Preparing Your EVS Department for a Joint Commission Inspection

Preparing your EVS Department for a Joint Commission inspection does not need to be stressful!

Given that an inspection lasts only a few days, there is only so much that the inspection team can accomplish. Typically, for the EVS Department, they will focus on your paperwork.

They want to see:

• Are you organized? Records are stored in binders, easily accessible, and clearly labelled.
• Are you up to date? You are up to date with the regulations, protocols and procedures.
• Do you have all the information they are looking for?

Start Here

You can break up your records as follows:

• Policy and Procedure Manuals
  • Gather all the policy and procedure documents for cleaning, disinfection, waste management, and infection control practices. Ensure they are all up to date. If not, then download and print out the newest version.
  • These should be in the Director’s office and/or a Training area.

• Training Records
  • Documents for all staff training:
    • cleaning protocols
    • safety procedures
    • hazardous materials handling
    • other relevant training.
  • Documentation should include the subject covered, training content, and attendee names.
  • If testing was given, you might include the results as well

• Safety Data Sheets
  • Ensure that SDS for all chemicals used by your staff are readily available and up to date.
  • The SDS is typically available off the manufacturer’s website. These must be printed and stored in a central location as well as in specific locations where the chemicals are stored or used. Speak to the Safety department for guidance on this.

• Infection Control Protocols
  • Gather your documentation of infection prevention policies, including hand hygiene protocols, PPE usage, and isolation cleaning procedures. Contact the Infection Control department for guidance.

• Quality Assurance Programs
  • Documentation of your QA program is critical. You must be able to demonstrate that you have an active program. You will want to show documentation of:
    • Goals and objectives
    • Audit schedules
    • Audit Results with
      • Name of auditor
      • Location inspected
      • Findings
      • Corrective actions
    • Photos are a great addition to this
    • A list of all your QA inspectors
    • Details of your training program, curriculum, and testing

• Incident Reports
  • Documentation of any incidents related to environmental services, including spills, exposures to hazardous materials, or any other safety incidents.
  • Be sure to include information on how these incidents were closed out.

• Patient Room Cleaning Logs:
  • Detailed logs showing the scheduling of room cleaning.

• Operating Room (OR) Cleaning Protocols
  • Documentation of cleaning procedures
  • Include, Start of day, between surgeries and terminal cleaning.

• Utility and Storage Areas
  • Ensure that documentation for the maintenance and organization of these areas is available.
  • Demonstrate compliance with storage guidelines and safety standards.

• Ceiling tiles
  • If you have a ceiling tile program it is good to present it in its’ own binder

• Vent Cleaning
  • If you have a vent inspection and cleaning program, again, you should present it in it’s own binder.

• Pest Control Logs
  • Provide documentation of your pest inspections, control measures taken, and any pest sightings and their resolutions.
  • Include details of where chemicals were used, and how much.

• Emergency Preparedness Documents
  • Provide a binder that details your department’s role in emergency planning. Include procedures for emergency cleanliness and sanitation standards.

You can of course get ahead of the paperwork by implementing an automated inspection software solution such as QA Inspector from Walsh Integrated. Walsh’s QA Inspector will help organize the paperwork required for a successful EVS Joint Commissions inspection, and much more. Walsh QA Inspector is an automated, mobile QA program that captures all your QA inspections, follow-ups, photos and notes in a single, easy to use dashboard. If you would like a free demo to see what Walsh Integrated can do for you and your facility,  book here.