36C24218Q0300-003.doc

Community ADHC Annual Inspection Form

Facility Name, Address & Contact Information:

Model Type (Medical, Social):

Date of Inspection:

Rating (Acceptable, Non-acceptable):

Explanation (If non-acceptable):

Name/Title of evaluator(s)/Signatures:

1. Rights and Responsibilities Posted

2. Observation of participants indicate attention to personal hygiene

3. Clients appear content

4. Staff attitude reflects caring and respect

5. A clients call for assistance is answered promptly and with courtesy

6. Daily staffing consists of at least 1:6

7. Maximum Daily Census

8. Social Work coverage includes:

P/T

F/T

Licensed

Certified

Consultation

9. Counseling services available by Social Services

10. Rehabilitation services provided with consult PT/OT

11. Recreation Services are provided to meet physical/social needs

12. Religious support is available

13. Barber/Beautician services are available

14. Evidence of interdisciplinary treatment plan

15. Evidence of patient/family involvement in treatment plan

16. Smoking areas are provided

17. Smoking is restricted

18. Alarm system for wandering patients

19. Transportation by facility owned vehicles

20. Transportation by contract provider

21. Vehicles w/chair accessible

22. Additional cost for transportation

Amount:

Indicators (RN Review):

1. Staffing Plan includes:

RN

LPN

NA

SW

PT/OT

OTHER

2. RN presence during program hours

3. Staff are CPR certified

4. Evidence of position descriptions for all staff

5. Record of pre-employment physicals for employees

6. Policy and Procedure Manual includes:

Inservice training and staff development

Infection Control

Emergency Medical Care

HIPPA

Administration and disposal of medication

7. Evidence of Medical Provider involvement in Rx plan

8. Medical service available for Rx planning and consultation

9. Each client has a health record that is available to authorized staff

10. LPN to assist with medication administration

11. Medications are clearly marked

12. Medications are stored appropriately

13. Narcotics are stored safely in double lock system

14. Administration of medication is appropriately documented

15. Supplies, oxygen and other equipment routinely inspected, dated & available

16. General housekeeping is acceptable

17. Premises is free of objectionable odors

18. Certified NAs available to assist with personal care/transfers

19. Clients are provided with privacy and call bell while toileting

20. Evidence of handicap accessibility ie. grab bars, ramps, and handrails

21. Staff Interviewed this visit: