CTH-II HOUSE MANAGER S MONTHLY SELF-INSPECTION Program: Date: SAFETY: Item Met Not Met (document action required)

Transcription

1 CTH-II HOUSE MANAGER S MONTHLY SELF-INSPECTION Program: Date: SAFETY: 1. Fire exits are unobstructed (including windows) 2. Fire equipment checked monthly/annually 3. Smoke detectors operable (all smoke detectors labeled and under 10 years old) 4. Emergency lights operable 5. Exit lights are working 6. Working flashlights on each level of the home (training data available) 7. Fire drills current, correctly performed & documented Date: 8. No flammables stored 9. All windows operable (stay open, at least 24 ) 10. Emergency Numbers Posted & current 11. Refrigerator/freezer temperatures adequate 12. Food Storage Safe: in refrigerator food is properly labeled, no leftovers over 3 days and thawing properly, in pantry food is in sealed bags, labeled and no food on floor 13. Water temperatures safe ( degrees) Water temps may be as high as 120 degrees if ALL individuals in the home have a current assessment stating they can regulate water temperature. 14. Light bulbs present in all sockets 15. Electrical outlets in good repair 16. Chemical Closet locked 17. All chemicals are properly labeled 18. Chemicals have corresponding MSDS sheet 19. First Aid Kit is present and complete (American Red Cross recommended pg. 23) 20. Sharps Container is secured & not more that ¾ full 21. Knives and other sharps are locked if necessary 22. Outside trash area is neat 23. No debris around the facility 24. Universal Precaution Kit (Infection Control Kit) 25. Emergency Food Bucket is available and sealed

2 26. Disaster Kit is available and fully stocked w/ Item if present Item if present Steripen Lantern Shake Light Stove/Can Crank radio Wall F/Light 27.Residential Fire Evacuation form current and available to staff 28. Carbon Monoxide detector (if gas appliances in home) clearance between top of stored items and sprinkler heads 30. Supply storage is adequate (nothing on floors- no fire hazards stored near mechanical equipment) FACILITY REPAIR: 1. Kitchen equipment is in good working order including both large and small appliances 2. Laundry equipment is in good working order 3. Carpet is in good repair 4. Flooring is in good repair 5. Furniture is in good repair 6. All lights are operable 7. Sufficient plates, cups, bowls, cooking utensils are available 8. Exterior of the home is in good repair including lawn and landscaping maintenance 9. Walls are in good repair (no holes or painting needed) 10. Exterior storage areas are in good repair 11. All special equipment (wheelchairs, shower chairs, lifts for example) are in good repair CLEANLINESS: 1. Home is free of unpleasant odors 2. Floors are clean & Baseboards are free from buildup 3. Furniture is clean 4. Food prep equipment and surfaces are clean including range, range hood and cabinet doors 5. Refrigerator and Freezer (inside/out) are clean 6. Tables/Chairs are clean (no food particles) 7. Closets are organized 8. Showers/tubs are clean 9. Commodes are clean

3 10. Sinks are clean 11. No personal items stored in bathrooms 12. Walls are clean 13. Garage and/or storage building is clean and organized 14. All window blinds are clean and in good repair 15. Light fixtures are free from dust and debris MEDICATION: 1. Medication Closet/Cabinet is locked 2. Narcotics are double locked 3. Topicals and orals are stored separately 4. No outdated meds present (including standing order meds) 5. No medication without a corresponding doctor s order 6. MAPs completed correctly (no cross outs, white outs, blanks) 7. PRN medication is properly documented 8. All medication errors properly documented and sent to the Director of Nursing 9. Date of last medication audit by House Manager: Date: 10. Weights and Blood Pressure Checks are properly documented INSPECTIONS: Copies of all inspections must be located at the facility 1. Annual Fire Marshall Inspection Completed DATE: 2. HVAC Inspection (initial and after structural changes) DATE: 3. Electrical Inspection (initial and after structural changes) DATE: 4. HVAC Filters have been changed DATE: 5. Homes serving Children: Annual DHEC Sanitation Inspection DATE: 6. Homes with Wells: Annual DHEC bacteria analysis DATE: 7. Sprinkled Fire System (Monthly, Quarterly, Annual, Five Year Inspections) Completed 8. Emergency lighting monthly activation test completed Location of lights tested: Unit passed test Yes No Person completing test: (activation test: emergency lights automatically come on when electrical power is disconnected. Lights stay on 30 seconds m in) Date last qtrly Date last annual DATE:

4 9. Battery- operated emergency lighting power test completed annually by maintenance. Annual DATE: Location of lights tested: Units passed test: Yes No Person completing test: 10. Mixing valve inspection is present (annually by maintenance) Date: ACCOUNTABILITY: 1. Staff schedule complete and posted 2. Staff ratio is adequate to meet accountability requirements 3. Staff can demonstrate their knowledge of bathing levels 4. Staff can demonstrate their knowledge of supervision levels 6. Accountability sheets are completed and kept in a orderly manner 7. Old schedules are kept in an orderly manner 8. Special Diets have corresponding menus 9. Shift Log present, up to date, contains accurate information and has been reviewed daily 10. Census logs are completed and turned in by the 3 rd of the month VAN(s): 1. Seat belts operable (including those for a wheelchair) 2. Fire Extinguisher and First Aid Kit Present 3. Gas Key present 4. Emergency numbers posted 5. Van is clean PETS: if applicable 1. Vet record available indicating current vaccinations 2. Animal is well taken care of 3. Animal is safe 4. Residents are safe House Manager: Date: Director Review: Date:

5 Comments: Corrective Action Required: Responsible staff: Correction deadline: Corrections Reviewed and Complete Administrator: Date: * Copy to remain at the facility and one to be included in the administrator s packet Revision date: 12/17/13