Information

  • Audit Title

Physical

Previous Quality Review

  • Were the previous findings reviewed with the Program Manager and Site Supervisor?

  • Are all maintenance items entered into Landport?

Physical Inspection

  • Rating Scale
    4: Exceptional
    3: Minor work needed
    2: Does not meet expectations
    1: Health and safety concern
    0: Health and safety hazard

Outside

  • General Cleanliness

  • Mailbox intact/clear of obstructions

  • Yard free of weeds/debris

  • Cigarette butt can is available and being emptied

  • Tree trimmed, free of overhangs

  • Driveway free of weeds/debris

  • Gutters clean and in place

  • Decks/patios swept and clear of clutter

  • Outdoor furniture in good condition

  • Summer

  • The lawn is healthy and free of bald patches (Jim only, does not affect score)

  • The property is free of wasp nests and beehives

  • The property is free of any burrows of rodents or small animals

  • Rock beds around house are covering the ground underneath (Jim only, does not affect score)

  • Plants around property are trimmed and healthy

  • Winter

  • Salt on site

  • Shovel on site

  • Driveway plowed/shoveled and de-iced

  • Walkways shoveled and de-iced

First Impressions

  • Were employee cars parked in the designated areas?

  • Were you greeted at the door by staff?

  • Was the smell acceptable?

  • Were the staff busy with work tasks?

  • What tasks were observed?

  • Room 1

Room 1

  • General Cleanliness

  • Working light bulbs

  • Mirror

  • Escape Plan

  • Closet is clean and organized

  • Windows intact and operational.

  • Smoke Alarm (under 10 years old, with manufacture date written on outside)

  • Manufacture date

  • Room 2

Room 2

  • General Cleanliness

  • Working light bulbs

  • Mirror

  • Escape Plan

  • Closet is clean and organized

  • Windows intact and operational.

  • Smoke Alarm (under 10 years old, with manufacture date written on outside)

  • Manufacture date

  • Room 3

Room 3

  • General Cleanliness

  • Working light bulbs

  • Mirror

  • Escape Plan

  • Closet is clean and organized

  • Windows intact and operational.

  • Smoke Alarm (under 10 years old, with manufacture date written on outside)

  • Manufacture date

  • Room 4

Room 4

  • General Cleanliness

  • Working light bulbs

  • Mirror

  • Escape Plan

  • Closet is clean and organized

  • Windows intact and operational.

  • Smoke Alarm (under 10 years old, with manufacture date written on outside)

  • Manufacture date

Bathroom 1

  • Location

  • General Cleanliness

  • Shower, sink and toilet are clean and operational

  • Floor clean, clear of mold and residue

  • Light bulbs work and are matching types

  • Windows intact and operational

  • Bathroom 2

Bathroom 2

  • Location

  • General Cleanliness

  • Shower, sink and toilet are clean and operational

  • Floor clean, clear of mold and residue

  • Light bulbs work and are matching types

  • Windows intact and operational

  • Bathroom 3

Bathroom 3

  • Location

  • General Cleanliness

  • Shower, sink and toilet are clean and operational

  • Floor clean, clear of mold and residue

  • Light bulbs work and are matching types

  • Windows intact and operational

  • Bathroom 4

Bathroom 4

  • Location

  • General Cleanliness

  • Shower, sink and toilet are clean and operational

  • Floor clean, clear of mold and residue

  • Light bulbs work and are matching types

  • Windows intact and operational

Kitchen

  • General Cleanliness

  • Oven is clean

  • Microwave is clean

  • Sink is clean

  • Refrigerator/Freezer is clean

  • Cabinets are clean and organized

  • Recipes/weekly menus available to clients

  • Fire escape plan clearly posted

  • Working light bulbs

  • Windows intact and operational

Dining Room

  • General Cleanliness

  • Table and chairs are intact and clean

  • Pictures/Artwork on walls

  • Closet is clean and organized

  • Working light bulbs

  • Windows intact and operational

  • Fire escape plan clearly posted

Living Room 1

  • Location

  • General Cleanliness

  • Furniture Cleanliness

  • Pictures/Artwork on walls

  • Operable TV

  • Games/entertainment options

  • Closet is clean and organized

  • Working light bulbs

  • Windows intact and operational

  • Fire escape plan clearly posted

  • Living Room 2

Living Room 2

  • Location

  • General Cleanliness

  • Furniture Cleanliness

  • Pictures/Artwork on walls

  • Operable TV

  • Games/entertainment options

  • Closet is clean and organized

  • Working light bulbs

  • Windows intact and operational

  • Fire escape plan clearly posted

  • Living Room 3

Living Room 3

  • Location

  • General Cleanliness

  • Furniture Cleanliness

  • Pictures/Artwork on walls

  • Operable TV

  • Games/entertainment options

  • Closet is clean and organized

  • Working light bulbs

  • Windows intact and operational

  • Fire escape plan clearly posted

Laundry Room

  • General Cleanliness

  • Clear of clothes on the floor

  • Lint trap clean (if dryer empty)

  • There is a lint catcher on the washing machine exhaust hose

  • Working light bulbs

  • Windows are intact and operational

  • Fire escape plan clearly posted

  • Optional smoke detector installed (under 10 years old, with manufacture date written on outside)

  • Manufacture date

  • Stairwell

Stairwell

  • General Cleanliness

  • Gate is intact, secure and operational

  • Railings are intact and secure

  • Steps are secure and free of tripping hazards

  • Working light bulbs

  • Hallway 1

Hallway 1

  • Location

  • General Cleanliness

  • Closet is clean and organized

  • Working light bulbs

  • Hallway 2

Hallway 2

  • Location

  • General Cleanliness

  • Closet is clean and organized

  • Working light bulbs

  • Hallway 3

Hallway 3

  • Location

  • General Cleanliness

  • Closet is clean and organized

  • Working light bulbs

  • Garage

Garage

  • General Cleanliness

  • General Organization

  • Working light bulbs

  • Clear of old site items (furniture, belongings of discharged clients, old mattresses, etc.)

  • Clear of construction items/supplies

  • Garage door is intact and operational

  • Windows intact and operational

Furnace/Boiler and Water Heater

  • Location

  • Clean furnace filter?

  • Date written on filter

  • Has the furnace/boiler been inspected within the last year?

  • Date of most recent furnace inspection/repair

  • Does the water temperature stay below 120° F?

  • Water Temperature

  • Location

  • Furnace/Boiler 2

  • Location

  • Clean furnace filter?

  • Date written on filter

  • Has the furnace/boiler been inspected within the last year?

  • Date of most recent furnace inspection/repair

  • Storage Room 1

Storage Room 1

  • Location

  • General Cleanliness

  • General Organization

  • Working light bulbs

  • Windows intact and operational

  • Storage Room 2

Storage Room 2

  • Location

  • General Cleanliness

  • General Organization

  • Working light bulbs

  • Windows intact and operational

  • Storage Room 3

Storage Room 3

  • Location

  • General Cleanliness

  • General Organization

  • Working light bulbs

  • Windows intact and operational

Staff Office

  • General Cleanliness

  • General Organization

  • Working light bulbs

  • Windows intact and operational

  • Office door closed and locked upon inspection

  • Client personal needs money effectively managed (if applicable)

  • Is there a calendar or Procentive schedule posted and regularly updated for ARMHS and therapy appointments?

  • Is the cleaning checklist being completed daily by staff?

  • Is the communication book being used daily by the staff?

  • All HR employment posters clearly visible

  • Missing items

  • Staff Office 2

Staff Office 2

  • Location

  • General Cleanliness

  • General Organization

  • Working light bulbs

  • Windows intact and operational

Medical

Medical Items

  • Do all medications appear to have been given correctly?

  • Are the backs of the med packs fully initialed, dated and timed?

  • Second Checks

  • Second check sheet completion 0: 0% complete 1: At least 25% complete 2: At least 50% complete 3: At least 75% complete 4: 100% complete

  • Was the medication cabinet closed and locked, and were all narcotics stored in a locked box, upon inspection?

  • Are narc counts accurate, and completed daily and during each administration?

  • Are all narc counts double-signed (shift change only)?

  • Is a supervisor completing narc counts daily (excluding weekends)?

  • Is a Program Manager completing narc counts weekly?

  • Is there at least one week of meds on backup?

  • Are liquid and solid medications kept in separate bins, or separated by an airtight plastic bag?

  • Is there an assigned medication passer for at least the current week?

  • Are HPN's being completed on CaraSolva at a minimum of weekly?

Licensing

Licensing Items

Site Specific Items

  • CO Alarm(s) (under 5 years old, with manufacture date written on outside - 10ft from all bedrooms)

  • Date

  • Other Smoke Alarms (under 10 years old, with manufacture date written on outside)

  • Date

  • Fire extinguisher present and serviced within last 12 months (one near kitchen, one near laundry)

  • New/Serviced/Recharged, Date

  • First Aid Kit and First Aid Manual

  • Bloodborne Pathogen Kit

  • Weather Radio (stays on when unplugged, has working batteries, tuned in)

  • Operational Flashlight (accessible to clients)

  • All client bulletin board items present

  • Missing items

Licensing Book

  • Are all Fire Drills (assigned via email) signed and filed in the Licensing Book?

  • Missing fire drills in licensing book

  • Are all Tornado Drills (assigned via email) signed and filed in the Licensing Book?

  • Missing tornado drills in licensing book

Server and Trackers

  • All fire drills (assigned via email) are signed and uploaded to the server.

  • Missing fire drills on the server

  • All tornado drills (assigned via email) are signed and uploaded to the server.

  • Missing tornado drills on the server

  • Programmatic paperwork is in compliance (Client Paperwork Compliance Master)

  • The site has no overdue staff orientations (Orientation Checklist Tracker)

  • Person-specific trainings are complete and up to date (Person Specific Training Master)

Documentation

Documentation

  • Have DPN's been created for each client on each day since the last audit?

  • Rating scale
    0: 0% complete
    1: At least 25% completed
    2: At least 50% completed
    3: At least 75% completed
    4: 100% completed

  • Staff completion (daily)

  • Number of completed notes:

  • Supervisor Review

  • Supervisor review (daily, excluding days off)

  • Number of notes opened and reviewed/completed within deadline:

  • Program Manager Review

  • Program Manager review (weekly, 3 business days if no SS)

  • Number of notes opened and reviewed/completed within deadline:

Signature and Comments

  • Auditor Signature

Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.