| Date Visited | {date_visited} | ||
|---|---|---|---|
| Location | {location} | ||
| Coordinator | {coordinator} | ||
| Location Phone | {loc_phone} | ||
| # Of Ind | {no_of_ind} | ||
| # Of Staff | {no_of_staff} | ||
Exterior |
|||
Observations |
Yes/No |
Comments |
|
| Steps/Ramp Strips in Good Condition | {chk1} | {cmt1} | |
| Ramp Strips in Good Condition | {chk2} | {cmt2} | |
| Hand Rails Secure | {ck3} | {cmt3} | |
| Lawn Moved/Trees and Shrubs Trimmed | {chk4} | {cmt4} | |
| Cracked/Peeling Paint | {chk5} | {cmt5} | |
| Functional Windows with Screens | {chk6} | {cmt6} | |
| Downspouts/Gutters Affixed | {chk7} | {cmt7} | |
| Pavement in Good Condition | {chk8} | {cmt8} | |
| Outside Free of Trash/Debris | {chk9} | {cmt9} | |
Interior |
|||
| Wheelchair Accessible (If Applicable) | {chk10} | {cmt10} | |
| Adequate Living/Work Space | {chk11} | {cmt11} | |
| Thermostat set at 72 degrees | {chk12} | {cmt12} | |
| Room Clean and Free from Clutter | {chk13} | {cmt13} | |
| Free for Apparent Hazards | {chk14} | {cmt14} | |
| Home Odor Free | {chk15} | {cmt15} | |
| Proper Trash Storage/Disposal | {chk16} | {cmt16} | |
| Plumbing Working Properly | {chk17} | {cmt17} | |
| Carpet Clean / Floors | {chk18} | {cmt18} | |
| Adequate Cleaning Supplies | {chk19} | {cmt19} | |
| Furniture Reflects Individual's Choice | {chk20} | {cmt20} | |
| Decorations Reflect Individual's Choice | {chk21} | {cmt21} | |
| Adequate Lighting | {chk22} | {cmt22} | |
| Adequate Window Coverings | {chk23} | {cmt23} | |
| Dryer Trap Free From Lint | {chk24} | {cmt24} | |
| Wallls Free From Marks | {chk25} | {cmt25} | |
Kitchen |
|||
| Appliances Clean | {chk26} | {cmt26} | |
| Appliances in Working Order | {chk27} | {cmt27} | |
| Adequate Food | {chk28} | {cmt28} | |
| Proper Food Storage (Rotate for Date) | {chk29} | {cmt29} | |
| Food Reflects Diets | {chk30} | {cmt30} | |
| Proper Food Handling | {chk31} | {cmt31} | |
| Adequate Utensils/Dinnerware | {chk32} | {cmt32} | |
| Walls Free From Marks | {chk33} | {cmt33} | |
Master Bathroom |
|||
| Allows for Privacy | {chk34} | {cmt34} | |
| Soap/Towels/Paper | {chk35} | {cmt35} | |
| Cleanliness | {chk36} | {cmt36} | |
| Personalized | {chk37} | {cmt37} | |
| Proper Ventilation | {chk38} | {cmt38} | |
| Walls from Marks | {chk39} | {cmt39} | |
Other Bathroom |
|||
| Allows for Privacy | {chk40} | {cmt40} | |
| Soap/Towel/Toilet Paper | {chk41} | {cmt41} | |
| Cleanliness | {chk42} | {cmt42} | |
| Personalized | {chk43} | {cmt43} | |
| Proper Ventilation | {chk44} | {cmt44} | |
| Walls free from Marks | {chk45} | {cmt45} | |
Other Bathroom |
|||
| Allows for Privacy | {chk46} | {cmt46} | |
| Soal/Towels/Toilet Paper | {chk47} | {cmt47} | |
| Cleanliness | {chk48} | {cmt48} | |
| Personalized | {chk49} | {cmt49} | |
| Proper Ventilation | {chk50} | {cmt50} | |
| Walls Free From Marks | {chk51} | {cmt51} | |
Bedroom (Residential) |
|||
| Allows for Privacy | {chk52} | {cmt52} | |
| Adequate Closets/Storage | {chk53} | {cmt53} | |
| Personal Items Kept in Rooms | {chk54} | {cmt54} | |
| Trash Cans Available | {chk55} | {cmt55} | |
| Walls Free From Marks | {chk56} | {cmt56} | |
| Cleanliness | {chk57} | {cmt57} | |
Bedroom 2 (Residential) |
|||
| Allows for Privacy | {chk58} | {cmt58} | |
| Adequate Closets/Storage | {chk59} | {cmt59} | |
| Personal Items Kept in Rooms | {chk60} | {cmt60} | |
| Trash Cans Available | {chk61} | {cmt61} | |
| Walls Free from Marks | {chk62} | {cmt62} | |
| Cleanliness | {chk63} | {cmt63} | |
Bedroom 3 (Residential) |
|||
| Allows for Privacy | {chk64} | {cmt64} | |
| Adequate Closets/Storage | {chk65} | {cmt65} | |
| Personal Items Kept in Rooms | {chk66} | {cmt66} | |
| Trash Cans Available | {chk67} | {cmt67} | |
| Walls Free From Marks | {chk68} | {cmt68} | |
| Cleanliness | {chk69} | {cmt69} | |
Medical |
|||
| 45 Days Reviews | {chk70} | {cmt70} | |
| Ensure New Meds are in Place (if Applicable) | {chk71} | {cmt71} | |
| Are New/Existing PMOFs filled? Psych & Non Psych | {chk72} | {cmt72} | |
| Are all MARs filled out Completely? Documentation on reverse | {chk73} | {cmt73} | |
| Check PMOFs to Ensure they are filled out | {chk74} | {cmt74} | |
Individual's Personal Items |
|||
| Log Maintained | {chk75} | {cmt75} | |
| Present in the home | {chk76} | {cmt76} | |
| Good Condition | {chk77} | {cmt77} | |
Activity Logs |
|||
| Activity Noted Being done at visit | {chk78} | {cmt78} | |
Vehicle |
|||
| Mileage Log Completed up to date | {chk79} | {cmt79} | |
| Clean | {chk80} | {cmt80} | |
| Damage Present (is it old or new; location of damage) | {chk81} | {cmt81} | |
| Username | |||
| Ipaddress | |||