ICF MONTHLY QI/OBSERVATION FORM
Name of person completing QI observation:
*
First Name
Last Name
Email of person completing QI observation:
*
example@example.com
ICF LOCATION:
*
Park West
Johnstown
PW OFFICE
Apartment/Area:
*
JT
A1
A2
A3
B1
B2
B3
C2
C3
OFFICE
Oxygen signs posted properly in home and in good condition on doors, when applicable?
Yes
No
N/a
All textures and eating/feeding strategies are current and reflected in home?
Yes
No
N/a
All meal placemats are current and reflected in home?
Yes
No
N/a
Proper texture modification or liquid consistency supplies and meal adaptive equipment are available in home?
Yes
No
N/a
Communication Supplies or Equipment are available and in working order, with evidence of using in home?
Yes
No
N/a
All diets current and reflected in apartment?
Yes
No
N/a
All menus current and reflected in apartment?
Yes
No
N/a
Substitutions correctly documented on menu?
Yes
No
N/a
Proper dietary supplies are available?
Yes
No
N/a
Food labelled and stored properly in cabinets and refrigerator?
Yes
No
N/a
Meal intake and supplement intake documentation completed?
Yes
No
N/a
Transfer/Mobility information current and reflected in home?
Yes
No
N/a
Gait belts present in home?
Yes
No
N/a
Range of motion/positioning/turn schedules present and evidence that staff are following plan for these?
Yes
No
N/a
All adaptive equipment, lifts, wheelchairs, shower chairs, beds, etc. in working order, clean, available and evidence of staff following plan for them?
Yes
No
N/a
OFFICE: Check storage areas in office to ensure no paper or chemical storage and nothing above 18 inch line?
Yes
No
N/a
OFFICE: Is oxygen stored in racks properly?
Yes
No
N/a
OFFICE: Are full and empty oxygen tanks labelled and stored separately?
Yes
No
N/a
OFFICE: Is oxygen storage room clean and organized?
Yes
No
N/a
OFFICE: Is sign on door present for oxygen storage?
Yes
No
N/a
Explanation of any concern/problem area:
*
Documentation issues: (list below)
*
Other notes or positive reviews:
*
When asked, did DSPs have any concerns--list below:
*
Submit
Should be Empty: