This form is completed monthly by the Treatment Director or designee. Repairs for any items marked “no” are addressed in the corrective action plan. These forms are kept in a binder in the office for review by on-site team. Copy is sent to QI Department monthly.
Division -- Northern Kentucky South Bend Cincinnati DRC Columbia Las Vegas Columbus/Groveport Montgomery Shelter Services Oklahoma City Huntsville Cleveland Louisville Lawton SAFY Behavioral Health Charleston Lexington Somerset Arlington Findlay/Lima Muncie Dayton Birmingham Tiffin Sidney Greenville Canton/Akron Ft. Wayne Merrillville AMERICA RANCHO DRIVE PATRICK LANE DCR DESERT COTTAGE
Month Being Reported -- January February March April May June July August September October November December
Choose YES if issues are reported, otherwise choose NO. -- Yes No
Windows are in good repair, i.e., no broken glass, deterioration, or not shutting properly? -- Yes No
Spouting is in good repair, i.e., no dislocation, leaks or rust? -- Yes No
Doors and locks are secure and functioning? -- Yes No
Steps/sidewalk, rails are in good repair, i.e., no cracks/trips, points or looseness? -- Yes No
Roof does not have missing shingles, sags or leaks? -- Yes No
Wiring is in good repair, i.e., no bare wires/corrosion/or past burn marks? -- Yes No
Parking area is clean and available for use? -- Yes No
The exterior lights are in working condition? -- Yes No
Exterior signs are visible with no signs of deterioration? -- Yes No
Grass/landscaping has proper upkeep? -- Yes No
Storage areas have no unusual accumulation? -- Yes No
Trash area is neat and not overflowing? -- Yes No
Electric outlets have no open wiring? -- Yes No
Extension cords are not in use? -- Yes No
Cords (i.e. network cords, appliance, phone, etc) are kept in a manner that do not present a hazard to the flow of traffic in each room -- Yes No
Doors/locks/panic bars are in place where appropriate? -- Yes No
Stairs/railing/lighting are not loose and are in working condition? -- Yes No
Electrical appliances and wiring are in good condition? -- Yes No
Hot water temperature is not a hazard? -- Yes No
Heating and cooling equipment is operational? -- Yes No
Fire extinguishers are available for use, and have had an annual inspection? -- Yes No
Smoke alarms/detectors are operational with good batteries? -- Yes No
Exit lighting works? -- Yes No
Lighting fixtures have working bulbs and safe wire connections? -- Yes No
Kitchen equipment is safe and clean? -- Yes No
Closet and storage areas, hallways and stairways are free from clutter? -- Yes No
Stairs have secure handrails? -- Yes No
Glass doors are marked to prevent injury? -- Yes No
All owned property and furnishings are in good repair status? -- Yes No
Date of latest fire drill:
Are office fire drills conducted quarterly? -- Yes No
First aid supplies have been inventoried and are adequate? -- Yes No
First aid manuals are available? -- Yes No
Each file cabinet for client & foster parent files has working lock? -- Yes No
The DOM backs up her computer each Friday with a USB Flash Drive or USB external drive. The device is stored in a locked secured area in the Divisional office similar to the client/foster parent files or petty cash. -- Yes No
Corrective action plan for items addressed as no.
Person Completing Form
TD/Supervisor Signature
Inspection Date