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Home Visit Assessment

Bathroom

Are handholds sturdy and in appropriate places?

Can the toilet seat be raised?

Does the bathtub/shower have a nonslip surface?

Is the bathroom floor slick?

Electrical cords/appliances

Are cords frayed or damaged?

Do cords cross walking paths?

Emergency actions/evacuation route

Are emergency numbers available?

Are there means of egress from home?

Firearms

Are firearms present?

If yes, are they secured? (e.g., gun lock, locked case/cabinet, weapon and ammunition separated)

Fire extinguishers

Are fire extinguishers present?

If yes, are they accessible and in working order?

Is the patient or caregiver able to use them?

Heating and air-conditioning

Are controls accessible and easy to read?

Is the home an appropriate temperature year-round?

Hot water heater

Temperature set below 120° F (49°C)?

Kitchen safety (especially gas stoves)

Is it easy to tell if burner or oven gas is on?

Does the patient wear loose garments while cooking?

Lighting and night-lights

Is lighting present and sufficient?

Loose carpets and throw rugs

Are carpets and throw rugs present?

If yes, do they need to be secured or removed?

Pets

Are pets present?

If yes, are they easy to care for?

Smoke and carbon monoxide monitors

Are they present?

If yes, are they functioning and monitored?

Stairs

Does the home have stairs?

If yes, are they carpeted and is the carpeting secure?

Are stairs well lit?

Are there railings?

Tables, chairs, furniture

Is furniture sturdy, balanced, and in good repair?

Utilities (gas or electric)

Are the systems monitored and maintained?

Water source

Is water from a public source or a well?

Is the source functioning and safe?

Completion

Comments/Recommendations

Conducted by: Name & Signature

Home Visit Assessment Checklist

Created by: SafetyCulture Staff | Industry: Health Services | Downloads: 1

Conduct home visit assessments using this checklist and ensure that the patient home is safe and conducive to the patient’s wellness. Include optional photos so you can show to patients or their family members what need to be addressed or what is the ideal situation for the patient.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Home Visit Assessment

Bathroom

Are handholds sturdy and in appropriate places?

Can the toilet seat be raised?

Does the bathtub/shower have a nonslip surface?

Is the bathroom floor slick?

Electrical cords/appliances

Are cords frayed or damaged?

Do cords cross walking paths?

Emergency actions/evacuation route

Are emergency numbers available?

Are there means of egress from home?

Firearms

Are firearms present?

If yes, are they secured? (e.g., gun lock, locked case/cabinet, weapon and ammunition separated)

Fire extinguishers

Are fire extinguishers present?

If yes, are they accessible and in working order?

Is the patient or caregiver able to use them?

Heating and air-conditioning

Are controls accessible and easy to read?

Is the home an appropriate temperature year-round?

Hot water heater

Temperature set below 120° F (49°C)?

Kitchen safety (especially gas stoves)

Is it easy to tell if burner or oven gas is on?

Does the patient wear loose garments while cooking?

Lighting and night-lights

Is lighting present and sufficient?

Loose carpets and throw rugs

Are carpets and throw rugs present?

If yes, do they need to be secured or removed?

Pets

Are pets present?

If yes, are they easy to care for?

Smoke and carbon monoxide monitors

Are they present?

If yes, are they functioning and monitored?

Stairs

Does the home have stairs?

If yes, are they carpeted and is the carpeting secure?

Are stairs well lit?

Are there railings?

Tables, chairs, furniture

Is furniture sturdy, balanced, and in good repair?

Utilities (gas or electric)

Are the systems monitored and maintained?

Water source

Is water from a public source or a well?

Is the source functioning and safe?

Completion

Comments/Recommendations

Conducted by: Name & Signature