Assisted Living - duplicate

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

EVALUATiON

• Overall risk rating?

  Above Average

  Average

  Below Average

• Property Coverage Rating?

  Above Average

  Average

  Below Average

• General Liability Coverage Rating?

  Above Average

  Average

  Below Average

• Fleet Coverage Rating?

  Above Average

  Average

  Below Average

OVERVIEW

• Ownership?

  For Profit

  Non-Profit

• Name of owner:

• Board of Directors?

  Yes

  No

  N/A

• Number of buildings?

  1

  2

  3

  4

  5

• Age of building(s)?

• Date operations began?

LOSSES

• Source of losses?

  Agent

  Carrier

  Agent & Carrier

  Owner

Describe losses:

ASSISTED LIVING ENVIRONMENT

• Number of Licensed Assisted Living units?

• Current Assisted Living census?

• Is there a manager on site 24/7 for Assisted Living?

  Yes

  No

  N/A

• Memory Care Assisted Living?

  Yes

  No

  N/A

• Current Memory Care Census?

• Is there a manager on site 24/7 for Memory Care?

  Yes

  No

  N/A

• Are there stoves in any of the apartments?

  Yes

  No

  N/A

• Is an emergency call system provided to residents?

  Yes

  No

  N/A

• What type of call notification system is used?

  Pendant

  Pull cords

  Pull cords and pendant

• How many meals are served each day?

  1

  2

  3

MEDICATION MANAGEMENT

• Are there residents who self administer their medications?

  Yes

  No

  N/A

• Is an assessment done for self administration of medications?

  Yes

  No

  N/A

• What type of medication storage is used by residents who self administer medication?

  Locked box

  Cart

  Locked Room

• What staff administer medications?

  Select Nurses only Med techs All staff

  • Nurses only
  • Med techs
  • All staff

• Is a medication cart used?

  Yes

  No

  N/A

• Is it stored in a locked room when not in use?

  Yes

  No

  N/A

• Are there any procedures used to minimize med errors? explain:

• How are med errors documented and reported?

• Does a nurse review all medication changes?

  Yes

  No

  N/A

OUTSIDE SERVICES

• Does community provide outside services for Meals on Wheels?

  Yes

  No

  N/A

• Who delivers the meals and to whom are they delivered?

• Is Home Health provided outside the community?

  Yes

  No

  N/A

• Is Hospice care provided to those outside the community?

  Yes

  No

  N/A

• Is Respite Care provided in the community?

  Yes

  No

  N/A

• Is Adult Daycare provided in the community?

  Yes

  No

  N/A

STAFFING

• Staffing practices narrative: Staff are professional, experienced and training is at or above the industry standard.

• Name of Administrator?

• How many years as a licensed Administrator?

• How many years at this community.

• Is there a nurse manager?

  Yes

  No

  N/A

• Name of Nurse Manager?

• How many years as a nurse?

• How long in current position?

• How long at community?

LINE STAFF

• Total number of staff?

• Number of Maintenance Staff?

• Number of Housekeeping Staff?

• Number of Dietary Staff?

• Number of care staff to include Nurses and Care Staff?

• Current PPD?

1st Shift Staffing?

• RN

• LPN

• Caregiver/CNA

2nd Shift Staffing

• RN

• LPN

• Caregiver/CNA

3rd Shift Staffing

• RN

• LPN

• Caregiver/CNA

• Is Agency staff used?

  Yes

  No

  N/A

• Are background checks done for employees?

  Yes

  No

  N/A

• Who conducts the background checks?

• Are back ground checks done for volunteers?

  Yes

  No

  N/A

• Are drug tests done for employees?

  Yes

  No

  N/A

• Pre-employment?

  Yes

  No

  N/A

• Reasonable suspicion?

  Yes

  No

  N/A

• Random?

  Yes

  No

  N/A

• Post injury?

  Yes

  No

  N/A

TRAINING

• Staff training narrative: Staff training is at or above the industry standard.

• Is on-line training used?

  Yes

  No

  N/A

• Name of on-line training program?

• How often are in-house in-services done?

  Weekly

  Bi-weekly

  Monthly

  Bi-annually

  Annually

STATE SURVEY RESULTS

• Last survey date:

• Results of survey:

CLINICAL RISK MANAGEMENT PROGRAM

• Clinical risk management narrative: All components of the formal documented policies and procedures are reviewed annually and adjustments made by management are done on an as needed basis. Current clinical risk program is considered average and is the industry standard.

Safety Committee

• Is there a formal Safety Committee in place?

  Yes

  No

  N/A

• How often do they meet?

  Weekly

  Bi-weekly

  Monthly

  Bi-annually

  Annually

• Are there meetings documented?

  Yes

  No

  N/A

• Are employee accidents discussed at the Safety Committee meetings?

  Yes

  No

  N/A

• Are resident falls discussed at the meeting?

  Yes

  No

  N/A

• Who are the members of the committee?

FIRE DRILLS

• Are fire drills conducted?

  Yes

  No

  N/A

• How often are they conducted?

  Monthly rotating shifts

  Quarterly rotating shifts

• Are they conducted in Memory Care?

  Yes

  No

  N/A

• Are procedural issues discussed with staff and corrected immediately?

  Yes

  No

  N/A

• Are results of Fire Drills reviewed by Safety Committee or Quality Assurance Committee?

  Yes

  No

  N/A

QUALITY ASSURANCE COMMITTEE

• Is there a Quality Assurance Committee?

  Yes

  No

  N/A

• How often does the committee meet?

  Weekly

  Bi-weekly

  Monthly

  Bi-annually

  Annually

• Who are the members of the committee?

FALL MANAGEMENT

• Are residents assessed for falls before admission?

  Yes

  No

  N/A

• How do staff know if a resident is a high risk for falls?

• Describe some fall prevention measures that may be put into place for a resident:

• Is there a formal falls report or incident form in place?

  Yes

  No

  N/A

• Who reviews this report?

• Are gait belts used?

  Yes

  No

  N/A

• Is the use of gait belts enforced?

  Yes

  No

  N/A

• Are these reports discussed with the Quality Assurance committee?

  Yes

  No

  N/A

• Are staffed trained on proper use of straps for shower chairs and tub chairs?

  Yes

  No

  N/A

• Who provides the training?

• Is training documented?

  Yes

  No

  N/A

• Are lifts used?

  Yes

  No

  N/A

• What types of lifts?

  Select Full Lifts Sit to stand lifts Other

  • Full Lifts
  • Sit to stand lifts
  • Other

ADMISSION/ DISCHARGE

• Is there a formal admission packet in place?

  Yes

  No

  N/A

• Does the admission packet address when a resident is no longer appropriate and should be moved to a higher level of care?

  Yes

  No

  N/A

• Does the admission packet address resident conduct policies?

  Yes

  No

  N/A

RESIDENT COMMUNICATION AND MONITORING

• Are residents assessed before admission by a nurse or administrator?

  Safe

  At Risk

  N/A

• Does a physician assess the resident before admission?

  Yes

  No

  N/A

• After admission, how often is residents condition assessed and documented?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• After admission how often do residents have to be re-assessed by their physician?

  Weekly

  Bi-weekly

  Monthly

  Bi-annually

  Annually

• What would trigger family notification? Fall, altercation, change in medications, room change, any change in contrition.

E-CHARTING

• Is e-charting used?

  Yes

  No

  N/A

• Does it include e-mars?

  Yes

  No

  N/A

• Name of e-charting in use?

SKIN TEARS/ DECUBITUS CONTROL

• Do you currently have any residents with pressure ulcers?

  Yes

  No

  N/A

• We're they acquired at the community?

  Yes

  No

  N/A

• If not acquired at community where were they acquired?

• Number of current pressure ulcers?

• How often do staff assess resident's skin?

  Select Daily Weekly with each shower

  • Daily
  • Weekly
  • with each shower

• Is a wound care clinic used by residents when necessary?

  Yes

  No

  N/A

• Is Home Health involved in prevention?

  Yes

  No

  N/A

• Is Dietary involved in prevention?

  Yes

  No

  N/A

RESIDENT ABUSE TRAINiNG

• Is resident abuse training done upon hire?

  Yes

  No

  N/A

• How many times per year are employees updated on resident abuse training?

  Weekly

  Bi-weekly

  Monthly

  Bi-annually

  Annually

• Is the training documented?

  Yes

  No

  N/A

• Where is training documented?

• Are volunteers required to complete resident abuse training?

  Yes

  No

  N/A

• Is there a formal policy and procedure in place for investigating and reporting abuse?

  Yes

  No

  N/A

• Who is in charge of investigating abuse allegations?

DO NOT RESUSCITATE

• Are there residents with Do Not Resuscitate orders?

  Yes

  No

  N/A

• Is it a state provided form or just a physician's order?

  State form

  Physicians order

• Does a physician have to sign the form or order?

  Yes

  No

  N/A

• Is the form or acknowledgement signed by the resident or a family member?

  Yes

  No

  N/A

• Where is the form kept?

  Chart

  Electronic medical record

• How are residents who have a DNR identified?

  Chart

  Posted in their room

  E-mar

  Chart and posted in room

CPR

• Are staff trained in CPR?

  Yes

  No

  N/A

• Which staff are trained?

  Nurses only

  Med techs

  All staff

• Is training documented?

  Yes

  No

  N/A

ELOPEMENT RISK MANAGEMENT

• Is a formal elopement risk assessment done before admission?

  Yes

  No

  N/A

• How often are re-assessments done?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• What system is used to manage elopement risk?

• Are doors locked at all times?

  Yes

  No

  N/A

• Are all doors alarmed?

  Yes

  No

  N/A

• How are door alarms silenced?

  Code

  Key

• How often are door alarms tested and by whom?

• Is testing documented?

  Yes

  No

  N/A

• Yes

  No

  N/A

• Is there a wander guard system in place?

  Yes

  No

  N/A

• How often are transmitters tested?

• Is testing documented?

  Yes

  No

  N/A

• Is there an elopement policy in place?

  Yes

  No

  N/A

• How often are staff in-serviced on the elopement policy and procedures?

  Upon hire

  Monthly

  Quarterly

  Bi-annually

  Annually

• Is training documented?

  Yes

  No

  N/A

• How often is the elopement policy reviewed and updated?

  Monthly

  Quarterly

  Bi-annually

  Annually

  As needed

• Are residents required to sign out before leaving the community?

  Yes

  No

  N/A

• Is there video monitoring in the community?

  Yes

  No

  N/A

• Where are cameras located?

PETS & THE EDEN ALTERNATiVE

• Are pets allowed in the community?

  Yes

  No

  N/A

• Is there a formal pet policy in place?

  Yes

  No

  N/A

• Is there a formal policy in place for visitors who bring pets into the community?

  Yes

  No

  N/A

• Does the policy include providing up-to-date veterinary health reports before pets are brought to the community?

  Yes

  No

  N/A

SLIPS, TRIPS AND FALL EXPOSURE

• Type of flooring in resident corridors?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in employee corridors?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in resident apartments?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in resident dining areas?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in commercial kitchen?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in resident bathroom?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in common area bathrooms?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Are exterior sidewalks and parking lots in good repair?

  Yes

  No

  N/A

• List issues with parking lot and/ or sidewalk:

PUBLIC/PRIVATE PROTECTiON

• Distance to closest fire hydrant (In feet).

• Distance to fire department (In miles)

• Is fire department career or volunteer?

  Career

  Volunteer

  Both

• Are all sides of the property accessible to the fire department?

