10-20-16 corrections made

SELF INSPECTION – AGENCY
FINAL SCORE: / %
Corrective Action Plans are due for scores of 93% and below
Program Site: / Date:
Shift: First Second Third / Inspected by:
A: OUTSIDE
(Condition & Safety) / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
A 1. Address/name - visible from street
A 2. Exterior lights – flood/porch/side of building
A 3. Do doors lock with an outside key
A 4. Windows/screens - on windows that open
A 5. Exterior building and yard in good repair, free from hazards/refuse/litter, and environmentally safe.
A 6. Doorbell/knocker –can be heard inside
A 7. Security system – working (if applicable)
A 8. Door and top of dumpster closed / Trash receptacles lined and covered
A 9. Smoking receptacles – where appropriate (outside of front door at all sites and at designated smoking areas only)
B: INSIDE
(General Cleanliness & Safety) / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
B 1. General interior housekeeping good (free of dust build up and spills) This includes all rooms of the site
(Furniture, walls, ceilings, floors, windows, ceiling fans and lights, etc.)
B 2. Stairways/railings – secure and in good repair
B 3. Hallways – free of obstacles
B 4. Telephone – one private non-pay (Stabilization Unit and Hartmann sites)
B 5. Fireproof trash cans – available and clean
(Rubbermaid OK)
B 6. Washer / Dryer area clean inside including lint trap, behind and around appliances
B 7. Children toys in child care sites – cleaning checklist done
B 8. The monthly fire extinguisher and emergency/exit light logs completed.
B 9. All electrical outlets are covered and electrical cords not exposed to cause tripping.
B 10. Any electrical cord or any cord exposed to traffic is securely taped with duct tape
Page 1 Totals
C: CLEANING SUPPLIES
(Use and Storage) / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
C 1. Approved cleaning supplies/chemicals – in original container. Bleach safety instructions must be kept near bottle of bleach
C 2. Cleaning supplies/chemicals not stored with food items. Locked when not in use, including items under sinks and in wash/dryer areas where children are present
C 3. Supplies stored (6) inches off floor and (18) inches from ceiling
D: BATHROOMS / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
D 1. Cleaned and disinfected
D 2. Handicap accessible – at least one
D 3. Hand washing sign posted near the sink
D4 Toilet paper, paper towels, tissues and liquid soap available (exposed bar soap is not permitted unless in private bathroom)
D5 Toilet paper rolls and paper towels on dispenser and not found on sinks, toilet lids or floor
E: KITCHEN/BREAK AREAS / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
E 1. Sinks, counter tops, appliances clean and odor free
E 2. No dirty dishes in sink
E 3. Paper towels available on a dispenser
E 4. Plastic cutting boards only
E 5. Thermometer (1) in refrigerator and (1) in freezer with checklist posted (refrigerator between 34 and 41 degrees; freezer 0 to 10 degrees) Temps checked daily
E 6. Microwave cleaned inside and out, including ceiling;, toaster free of crumbs and clean
E 7. No toaster oven on site?
E 8. Inside of the refrigerator(s) and freezer (s) is clean without spilled liquids and freezer defrosted
E 9. Sinks, counter tops, appliances clean and odor free
E 10. Open staple food and single-use items / supply items separated and placed in a covered and dated container (this includes ketchup, mustard, mayo, hot sauce, seasonings, - etc.) Please check boxes for expiration dates.
Page 2 Totals
F. FIRE/SAFETY/DISASTER / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
F 1. AM/FM radio, smoke detectors, weather radio, and flash lights working with battery back-up- Batteries changed, dated and initialed on each item with tape twice a year in Spring and Fall
F 2. Fire Extinguisher(s) are fully charged, pin in place and extinguisher tag is current
F 3. First aid kit and personal protective equipment available and not behind locked door
F 4. Flashlights (2) available
F 5. Exits lights have all letters lit and are clearly marked. Emergency lights work when tested for 30 seconds and are clearly marked. Emergency Light Log is completed monthly
F 6. Smoke detectors installed near and near kitchen areas and in other locations as necessary, and are dated, labeled and working
F 7. There are “No smoking” signs posted in appropriate places. Especially at front doors
G. REQUIRED POSTINGS / MANUALS / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
G.1. MSDS binder and sheets on site –
(Check below the MSDS binder(s) at site)
_____Agency ______Family Dollar ______Art
G.2. Emergency evacuation plan with utilities cut-off present (water, gas, electric) Outside designated area is clearly posted on evacuation plan and the inside evacuation place highlighted and marked
G.3. Emergency Phone Tree at least one per site and updated quarterly (Jul, Nov, Mar, and June)
G.4. Emergency Phone List is placed at the front desk phone and at other office phones
G.5. Licenses – business with occupancy (if applicable at site) posted on wall
G.6. Abuse reporting (if applicable)
G.7. Healthcare Facility Regulation Inspection report posted on wall (if applicable)
G.8. Program rules (if applicable)
G.9 Ombudsman information
G.10. Complaint and grievance information for clients, family, etc. posted
G.11. Door signs (microwave, weapons, no smoking, HIPPA, sign in, no soliciting) posted at front entrance
Page 3 Totals
H. ITEMS KEPT IN THE RED SAFETY NOTEBOOK: / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
H 1. Emergency/Disaster drill completed quarterly for day sites and monthly for 24/7 sites (different shift each month)
H 2. Fire drill report completed monthly for all sites
H 3. Fire Marshall report with accurate annual year
H 4. Refrigerator/freezer cleaning checklist
H 5. EOC Self Inspection – AGENCY checklist
H 6. Toy disinfectant checklist – child care sites only
H 7. Water temperature checklist -child care sites
I: NURSING OFFICE / TREATMENT ROOM / YES / NO / N/A / Needs Repair / Comments or
Date Work Order Submitted
I 1. Locked when not in use
I 2. Sink/counter - clean-hand washing sign near sink, approved liquid anti-bacterial soap present or approved hand sanitizer, paper towels and tissues available
I 3. Exam table has clean paper
I 4. Gloves present
I 5. Thermometer / otoscope with disposable covers (if applicable)
I 6. Cotton balls/tongue depressors in covered containers
I 7. Biohazard Container - labeled with biohazard sign and not stored with clean items
I 8. Covered trash can available.
I 9. Client standard precaution sheet posted.
I 10. Medication / vaccine refrigerator has “NO FOOD” sign posted on front. A vaccine refrigerator checklist with daily temperature readings to be completed when medication is present (vaccine stored at 34-41 degrees F.)
I 11. Specimen refrigerator has a sign posted stating “specimens only”
Page 4 Totals
Totals from previous pages / # YES / #NO / # N/A
Page 4 Totals
Page 3 Totals
Page 2 Totals
Page 1 Totals
TOTAL
PERCENTAGE TO POST ON PAGE 1

WORKSHEET
# yes ÷ (no + yes) = %

Example below

#yes 35 yes = 35

# no + yes + 5 no and 35 yes = 40 = 35 ÷ 40 = 88%

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