ROOM SETUP
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Bulletin Board
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Educational Information available/visible?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Well Organized?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Cleaner for cots available/used?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Adequate supplies available?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Lunch time schedules posted?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Voicemails Updated?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Bathroom key is easily accessible?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
Substitute Information
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Location:
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Substitute Information is:
Organized?
Clear?
Easy to Understand? -
Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Complete with list of "Alerts"?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
Medication Storage and Administration
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Medication secured in a locked cabinet?
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Will have corrected by:
- 5 Work Days-1 Week
- 10 Work Days-2 Weeks
- 1 Month
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Keys to medication secure? Duplicate set kept?
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Controlled substances count by RN documented?
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Will have corrected by:
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Rx label and Medication Authorization match?
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Any medications left in the clinic from last school year?
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Any expired medications on campus?
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Classroom medications secure and monitored weekly by RN?
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Will have corrected by:
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Any missing medications?
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Protocol followed for missing medication?
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Will have corrected by:
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Epi-Pens accessible and clearly marked?
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Will have corrected by:
Case Management SHARS
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Monthly SHARS up to date and on Monthly Report by 5th working day of the month?
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Will have corrected by:
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Copies of SHARS filed?
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Will have corrected by:
IHCP/Orders
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EAP's complete with MD orders when appropriate?
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Will have corrected by:
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Diabetic IHCP's complete with MD orders and signatures complete?
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Seizure IHCP's complete with MD orders and signatures complete?
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Allergy/Anaphylaxis IHCP complete with orders and signatures complete?
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Will have corrected by:
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Epinephrine Delivery devices clearly marked in unlocked cabinet?
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Will have corrected by:
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Epi-Trainers REMOVED, clearly marked, and in another location?
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Will have corrected by:
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PEEP's (Personal Emergency Evacuation Plan) completed and signed?
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Medical procedure IHCP complete with MD orders and signature complete?
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Will have corrected by:
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Attend meetings as needed? (ARD's, 504, etc)
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Will have corrected by:
Documentation of Competency for Staff
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CPR Certified Staff-(at least 2 per campus)
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Will have corrected by:
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UDCA (Unlicensed Diabetic Care Assistant)
Full Time RN on campus=1 per campus minimum -
Will have corrected by:
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Medication Administration:2 per Campus
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Will have completed by:
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Special Procedures: (if needed)
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Will have completed by:
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All training forms are complete and have signatures for: UDCA's, Medication Adminstration Staff Members, and Special Procedures Staff.
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Will have corrected by:
Medical Alert/Emergency Contact Information
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Medical Alert list printed and acknowledged?
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Will have corrected by:
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New medical alerts entered and confirmed in Nurse Aid?
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Will have corrected by:
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Medical Conditions Information entered into Nurse Aid?
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Will be corrected by:
Daily Log Documentation (review/Audit Nurse Aid)-Random**
Immunizations
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Effective tracking system in place to monitor compliance of all students?
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Will have corrected by:
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Immunizations entered into E-school in a timely matter (2 weeks for new students)
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Will have corrected by:
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Process in place to deal with non-compliance of immunizations?
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Will have corrected by:
Pregnant and Parenting students (Secondary)
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Process in place to identify pregnant/parenting students (Notification of process to faculty/staff)
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Will have corrected by:
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RN refers students for necessary services
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Will have corrected by:
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RN provides prenatal/parenting education to students?
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Will have corrected by:
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RN provides regular follow-up with pregnant students
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RN collaborates with Homebound services?
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Will have corrected by:
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Completed case files are sent to PRS Coordinator after student returns to school or at the end of the school year?
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Will have corrected by:
Campus Projects (Sports Physicals, Back to school, Presentations)
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List:
Vision and Hearing
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Copies of referrals available?
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Will have corrected by:
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Will have corrected by:
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Nurse Aid data entry completed by April 1st?
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Will have corrected by:
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Monthly biological checks of audiometer documented and stored in audiometer ?
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Will have corrected by:
Spinal Screening
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2nd Semester Spinal screening completed by the end of March?
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Will have completed by?
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Are second semester referrals in progress (P) or completed by the end of March?
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Nurse Aid data entry for Spinal Screening completed by April 1st?
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Will have corrected by:
Acanthosis Nigricans Screening
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1st semester AN screenings completed by end of December?
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Will have corrected by:
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1st Semester AN Referrals* in Progress (P) or Completed (C) by end of December?
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Will have corrected by:
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2nd Semester AN screenings done by the end of February?
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Will have completed by:
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2nd Semester AN Referrals* in Progress (P) or completed (C) by the end of February?
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Will have corrected by:
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ANTES Data* entry in progress (P) or completed (C) by April 1st?
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Will have corrected by:
Risk Management
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Accident and Incident reports completed per HEBISD protocol?
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Will have completed by:
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RN follows communicable disease protocols (% of absenteeism, TCHD reportable diseases, exclusion criteria)?
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Will have corrected by:
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Campus Concerns/Issues:
NOTES
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Signature of RN/LVN:
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Signature of Evaluator: