Home Healthcare Client Location Hazard Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date/Time

  Date
• Client Name:
  Address

• Address:
  City:
  State:
  Zip
  Phone:
  Email:

Environment Surrounding Client Home:

• In what type of structure or residence does client reside?

  Single Family Home

  Apartment

  Condominium

  Other

• If apartment how many floors:

  1

  2

  3

  4

  More than 4

• Elevator?

  Yes

  No

• How does one enter or exit home? (Describe security, alarm systems, locking devices, etc.)

• Is there adequate exit/entrance lighting?

  Yes

  No

• Signs of Vandalism?

  Yes

  No

• Loitering?

  Yes

  No

General Employee Safety

• Describe clients overall health:

  Select Yes No N/A

  • Yes
  • No
  • N/A

• How many medications does client take daily?

• How are medications tracked?

  Select Pre-poured Lined Up Pill Box Other No method

  • Pre-poured
  • Lined Up
  • Pill Box
  • Other
  • No method

• Are there medications in the home that are no longer taken?

  Select Yes No

  • Yes
  • No

• Does client wear a hearing aid?

  Select Yes No

  • Yes
  • No

• How many individuals live in the home? (#) What are their relation to client?

• Are there any pets in the home?

  Yes

  No

• # of Cats_________________ # of Dogs_________________- Other__________________

• Any History of biting or Scratching?

  Yes

  No

• Excessive barking?

  Yes

  No

• Any history of Jumping on Guests? If yes is there any place to contain pet during employee visits?

• Proof of vaccinations last two years?

  Yes

  No

• Excessive pet hair build up?

  Yes

  No

• Has the client, or anyone else who may be residing and/or expected to visit, have any; Criminal History: Name Psychological disorders: Name Violent/combative behavior: Name

• Have these issues been addressed in the care plan? Explain:

• Are there visible signs of, or behaviors of excesive alcohol and/or prescription pain killers or other mood-altering medications present with this client?

  Yes

  No

• Expalin above issues:

• Any history or evidence of abuse?

  Yes

  No

• Are there firearms present in the clients residence?

  Yes

  No

• How are they secured?

• Any evidence of mold or fungus?

  Yes

  No

• Is food properly stored in a sanitary manner?

  Yes

  No

• Food and non-food items stored in the same cabinet/closet?

  Yes

  No

• Spoiled food or beverage in the home?

  Yes

  No

• Signs of roaches, rodent or varmint infestations?

  Yes

  No

• Any signs of bed bugs?

  Yes

  No

• Any cleaning products and/or other potential poisons that are not labeled or stored in original containers?

  Yes

  No

• Excessively loud noise inside or outside of home?

  Yes

  No

• Doors equipped with proper locking mechanisms?

  Yes

  No

• Identify potential security issues or personal safety concerns:

Fire/ Life Safety

• Are there any space heaters in use?

  Yes

  No

• Are heaters, including wood burning stovves or gas fireplaces, equipped with screens or barriers to prevent contact with open flames or hot surfaces?

  Yes

  No

• If no, describe concerns and possible solutions:

• Are combustible items stored away from any stove, heater, or fireplace in the home?

  Yes

  No

• If no, describe concerns and possible solutions?

• Are appliances properly ventilated to homes exterior?

  Yes

  No

• Any examples of overloaded electrical ciruits or outlets, etc.

  Yes

  No

• Any damaged electrical cords?

  Yes

  No

• Any evidence of candle use?

  Yes

  No

• Excessive trash build up, clutter or signs of hoarding?

  Yes

  No

• Unsafe smoking materials?

  Yes

  No

• Curtains and towels stored at least 12 inches from heat sources, kitchen burners and other potential ignition sources?

  Yes

  No

• Home equipped with appropriate number of working smoke detectors?

  Yes

  No

• Smoke detectors tested periodically?

  Yes

  No

• Is home equipped with a carbon monoxide detector?

  Yes

  No

• Working fire exinguisher available?

  Yes

  No

• Indicate location of fire extinguisher?

• Is there an updated emergency contacts list?

  Yes

  No

• If oxygen is used in the home, is it properly stored?

  Yes

  No

• Are working flashlights readily available?

  Yes

  No

• Is there ready access to a telephone?

  Yes

  No

• Is there an emergency exit plan?

