36C24418Q0128-001.docx

Community Residential Care Social Work Inspection Report

Date of Evaluation:__________________ Type of Evaluation: Initial________ Re-Evaluation________ Name of Home:______________________________________________Phone:____________________ Address:___________________________________City:___________________State:_____Zip:_______ Type of Facility # of beds

BUILDING PLAN / CONDITION

1. Comfortable dining area – adequate in size for the number of residents

2. Comfortable living room area-adequate in size to accommodate a reasonable proportion of residents

3. At least one functional toilet and lavatory, and bathing or shower facility for every six people living in the facility including provider and staff

4. Bedrooms have all required furnishings, bed linens and spreads are clean and in good condition

5, Residents rooms are free from dangerous and unsanitary clutter

6. Provision is made for privacy in shared rooms

7. Laundry service is provided

8. Sanitary procedures are followed in laundry area, including separation of clean and dirty clothing, sufficient hot water and sufficient space to fold clean clothing

9. All areas of the home are odor free

10. All areas of home have proper lighting and ventilation

11. A comfortable temperature is maintained throughout the facility

12. If wheel chairs are in use all areas of the home are accessible

13. Exterior of home is clean and facility is well maintained

ACTIVITIES/EMOTIONAL ATMOSPHERE

1. Facility plans and facilitates appropriate recreation and leisure activities to meet individual needs as specified in the statement of needed care and state regulations (if applicable)

2. Positive rapport observed between sponsor and residents

3. Staff encourages appropriate resident independence

4. Staff is able to set appropriate behavioral limits and interpersonal boundaries

FINANCIAL

1. Residents who are capable are allowed to manage their own personal financial affairs

2. Residents cash resources are safeguarded. Deposits and withdrawals are documented with resident and sponsor signatures

PRIVACY

1. Residents have access to a phone with reasonable privacy

2. Mail is delivered unopened and uncensored

3. Privacy of self and possessions is safeguarded by sponsor

4. Home respects residents' rights and confidentiality

WORK

Residents do not perform household duties, other than personal housekeeping tasks, unless the resident receives compensation for these duties or is told in advance they are voluntary and the patient agrees to do them

FREEDOM OF ASSOCIATION

1. Residents may receive and associate freely with persons and groups of their own choosing both within and outside the facility in accordance with the facility rules

2. Residents may leave and return freely to the facility in accordance with the house rules

3. Residents may practice the religion of their choice or freely abstain from religious practice

RECORDS

1. Residents records are maintained in a secure place

2. Confidentiality of residents' information is maintained. Records are disclosed only with residents' permission or as required by law.

3. Resident demographic information including emergency contact numbers is included in the chart

4. Individualized Plan of Care is present in the chart

5. Resident records include History and Physical, list of current medications, DNR (or state equivalent) Advanced Directives (if resident choose to complete) Progress Notes, Physician order to place veteran in Residential (e.g. VA forms 10-2406), patient agreement (VA form 2409 and sponsor agreement, (VA Form 2410), copies of resident's rights and house rules signed by the resident. Clearance from communicable disease as required by the State, e.g. TB Clearance

5. Copy of all signed agreements with the resident or resident’s fiduciary

6. A record of all financial transactions with the resident or the resident’s fiduciary

7. For state licensed facilities, a copy of the current license was obtained for VA records

8. For state licensed facilities, a copy of the annual state survey was obtained for VA records. Review survey and ensure deficiencies have been corrected.

9. Residents rights and contact information for the Ombudsman are posted

STAFF

1. Records of orientation, training and ongoing education are present for each staff person

2. Staff behavior and interaction with residents convey an attitude of concern and caring

3. General observation of residents indicates an acceptable level of personal hygiene and grooming

4. Staff is on duty 24 hours per day

5. Adequate staff is scheduled to provide care services based on the needs of current residents

6. State required clearance from communicable disease, e.g. TB Clearance

7. Criminal background checks indicating employee is cleared to work in residential care setting (Criminal background check regulations differ by state)

8. VA CRC Sponsor Guide was reviewed

OVERALL ASSESSMENT

Rating:

Excellent______ Satisfactory ______ Marginal:______ Unsatisfactory:______

COMMENTS:

Signature:____________________________________________________ Date:_____________________

Signature:____________________________________________________ Date:_____________________