CBIZ North Atlantic Loss Control - Behavioral Health Onsite Safety & Hazard Assessment

• Audit Title

• Client / Site

• Client Site Photos

  Media

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1.0 Employer Posting

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Age Demographic

  Yes

  No

  N/A

• Accredidation

• Men's/Women or Mixed Facility

  Yes

  No

  N/A

• State Run/Private

  Yes

  No

  N/A

• Type of Facility

  Select Substance Abuse Assisted Living Mental Health Hospice

  • Substance Abuse
  • Assisted Living
  • Mental Health
  • Hospice

• Short Term or Long Term

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Recommended Length of Program

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Average Length of Stay

  Yes

  No

  N/A

• Residential or Inpatient

  Yes

  No

  N/A

• Number of Beds

• Nurse to Patient Ratio

• Involuntary/Voluntary Committment

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Lock Down Facility

  Yes

  No

  N/A

• Length of Shift (hours)

• Shifts per week

• Modality

• Attending Physician/Director

  Yes

  No

  N/A

Security

• Security Guards

  Yes

  No

  N/A

• Number of Orderlies on Duty

• Video Surveillance

  Yes

  No

  N/A

• Health Care Staff Tracking Devices

  Yes

  No

  N/A

• Staff Work Areas Restricted from Patients

  Safe

  At Risk

  N/A

• Auto Locking Doors

  Yes

  No

  N/A

• Nurses On Duty Off-Site

  Safe

  At Risk

  N/A

Training

• What Type of Training

  Yes

  No

  N/A

• Training Frequency

  Yes

  No

  N/A

• Follow up training After Incident

  Yes

  No

  N/A

• Nurse Credentials

  Select Yes No N/A

  • Yes
  • No
  • N/A

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• Auditor

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