  Yes

  No

• When was the last furnace inspection: (Enter date)

Slip,Trip and Fall Safety

• Is lighting adequate inside and outside of the home?

  Yes

  No

• If no, describe concerns and possible solutions?

• Are exterior walkways in good condition (no uneven or broken sections).

  Yes

  No

• Are steps to client residence in good condition and free of tripping hazards?

  Yes

  No

• Do exterior steps have appropriate handrails?

  Yes

  No

• Are there arrangements for snow and ice removal from sidewalks and ice salt/sanding prior to staff arrival?

  Yes

  No

• Are floor rugs used at entrances, bathrooms, bedrooms or kitchen?

  Yes

  No

• Describe any concerns with rugs?

• Clear pathways are present into the home and from room to room?

  Yes

  No

• Are floor surfaces in living areas in good condition to prevent trips and falls?

  Yes

  No

• Carpets well fastened, no frayed sections?

  Yes

  No

• Is furniture positioned to provide clear traffic areas?

  Yes

  No

• Has furniture with wheels been eliminated or equipped with wheel locking devices?

  Yes

  No

• Any awkwardly placed furniture?

  Yes

  No

• Identify any hinderances to providing client assistance:

• Do all stairways have securely affixed handrails on both sides?

  Yes

  No

• Do handrails extend beyond lentgh of steps?

  Yes

  No

• Are stairways free of clutter and storage?

  Yes

  No

• Are there light switches at top and bottom of stariways?

  Yes

  No

• Night lighting available and installed?

  Yes

  No

• Extension cords used?

  Yes

  No

• Describe efforts to eliminate trip hazards from cords?

• Can items in closets and cupboards be reached without using a step stool?

  Yes

  No

• Are stove knobs all installed and easily reachable?

  Yes

  No

• Non-slip mats installed in bathing areas?

  Yes

  No

Blood-borne Pathogens/Personal Protective EquipmentSafet

• Are there any exposures to: Infectious diseases, biological or chemicals that will impact employee safety?

  Yes

  No

• Review care plan and record appropriate employee training and PPE needs:

• Any sharps exposures?

  Yes

  No

• Appropriate sharps containers and handling in place?

  Yes

  No

Safe Patient Handling/Ergonomics

• Is client ambulatory?

  Yes

  No

• Based on current client assessment (weight/mobility/special needs) what mobility issues are present? Decribed assistive devices and equipment needs?

• Client family willing to utilize appropriate lifting devices?

  Yes

  No

• Are restrooms appropriately sized and not too restrictive?

  Yes

  No

• Grab bars installed in restrooms?

  Yes

  No

• Heavy objects stored on lower shelves?

  Yes

  No

• Check Equipment needed?

• Gait Belt

• Sit-to-stand lift?

• Total Lift device?

• Adjustable bed?

• Grab bars in shower and bathroom.

• Rasing seat commode?

• Bathing chair/stool?

• Portable toilet?

• Wheel chair?

• Walker?

• Repositioning sheets?

• Bariatric equipment: bed, commode, walker, etc.

• Slide board?

• Pivot disk?

• Other equipment necessary or comments:

Wandering or Exit seeking Behaviors

• Does client exhibit disorientation regarding self, time, location, etc.

  Yes

  No

• Describe family concerns in this area:

• Does client wander or seek to exit home?

  Yes

  No

• Describe control measures:

• Have there been any reports of client being formally missing and a search conducted?

  Yes

  No

• If yes, describe event and actions taken. Is this addressed in care plan?

Vehicle Safety

• Is employee expected to transport client or run errands?

  Yes

  No

• Will transport be done using clients vehicle?

  Yes

  No

• Is vehicle insurance current?

  Yes

  No

• Is employee familiar with this type of vehicle?

  Yes

  No

• Are appropriate assist devices/equipment available?

  Yes

  No

• Does employee have valid drivers license and up to date insurance card?

  Yes

  No

• Will client need assistance entering/exiting vehicle?

  Yes

  No

• Has vehicle been serviced appropriately and inspected? (Brakes, signals, lights, tires, etc.)

  Yes

  No

• Discuss any requirements or issues related to client transportation:

Other-Special Circumstances

• Enter comments/concerns or other pertinent information:

• Completed by:

  Sign