QA
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Site conducted
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Conducted on
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Prepared by
PERSONAL FILE/Therap
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Cover: Current photograph of individual anywhere in file; Allergies
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Flap One: Personal Information Sheet; Guardianship papers* (if applicable)
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Flap Two: General Consent, Appointment of Agent & Medication consent*, Consent for psychotropic meds*
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Flap Three: Current medical card (KanCare Card, Medicare (if applicable)
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Flap Four: Doctor's orders (current Med. Review and all prior orders for the last year)
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Flap Five: General physical (this is good for two years)
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Comments:
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Comments:
PERSONAL BOOK
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Tab one: Current Personal Information Sheet
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Tab Two: MAR's
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Tab Three: Treatment Record
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Tab Five: Data Sheets (completed as appropriate)
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Tab Six: Behavior Plan/PMP/PMD
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Tab Seven: Risk Assessment (if applicable)
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Tab Eight: Person Centered Support Plan
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Tab Nine: Inventory Sheet
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Any documents over a year old should be reported to the supervisor.
Conduct a Medication Check for each Person
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Topicals separate from ingestibles
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Refrigerated meds are separate
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Cabinet/box clean - and LOCKED!
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No expired medications in the house
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Sharps containers are emptied as appropriate
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Accountability log completed at each shift change
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Accountability log reflects both staffs initials
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Legend filled out correctly
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Comments:
Menu
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Menu completed and posted on refrigerator.
Money Box
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Money Box: Locked and secured
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Receipts are present
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Box itself neat and orderly
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All transactions have been reflected
Cameras (if applicable)
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System is on and functional.
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System is secured.
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Footage is recording
EVACUATION/SHELTER IN PLACE (turned in yearly)
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Evacuation and Shelter in Place drills completed and documented.
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Time drill took
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Number of participants
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Refusals
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Concerns noted
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Emergency Kit: all items present
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Health maintenance manual present (Disaster box)
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Emergency Notebook in Disaster Box
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Check R drive for SDS access
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Comments:
Bulletin Board/Notebook
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Emergency Procedures (CL)
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Equal Housing papers
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ANE Reporting
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Cell Phone List/House numbers
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Evac. Plan
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Scan Sheet
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Current House Hours
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Calendar for the year
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Ability Point Activities
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Section 8 paper
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Comments:
Electrical Safety
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Area is clear in front of breaker switch boxes.
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Breaker switches identified inside or outside box.
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Outlets functioning and in good condition.
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Power strips are utilized when necessary.
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Light fixtures and covers in good condition.
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Appliance cords in good condition.
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Comments:
LIVING ROOM CLEANLINESS
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Furniture dusted
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Flooring clean
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Sink area
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Counters
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Cabinets
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Stove/oven
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Comments:
Supplies
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Are supplies stored properly
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Reasonable amount on hand
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Using authorized supplies
Bathrooms
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Sink
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Floor
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Toilet
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Tub/shower
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Comments:
Laundry Area
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Washer
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Dryer/lint tray
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Floor
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Comments:
Dining Room/Kitchen
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Table/chairs
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Floor
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Trash
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Commons area
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LAWN
OFFICE CLEANLINESS
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Paperwork
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Carpet/floor
THERMOSTAT
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Set temperature
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Actual reading
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Carbon monoxide detector
CHECK REFRIGERATOR/FREEZER
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Thermometer in place and working in both the refrigerator and freezer (not in door).
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Leftover food is covered, labeled, and dated in both the refrigerator and freezer.
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All leftover food should be discarded at the end of the shift, if not sooner.
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Check refrigerator and freezer for cleanliness.
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Ice storage containers are clean.
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3-day supply of food is present.
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Comments:
Pantries/Cupboard
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Orderly fashion
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No food stored on the floor
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No expired food is present.
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Comments:
SAFETY & FIRE
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Locks are in working order - home safe and secure.
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Windows will open (one per room).
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Walkways, sidewalks, railings in good condition.
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Water temperature devices in place. Temperature setting at tank:
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Combustible/flammable material properly stored in safe location.
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Separate Location:
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Furniture and equipment in good repair and working order.
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Stairs are in good condition and well lit.
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Adequate ventilation/lighting
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Free from insect and rodent infestation
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Main routes of travel kept free of obstacles and stored materials
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Emergency routes posted
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All legal exits marked (HUD).
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911 stickers either on the phone or posted.
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Vents are clean.
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Doors can be opened from inside of all rooms, even when locked.
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Fire extinguisher/safety equipment accessible.
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Fire extinguishers up to date & fully charged. (service date)
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Oxygen cylinders are stored in racks.
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Fire Blankets are present and accessible.
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Comments:
Vehicle
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Transportation log completed daily, or as appropriate.
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Pre & Post trip inspections are present for KDOT vehicles and 9 passengers and above vehicles.
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Vehicle is being properly maintained.
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First aid kit is accessible and properly maintained.
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Emergency Procedure Notebook is present
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Flashlight, belt cutter, and current insurance card are present
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Fire Extinguisher is properly checked and maintained (if applicable)
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Driveway
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Comments:
