Service Outlet Compliance and Update

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Elements of programme

• This service outlet is classified as :

  Select Therapeutic Programme Model Independent Living Programme Self Directed

  • Therapeutic Programme Model
  • Independent Living Programme
  • Self Directed

• The required Augmentative and Communication plans that are required include:

  Select Visual Day Planner Meal Plan Activity Plan Shift Plan

  • Visual Day Planner
  • Meal Plan
  • Activity Plan
  • Shift Plan

• Client Names and Diagnosis

• Staffing and Roster Requirements

  Select 24 Hour Support Sleepover Wake Shift Day Shift 6am-10pm 1 Staff to 1 Client 2 Staff to 1 Client 1 Staff Mixed Staffing Levels

  • 24 Hour Support
  • Sleepover
  • Wake Shift
  • Day Shift 6am-10pm
  • 1 Staff to 1 Client
  • 2 Staff to 1 Client
  • 1 Staff
  • Mixed Staffing Levels

• Transport Requirements and Access to Vehicles

  Select Access to Bus Allocated a Vehicle Vehicle on request Staff Vehicles and Mileage Other Transport

  • Access to Bus
  • Allocated a Vehicle
  • Vehicle on request
  • Staff Vehicles and Mileage
  • Other Transport

• Priority Programmes

  Select Communication Daily Living Skills Gardening Leisure Skills Community Access Day Service Family Contact School Clinical Therapy Interventions

  • Communication
  • Daily Living Skills
  • Gardening
  • Leisure Skills
  • Community Access
  • Day Service
  • Family Contact
  • School
  • Clinical Therapy Interventions

• Staffing Stability and Team Resilience

• Site or Home improvement and maintenance requirements and plans

• Matters of Concern identified:

  Media

• Photo evidence of positive outcomes for this arrangement

  Media

• Additional Information and comment:

• Signature of Staff person providing site orientation

  Sign

• Employee being orientated:

  Sign