blank rms with n infrmatin that can be used t speed up the prcess if yu d nt have a hspital specific database. Westech Systems, Inc. Auditing Training Manual Page 52 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

53 Revisin Seven D - DRAFT *% After yu have finished auditing, its nw time t retrieve the audits frm the palm and put them n t the cmputer. Plug the palm int the PC. Frm the desk tp, pen the SA Audit Sftware, click n the palm pilt tab (MAKE SURE YOU SELECT THE CORRECT PALM USER ID) and then the Retrieve Audits tab. Press the ht sync buttn n the palm (make sure the palm is n prir t pressing the buttn). Yu shuld get a message n the bttm f the screen shwing hw many audits have been retrieved. When retrieving audits it desn t matter which database is currently laded. The prgram will uplad the results frm multiple sites and send the prper data t the prper database. Westech Systems, Inc. Auditing Training Manual Page 53 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

54 Revisin Seven D - DRAFT *%-* When an audit has been cmpleted, yu can nw run a reprt and analyze the data that was cllected. G t the SA Audit screen and click n the Reprts tab. Click the Audit histry tab. There yu will see tw areas t chse frm, Summary and Details. The Summary tab will generate reprts by rm number, date f audit, rm type, high level functinal area, functinal areas, building flr, rm use r by auditr. The Details tab will generate reprts by prmpts scred, prmpt rati reprt, crrective actin plan, crrective actin plan by high level functinal area, crrective actin plan by functinal areas, crrective actin plan by building flr r crrective actin plan by rm use. Under the same reprts tab, anther area is Table Listings. Here reprts can be generated by rms, prmpt cmments, high level functinal areas, functinal areas, building flr, rm use, auditrs, prmpts r schemes., - The auditing prgram will nt allw yu t start an audit until yu have set up yur auditr ID. This can be dne by selecting the Optins tab frm the SA Audit screen. Then g t the Edit Tables, frm this screen select Auditrs. When the Edit Auditrs ID cmes up yu are able t add yur Auditr ID number as well as yur name. After the data has been entered, click n the Update tab and yur Auditr number and name will be saved in the system. The varius tabs cntained n the SA Audit screen will be used fr the fllwing functins when that tab is clicked Optins gives basic setup features such as setting up a new auditr ID Reprts generates detailed reprts n the cmpleted audits Database makes it pssible t change the database frm ne facility t anther and t backup databases. Help tells yu what versin f the SA Audit prgram is being used Audits displays the audits individually by rm number r all at nce by the date Audit Detail shws the prmpt scres fr each inspectin element cntained in each audit Palm Pilt used t transfer data between the PC and the Palm Westech Systems, Inc. Auditing Training Manual Page 54 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

55 Revisin Seven D - DRAFT Graphs displays graphs that shw auditing trends by date, rm number, rm type r auditr Setup ability t change system settings (please cnsult with an I.T prfessinal prir t making any changes). "$*(! "$ T a reprt yu have t first exprt the reprt frm SA Audit t either a Wrd dcument r Excel Spreadsheet. T d this g thrugh the same prcedures that yu nrmally wuld g thrugh t print a reprt. When yu get t the screen yur yu nrmally click n the printer icn (see screen capture belw) press the envelpe with the arrw instead. After yu press the envelpe icn the fllwing screen will cme up. Make sure yu click n the frmat dialgue bx and pick either a wrd fr windws dcument r excel file. After yu click n.k. n the screen in the abve example the fllwing dialgue bx will cme up. Yur next task is t click n my dcument create a new flder if yu want r pick an existing flder and then rename the reprt apprpriately (always wise t put in the date). Westech Systems, Inc. Auditing Training Manual Page 55 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

56 Revisin Seven D - DRAFT Once yu save the dcument in the wrd r excel frmat yu can edit it r it. Westech Systems, Inc. Auditing Training Manual Page 56 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

