Site Audit - 245D (2018)

• Audit Title

Previous Quality Review

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

  Yes

  No

  N/A

• Are all maintenance items entered into Landport?

  Yes

  No

  N/A

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

  Yes

  No

• Yard free of weeds/debris

  Yes

  No

• Cigarette butt can is available and being emptied

  Yes

  No

  N/A

• Tree trimmed, free of overhangs

  Yes

  No

• Driveway free of weeds/debris

  Yes

  No

• Gutters clean and in place

  Yes

  No

• Decks/patios swept and clear of clutter

  Yes

  No

  N/A

• Outdoor furniture in good condition

  Yes

  No

  N/A

• Summer

  Off

  On

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

  Yes

  No

  N/A

• The property is free of wasp nests and beehives

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Plants around property are trimmed and healthy

  Yes

  No

  N/A

• Winter

  Off

  On

• Salt on site

  Yes

  No

• Shovel on site

  Yes

  No

• Driveway plowed/shoveled and de-iced

  Yes

  No

• Walkways shoveled and de-iced

  Yes

  No

First Impressions

• Were employee cars parked in the designated areas?

  Yes

  No

  N/A

• Were you greeted at the door by staff?

  Yes

  No

  N/A

• Was the smell acceptable?

  Yes

  No

  N/A

• Were the staff busy with work tasks?

  Yes

  No

  N/A

• What tasks were observed?

  Select Client interaction Cleaning Client outing/errand Documentation Medication administration Office work On break Nothing. Standing, sitting, personal activity

  • Client interaction
  • Cleaning
  • Client outing/errand
  • Documentation
  • Medication administration
  • Office work
  • On break
  • Nothing. Standing, sitting, personal activity

• Room 1

  Off

  On

Room 1

• General Cleanliness

• Working light bulbs

  Yes

  No

  N/A

• Mirror

  Yes

  No

  N/A

• Escape Plan

  Yes

  No

• Closet is clean and organized

  Yes

  No

  N/A

• Windows intact and operational.

  Yes

  No

  N/A

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

  Yes

  No

• Manufacture date

• Room 2

  Off

  On

Room 2

• General Cleanliness

• Working light bulbs

  Yes

  No

  N/A

• Mirror

  Yes

  No

  N/A

• Escape Plan

  Yes

  No

• Closet is clean and organized

  Yes

  No

  N/A

• Windows intact and operational.

  Yes

  No

  N/A

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

  Yes

  No

• Manufacture date

• Room 3

  Off

  On

Room 3

• General Cleanliness

• Working light bulbs

  Yes

  No

  N/A

• Mirror

  Yes

  No

  N/A

• Escape Plan

  Yes

  No

• Closet is clean and organized

  Yes

  No

  N/A

• Windows intact and operational.

  Yes

  No

  N/A

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

  Yes

  No

• Manufacture date

• Room 4

  Off

  On

Room 4

• General Cleanliness

• Working light bulbs

  Yes

  No

  N/A

• Mirror

  Yes

  No

  N/A

• Escape Plan

  Yes

  No

• Closet is clean and organized

  Yes

  No

  N/A

• Windows intact and operational.

  Yes

  No

  N/A

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

  Yes

  No

• Manufacture date

Bathroom 1

• Location

• General Cleanliness

• Shower, sink and toilet are clean and operational

  Yes

  No

  N/A

• Floor clean, clear of mold and residue

  Yes

  No

• Light bulbs work and are matching types

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

• Bathroom 2

  Off

  On

Bathroom 2

• Location

• General Cleanliness

• Shower, sink and toilet are clean and operational

  Yes

  No

  N/A

• Floor clean, clear of mold and residue

  Yes

  No

• Light bulbs work and are matching types

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

• Bathroom 3

  Off

  On

Bathroom 3

• Location

• General Cleanliness

• Shower, sink and toilet are clean and operational

  Yes

  No

  N/A

• Floor clean, clear of mold and residue

  Yes

  No

• Light bulbs work and are matching types

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

• Bathroom 4

  Off

  On

Bathroom 4

• Location

• General Cleanliness

• Shower, sink and toilet are clean and operational

  Yes

  No

  N/A

• Floor clean, clear of mold and residue

  Yes

  No

• Light bulbs work and are matching types

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

Kitchen

• General Cleanliness

• Oven is clean

  Yes

  No

• Microwave is clean

  Yes

  No

• Sink is clean

  Yes

  No

• Refrigerator/Freezer is clean

  Yes

  No

• Cabinets are clean and organized

  Yes

  No

  N/A

• Recipes/weekly menus available to clients

  Yes

  No

  N/A

• Fire escape plan clearly posted

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

  N/A

• Windows intact and operational

  Yes

  No

  N/A

Dining Room

• General Cleanliness

• Table and chairs are intact and clean

  Yes

  No

  N/A

• Pictures/Artwork on walls

  Yes

  No

  N/A

• Closet is clean and organized

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

• Fire escape plan clearly posted

  Yes

  No

  N/A

Living Room 1

• Location

• General Cleanliness

• Furniture Cleanliness

• Pictures/Artwork on walls

  Yes

  No

  N/A

• Operable TV

  Yes

  No

  N/A

• Games/entertainment options

  Yes

  No

  N/A

• Closet is clean and organized

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

• Fire escape plan clearly posted

  Yes

  No

  N/A

• Living Room 2

  Off

  On

Living Room 2

• Location

• General Cleanliness

• Furniture Cleanliness

• Pictures/Artwork on walls

  Yes

  No

  N/A

• Operable TV

  Yes

  No

  N/A

• Games/entertainment options

  Yes

  No

  N/A

• Closet is clean and organized

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

• Fire escape plan clearly posted

  Yes

  No

  N/A

• Living Room 3

  Off

  On

Living Room 3

• Location

• General Cleanliness

• Furniture Cleanliness

• Pictures/Artwork on walls

  Yes

  No

  N/A

• Operable TV

  Yes

  No

  N/A

• Games/entertainment options

  Yes

  No

  N/A

• Closet is clean and organized

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

• Windows intact and operational

  Yes

  No

  N/A

• Fire escape plan clearly posted

  Yes

  No

  N/A

Laundry Room

• General Cleanliness

• Clear of clothes on the floor

  Yes

  No

• Lint trap clean (if dryer empty)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

• Windows are intact and operational

  Yes

  No

  N/A

• Fire escape plan clearly posted

  Yes

  No

  N/A

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

  Yes

  N/A

• Manufacture date

• Stairwell

  Off

  On

Stairwell

• General Cleanliness

• Gate is intact, secure and operational

  Yes

  No

  N/A

• Railings are intact and secure

  Yes

  No

  N/A

• Steps are secure and free of tripping hazards

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

  N/A

• Hallway 1

  Off

  On

Hallway 1

• Location

• General Cleanliness

• Closet is clean and organized

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

  N/A

• Hallway 2

  Off

  On

Hallway 2

• Location

• General Cleanliness

• Closet is clean and organized

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

  N/A

• Hallway 3

  Off

  On

Hallway 3

• Location

• General Cleanliness

• Closet is clean and organized

  Yes

  No

  N/A

• Working light bulbs

  Yes

  No

  N/A

• Garage

  Off

  On

Garage

• General Cleanliness

• General Organization

• Working light bulbs

  Yes

  No

  N/A

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

  Yes

  No

• Clear of construction items/supplies

  Yes

  No

• Garage door is intact and operational

  Yes

  No

  N/A

• Windows intact and operational

  Yes

  No

  N/A

Furnace/Boiler and Water Heater

• Location

• Clean furnace filter?

  Yes

  No

  N/A

• Date written on filter

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

  Yes

  No

  N/A

• Date of most recent furnace inspection/repair

  Date

• Does the water temperature stay below 120° F?

