Home Healthcare Worker Safety Checklist

• Facility Name

• Patient Home Address
  Address

• Healthcare Worker

• Conducted on

  Date

Home Healthcare Worker Safety

• My home health employer has an active safety program with a safety manager and a safety committee that includes employees from across the company

  Yes

  No

  N/A

• My employer provides initial and annual safety training

  Yes

  No

  N/A

• Annual training reviews new safety issues identified throughout the previous year

  Yes

  No

  N/A

• I have received training in ergonomics and safe patient handling and have a way to obtain necessary ergonomic equipment for the home I work in

  Yes

  No

  N/A

• Training includes latex allergy hazards, and nonlatex gloves are made available

  Yes

  No

  N/A

• The bloodborne pathogens plan is part of training, is updated annually, and is always available to workers

  Yes

  No

  N/A

• I am a part of the selection process for needle devices with safety features

  Yes

  No

  N/A

• I consistently follow standard precautions with all blood and potentially infectious materials

  Yes

  No

  N/A

• I have a properly labeled, leak-proof, puncture-resistant sharps container

  Yes

  No

  N/A

• An infection control plan has been developed

  Yes

  No

  N/A

• I consistently follow infection control and prevention measures (e.g., hand washing)

  Yes

  No

  N/A

• I am taught how to identify stressors and techniques for reduction

  Yes

  No

  N/A

• I have access to an employee assistance plan or other means of counseling support

  Yes

  No

  N/A

• There is a no-weapons policy for patient homes, or a policy requiring weapons to be disabled and locked up before the worker arrives

  Yes

  No

  N/A

• Locations of new patients are researched to determine local crime statistics

  Yes

  No

  N/A

• I am taught how to recognize violent or aggressive behavior and how to defuse an angry patient

  Yes

  No

  N/A

• I am taught to recognize illegal drug activities

  Yes

  No

  N/A

• I am taught what to do if I feel uncomfortable about a patient’s community or if I believe that I am in danger

  Yes

  No

  N/A

• Iam taught how to identify verbal abuse and what to do about it

  Yes

  No

  N/A

• There is an animal control policy requiring animals to be restrained

  Yes

  No

  N/A

• I am taught how to deal with bad weather

  Yes

  No

  N/A

• I am taught what to do in the event of a chemical spill or an act of terrorism

  Yes

  No

  N/A

• I am taught safe driving skills and how to report incidents and traffic offenses

  Yes

  No

  N/A

• My employer verifies safe driving records for all home healthcare providers

  Yes

  No

  N/A

• I have a cell phone or other reliable way to communicate with an employer or law enforcement

  Yes

  No

  N/A

• I am taught to observe surroundings and park in well-lit areas, away from visual obstructions

  Yes

  No

  N/A

• I wear sturdy, low-heeled, slip-resistant shoes

  Yes

  No

  N/A

Completion

• Additional Comments

• Healthcare Worker Name & Signature

  Sign