36C24418Q0128-004.docx

Community Residential Care Nursing Inspection Report

Date of Evaluation:____________________ Type of Evaluation: Initial_______ Re-Evaluation________ Name of Home:______________________________________________Phone:_______________________ Address: ___________________________________City:__________________ State:______ Zip:_______ Names (s) of the Sponsor (s):________________________________________________________________ State License Information:__________________________________________________________________

PROVIDERS/SPONSOR HAVE SKILLS AND ABILITY TO

1. Provide personal care

2. Provide emotional/supportive care

3. Manage medications including refills

4. Protect resident’s privacy

5. Protect resident’s confidentiality

6. Identify changes in medical condition and able to make appropriate contact to address these changes

7. Maintain record of resident’s medical problems and allergies

8. Provide transportation to needed medical appointments

9. Provide necessary nursing care and first aid

STAFF

1. Facility employees RN and license is current

2. Facility employees LPN/LVN and license is current

3. Facility employees Certified Nurses Aids and licenses are current

4. Facility staff who pass medications are trained / certified

5. Facility staff who pass medications have Nursing delegation

6. Facility staff receive orientation and on going education in patient care

MEDICATIONS

1. Locked area for medications

2. Medications stored in original containers

3. Self administration policy

4. Residents who self administer medications have MD approval

5. Residents who self administer medications have locked storage area and rooms have been inspected to ensure meds are secured in locker

6. OTC medications are used in accordance to VA and State policy

7. OTC medications are kept in medication room and uses is documented

8. Medications needing refrigeration are in separate refrigerator or in a marked container in the kitchen refrigerator

9. Refrigerator is clean

10. Refrigerator temperature is at or below 40 degrees F

11. Medication records includes doses given or missed & why

12. MD orders in place for all medications

13. PRN medications are recorded and effectiveness noted

14. Psychoactive prescription, administration and reassessment meets state standards

15. Policy implemented for disposal of discontinued & expired meds

16. Policy implemented to prevent diversion of controlled drugs

17. Provision is made to ensure safety of mailed medications

18. Needles and sharps are properly disposed

EMERGENCY SITUATIONS

1. Emergency numbers posted both local and family

2. Staff able to provide basic first aid

3. Staff able to perform CPR

4. Staff able to perform Heimlich maneuver

5. First aid manual is available to staff at all times?

6. First aid supplies are maintained and available to staff at all times

INFECTION CONTROL

1. Universal precautions are used at all times

2. Proper hand washing methods are in evidence

3. Immunization for pneumonia

4. Facility ensures residents are offered and receive Annual Flu Shots

5. TB screening of staff

6. Pet immunization records are available

7. TB screening of residents

OVERALL ASSESSMENT

Rating: Excellent _____ Satisfactory:______ Marginal:______ Unsatisfactory:______

COMMENTS:

Signature:____________________________________________________ Date:_____________________