  Yes

  No

  N/A

• Describe why the fire department can't access all sides of the building:

• Are adequate fire extinguishers available?

  Yes

  No

  N/A

• Public/Private Protection Narrative: Access to the facility would be considered adequate and no concers were noted at time of survey.

• Total square footage:

• Number of smoke division?

• Construction quality?

  Good

  Fair

  Poor

• Number of stories?

  1

  2

  3

  4

  5

LIFE SAFETY

• Life safety narrative: Life Safety for the community is adequate and inspected by the state Life Safety and Fire Marshall on an annual basis. The buildings and safety systems are designed for occupancy and no concerns are noted at this time.

Fire, Sprinklers, Alarms

• Company who services sprinklers?

• Alarm monitoring company?

• Company that services UL 300 system?

• Company who services fire extinguishers?

• Do all buildings have heat and smoke detection sensors?

  Yes

  No

  N/A

• Are all buildings 100% sprinklered?

  Yes

  No

  N/A

• Is it a wet or dry system?

  Wet

  Dry

• Are attics sprinklered?

  Yes

  No

  N/A

• Wet or dry sprinklered?

  Wet

  Dry

• Do you have parking garages?

  Yes

  No

  N/A

• Are they sprinklered?

  Yes

  No

  N/A

• Wet or dry sprinklered?

  Wet

  Dry

• Sprinkler system meets NFPA25?

  Yes

  No

  N/A

• Is the sprinkler system over 50 years old?

  Yes

  No

  N/A

• Is the system protected during cold and freezing weather?

  Yes

  No

  N/A

• Are sprinkler heads subject to damage covered with guards?

  Yes

  No

  N/A

• Are sprinkler heads clear of obstruction by 18"?

  Yes

  No

  N/A

• Are sprinkler heads clear of damage, paint, corrosion, etc.?

  Yes

  No

  N/A

• Do all Fire Department connections have caps in place?

  Yes

  No

  N/A

• Is a building layout available?

  Yes

  No

  N/A

• How often are kitchen vent hoods cleaned by staff?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• How often are kitchen hoods cleaned by a professional?

  Select Monthly Quarterly Bi-annually Annually

  • Monthly
  • Quarterly
  • Bi-annually
  • Annually

• What commercial cleaning company cleans the kitchen hood vents?

• Yes

  No

  N/A

EMERGENCY POWER

• Do you have a generator?

  Yes

  No

  N/A

• Type of fuel used in generator?

  Natural Gas

  Butane

  Gasoline

  Diesel

• How much fuel for generator is stored on-site?

• Where is the fuel stored?

• If emergency fuel is not stored on-site where is it obtained?

• How much load will generator provide?

• How often is generator load tested?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• How long does the load test last?

• Where are enunciator panels located?

• Do you test your emergency lighting?

  Yes

  No

  N/A

• How often are emergency lights tested?

• Are emergency exits clear from clutter?

  Yes

  No

  N/A

• Are there lighted EXiT signs at all exits?

  Yes

  No

  N/A

• Do windows lock from the inside?

  Yes

  No

  N/A

• How far will windows open?

• Are windows easily accessible for emergency response personnel?

  Yes

  No

  N/A

CONSULTANTS AND CONTRACTORS

• Do you have any nurse consultants?

  Yes

  No

  N/A

• Name of nurse consultant or name of company which provides consulting?

• Do you have a pharmacy consultant?

  Yes

  No

  N/A

• Name of pharmacy consultant or company who provides consultant?

• Is therapy outsourced?

  Yes

  Employees of community

• Name of therapy provider?

• Registered Dietician as a consultant?

  Yes

  No

  N/A

• Name of Registered Dietician?

• Yes

  No

  N/A

• Is there a contracted Social Worker?

  Yes

  No

  N/A

• Name of Social Worker or company providing services?

• Are Hospice services provided from outside vendors?

  Yes

  No

  N/A

• Are Home Health Care services provided by outside vendors?

  Yes

  No

  N/A

• Are beautician services provided within the community?

  Yes

  No

  N/A

• Are Certificates of Insurance on file for all contractors?

  Yes

  No

  N/A

• Are current licenses/credentials on file for the above consultants/subcontractors?

  Yes

  No

  N/A

• Do you have a contract with your Medical Director?

  Yes

  No

  N/A

• Do you have a Certificate of Insurance for the Medical Director?

  Yes

  No

  N/A

• Do you have current copies of the medical director's credentials on file?

  Yes

  No

  N/A

COMMUNiTY TRANSPORTATION AND DRIVER TRAINING

• Are any buses in the fleet?

  Yes

  No

  N/A

• Number of buses?

  1

  2

  3

  4

  5

• Condition of buses?

  Above Average

  Average

  Below Average

• Are there any vans in the fleet?

  Yes

  No

  N/A

• Yes

  No

  N/A

• Number of vans?

  1

  2

  3

  4

  5

• Condition of vans?

  Good

  Fair

  Poor

• Are there any cars in the fleet?

  Yes

  No

  N/A

• Number of cars?

  Yes

  No

  N/A

• Condition of cars?

  Good

  Fair

  Poor

• Are there any trucks in the fleet?

  Yes

  No

  N/A

• Number of trucks?

  Yes

  No

  N/A

• Condition of trucks?

  Good

  Fair

  Poor

• Who are authorized drivers?

• Is there a written personal use policy for automobiles?

  Yes

  No

  N/A

• Are MVR checks done for drivers?

  Yes

  No

  N/A

• By whom?

• How often are MVR checks updated?

• How often are automobiles used?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• Average radius in miles automobiles are driven per trip?

• Who provides driver training?

• Is training documented?

  Yes

  No

  N/A

• Does the training include properly securing wheelchairs?

  Yes

  No

  N/A

• Is a CDL or Chauffeur license required for any of your automobiles?

  Neither

  Both

  Chauffeur

  CDL

• Who does automobile maintenance and repairs?

• How often is maintenance done?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• Are automobiles stored in a garage?

  Yes

  No

  Some are

PROPERTY

• What lies to the north of the property?

  Businesses

  Single family homes

  Apartments

  Church

  Vacant lots

• What lies to the south of the property?

  Businesses

  Single family homes

  Apartments

  Church

  Vacant lots

• What lies to the east of the property?

  Businesses

  Single family homes

  Apartments

  Church

  Vacant lots

• What lies to the west of the property?

  Businesses

  Single family homes

  Apartments

  Church

  Vacant lots

CONSTRUCTION TYPE

• Roofing material?

  TIn

  Shingle

  Tile

• Roof slope?

  Sloping

  Flat

  Hip

• Siding?

  Brick

  Vinyle

  Stucco

  Block

  Wooden

• Framing?

  Wooden

  Aluminum

  Metal

HEAT SOURCE

• Heat source in common areas?

  Boilers

  Electric

  PTAC

  Gas furnace

• Heat source in resident rooms?

  Natural Gas

  Butane

  Gasoline

  Diesel

• Are there any fireplaces?

  Yes

  No

  N/A

• How many fireplaces?

  1

  2

  3

  4

  5

• Are they gas, electric or wood burning?

  Gas

  Electric

  Wood burning

MODIFICATIONS

• Any recent modifications to building(s)?

  Yes

  No

  N/A

• Please list modifications with date modifications were completed:

SMOKING

• Are residents allowed to smoke?

  Yes

  No

  N/A

• Is a smoking assessment completed?

  Yes

  No

  N/A

• Are residents accompanied by a staff member to smoke?

  Yes

  No

  N/A

• Do residents a smoke inside or outside?

  Inside

  Outside

  In a designated area

INSURANCE CLAIMS

• Are there any recent or pending insurance claims?

  Yes

  No

  N/A

• Please list any recent or pending insurance claims:

PICTURES

• Front Entrance

  Media