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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.