SCL LOCATION QI/AUDIT FORM
Date of audit:
Time of audit
HOME SAFETY CHECKLIST
All exits clear and functional?
Electrical boxes, water heater, furnace and heaters have clearance and no paper/boxes close?
Extension cords not used in place of permanent wiring?
No gas or oil products stored?
NO towels hanging near or on stove?
NO Smoking signs posted if oxygen present?
Oxygen stored safely if applicable?
All light bulbs 60 watts or less?
Are stove burners and tops free of grease?
Fire and Police Dept, physician, emergency #, guardian numbers posted near phone?
Meds stored secured, neat, organized, separated by route?
Is narcotic count completed, accurate if applicable?
Shower chair wheels sturdy and present?
First aid kit present?
PPE kit present gloves, masks, aprons?
KITCHEN-sinks, floors, counters, appliances clean in and out? Furniture in good repair, hand soap available?
LIVING AREA-dusted, floors, carpets, closet, furniture clean and in working order?
EMERGENCY DRILLS-Tornado and fire completed JOT FORM?
All adaptive devices are tested, present, and in working order?
BEDROOMS-dusted, floors, closets, carpets, furniture clean and in working order?
BATHROOMS-Toilets, sinks, shower/tub, floor Clean?, hand soap available?
LAUNDRY AREA-clean and lint cleaned out?
DOORS AND HALLWAYS-free of items and accessible
PETS-odor, messes, food/water bowls present, vet records available?
DO ALL VEHICLES USED FOR TRANSPORTATION APPEAR SAFE? FIRE EXTINGUISHER AND FIRST AID KIT IN VEHICLE?
Charts for all individuals present, organized and contain current information?
Evidence that staff are using proper documentation?
Physician orders signed and present?
Evidence that staff are aware of PCP and where to find information?
EXPLANATION OF PROBLEM AREAS AND FOLLOW UP NEEDS:
Name of person completing audit:
Email of person completing audit:
Should be Empty: