| Original Work Location |
{loc_name} |
| Temporary Work Location |
{ReportLabel2} |
| Document Date |
{doc_date} |
| Coordinator |
{coordinator} |
| Medication stored in separate bins for each individual |
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| Medication bins labeled properly |
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| Pills administered initialed on blister pack |
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| Liquids and other bulk medications properly labeled |
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| DCed/Expired medication removed from individual medication bins |
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| New medications and all PRNs accompanied with PMOF |
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| Cabinet neat, organized and devoid of items not belonging to it |
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| Controlled drugs under double lock |
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| Controlled drug count sheet signed and accurate by previous shift staff |
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| All missing pills from controlled drug accounted for |
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| Medication cabinet neat and well organized |
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| First Aid kit with enough supplies and with no item missing |
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| CPR Guard, thermometer/other assigned equipments in cabinet |
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| Blood pressure machine in working condition |
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| Finger-stick machine work; diabetic supply adequate (if applicable) |
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| Medical supply fitting for individual needs adequate |
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| MARs neat, stapled together with all binder rings intact |
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| All physician orders current, signed and dated |
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| All medications entered on MARs as seen in PMOFs & approved by RN |
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| All medication labels including Rx #s match physician orders and MAR |
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| All documentation in accordance with PMOFs & MTTP policies |
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| Medication errors/omissions explanations, RN notification documented |
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| All pills missing from bubble pack accounted for on MAR |
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| PRN/Stat (one time only) medication recorded correctly |
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| Medication cabinet locked and key handed over |
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| BP, pulse, blood sugar, weight etc documented as indicated (if app.) |
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| Seizure Chart updated (if applicable) |
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| Fluid/BM/positioning (if app.)/menstrual (if app.) charts updated |
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| Nurse Contact Logs checked for proper notification of RN as needed |
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| All verbally reported incidents properly documented/signed by staff |
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| Weight recorded for all consumers as indicated |
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| Activity schedule and Emergency Contact List current |
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| All menus updated to reflect current week |
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| Food supply appropriate per menus and adequate for at least 3 days |
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| Medical appointments (brown packet) thoroughly reviewed and instructions passed on |
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| All monies, receipts and other valuables handed over properly (if app.) |
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| All keys, including medication cabinet keys received by incoming staff |
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| All individuals accounted for, free of injury/complains, well dressed & well groomed |
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| All individual belongings accounted for, have adequate personal need supplies |
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| Individuals have adequate seasonal clothing/footwear/linen/towels/hygiene supplies |
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| Individual rooms/bathrooms/closets/cabinets/dressers clean and orderly |
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| Copy of Current IP/BP (if applicable) with up to date data sheets present |
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| Behavioral incidents (if applicable) verbally reported to authority and written report made |
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| Evidence of implementation of IP goals and BP (if applicable) present |
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| All areas of ALU/floor/carpet/appliances/cabinets etc. clean, neat and orderly |
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| Smoke detectors/carbon monoxide detectors/security systems in working order |
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| Fire extinguisher tag current/monthly fire drill done before due date |
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| Water thermometer (notify supervisor if temperature > 110 ?) |
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| ALU free of lice wires/holes in walls/broken furniture and other safety hazards |
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| Water thermometer/vacuum cleaner/kitchen appliances/washer-dryer working |
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| All lights including bedroom lamps working |
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| Any/all existing maintenance need reported |
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| Cleaning/laundry supplies adequate;cooking utensils in good condtion |
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| Over (inside & outside)/stove top clean; kitchen sink free of utensils, dishes |
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| All crockery & cutlery in complete sets and all other small items accounted for |
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| All furniture intact (tables & chairs with no loose legs) & arranged tastefully |
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| Hoyer lift/other common equipments (if applicable) in working condition |
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| Enough walk space between furniture and room free of fall hazard |
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| All household chores completed for the shift |
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| Vehicle parked in assigned location with/club lock on (unless in authorized use) |
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| Vehicle policy/registration/first aid kit in the glove compartment |
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| Vehicle free of unreported damage including minor scrapes/scratches |
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| Vehicle clean & neat and free of stains/spills etc. seat belts working |
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| Mileage accurately documented and is comparable with approved activities |
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| Vehicle keys/mileage log book taken by incoming staff |
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| No records |
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