Sage Recovery Villa 1

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Fire Extinguishers

• SAGE RECOVERY AUSTIN VILLA REHAB MONTHLY EXIT SIGN INSPECTION
  NOTE: All fire extinguishers for this facility shall be inspected monthly. All fire extinguishers for this facility are numbered and identified below. The person inspecting the fire extinguishers shall do a visual check. The visual inspection shall include ensuring the fire extinguisher is clear and unobstructed, is the correct type, within expiration, the safety pin is in place, the pressure gauge is in the green, and the hose is not damaged or deteriorated. The visual inspection also includes ensuring each fire extinguisher is clean and free of any dirt, dust, debris, grease, etc., and has not been tampered with. The inspector will then pass or fail each fire extinguisher and document below.

• Kitchen

  Pass

  Fail

  N/A

• Back Patio

  Pass

  Fail

  N/A

• Upstairs living room

  Pass

  Fail

  N/A

• Garage 1

  Pass

  Fail

  N/A

• Garage 2

  Pass

  Fail

  N/A

• HR Office

  Pass

  Fail

  N/A

• Break Room

  Pass

  Fail

  N/A

• Barn

  Pass

  Fail

  N/A

• Art Room

  Pass

  Fail

  N/A

• Fitness Center

  Pass

  Fail

  N/A

• Rec Center

  Pass

  Fail

  N/A

• Admin Building

  Pass

  Fail

  N/A

• Female Hall

  Pass

  Fail

  N/A

• Tech Office Hallway

  Pass

  Fail

  N/A

Exit Signs

• SAGE RECOVERY VILLA MONTHLY EXIT SIGN INSPECTION
  NOTE: All exit signs for this facility shall be inspected monthly. All exit signs for this facility are numbered and identified below. The person evaluating exit signs shall do a visual inspection, as well as a 90-second test. The visual inspection will include ensuring that the exit signs are mounted correctly, bulbs are intact and there is no dust buildup inside the light or sign. The 90-second test will include pushing the exit sign button to illuminate the sign for 90 seconds to ensure it is working properly. The inspector will then pass or fail, each individual exit sign and document below.
  Note: All emergency lights for this facility shall be inspected monthly. All emergency lights are numbered and identified below. The person inspecting the emergency lights shall do a visual inspection, as well as a 90-second test. The visual inspection will
  include ensuring that the emergency lights are mounted correctly, clean, and free of dust build-up. The 90-second test will include pushing the “push to test” button on each light for 90 seconds to ensure the battery and lights are fully functional. If the lights are dim or bulbs are burnt out, they are to be replaced. The inspector will then pass or fail each emergency light and document below.

• Upstairs - Pedernales Falls

  Pass

  Fail

  N/A

• Upstairs Patio

  Pass

  Fail

  N/A

• Womens Hall

  Pass

  Fail

  N/A

• Front door

  Pass

  Fail

  N/A

• Mens Hall 1

  Pass

  Fail

  N/A

• Mens Hall 2

  Pass

  Fail

  N/A

• Rec Center Lights

  Pass

  Fail

  N/A

• Admin Lights

  Pass

  Fail

  N/A

• Gym Lights

  Pass

  Fail

  N/A

• Art room Lights

  Pass

  Fail

  N/A

NARCAN - Present and Will Not Expire in the next 30 Days?

• Narcan 1

  Yes

  No

  N/A

• Narcan 2

  Yes

  No

  N/A

• Narcan 3

  Yes

  No

  N/A

• Narcan 4

  Yes

  No

  N/A

• Narcan 5

  Yes

  No

  N/A

• Narcan 6

  Yes

  No

  N/A

• Narcan 7

  Yes

  No

  N/A

• Narcan 8

  Yes

  No

  N/A

• Narcan 9

  Yes

  No

  N/A

• Narcan 10

  Yes

  No

  N/A

Medical

• SPECIFICALLY FOR INSIDE THE MEDICATION CLOSET

• Keys to med closet are not left unattended

  Yes

  No

  N/A

• No identifiable Patient Health Information left out

  Yes

  No

  N/A

• Narcotics are DOUBLE LOCKED

  Yes

  No

  N/A

• Medication in the medication closet is not expired

  Yes

  No

  N/A

• Medication in the medication fridge is not expired

  Yes

  No

  N/A

• Fridge temp logs completed daily

  Yes

  No

  N/A

• "Look-Alike Sound-Alike" posted in med closet and signed off on annually by Medical Director

  Yes

  No

  N/A

• "Do Not Use" Abbreviations List posted in Nursing Station and signed off on annually by Medical Director

  Yes

  No

  N/A

• "High Alert Medications" List posted in Nursing Station and signed off on annually by Medical Director

  Yes

  No

  N/A

• "Hazardous Medications" List posted in Nursing Station and signed off on annually by Medical Director

  Yes

  No

  N/A

Spill Kits

• SAGE RECOVERY AUSTIN VILLA MONTHLY SPILL KIT INSPECTION
  SPILL KITS are clearly labeled and placed strategically throughout the facility, all contents are present (absorbents, containment products, safety products), and all supplies are in good condition and unopened.

• Tech Office

  Pass

  Fail

  N/A

• Kitchen

  Pass

  Fail

  N/A

• Barn

  Pass

  Fail

  N/A

Refrigerators and Freezers

• REFRIGERATORS/FREEZERS FUNCTIONING APPROPRIATELY

  Yes

  No

  N/A

• ALL FOOD ITEMS ARE WITHIN EXPIRATION DATES

  Yes

  No

  N/A

• ARE KITCHEN CLEANING LOGS CURRENT

  Yes

  No

  N/A

• FRIDGE 1 TEMPERATURE LOGS ARE PRESENT AND COMPLETED DAILY

  Media

• FRIDGE 2 TEMPERATURE LOGS ARE PRESENT AND COMPLETED DAILY

  Media

• FREEZER 1 TEMPERATURE LOGS PRESENT AND COMPLETED DAILY

  Media

• FREEZER 2 TEMPERATURE LOGS PRESENT AND COMPLETED DAILY

  Media

Ford Van Items

• Are the seats properly installed and in good working order?

  Yes

  No

  N/A

• Is the Van free from trash and clutter? (Check Glove Box and all Storage Areas)

  Yes

  No

  N/A

• Is the First Aid kit present?

  Yes

  No

  N/A

• Is the Inspection and Registration in date?

  Yes

  No

  N/A

• Are the Van Transportation Logs completed for the previous month?

  Yes

  No

  N/A

• Are the Van Maintenance Logs completed for the previous month?

  Yes

  No

  N/A

• Are there any Check Engine Lights on?

  Select Pass Fail N/A

  • Pass
  • Fail
  • N/A

• Is the Oil Change overdue?

  Pass

  Fail

  N/A

• Is the Insurance card located in the binder?

  Yes

  No

  N/A

Room 1

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in the room or bathroom?

  Yes

  No

  N/A

Room 2

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in the room or bathroom?

  Yes

  No

  N/A

Room 3

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in room or bathroom?

  Yes

  No

  N/A

Room 4

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in room or bathroom?

  Yes

  No

  N/A

Room 5

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in the room or bathroom?

  Yes

  No

  N/A

Room 6

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in room or bathroom?

  Yes

  No

  N/A

Room 7

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in room or bathroom?

  Yes

  No

  N/A

Room 8

• Beds are in good working order?

  Yes

  No

  N/A

• Bedding is in satisfactory condition and free from holes or stains?

  Yes

  No

  N/A

• Furniture is in good condition?

  Yes

  No

  N/A

• Cords are organized and not hazardous?

  Yes

  No

  N/A

• Shower is free from mildew?

  Yes

  No

  N/A

• Sink has soap available?

  Yes

  No

  N/A

• Bathroom Cabinets are free of cleaning supplies?

  Yes

  No

  N/A

• Were any prohibited items found in room or bathroom?

  Yes

  No

  N/A

General EOC

• FLOORS FREE OF TRIP HAZARDS, WELL MAINTAINED, AND CLEAN

  Yes

  No

  N/A

• ALL SHREDDERS ARE FINE CROSS CUT

  Yes

  No

  N/A

• ADEQUATE LIGHTING IN ALL AREAS OF OPERATION

  Yes

  No

  N/A

• FAUCET AND PIPES ARE NOT LEAKING

  Yes

  No

  N/A

• VENTS ARE CLEAN FREE OF DUST

  Yes

  No

  N/A

• GARBAGE IS NOT OVERFLOWING AND HAVE LIDS

  Yes

  No

  N/A

• ALL COMMON AREA SINKS HAVE SOAP AVAILABLE

  Yes

  No

  N/A

• LIGHTING FIXTURES ARE CLEAN AND FREE OF DEAD INSECTS

  Yes

  No

  N/A

• HAZARDOUS SUBSTANCES ARE PROPERLY LABELED AND STORED

  Yes

  No

  N/A

• CLEANING SUPPLIES ARE PROPERLY LABELED AND STORED

  Yes

  No

  N/A

• RAIN GUTTERS ARE CLEAN AND INTACT

  Yes

  No

  N/A

• INDOOR/OUTDOOR FANS ARE CLEAN AND FUNCTIONING PROPERLY

  Yes

  No

  N/A

• TREE TRIMMING HAS BEEN PERFORMED AS NEEDED

  Yes

  No

  N/A

• HAS TOUCH UP PAINTING BEEN DONE FACILITY WIDE AS NEEDED

  Yes

  No

  N/A

• MAIN OUTDOOR AREAS HAVE BEEN POWER WASHED

  Yes

  No

  N/A

• Does facility have all items on emergency supplies list?

  Yes

  No

  N/A

Monthly

• HAS THE GENERATOR BEEN STARTED AND RUN FOR 30 MINUTES THIS MONTH

  Yes

  No

  N/A

• Completed By

Quarterly (Dec, Mar, June, Sept)

• CLEAN AC CONDENSATION LINES, COILS, CONDENSER, AIR FILTERS, AND EVAPORATION

  Yes

  No

  N/A

• Completed by