  Yes

  No

  N/A

• Water Temperature

• Location

• Furnace/Boiler 2

  Off

  On

• Location

• Clean furnace filter?

  Yes

  No

  N/A

• Date written on filter

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

  Yes

  No

  N/A

• Date of most recent furnace inspection/repair

  Date

• Storage Room 1

  Off

  On

Storage Room 1

• Location

• General Cleanliness

• General Organization

• Working light bulbs

  Yes

  No

  N/A

• Windows intact and operational

  Yes

  No

  N/A

• Storage Room 2

  Off

  On

Storage Room 2

• Location

• General Cleanliness

• General Organization

• Working light bulbs

  Yes

  No

  N/A

• Windows intact and operational

  Yes

  No

  N/A

• Storage Room 3

  Off

  On

Storage Room 3

• Location

• General Cleanliness

• General Organization

• Working light bulbs

  Yes

  No

  N/A

• Windows intact and operational

  Yes

  No

  N/A

Staff Office

• General Cleanliness

• General Organization

• Working light bulbs

  Yes

  No

  N/A

• Windows intact and operational

  Yes

  No

  N/A

• Office door closed and locked upon inspection

  Yes

  No

• Client personal needs money effectively managed (if applicable)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the cleaning checklist being completed daily by staff?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• All HR employment posters clearly visible

  Yes

  No

  N/A

• Missing items

  Select Age Discrimination, April 2012 Minimum Wage and Overtime, July 2016 Safety and Health on the Job, October 2015 Unemployed, September 2015 Worker's Compensation, April 2012 Employee Polygraph Protection Act (EPPA), July 2016 Equal Employment Opportunity (EEO), November 2009 National Labor Relations Act, September 2011 Family and Medical Leave Act (FMLA), April 2016 Occupational Safety and Health Act (OSHA), 2015 Uniformed Services Employment and Reemployment Rights Act (USERRA), October 2008 OSHA Log

  • Age Discrimination, April 2012
  • Minimum Wage and Overtime, July 2016
  • Safety and Health on the Job, October 2015
  • Unemployed, September 2015
  • Worker's Compensation, April 2012
  • Employee Polygraph Protection Act (EPPA), July 2016
  • Equal Employment Opportunity (EEO), November 2009
  • National Labor Relations Act, September 2011
  • Family and Medical Leave Act (FMLA), April 2016
  • Occupational Safety and Health Act (OSHA), 2015
  • Uniformed Services Employment and Reemployment Rights Act (USERRA), October 2008
  • OSHA Log

• Staff Office 2

  Off

  On

Staff Office 2

• Location

• General Cleanliness

• General Organization

• Working light bulbs

  Yes

  No

  N/A

• Windows intact and operational

  Yes

  No

  N/A

Medical Items

• Do all medications appear to have been given correctly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Second Checks

  Off

  On

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is a Program Manager completing narc counts weekly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Licensing Items

Site Specific Items

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

  Yes

  No

• Date

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

  Yes

  No

• Date

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

  Yes

  No

• New/Serviced/Recharged, Date

• First Aid Kit and First Aid Manual

  Yes

  No

• Bloodborne Pathogen Kit

  Yes

  No

  N/A

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

  Yes

  No

• Operational Flashlight (accessible to clients)

  Yes

  No

• All client bulletin board items present

  Yes

  No

  N/A

• Missing items

  Select Vulnerable Adult Act Emergency On-call Grievance Procedure 245D Facility/Program Abuse Prevention Plan (updated at most recent move-in) HIPAA Current License CFC Discipline Policy (CFC) Family Disaster Plan (CFC) Emergency Response and Reporting Review (CFC)

  • Vulnerable Adult Act
  • Emergency On-call
  • Grievance Procedure
  • 245D
  • Facility/Program Abuse Prevention Plan (updated at most recent move-in)
  • HIPAA
  • Current License
  • CFC Discipline Policy (CFC)
  • Family Disaster Plan (CFC)
  • Emergency Response and Reporting Review (CFC)

Licensing Book

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

  Yes

  No

• Missing fire drills in licensing book

  Select 01/2017 02/2017 03/2017 04/2017 05/2017 06/2017 07/2017 08/2017 09/2017 10/2017 11/2017 12/2017 02/2018 02/2018 (2) 03/2018 04/2018 05/2018 06/2018 07/2018 08/2018 09/2018 10/2018 11/2018 12/2018

  • 01/2017
  • 02/2017
  • 03/2017
  • 04/2017
  • 05/2017
  • 06/2017
  • 07/2017
  • 08/2017
  • 09/2017
  • 10/2017
  • 11/2017
  • 12/2017
  • 02/2018
  • 02/2018 (2)
  • 03/2018
  • 04/2018
  • 05/2018
  • 06/2018
  • 07/2018
  • 08/2018
  • 09/2018
  • 10/2018
  • 11/2018
  • 12/2018

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

  Yes

  No

• Missing tornado drills in licensing book

  Select 01/2017 02/2017 03/2017 04/2017 05/2017 06/2017 07/2017 08/2017 09/2017 10/2017 11/2017 12/2017 02/2018 02/2018 (2) 03/2018 04/2018 05/2018 06/2018 07/2018 08/2018 09/2018 10/2018 11/2018 12/2018

  • 01/2017
  • 02/2017
  • 03/2017
  • 04/2017
  • 05/2017
  • 06/2017
  • 07/2017
  • 08/2017
  • 09/2017
  • 10/2017
  • 11/2017
  • 12/2017
  • 02/2018
  • 02/2018 (2)
  • 03/2018
  • 04/2018
  • 05/2018
  • 06/2018
  • 07/2018
  • 08/2018
  • 09/2018
  • 10/2018
  • 11/2018
  • 12/2018

Server and Trackers

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

  Yes

  No

• Missing fire drills on the server

  Select 01/2017 02/2017 03/2017 04/2017 05/2017 06/2017 07/2017 08/2017 09/2017 10/2017 11/2017 12/2017 02/2018 02/2018 (2) 03/2018 04/2018 05/2018 06/2018 07/2018 08/2018 09/2018 10/2018 11/2018 12/2018

  • 01/2017
  • 02/2017
  • 03/2017
  • 04/2017
  • 05/2017
  • 06/2017
  • 07/2017
  • 08/2017
  • 09/2017
  • 10/2017
  • 11/2017
  • 12/2017
  • 02/2018
  • 02/2018 (2)
  • 03/2018
  • 04/2018
  • 05/2018
  • 06/2018
  • 07/2018
  • 08/2018
  • 09/2018
  • 10/2018
  • 11/2018
  • 12/2018

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

  Yes

  No

• Missing tornado drills on the server

  Select 01/2017 02/2017 03/2017 04/2017 05/2017 06/2017 07/2017 08/2017 09/2017 10/2017 11/2017 12/2017 02/2018 02/2018 (2) 03/2018 04/2018 05/2018 06/2018 07/2018 08/2018 09/2018 10/2018 11/2018 12/2018

  • 01/2017
  • 02/2017
  • 03/2017
  • 04/2017
  • 05/2017
  • 06/2017
  • 07/2017
  • 08/2017
  • 09/2017
  • 10/2017
  • 11/2017
  • 12/2017
  • 02/2018
  • 02/2018 (2)
  • 03/2018
  • 04/2018
  • 05/2018
  • 06/2018
  • 07/2018
  • 08/2018
  • 09/2018
  • 10/2018
  • 11/2018
  • 12/2018

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

  Yes

  No

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Documentation

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

  Yes

  No

  N/A

• 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

  Off

  On

• Supervisor review (daily, excluding days off)

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

• Program Manager Review

  Off

  On

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

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

• Auditor Signature

  Sign

Comments