Choose YES if issues reported, otherwise choose NO. -- Yes No
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
Quarter -- 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
This form is completed quarterly by the assigned QI Assistant. Repairs for any items marked "no" are addressed in the corrective action plan. These forms are kept in a binder in the office. Copy is sent to QI Department quarterly upon completion.
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
Hazardous materials containers labeled appropriately? Does office staff have access to MSDS sheets? -- 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
Master key list completed and current? -- Yes No
Kitchen equipment is safe, clean and in good working order? -- Yes No
Closet and storage areas, hallways and stairways are free from clutter preventing entry? -- Yes No
Furnace rooms are not used for storage of paper goods, files, or combustible materials? -- Yes No
Materials are stored with at least 18” clearance from any ceilings or sprinkler heads? -- Yes No
Stairs have secure handrails? -- Yes No
The facility is cleaned at least twice per week? -- Yes No
Glass doors are marked to prevent injury? -- Yes No
All 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 readily available and visible? -- Yes No
Designated safe area(s) designated by signage? -- Yes No
Visitor sign-in sheets used? -- Yes No
Each file cabinet for client & foster parent files has working lock and in a secure location? -- Yes No
Files signed out when removed from file room? -- 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
Fax machines and printers kept in secured location? -- Yes No
Confidential information kept secure (files, paperwork, computer screens)? -- Yes No
Smoking is prohibited in offices and on the premises -- Yes No
If toys are provided in office or play area, they are clean, and in safe working order -- Yes No
Hand-washing signs are posted in all restrooms -- Yes No
Corrective action plan for any item addressed as “no”:
Date Corrective Action Completed:
Person Completing Form
TD/Supervisor Signature
Inspection Date