TC Recovery Unplugged Austin TREATMENT CENTER

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Audit Number

Van 1 Items

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

  Yes

  No

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

  Yes

  No

• Is the First Aid kit present?

  Yes

  No

• Is the Inspection and Registration in date?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• Are the Check Engine Lights off?

  Yes

  No

• Is the Oil Change overdue?

  Yes

  No

Van 2 Items

• Are the seats in good working order?

  Yes

  No

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

  Yes

  No

• Is the First Aid kit present?

  Yes

  No

• Is the Inspection and Registration in date?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• Are the Check Engine Lights off?

  Yes

  No

• Is the Oil Change overdue?

  Yes

  No

Van 3 Items

• Are the seats in good working order?

  Yes

  No

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

  Yes

  No

• Is the First Aid kit present?

  Yes

  No

• Is the Inspection and Registration in date?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• Are the Check Engine Lights off?

  Yes

  No

• Is the Oil Change overdue?

  Yes

  No

Medical

• SPECIFICALLY FOR INSIDE THE NURSES STATION

• Are all medications within expiration?

  Yes

  No

• All Medication Destruction Logs have been completed

  Yes

  No

• Medication Fridge Temp Logs Completed Daily

  Yes

  No

• Keys to Safe are not left unattended

  Yes

  No

• No identifiable Patient Health Information left out

  Yes

  No

• Narcotics are DOUBLE LOCKED

  Yes

  No

• "Look Alike Sound Alike" posted in Nurses Station and signed off on annually by Medical Director

  Yes

  No

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

  Yes

  No

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

  Yes

  No

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

  Yes

  No

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

• 1

  Yes

  No

• What is the issue?

  Not Present

  Expired

• 2

  Yes

  No

• What is the issue?

  Not Present

  Expired

• 3

  Yes

  No

• What is the issue?

  Not Present

  Expired

• 4

  Yes

  No

  N/A

• What is the issue?

  Not Present

  Expired

• 5

  Yes

  No

  N/A

• What is the issue?

  Not Present

  Expired

• 6

  Yes

  No

  N/A

• What is the issue?

  Not Present

  Expired

• 7

  Yes

  No

  N/A

• Whats the issue?

  Not Present

  Expired

• 8

  Yes

  No

  N/A

• Not Present

  Expired

• 9

  Yes

  No

  N/A

• Not Present

  Expired

FIRE SAFETY

Fire Extinguishers

• RECOVERY UNPLUGGED AUSTIN TREATMENT CENTER MONTHLY FIRE EXTINGUISHER 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.

• 1 RESTROOOM HALLWAY BY MSDS

  Pass

  Fail

• 2 SIDE ENTRANCE

  Pass

  Fail

• 3 HAND WASHING SINK

  Pass

  Fail

• 4 STAGE RIGHT

  Pass

  Fail

• Fire Extinguisher inspections are all up to date and noted on tag.

  Pass

  Fail

Emergency Lights

• RECOVERY UNPLUGGED AUSTIN TREATMENT CENTER MONTHLY EMERGENCY LIGHT INSPECTION
  
  
  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.

• 1 FRONT DOOR

  Pass

  Fail

• Add media

  Media

• 2 BATHROOM HALLWAY ABOVE FIRE EXTINGUISHER

  Pass

  Fail

• Add media

  Media

• 3 ABOVE ADMISSIONS OFFICE DOOR

  Pass

  Fail

• Add media

  Media

• 4 ABOVE DOUBLE DOORS TO MAIN ROOM

  Pass

  Fail

• Add media

  Media

• 5 EXIT BY KITCHEN

  Pass

  Fail

• Add media

  Media

• 6 SIDE ENTRANCE

  Pass

  Fail

• Add media

  Media

• 7 BACK WALL OF STAGE

  Pass

  Fail

• Add media

  Media

• 8 BACK FIRE EXIT HALL WAY

  Pass

  Fail

• Add media

  Media

Smoke Detectors

• RECOVERY UNPLUGGED AUSTIN REHAB MONTHLY SMOKE DETECTOR INSPECTION
  
  
  Note: All battery operated smoke detectors for this facility shall be tested and inspected monthly. All battery operated smoke detectors for this facility are numbered and identified below. The person inspecting the smoke detectors shall physically test the batteries by operating the testing button and hearing the alarm. They shall also ensure each battery operated smoke detector is clean and free of dust. The inspector will then pass of fail each battery operated smoke detector and document below. Batteries will be replaced in each battery operated smoke detector every December and June and will also be documented below in those months.
  

• 1 Hallway by Bathrooms

  Pass

  Fail

• 2 Medical Hall

  Pass

  Fail

• 3 Clinical Office Wall

  Pass

  Fail

• 4 Stage Back Wall

  Pass

  Fail

Spill Kits

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

• 1 MSDS Corner

  Pass

  Fail

• 2 Kitchen Closet

  Pass

  Fail

Refrigerators and Freezers

• REFRIGERATORS/FREEZERS FUNCTIONING APPROPRIATELY

  Yes

  No

  N/A

• TEMPERATURE LOGS PRESENT AND COMPLETED DAILY

  Yes

  No

  N/A

• ALL FOOD ITEMS ARE WITHIN EXPIRATION DATES

  Yes

  No

  N/A

• ARE KITCHEN CLEANING LOGS CURRENT

  Yes

  No

  N/A

Monthly

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

  Yes

  No

  N/A

• Completed by:

  David

Quarterly (Dec, Mar, June, Sept)

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

  Yes

  No

  N/A

• Completed by:

  David

• REPLACE AC FILTERS

  Yes

  No

  N/A

• Completed by:

  David

General EOC

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

  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 SINKS HAVE SOAP AVAILABLE

  Yes

  No

  N/A

• LIGHTING FIXTURES ARE CLEAN AND FREE OF DEAD INSECTS

  Yes

  No

  N/A

• ALL LICENSES AND CERTIFICATIONS HANGING ARE CURRENT/NOT EXPIRED

  Yes

  No

  N/A

• HAZARDOUS SUBSTANCES ARE PROPERLY LABELED AND STORED

  Yes

  No

  N/A

• Take Photo of issue

  Media

• 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

• Add media

  Media

• HAS TOUCH UP PAINTING BEEN DONE FACILITY WIDE AS NEEDED

  Yes

  No

  N/A

• Add media

  Media

• MAIN OUTDOOR AREAS HAVE BEEN POWER WASHED

  Yes

  No

  N/A

• Add media

  Media

• Does facility have all items on emergency supplies list?

  Yes

  No

  N/A

• RECOVERY UNPLUGGED AUSTIN TREATMENT CENTER CULTURE AUDIT : This section serves to ensure consistent standards and staff priorities

• Is there music playing in the front lobby?

  Yes

  No

  N/A

• Is the lobby clean and clear of clutter?

  Yes

  No

  N/A

• Is the lobby open? Not being used as a work space?

  Yes

  No

  N/A

• Is there music playing in the main group room?

  Yes

  No

  N/A

• Is the main group room clean and organized between groups?

  Yes

  No

  N/A

• Were the group rooms neat and orderly?

  Yes

  No

  N/A

• Which rooms weren't?

  Select Group Room A Group Room B Group Room C Group Room D

  • Group Room A
  • Group Room B
  • Group Room C
  • Group Room D

• Is music being playing during meal time?

  Yes

  No

  N/A

• Were the staff assisting clients? Were they available and interacting with clients?

  Yes

  No

  N/A

• Is the staff encouraging the use of music as a coping mechanism and healthy outlet?

  Yes

  No

  N/A

• Is the staff attitude one of hope and positive encouragement?

  Yes

  No

  N/A

• Are the lights on in the back hallway?

  Yes

  No

  N/A

• Is there proper light on the stage in main room?

  Yes

  No

  N/A

• Is the tech office clean?

  Yes

  No

  N/A

• Are staff badges worn? Presented correctly?

  Yes

  No

  N/A

• Are all the lights functioning?

  Yes

  No

  N/A

• Is the furniture in good condition?

  Yes

  No

  N/A

• Are the common areas clean?

  Yes

  No

  N/A

• Is the side yard clear of debris?

  Yes

  No

  N/A

• Are the trash cans emptied?

  Yes

  No

  N/A

• Are the floors clean?

  Yes

  No

  N/A