Advanced Home Care- Home Safety Assessment

• Patient Name

• Patient or Caregiver Email Address

• Conducted on

  Date

• Prepared by (if not completed by patient listed above, please enter YOUR name and relationship to the patient)

• Location (In-Store or In-Home)
  Address

• AHC Specialist (if available)

• Let's take a tour around your home and consider some easy steps to increase your SAFETY, MOBILITY and INDEPENDENCE!

Entrance & General

• Steps and walkways in good repair with no crumbling edges or broken boards

• Secure railing that is easy to grasp with both hands

• Lights that illuminate a wide area of the entrance, yard and walkway

• Peephole or windows in the front door low enough for all residents to use

• Deadbolt lock does not require a key to open from the inside (unless wandering is an issue)

• Doorways wide enough to pass through using walker, wheelchair or carrying a load

• Front steps and walkways around the home are free of clutter, snow, leaves or other debris

• One working carbon monoxide detector on each floor

• Create an emergency escape plan and pre-arrange for a family member or caregiver to help you escape if needed

• Windows and screens easy to open and close

• Thermostat easy to read and reach

• Keep ashtrays, smoking materials, candles, hot plates and other potential fire sources away from curtains, furniture, beds and bedding. Remember: NEVER smoke while using oxygen

Living Room

• All walking surfaces are free of clutter, electrical cord, boxes, furniture, appliances and other objects that could pose a tripping hazard—especially in the event of an emergency or fire

• Carpets, rugs and mats lie flat or secured to keep them from slipping

• No electric or phone cords running under rugs and carpeting or across open areas

• No frayed electrical cords. Electric outlets and switches are not overloaded (not warm to the touch)

• Easy access to a telephone from every room (consider a Personal Emergency Response Device as well). Also, make sure all emergency phone numbers are posted on or near all phones

• Adequate lighting and accessible light switches that can be turned on without walking across a dark room

• Sofas and chairs high and firm enough for easy sitting and rising. Plus, no casters or wheels on the furniture

• All chimneys have been professionally inspected and cleaned within the last year. Also, all chimney openings are clear of leaves and other debris that could clog them

• All portable space heaters and wood-burning heating equipment are at least three feet from walls, furniture, curtains, rugs, newspapers and other flammable or combustible materials

Kitchen & Dining Area

• Clear walkways, free of clutter

• Floor not waxed or slippery; use non-skid wax

• Doorways wide enough to pass through with walker, wheelchair or when carrying a load

• Appliances in good working condition with “on” indicators working and controls clearly marked

• Towels, curtains and other cloth items that may catch fire located at a safe distance from flames and heat sources

• Ventilation systems and range exhaust working properly

• Electrical appliances and extension cords are located a safe distance away from the range and water sources

• Fire extinguisher in good working order and accessible in case of an emergency

• Stable step stool with a handrail for reaching high items, although it is best to locate frequently used items between eye and knee level

Bedroom

• Floor free of clutter. Remove clothes, shoes, towels and magazines

• Make sure there is a clear path from the bed to the bathroom

• Bed no lower than the back of the user’s knees

• Chair with armrests and firm seat to reduce falls while dressing

• No casters or wheels on furniture

• Easy access to a telephone from every room (consider a Personal Emergency Response Device as well). Also, make sure all emergency phone numbers are posted on or near all phones

• No throw rugs

• Night light

• A flashlight within reach of the bed in case of a power outage

• Ensure that electrically-heated blankets are not folded, covered by other objects, or tucked-in when not in use and that the cord is not pinched or crushed by the bed

• Smoke alarms are placed inside and just outside bedrooms. Test batteries in the smoke detectors twice a year when adjusting clocks for daylight savings time

Bathroom

• Floor free of clutter. Remove clothes, shoes, towels and magazines

• No glass shower doors. Safety hazard in the event of a fall

• Strong grab bars in the shower or bath

• Non-skid floor surface in tub or shower

• Shower bench or seat with handheld shower wand

• Set your hot water heater to no more than 120 degrees Fahrenheit to help prevent burns

• Be sure the bathroom floor is slip-resistant or is covered with slip-resistant materials. No throw rugs.

• Strong grab bars near the toilet

• Raised toilet seat present, if needed

• All hair dryers, shavers, curling irons and other small electrical appliances are away from sinks, tubs and other water sources

• Electrical receptacles in the bathroom are protected by ground-fault circuit interrupters (GFCIs)

• Night light

• All medications should be stored in child-resistant enclosures and clearly marked to prevent children from accessing the medication

Basements, Garages & Workshops

• Staircases have light switches at top and bottom, and handrails running the full length

• Extension cords not overloaded (wattage of items plugged in does not exceed capacity of cord)

• Work areas where tools are used are well lit

• Flammable liquids stored outside

• Work areas clear of tripping hazards

• Safety locks on all power tools

• Advanced Home Care provides a full line of home care products and services that provide SAFETY , INDEPENDENCE and COMFORT!
  
  Below you will find suggested products for areas of your home where you may experience challenges. Mark items of interest for a reminder on your report at the end of this assessment.

Entrance & General

• Folding Suitcase Ramp (available in 5ft or 7ft)
  

  

• Would you like to mark this item?

• Metro Car Handle

  

• Would you like to mark this item?

• Hurrycane

  

• Would you like to mark this item?

• EZ Fold-N-Go Walker

  

• Would you like to mark this item?

• Standard Rollator (Rolling Walker with Seat)

  

• Would you like to mark this item?

• Nitro Rollator

  

• Would you like to mark this item?

• Duet Rollator/ Companion Chair Combination

  

• Would you like to mark this item?

• Rebel Wheelchair

  

• Would you like to mark this item?

Living Room

• Golden Technologies Lift Chairs
  (We offer the largest selection of lift chairs anywhere available with options such as Heat, Massage, Foot Extension and Fabric Guard and an extensive fabric catalogue!)

  

• Would you like to mark this item?

• Assist-A-Tray (Standing Aid with Table)

  

• Would you like to mark this item?

Bedroom

• Security Pole

  

• Would you like to mark this item?

• Bedcane

  

• Would you like to mark this item?

• EZ Adjust Bedrail

  

• Would you like to mark this item?

• Home Bed Assist Rail

  

• Would you like to mark this item?

• Bedside Commode

  

• Would you like to mark this item?

• Transfer Board

  

• Would you like to mark this item?

• Sock Donner

  

• Would you like to mark this item?

Bathroom

• Handheld Shower

  

• Would you like to mark this item?

• Bath Mat (non-slip)

  

• Would you like to mark this item?

• Tub Seat/ Shower Chair

  

• Would you like to mark this item?

• Transfer Bench

  

• Would you like to mark this item?

• Bi-Level Grab Bar

  

• Would you like to mark this item?

• Suction Grab Bar

  

• Would you like to mark this item?

• Knurled Grab Bar

  

• Would you like to mark this item?

• Curve Grab Bar

  

• Would you like to mark this item?

• Security Pole with Curve Grab Bar

  

• Would you like to mark this item?

• Raised Toilet Seat

  

• Would you like to mark this item?

• Toilet Safety Frame

  

• Would you like to mark this item?

• Thank you for using our Home Safety Assessment! We hope this tour was beneficial to you! At the end of this assessment you will have the opportunity to send your results, in the form of a PDF, via email to our staff at Retail@advhomecare.org . Our specialists can then contact you, upon receipt of your results' report, to go over any questions or concerns you may have regarding the assessment as well as offer more information (such as pricing and inventory availability) about the products you marked on the previous page. Need to contact us? Give us a call at 800.868.8822, visit us online at www.advhomecare.org or in-store! Our retail locations are open Monday- Friday 9am-5pm. A full listing of our locations can be found below. ***Remember to select the retail location nearest you so that your results can be directed appropriately.

GEORGIA

• 3780 Eisenhower Pkwy Suite 5, Macon, GA 31206

• 800 Whitlock Ave. NW Suite 126, Marietta, GA 30064

• 5901 Goshen Springs Rd. Suite G, Norcross, GA 30071

NORTH CAROLINA

• 1806 N Sandhills Blvd., Aberdeen, NC 28315

• 120 Sweeten Creek Road, Asheville, NC 28803

• 1225 Huffman Mill Road, Suite 104, Burlington, NC 27215

• 1231 NE Maynard Road, Cary, NC 27513

• 2520 Whitehall Park Drive, Suite 950, Charlotte, NC 28273

• 105 W. Highway 54, Suite 267, Durham, NC 27713

• 2391 Court Drive, Suite 105, Gastonia, NC 28054

• 1018 N. Elm Street, Greensboro, NC 27401

• 1005 W.H. Smith Blvd., Greenville, NC 27834

• 375 Main Ave. NE, Hickory, NC 28601

• 2110 Westchester Drive, High Point, NC 27262

• 461 Harper Ave SW, Lenoir, NC 28645

• 8380 Hwy 87, Reidsville, NC 27320

• 1406B W. Innes Street, Salisbury, NC 28144

• 567 W. Main Street, Sylva, NC 28779

• 1100 S. Stratford Road, Winston-Salem, NC 27103

• 744 Church Street N, Concord, NC 28025

• 4001 Piedmont Parkway, High Point, NC 27265

• 1620 Wright St , Wilmington, NC 28401

SOUTH CAROLINA

• 2067 Celanese Rd, Rock Hill, SC 29732

TENNESSEE

• 951 Highway 126, Bristol, TN 37620

• 105 Jack White Drive, Kingsport, TN 37664

VIRGINIA

• 48 West Main St, Christiansburg, VA 24073

• 7669 Limestone Drive Suite 120, Gainesville, VA 20155

• 72 St. John Pl, Salem, VA 24153

• 165 Wise Plaza Road, Wise, VA 24293

• 480 South Commerce Ave, Suite D, Front Royal, VA 22630

• 525 Amherst St, Suite 100, Winchester, VA 22601

• 762 South Main St, Woodstock, VA 22664