Loc Name

Doc Date

Coordinator

MEDICATION/CABINET

Medication stored in separate bins for each individual

Medication bins labeled properly

Pills administered initialed on blister pack

Liquids and other bulk medications properly labeled

DCed/Expired medication removed from individual medication bins

New medications and all PRNs accompanied with PMOF

Cabinet neat, organized and devoid of items not belonging to it

Controlled drugs under double lock

Controlled drug count sheet signed and accurate by previous shift staff

All missing pills from controlled drug accounted for

Medication cabinet neat and well organized

First Aid kit with enough supplies and with no item missing

CPR Guard, thermometer/other assigned equipments in cabinet

Blood pressure machine in working condition

Finger-stick machine work; diabetic supply adequate (if applicable)

Medical supply fitting for individual needs adequate

MEDICATION

MARs neat, stapled together with all binder rings intact

All physician orders current, signed and dated

All medications entered on MARs as seen in PMOFs & approved by RN

All medication labels including Rx #s match physician orders and MAR

All documentation in accordance with PMOFs & MTTP policies

Medication errors/omissions explanations, RN notification documented

All pills missing from bubble pack accounted for on MAR

PRN/Stat (one time only) medication recorded correctly

Medication cabinet locked and key handed over

BP, pulse, blood sugar, weight etc documented as indicated (if app.)

OTHER

Seizure Chart updated (if applicable)

Fluid/BM/positioning (if app.)/menstrual (if app.) charts updated

Nurse Contact Logs checked for proper notification of RN as needed

All verbally reported incidents properly documented/signed by staff

Weight recorded for all consumers as indicated

Activity schedule and Emergency Contact List current

All menus updated to reflect current week

Food supply appropriate per menus and adequate for at least 3 days

Medical appointments (brown packet) thoroughly reviewed and instructions passed on

All monies, receipts and other valuables handed over properly (if app.)

All keys, including medication cabinet keys received by incoming staff

All individuals accounted for, free of injury/complains, well dressed & well groomed

INDIVIDUALS

All individual belongings accounted for, have adequate personal need supplies

Individuals have adequate seasonal clothing/footwear/linen/towels/hygiene supplies

Individual rooms/bathrooms/closets/cabinets/dressers clean and orderly

Copy of Current IP/BP (if applicable) with up to date data sheets present

Behavioral incidents (if applicable) verbally reported to authority and written report made

Evidence of implementation of IP goals and BP (if applicable) present

HOME/ENVIRONMENT

All areas of ALU/floor/carpet/appliances/cabinets etc. clean, neat and orderly

Smoke detectors/carbon monoxide detectors/security systems in working order

Fire extinguisher tag current/monthly fire drill done before due date

Water thermometer (notify supervisor if temperature > 110o)

ALU free of lice wires/holes in walls/broken furniture and other safety hazards

Water thermometer/vacuum cleaner/kitchen appliances/washer-dryer working

All lights including bedroom lamps working

Any/all existing maintenance need reported

Cleaning/laundry supplies adequate;cooking utensils in good condtion

Over (inside & outside)/stove top clean; kitchen sink free of utensils, dishes

All crockery & cutlery in complete sets and all other small items accounted for

All furniture intact (tables & chairs with no loose legs) & arranged tastefully

Hoyer lift/other common equipments (if applicable) in working condition

Enough walk space between furniture and room free of fall hazard

All household chores completed for the shift

VEHCILES

Vehicle parked in assigned location with/club lock on (unless in authorized use)

Vehicle policy/registration/first aid kit in the glove compartment

Vehicle free of unreported damage including minor scrapes/scratches

Vehicle clean & neat and free of stains/spills etc. seat belts working

Mileage accurately documented and is comparable with approved activities

Vehicle keys/mileage log book taken by incoming staff