57 Revisin Seven D - DRAFT! It shuld be nted that the fllwing tables will differ slightly at the different facilities acrss BC. Specifically: Srt Field One: The high level functinal areas shuld remain the same at all facilities Srt Field Tw: The hspital specific functinal areas will be different at all facilities based n whether r nt an existing database was used t initially ppulate yur audit database. If an existing database was nt used yur table will clsely resemble the listing belw. Srt Field Three: The building flr srt field is entirely facility specific and is nt listed belw. An example culd be Burrard-Fur which stands fr Burrard Building furth flr. Srt Field Fur: The hspital rm use srt field will be different at all facilities based n whether r nt an existing database was used t initially ppulate yur audit database. If an existing database was nt used yur table will clsely resemble the listing belw.,.%, ACUTE CARE AREAS ADMINISTRATION CRITICAL CARE AREAS COMMON SUPPORT AREAS DAY CARE SERVICES DIAGNOSTIC CARE RESIDENTIAL CARE VERIFY DATA,-, AMBULATORY CARE ANGIO SUITES AUTOPSY BIOMED BONE MARROW TRANS BURN UNIT CARDIAC CARE UNIT CARE PROGRAM CENTRAL STORES CENTRAL SUPPLY CHEMICAL-ALCOHOL TRT CYTOLOGY DIAGNOSTIC IMAGING DISTRIBUTION AREAS EATING DISORDER ELECTRODIAGNOSTIC LB ELEVATORS EMERGENCY ENDOSCOPY LINEN RECEIVING LOADING DOCKS LOBBIES MEDICAL DAYCARE MEDICAL GENETICS MEETING ROOMS MISCELLANEOUS NEONATAL ICU NON STERILE SUPPLY NUCLEAR MEDICINE OPERATING ROOMS OPTHALMOLOGY CLINICS ORTHOPEDICS OUTPATIENT CLINICS PHARMACIES PLANT ROOMS POST ANESTH RECOV PSYCHIATRIC RADIATION TREATMENT Westech Systems, Inc. Auditing Training Manual Page 57 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

58 Revisin Seven D - DRAFT ENGINEER WORKSHOPS ENTRANCES EXTERNAL SURROUNDS FOOD AREA HEALTH RECORDS STOR HIV INPATIENT UNITS INTENSIVE CARE UNIT ISOLATION AREAS LABORATORIES LABOUR & DELIVERY LAUNDRY LIBRARIES RENAL DIALYSIS RESEARCH RESIDENTIAL SOILED ROOMS SPECIAL CARE NURSERY SPECIAL TREAT AREAS STAIRWELLS STERILE SUPPORT AREAS SURGICAL DAY CARE TRANSITIONAL CARE WAITING AREAS VERIFY DATA,,* ). BEAUTY SALON PATIENT ROOM ACUTE CAFE-RETAIL AREA PATIENT ROOM REHAB CAFETERIA PATIENT ROOM CAST ROOM PATIENT ROOM PSYCHIATRY CHANGE AREA PAT RM RESIDENTIAL CHAPEL PATIENT RES DINING CHEMOTHERAPY PHOTO COPY ROOM COMPUTER LAB PLANT OPERATIONS CONFERENCE-MEETING PLAYROOM COOLER POWER PLANT CORRIDOR-HALLWAY PROCEDURE ROOM DIAGNOSTIC AREAS QUIET ROOM DICTATION-CHARTING RECEPTION DINING ROOM RECREATION RESIDENT ELEVATOR REHAB ENTRANCE RENAL EXAM ROOMS SCRUB SINK FILE STORAGE SHIPPING RECEIVING GIFT SHOP SHOWER-TUB ROOM GYM-PATIENT SLEEP ROOM GYM-STAFF SMOKE ROOM HOSTEL STAIRWELL HOUSEKEEPING CLOSET STERILE CORE ICU BED STERILE PROCESSING INTERNS CALL ROOM STORAGE-EQUIPMENT KITCHEN-MAIN STORAGE-MISC KITCHEN-PANTRY STRETCHER-TREAT BAY LABOR AND DELIVERY TREATEMENT ROOM LABORATORY UTILITY-CLEAN LAUNDRY UTILITY-SOILED LIBRARY WAITING AREA LINEN HOLDING AREA WAREHOUSE LOBBY WASHROOM-PATIENT Westech Systems, Inc. Auditing Training Manual Page 58 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

59 Revisin Seven D - DRAFT LOCKER ROOM LOUNGE-DOCTOR LOUNGE-PATIENT LOUNGE-STAFF MECHANICAL MEDICATION ROOM MORGUE MULTIPURPOSE ROOM NURSE STATION NURSERY OFFICE OPERATING ROOM OPERATING THEATRE OUTSIDE PATIO PATIENT RECOVERY WASHROOM-PUBLIC WASHROOM-STAFF WASTE COLLECTION VERIFY DATA ERROR IN CAD UNDER CONSTRUCTION Westech Systems, Inc. Auditing Training Manual Page 59 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

60 Revisin Seven D - DRAFT CARTS-HAMPERS COMMODE SEATING DESK-TABLE-COUNTERS IV POLE-PUMP-SUCT WALL MOUNTED EQUIP PICS-B BOARDS-SIGNS LIFTS-TRACTION BAR PC MON-TV-APPLIANCE OVERBED TABLES SHARPS CONTAINERS SHELV-CAB-LOCK-CUP WHEEL-GERI-CHAIRS WR STALL PARTITION ADHESIVE RESIDUE BAD ODOUR BLOOD COBWEBS DEBRIS DUST DUST BALLS FECES-URINE FINGER MARKS GLOSS NOT APPROP GRAFFITI MINERAL DEPOSITS SHARPS OVER 3/4 OVERLFLOWING REMOVABLE RESIDUE REMOVABLE SPOTS SCUFF MARKS SOILED SOIL- FLUID BUILDUP STRINGS OR WIRE REQUIRES ATTENTION CARTS - HAMPERS COMMODE COUCHES - STOOLS - CHAIRS DESKS - TABLES - COUNTERS IV POLES - PUMPS - SUCTION WALL MOUNTED EQUIPMENT PICTURES - BULLETIN BOARDS - WALL SIGNAGE LIFTS - TRACTION BARS COMPUTER MONITORS - TELEVISIONS - APPLIANCES OVERBED - BEDSIDE TABLES SHARPS CONTAINERS SHELVING - CABINETS - LOCKERS - CUPBOARDS WHEEL - GERI -CHAIRS WASHROOM STALL PARTITIONS ADHESIVE RESIDUE BAD ODOUR BLOOD COBWEBS DEBRIS PRESENT DUST DUST BALLS FECES - URINE FINGER MARKS GLOSS NOT APPROPRIATE GRAFFITI MINERAL DEPOSITS SHARPS CONTAINERS OVER 3/4 FULL OVERLFLOWING REMOVABLE RESIDUE REMOVABLE SPOTS SCUFF MARKS SOILED SOILED - FLUID BUILDUP STRINGS OR WIRE REQUIRES ATTENTION Westech Systems, Inc. Auditing Training Manual Page 60 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

61 Revisin Seven D - DRAFT * ' RISK1 RISK2 RISK3 RISK4 TMP ZND R1-VERY HIGH RISK R2-HIGH RISK R3-MODERATE RISK R4-LOW RISK TEMPLATE NO DUTY * ' Scheme: NORMAL - NORMAL INSPECTION Rm Type: RISK1 - R1-VERY HIGH RISK Prmpt Descriptin Type Weight DOORS S WALLS S CEILINGS S VENTS\REGISTERS\HOO S HARD FLOORING S CARPET\MATS S INT- WINDOW\GLASS S WINDOW COVERING S CUBICLE CURTAIN S BEDS\STRETCHERS\EXA S PATIENT EQUIPMENT S FURNISH\FIXTURES S LIGHT FIXTURES S PHONES S HIGH DUSTING S BASEBOARDS S WASTE CONTAINERS S SINK\TUB\SHOWER S TOILET\URINAL\HOPPER S LOCATION-COMMENTS P 0 Scheme: NORMAL - NORMAL INSPECTION Rm Type: RISK2 - R2-HIGH RISK Prmpt Descriptin Type Weight DOORS S WALLS S CEILINGS S VENTS\REGISTERS\HOO S HARD FLOORING S CARPET\MATS S INT- WINDOW\GLASS S WINDOW COVERING S CUBICLE CURTAIN S BEDS\STRETCHERS\EXA S PATIENT EQUIPMENT S 9 Westech Systems, Inc. Auditing Training Manual Page 61 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

62 Revisin Seven D - DRAFT FURNISH\FIXTURES S LIGHT FIXTURES S PHONES S HIGH DUSTING S BASEBOARDS S WASTE CONTAINERS S SINK\TUB\SHOWER S TOILET\URINAL\HOPPER S LOCATION-COMMENTS P 0 Scheme: NORMAL - NORMAL INSPECTION Rm Type: RISK3 - R3-MODERATE RISK Prmpt Descriptin Type Weight DOORS S WALLS S CEILINGS S VENTS\REGISTERS\HOO S HARD FLOORING S CARPET\MATS S INT- WINDOW\GLASS S WINDOW COVERING S CUBICLE CURTAIN S BEDS\STRETCHERS\EXA S PATIENT EQUIPMENT S FURNISH\FIXTURES S LIGHT FIXTURES S PHONES S HIGH DUSTING S BASEBOARDS S WASTE CONTAINERS S SINK\TUB\SHOWER S TOILET\URINAL\HOPPER S LOCATION-COMMENTS P 0 Scheme: NORMAL - NORMAL INSPECTION Rm Type: RISK4 - R4-LOW RISK Prmpt Descriptin Type Weight DOORS S WALLS S CEILINGS S VENTS\REGISTERS\HOO S HARD FLOORING S CARPET\MATS S INT- WINDOW\GLASS S WINDOW COVERING S CUBICLE CURTAIN S BEDS\STRETCHERS\EXA S PATIENT EQUIPMENT S FURNISH\FIXTURES S LIGHT FIXTURES S PHONES S HIGH DUSTING S 4 Westech Systems, Inc. Auditing Training Manual Page 62 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

63 Revisin Seven D - DRAFT BASEBOARDS S WASTE CONTAINERS S SINK\TUB\SHOWER S TOILET\URINAL\HOPPER S LOCATION-COMMENTS P 0 Westech Systems, Inc. Auditing Training Manual Page 63 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

64 Revisin Seven D - DRAFT # ) -.# If new reprts r features are created fr the system then Westech will the cntact at each health authrity t instruct them t update the system. The fllwing are the steps that are required t update the system. 1. Dwnlad the latest SA Audit Update.exe frm tclean.cm. Click n 1. Sftware dwnlads 2. Stand Alne Audit (n the right) 3. The blue text Dwnlad nw. When the file dwnlad bx cmes up save the file t yur USB Key r t yur desktp depending n where yur SA Audit sftware resides. Make sure yu write dwn the latest versin f the SA Audit prgram fr the cmputer and the palm pilt (they are different; in the example belw SA Audit n the Cmputer is versin and SA Audit fr the Palm is ). 2. Run the update.exe file frm the USB key (r desktp) and fllw all the instructins. This step will update the SA Audit prgram n the cmputer (t run this file simply duble click n the blue icn). 3. After updating the SA Audit prgram n the cmputer update the SA Audit prgram n the palm pilt by ding the fllwing: a. Start SA Audit n yur cmputer Westech Systems, Inc. Auditing Training Manual Page 64 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

65 Revisin Seven D - DRAFT b. Click n the Palm Pilt tab (see belw) 4. Click n the Optin menu n the tp left. 5. Click n the Palm Pilt ptin under the Optin menu and then pick n the lad audit prgram ptin. 6. Then fllw the specific instructins n the screen. Keep in mind that when the prgram asks yu fr the Palm User I.D it is referring t the name f yur Palm Pilt and NOT yur Auditr I.D. 7. Start the SA Audit prgram n the Laptp and press Palm Pilt tab and then chse Send a database t Palm. 8. Make sure that bth the cmputer and Palm have the crrect versin number by ding the fllwing: a. Latest Cmputer SA Audit Versin Number is n the screen when yu first lad the prgram b. Latest Palm Pilt SA Audit Versin Number is n the screen when yu first lad the prgram (after yu have laded the database as described abve in step 7). &# "/! T fllwing steps will enable yu t easily create a backup file f the different databases yu are using. Specifically the system will autmatically create a backup ZIP file (cmpressed file) and give it a name with the current date and time. Make sure yu are in the right database yu want t backup by ensuring the name is n the tp bar. If the crrect database is nt listed n the tp bar then click n the change current database ptin. Pick the right database. Once the crrect database is laded click n the database tab again and chse the backup database ptin. The prgram will autmatically create a database zipped with the hspital name and the current date and time stamp. This file will be stred in the winzip flder under the flder where yu databases are stred. The next time yu backup a file the previus backup file will be mved t the archive flder under the winzip flder. Westech Systems, Inc. Auditing Training Manual Page 65 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

66 Revisin Seven D - DRAFT In the fllwing example the databases are stred in the FHA directry and the zip file with the database name with time and date gt stred in the FHA\Winzip directry. In this example, the same database was backed up a minute later and yu can see that the file is put in a FHA\Winzip\Archive directry. T the zip file simply g t Outlk and insert the newly created zip file. Always make sure yu check the time and date t ensure that yu are sending the right file. If yu dn t have n yur cmputer cpy the zip file t a USB key. Westech Systems, Inc. Auditing Training Manual Page 66 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

67 Revisin Seven D - DRAFT $ Future Maintenance Cmments: When testing mark and spts make sure that they are nt remvable Ability t assign multiple maintenance cmments t each inspectin element. Area under cnstructin put in verall cmment sectin We shuld be selective as what we put in here. Sprinkler heads & bugs in the light lenses are fair play, it is a cleaning issue. But the auditr shuld put these items in the maintenance cmments as well as failing the item if it is bad enugh. Ceiling tile that need replacing MANAGEMENT ISSUES If a building has an area that is mre prne t dirt than this area will require mre attentin. We have t stick t a set standard fr measuring cleanliness. We are ding cleaning audits, peratinally we have t adjust fr items that are nt cleaned by husekeeping such as rental TV s and phnes Other Issues The larger and less imprtant the item will have mre latitude Maybe take ut 85/15 rule Maybe a list f shw stppers depends n item yu are lking at, if yu g int an area where a VRE clean happened the 85/15 means nthing. Walls with residue frm cleaning: at the end f the day it has t lked like it has been cleaned. Define what is excessive residue. Minimal amunts f residue is.k, but nt in a high prfile area, Glass surfaces such as windws, mirrrs, TV and mnitr screens etc. shuld be streak free. Maybe define where the 85/15 rule des apply. Maybe the ruling depends n the area type. Westech Systems, Inc. Auditing Training Manual Page 67 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

68 Revisin Seven D - DRAFT &0', Health Authrity/Site: Building Name: Risk Categry (1, 2, 3 r 4): Functinal Area: Rm Name Rm Number Inspectin Element Put a check mark under the apprpriate clumn, skip if nt applicable Pass Fail Cde Cmment Cde If an item fails put ne f the fllwing numbers crrespnding t the cmment in the Cde Clumn. 1 DOORS 2 WALLS 3 CEILINGS 4 VENTS\REGISTERS\HOOD 5 HARD FLOORING 6 CARPET\MATS INT- WINDOW\GLASS\ 7 MIRROR 8 WINDOW COVERING 9 CUBICLE CURTAIN 10 BEDS/EXAM TABLES STRETCHERS 11 PATIENT EQUIPMENT 12 FURNISH\FIXTURES 13 LIGHT FIXTURES 14 PHONES 15 HIGH DUSTING 16 BASEBOARDS 17 WASTE CONTAINERS 18 SINK\TUB\SHOWER 1-Adhesive Residue 2- Bad Odur 3- Bld 4- Cbwebs 5- Dust 6- Dust Balls 7- Debris 8- Feces/Urine 9-Finger Marks 10- Graffiti 11- Mineral Depsits 12- N Apprpriate Glss 13- Overflwing 14- Remvable Residue 15-Remvable Spts 16-Scuffs Marks 17-Sharps ver ¾ 18-Siled 19-Siled Buildup 20-String r Wire 21-Requires Attentin 19 TOILET\URINAL\HOPPERS FLOOR DRAINS Cmments: Westech Systems, Inc. Auditing Training Manual Page 68 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

69 Revisin Seven D - DRAFT Name f Auditr: Date: Westech Systems, Inc. Auditing Training Manual Page 69 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

70 Revisin Seven D - DRAFT ' *1 Each health authrity shuld append a list f any specific cleaning requirements nt cvered in this manual. Sme f the typical items that may r may nt be the respnsibility f the husekeeping department are as fllws: In sme areas nly the flrs, garbage and/r cunters are cleaned by husekeeping. Sprinklers Expsed pipes Laundry equipment Telecmmunicatin rms Cmputer rms Sharp cntainers Cmputer Keybards Cmputer CPU s The inside f lights (i.e., bugs in lights) Appliances such as fridges and micrwaves Islettes and bassinettes. Carpet stains Graffiti Filling and cleaning dispensers Sanitary napkins Tilet paper Paper twel Sap Tys Etc. Westech Systems, Inc. Auditing Training Manual Page 70 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)

71 Revisin Seven D - DRAFT Access Panel Dr Flding Grille Westech Systems, Inc. Auditing Training Manual Page 71 f Attachment A t Appendix 4E Cleaning Outcme Standards (RJH)