Title Page
-
Document No.
-
Audit Title
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
-
Date/Time
-
Client Name:
-
Address:
City:
State:
Zip
Phone:
Email:
Environment Surrounding Client Home:
-
In what type of structure or residence does client reside?
-
If apartment how many floors:
-
Elevator?
-
How does one enter or exit home? (Describe security, alarm systems, locking devices, etc.)
-
Is there adequate exit/entrance lighting?
-
Signs of Vandalism?
-
Loitering?
General Employee Safety
-
Describe clients overall health:
- Yes
- No
- N/A
-
How many medications does client take daily?
-
How are medications tracked?
- Pre-poured
- Lined Up
- Pill Box
- Other
- No method
-
Are there medications in the home that are no longer taken?
- Yes
- No
-
Does client wear a hearing aid?
- Yes
- No
-
How many individuals live in the home? (#) What are their relation to client?
-
Are there any pets in the home?
-
# of Cats_________________ # of Dogs_________________- Other__________________
-
Any History of biting or Scratching?
-
Excessive barking?
-
Any history of Jumping on Guests? If yes is there any place to contain pet during employee visits?
-
Proof of vaccinations last two years?
-
Excessive pet hair build up?
-
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?
-
Expalin above issues:
-
Any history or evidence of abuse?
-
Are there firearms present in the clients residence?
-
How are they secured?
-
Any evidence of mold or fungus?
-
Is food properly stored in a sanitary manner?
-
Food and non-food items stored in the same cabinet/closet?
-
Spoiled food or beverage in the home?
-
Signs of roaches, rodent or varmint infestations?
-
Any signs of bed bugs?
-
Any cleaning products and/or other potential poisons that are not labeled or stored in original containers?
-
Excessively loud noise inside or outside of home?
-
Doors equipped with proper locking mechanisms?
-
Identify potential security issues or personal safety concerns:
Fire/ Life Safety
-
Are there any space heaters in use?
-
Are heaters, including wood burning stovves or gas fireplaces, equipped with screens or barriers to prevent contact with open flames or hot surfaces?
-
If no, describe concerns and possible solutions:
-
Are combustible items stored away from any stove, heater, or fireplace in the home?
-
If no, describe concerns and possible solutions?
-
Are appliances properly ventilated to homes exterior?
-
Any examples of overloaded electrical ciruits or outlets, etc.
-
Any damaged electrical cords?
-
Any evidence of candle use?
-
Excessive trash build up, clutter or signs of hoarding?
-
Unsafe smoking materials?
-
Curtains and towels stored at least 12 inches from heat sources, kitchen burners and other potential ignition sources?
-
Home equipped with appropriate number of working smoke detectors?
-
Smoke detectors tested periodically?
-
Is home equipped with a carbon monoxide detector?
-
Working fire exinguisher available?
-
Indicate location of fire extinguisher?
-
Is there an updated emergency contacts list?
-
If oxygen is used in the home, is it properly stored?
-
Are working flashlights readily available?
-
Is there ready access to a telephone?
-
Is there an emergency exit plan?
-
When was the last furnace inspection: (Enter date)
Slip,Trip and Fall Safety
-
Is lighting adequate inside and outside of the home?
-
If no, describe concerns and possible solutions?
-
Are exterior walkways in good condition (no uneven or broken sections).
-
Are steps to client residence in good condition and free of tripping hazards?
-
Do exterior steps have appropriate handrails?
-
Are there arrangements for snow and ice removal from sidewalks and ice salt/sanding prior to staff arrival?
-
Are floor rugs used at entrances, bathrooms, bedrooms or kitchen?
-
Describe any concerns with rugs?
-
Clear pathways are present into the home and from room to room?
-
Are floor surfaces in living areas in good condition to prevent trips and falls?
-
Carpets well fastened, no frayed sections?
-
Is furniture positioned to provide clear traffic areas?
-
Has furniture with wheels been eliminated or equipped with wheel locking devices?
-
Any awkwardly placed furniture?
-
Identify any hinderances to providing client assistance:
-
Do all stairways have securely affixed handrails on both sides?
-
Do handrails extend beyond lentgh of steps?
-
Are stairways free of clutter and storage?
-
Are there light switches at top and bottom of stariways?
-
Night lighting available and installed?
-
Extension cords used?
-
Describe efforts to eliminate trip hazards from cords?
-
Can items in closets and cupboards be reached without using a step stool?
-
Are stove knobs all installed and easily reachable?
-
Non-slip mats installed in bathing areas?
Blood-borne Pathogens/Personal Protective EquipmentSafet
-
Are there any exposures to: Infectious diseases, biological or chemicals that will impact employee safety?
-
Review care plan and record appropriate employee training and PPE needs:
-
Any sharps exposures?
-
Appropriate sharps containers and handling in place?
Safe Patient Handling/Ergonomics
-
Is client ambulatory?
-
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?
-
Are restrooms appropriately sized and not too restrictive?
-
Grab bars installed in restrooms?
-
Heavy objects stored on lower shelves?
-
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.
-
Describe family concerns in this area:
-
Does client wander or seek to exit home?
-
Describe control measures:
-
Have there been any reports of client being formally missing and a search conducted?
-
If yes, describe event and actions taken. Is this addressed in care plan?
Vehicle Safety
-
Is employee expected to transport client or run errands?
-
Will transport be done using clients vehicle?
-
Is vehicle insurance current?
-
Is employee familiar with this type of vehicle?
-
Are appropriate assist devices/equipment available?
-
Does employee have valid drivers license and up to date insurance card?
-
Will client need assistance entering/exiting vehicle?
-
Has vehicle been serviced appropriately and inspected? (Brakes, signals, lights, tires, etc.)
-
Discuss any requirements or issues related to client transportation:
Other-Special Circumstances
-
Enter comments/concerns or other pertinent information:
-
Completed by: