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Health and Safety
2022
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Todays's Date
MM
/
DD
/
YYYY
Location
SHOULDERS HOUSE
ASHER HOUSE
Clear selection
Reviewer Name and Title
Your answer
Date of Last Fire Extinguisher Inspection
MM
/
DD
/
YYYY
Fire Exits Cleared
Yes
No
Clear selection
Smoke detectors checked and are operating properly
Yes
No
Clear selection
Emergency lighting: unobstructed, operational, emergency lights, flashlights available
Yes
No
Clear selection
Combustibles stored near heat source/water heater
Yes
No
Clear selection
Exits are unobstructed
Yes
No
Clear selection
Evacuation maps are accurate and properly located at height of viewing
Yes
No
Clear selection
Non-approved items (candles, warmers, unapproved space heaters etc.) observed
Yes
No
Clear selection
Kitchen exhaust hood: maintained, clean & free of grease, inspected (oven clean)
Yes
No
Clear selection
Kitchen hood extinguishing system: operational, inspected (oven and stove working properly)
Yes
No
Clear selection
Proper storage in refrigerator / freezer (no mixing of meds/food/blood products)
Yes
No
Clear selection
Is there food that has past expiration dates
Yes
No
Clear selection
Refrigerator/Freezers/Ice Machines: clean, maintained in good repair
Yes
No
Clear selection
Kitchen: area clean, appropriately furnished; appliances are clean and in good working order
Yes
No
Clear selection
The organization stores and disposes of infectious waste (such as used sharps and body fluids) in a
manner that minimizes the risk of infection
Yes
No
Clear selection
Chemicals are properly stored in locked closets/cabinets
Yes
No
Clear selection
All sharps, including knives and scissors, are disposed of properly and locked.
Yes
No
Clear selection
The organization uses standard precautions, including the use of personal protective equipment (such as
gloves and face shields), to reduce the risk of infection.
Yes
No
Clear selection
Latex free gloves are available
Yes
No
Clear selection
Adequate separation of clean and soiled supplies
Yes
No
Clear selection
Hand Hygiene procedures properly performed by staff during rounds (all sinks have hand soap, paper
towels)
Yes
No
Clear selection
Non-Alcohol gel / Soap dispensers available and utilized
Yes
No
Clear selection
Medication is placed in a safe or filling cabinet etc. and is locked
Yes
No
Clear selection
First Aid Kits are current with no dates expired
Yes
No
Clear selection
Over-the-counter medication are current (within one year)
Yes
No
Clear selection
Medications are current and do not need to be destroyed
Yes
No
Clear selection
The organization provides outside areas for use by clients, based on the individual’s needs and are
suitable to the individual’s age or other characteristics
Yes
No
Clear selection
Landscaping: appropriate, good overall appearance, free of debris, lawn mowed, shrubs trimmed, raked,
free of weeds
Yes
No
Clear selection
Walkways and patios: are clean and uncluttered, used appropriately, in good condition, and resistant to
trips and falls
Yes
No
Clear selection
Fencing / Gates: appropriate, in good condition, secured as appropriate
Yes
No
Clear selection
Exterior doors, windows, screens, etc.: in good repair and operational
Yes
No
Clear selection
Exterior building condition: appropriate and in good repair (paint, stucco, etc.)
Yes
No
Clear selection
Exterior furniture: appropriate and in good condition
Yes
No
Clear selection
Exterior lighting: appropriate and functional
Yes
No
Clear selection
All windows close and open properly (they do not get stuck), if any windows are fire exits are they
accessible
Yes
No
Clear selection
Areas used by individuals served are safe, clean, and comfortable and are maintained in an orderly
fashion.
Yes
No
Clear selection
Floor covering: appropriate, clean, vacuumed, and in good repair
Yes
No
Clear selection
Walls: in good repair
Yes
No
Clear selection
Client beds: have mattress cover, pillow with cover, sheets, blankets, as appropriate. Beds are made,
and clean for new intake.
Yes
No
Clear selection
Stairs: unobstructed, clean, in good repair, not storage in stairwells
Yes
No
N/A
Clear selection
Furnishings and equipment reflect the ability and needs of the individual served.
Yes
No
Clear selection
The organization keeps furnishings and equipment safe and in good repair.
Yes
No
Clear selection
Furniture: appropriate, clean, free of tears, breakage, and free of odor.
Yes
No
Clear selection
Shelves / Bracketing: appropriate and in good repair
Yes
No
Clear selection
Washer & Dryers: clean, in good repair
Yes
No
Clear selection
Restrooms: clean, odor free, non-slip devices in tub/shower
Yes
No
Clear selection
The organization provides storage space to meet the needs of the individual served.
Yes
No
Clear selection
Lighting: appropriate and functioning; is controlled by the individuals served, consistent with care, treatment, or services provided
Yes
No
Clear selection
The organization maintains ventilation, temperature, and humidity levels suitable for the care, treatment, or
services provided.
Yes
No
Clear selection
Vehicles meet state and city legal requirements (insurance, current registration are in vehicles)
Yes
No
Clear selection
Vehicle is properly maintained and has service checks, as appropriate
Yes
No
Clear selection
Vehicle drivers have completed driver safety training
Yes
No
Clear selection
Vehicle drivers are listed as a driver in HR and copy of DL & Insurance is on file with HR manager
Yes
No
Clear selection
What are your recommendations for any areas needing improvement?
Your answer
What actions have been taken to respond to the recommendations?
Your answer
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