Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
DOCUMENTATION
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Health Department Inspection
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Fire Department Inspection
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Kitchen Hood Inspection
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HVAC Inspection
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Sprinkler System Inspection
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Staffing Roster
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Organizational Chart
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Employee Training Hours<br>(16 Hours Annually)
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CPR & First Aid Certification<br>(One per Shift)
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Daily Activity Log <br>(24 Hour Period)
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Rounds Conducted<br>(Once per Hour)
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Documented Head Counts <br>(3 Per Day)
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Arrival & Departure Log
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Fire Extinguisher Check Log
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Smoke Detector Check Log
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Emergency Lighting Check Log
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Exit Signage Check Log
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Menu w/ Approval from Dietician
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Drug Screening Documentation<br>(10% of State Population per Month)
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Inventory of Resident Personal Property
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Resident Orientation Program
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Inmate State Pay Signature Log
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Worksite Staff Visit Log
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Detailed List of Worksites
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List of all Programming Available at Facility
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Key Control & Procedures
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EOR Log
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Vermin & Pest Control
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Fire or Emergency Drills <br>(One per Month)
FACILITY MANAGEMENT
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Number of Beds
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Number of State Residents
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Employee Files
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Background Check<br> (Pre Employment)
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List of Prohibitions
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Code of Ethics<br>(Each Employee Shall Sign)
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Employee Age Requirement <br>(18 Years Old or Older)
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Employee Compensation <br>(At Least Minimum Wage) <br>(Posted)
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Female Staff on Duty
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24 Hour Awake Supervision
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Public Information Officer
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Facility has Fully Licensed & Approved Medical Provider.
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Resident Records are Kept & are Secure
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Access to a Legal Library Provided
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Visitation List Utilized
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Legal Supplies Provided as Needed
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No Residents in a Position of Authority
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No Residents Perform Security Duties
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Resident Rights Posted
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Grievance Procedures Posted
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Visitation Scheduled Posted
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Laundry Schedule Posted
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No Employees on Supervision
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Special Diet Options Offered
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Hygiene Products Provided
FOOD SERVICE
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Food Preparation Area Sanitation
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Kitchen Utensils Clean & Properly Stored
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Ice Maker & Scoop Sanitation <br>(Properly Stored)
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Spice Bin & Scoop Sanitation <br>(Properly Stored)
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Stove Sanitation
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Oven Sanitation
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Deep Fryer Sanitation
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Meat Slicer Sanitation
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Microwave Sanitation
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Can Opener Sanitation
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Stove Hood Sanitation
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Serving Line Sanitation
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Dishwashing - Area Sanitation
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Dishwashing - Accurate Temperature Reading
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Dishwashing - Sanitation Rinse Used
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Personnel - Clean Clothing & Hair Restraints
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Personnel - Workers Checked for Cuts or Open Wounds. Screened for Infectious Diseases
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Personnel - No Eating or Drinking
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Personnel - Workers Properly Supervised
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Kitchen Floors - Clean & In Good Repair
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Kitchen Walls - Clean & In Good Repair
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Kitchen Ceiling - Clean & In Good Repair
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Hand Washing - Sink Installed & Maintained
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Hand Washing - Soap Available
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Hand Washing - Towels or Drying Device
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Hand Washing - Proper Waste Receptacle
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Freezer - Sanitation
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Freezer - Lighting & Shield
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Freezer - Correct Temperature <br>(0 Degrees or Less)
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Refrigerator - Sanitation
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Refrigerator - Lighting & Shield
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Refrigerator - Correct Temperature <br>(40 Degrees or Less)
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Dry Storage - Sanitation
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Dry Storage - All Product Off the Floor
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Dry Storage - Lighting
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Certified Food Manager on Staff
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Choking Poster Displayed <br>(KRS 217.285)
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Garbage Cans Cleaned & Covered
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Insect & Rodent Control
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Janitor Equipment Stored Correctly & Clean
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Toxic Items Properly Stored & Secured
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Kitchen Tool Accountability
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All Outer Openings Protected
FACILITIES
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Wiring Issues & Condition<br>(KY Fire Code)
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Ceiling Sanitation & Condition<br>(KY Fire Code)
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Evacuation Plans Current & Posted<br>(KY Fire Code)
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1 to 8 Ratio - Toilets & Urinals<br>(Contract Section 30.030)
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1 to 8 Ratio - Showers<br>(Contract Section 30.030)
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1 to 8 Ratio - Sinks<br>(Contract Section 30.030)
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Telephones Available for Resident Use<br>(Contract Section 30.030)
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Adequate Laundry Facilities<br>(Contract Section 30.030)
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Temperature Range - 65 / 85 Degrees<br>(Contract Section 30.030)
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All Tools Secured or Supervised<br>(Contract Section 30.040)
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MSDS Sheets Available & Current
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Chemical Properly Stored & Secured
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Living Area Amenities (Bed, Sheets, Pillow, Storage, & Chair)<br>(Contract Section 30.030)
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Electrical Boxes & Light Switch Covers in Place & In Good Condition <br>(KY Fire Code)
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Living Area Square Footage - 50 ft. per Resident (Contract Section 30.030)
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Room Lighting & Night Lights are in Place & Functional (Contract Section 30.030)
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Emergency Lighting is in Place & Functional<br>(KY Fire Code)
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Fire Extinguishers are Functional<br>(KY Fire Code)
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Exits Free From Obstructions<br>(KY Fire code)
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Hallways Free From Clutter & Obstruction
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Exit Signage in Place & Functional<br>(KY Fire Code)
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Two Separate Entrances <br>(Contract Section 30.030)
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General Housekeeping & Clutter Buildup <br>(KY Fire Code)
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Common Area Sanitation -<br>(Recreation, Weight, & TV Areas)<br>(Contract Section 30.060)
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Visitation Area Sanitation<br>(Contract Section 30.030)
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Shower Sanitation<br>(Contract Section 30.060)
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Restroom Sanitation<br>(Contract Section 30.060)
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Living Area Sanitation<br>(Contract Section 30.060)
