Ontario Central Forms Repository - Home Page
[pic]
|Ministry of Health
and Long-Term Care
Homes for Special Care
|Home for Special Care (HSC)
Licence Inspection Report
| |
|Instructions: |
|If space is insufficient, attach additional sheet. |
|Each section of the report must be completed. |
|Where there is non-compliance, compliance requirement and date must be included on report. |
|Do not use white out. |
|Changes to report need to be made prior to signatures and changes should be initialed by HSC Field Staff and Homeowner. |
|Report must be provided to Ministry of Health and Long-Term Care by December 31. |
|Copy of inspection report to be provided to licensed homeowner. |
|Name of Home |Home License Number |
| | |
|Address of Home |Telephone (incl. Area Code) |Licensed HSC Capacity |
| | | |
|Name of Licensed Homeowner |
| |
|Address of Licensed Homeowner |Telephone (incl. Area Code) |
| | |
|Name of Manager/Operator (if different from owner) |
| |
|Address of Manager/Operator |Telephone (incl. Area Code) |
| | |
|HSC Staff Conducting Review |HSC Office |Date of Inspection (yyyy/mm/dd) |
| | | |
|Who resides in the Home? Check appropriate boxes |
| Owner Manager/Operator Home Staff | Children’s Ages: | |/ | |/ | |
| Other (Specify) |
| |
|HSC Residents: |Other: (non-HSC Residents) |
| |Male |
|Accommodation Provided |
| | | | |
|Number of Bedrooms with One Tenant per Bedroom: | |Number of Bedrooms with Two Tenants per Bedroom: | |
| | | | |
|Number of Bedrooms with Three Tenants per Bedroom: | |Number of Bedrooms with Four Tenants per Bedroom : | |
| | |
|Other – Please describe: | |
| |
|Original – Ministry of Health and Long-Term Care; Copy – Homes for Special Care Office |
| HSC Licence Inspection Report |
|om4e |
|The following are to be reviewed when inspecting an HSC for licence purposes. |
| |
|YES = compliance and satisfactory NO = non-compliance and requires improvement/correction |
|Residential Environment |
|Physical Environment and Health and Safety Issues |
|Fire and Safety | N | Y | Compliance Requirements and Date | Notes |
|Does the Home have a fire safety plan in place | | | | |
|specifying Home Staff’s duties in the event of a fire?| | | | |
|Are monthly fire drills completed? | | | | |
|Are location of fire exits known to residents and Home| | | | |
|Staff? | | | | |
|Are hallways and stairways clear of debris and well | | | | |
|lit? | | | | |
|Bedrooms | N | Y | Compliance Requirements and Date | Notes |
|Are the tenants’ bedrooms located at or above the | | | | |
|ground floor? | | | | |
|Are bedrooms adequate in size? | | | | |
|(not less than 60 sq.ft./5.57m2 ) | | | | |
|Are the bedrooms adequately ventilated | | | | |
|and lit by natural light? | | | | |
|Is each bed placed so as not to overlap a window or | | | | |
|radiator, and at least 30” from another bed? | | | | |
|Do windows have appropriate coverings? | | | | |
|Do the tenants have access to their bedrooms at all | | | | |
|times? | | | | |
|Is the furniture sufficient for the number of tenants | | | | |
|in the room? | | | | |
|Are bedroom furniture, floors and mattresses clean and| | | | |
|in good repair? | | | | |
|Are bedrooms, including floors, vacuumed and cleaned | | | | |
|on a regular basis? | | | | |
|Are tenants permitted to decorate their bedrooms and | | | | |
|have they decorated them? | | | | |
|Rooms, Floors, Stairs, Landings | N | Y | Compliance Requirements and Date | Notes |
|Is there a common indoor sitting area provided with | | | | |
|24-hour access? | | | | |
|Is there a minimum of one television provided | | | | |
|for tenant’s use in the common area? | | | | |
|Is there adequate lighting in the common area? | | | | |
|Do the common and dining areas adequately accommodate | | | | |
|all of the tenants? | | | | |
| HSC Licence Inspection Report |
|om4e |
|Rooms, Floors, Stairs, Landings | N | Y | Compliance Requirements and Date | Notes |
|Are the common and dining areas and furniture clean | | | | |
|and in good repair (wallpaper, paint and flooring)? | | | | |
|Is the general environment of rooms bright and | | | | |
|cheerful? | | | | |
|Is the Home equipped with handrails on stairways, | | | | |
|non-skid finishes and coverings on floors and | | | | |
|stairways? | | | | |
|Is the Home free of faulty floors or missing treads on| | | | |
|stairs or loose carpeting, which could cause tripping,| | | | |
|or slipping? | | | | |
| | | | | |
|Sanitary Facilities | N | Y | Compliance Requirements and Date | Notes |
|Are all sanitary facilities working and in good | | | | |
|repair? | | | | |
|Do the tenants have 24-hour access to the bathrooms | | | | |
|and are they easily accessible with privacy? | | | | |
|Is every tub and shower facility furnished with grab | | | | |
|bars and slip resistant material that adheres to the | | | | |
|bottom of tub/shower? | | | | |
|Are wash basins, toilets, urinals, bath tubs and | | | | |
|shower stalls cleaned and sanitized once every day and| | | | |
|are wastebaskets emptied regularly? | | | | |
|Are residents provided with adequate supplies of | | | | |
|personal grooming/hygiene items? | | | | |
|Are hot water tanks set at 60 degrees Celsius (140 | | | | |
|degrees Fahrenheit) and the water temperature | | | | |
|controlled at fixture outlets/faucets controlled so | | | | |
|water temperature does not exceed 49 degrees Celsius | | | | |
|(120.2 degrees Fahrenheit)? | | | | |
|Is the ratio of tenant use to basins, tubs and toilets| | | | |
|sufficient to meet the needs of the tenants (1 flush | | | | |
|toilet/6 tenants; 1 bath tub or shower for every 12 | | | | |
|tenants)? | | | | |
|Towels, Linens, Laundry | N | Y | Compliance Requirements and Date | Notes |
|Are there sufficient clean towels, washcloths and bed | | | | |
|linens available to all tenants and are these changed | | | | |
|at lease once per week? | | | | |
|Are laundry receptacles for soiled laundry | | | | |
|provided? | | | | |
|Are laundry services provided to the tenants? | | | | |
|Is there access to the washer, dryer, iron and ironing| | | | |
|board and laundry supplies for those tenants who | | | | |
|choose and are able to do their own laundry? | | | | |
|Is the laundry equipment clean and in good working | | | | |
|order? | | | | |
| HSC Licence Inspection Report |
|om4e |
|Windows, Ventilation, Lighting, Heating | N | Y | Compliance Requirements and Date | Notes |
|Is there adequate ventilation in all rooms to minimize| | | | |
|excess heat and odours? | | | | |
|Is the home in compliance with the Smoke-Free Ontario | | | | |
|Act? (i.e. Home to be smoke free unless there is a | | | | |
|controlled smoking area in the home which has been | | | | |
|approved by the Ministry of Health and Long-Term | | | | |
|Care.) | | | | |
|Do all windows that open have an attached | | | | |
|screen in proper working order and coverings | | | | |
|(i.e. shades, blinds and curtains)? | | | | |
|Is adequate lighting provided throughout the Home’s | | | | |
|hallways, stairways, landings, and ramps and at all | | | | |
|entrances and exits? | | | | |
|Is the temperature of the Home kept comfortable (i.e. | | | | |
|minimum 21 C [69.8F] in winter and at least one air | | | | |
|conditioned room in periods of extreme heat in | | | | |
|summer)? | | | | |
|Kitchen Facilities/Food Preparation | N | Y | Compliance Requirements and Date | Notes |
|Are kitchen countertops and other food preparation | | | | |
|surfaces kept clean? | | | | |
|Are the eating and cooking utensils clean and in good | | | | |
|condition (i.e. no cracked or chipped dishes)? | | | | |
|Are Home Staff knowledgeable in food preparation? | | | | |
|Is a satisfactory standard of dishwashing used? | | | | |
|Are separate cutting boards used? (1 for raw | | | | |
|meats, seafood, 2nd for poultry and turkey | | | | |
|and 3rd for raw fruits and vegetables)? | | | | |
|Are there adequate kitchen equipment, supplies and | | | | |
|food storage area? | | | | |
|Are cleaning, toxic and hazardous materials stored | | | | |
|separately from supplies and clearly labelled? | | | | |
|Are there convenient hand washing facilities provided | | | | |
|in or near the kitchen and are clean hand towels and | | | | |
|napkins provided? | | | | |
|Are perishable foods refrigerated as required? | | | | |
|Garbage Receptacles, Screening | N | Y | Compliance Requirements and Date | Notes |
|Is all garbage contained in receptacles that are | | | | |
|covered with tight-fitting lids? | | | | |
|Are the premises adequately protected | | | | |
|And screened against rodents, flies and | | | | |
|other pests? | | | | |
|Outdoor Area | N | Y | Compliance Requirements and Date | Notes |
|Is the outdoor area of the Home well maintained, free | | | | |
|of debris and in good repair? | | | | |
|Is an outdoor seating area for seasonal use provided | | | | |
|which is comfortable and adequate for the number of | | | | |
|tenants in the Home? | | | | |
| HSC Licence Inspection Report |
|om4e |
|General Health |
|Nutrition | N | Y | Compliance Requirements and Date | Notes |
|Does the meal plan meet the “recommended daily intake”| | | | |
|for energy essential nutrients as stated in Canada’s | | | | |
|Food Guide, including the availability of fresh fruits| | | | |
|and vegetables? | | | | |
|Are adequate portions and variety of foods provided | | | | |
|(according to individual needs)? | | | | |
|Are tenants consulted during meal planning? | | | | |
|Are special diets provided (i.e. cultural, physician | | | | |
|ordered and preferences)? | | | | |
|Are meals provided on a flexible time schedule? | | | | |
|Are nutritional snacks provided for tenants? | | | | |
|Are packed lunches or late meals provided or saved for| | | | |
|tenants when advanced notice is given? | | | | |
|Are menus posted? | | | | |
|Personal Care | N | Y | Compliance Requirements and Date | Notes |
|Are tenants who require assistance, assisted with | | | | |
|personal care (i.e. hygiene and grooming)? | | | | |
|Is information and teaching about personal care | | | | |
|available for residents? | | | | |
|Are tenants provided with the opportunity to | | | | |
|individually purchase clothing? | | | | |
|Medical/Dental Care | N | Y | Compliance Requirements and Date | Notes |
|Do tenants have personal physicians? | | | | |
|Do tenants receive yearly physical examinations? | | | | |
|Do Home Staff handle emergency situations in a timely | | | | |
|and appropriate manner (i.e. contact relevant people)?| | | | |
|Do tenants get regular dental care? | | | | |
|Medication | N | Y | Compliance Requirements and Date | Notes |
|Is medication stored in a locked cabinet? | | | | |
|Does the Home have an appropriate system | | | | |
|of medication management (i.e. blister packs | | | | |
|and MAR sheets)? | | | | |
|Does the Home maintain a list of contents for drug | | | | |
|cabinets and update them on a regular basis (weekly)? | | | | |
|Does the Home Owner/Home Staff monitor and report | | | | |
|noted unusual behaviour possibly linked to side | | | | |
|effects of medication? | | | | |
| HSC Licence Inspection Report |
|om4e |
|Communicable Diseases | N | Y | Compliance Requirements and Date | Notes |
|Does the Home use routine practices | | | | |
|(infection control precautions) to promote | | | | |
|infection control? | | | | |
|Emergency Care | N | Y | Compliance Requirements and Date | Notes |
|Does the Home have appropriate procedures in place to | | | | |
|respond to emergency care situations? | | | | |
|Are Home Staff trained in first aid measures and CPR | | | | |
|available at all times in the home? | | | | |
|Are tenants familiar with emergency procedures? | | | | |
|Are first aid kits available and updated on a regular | | | | |
|basis? | | | | |
|Tenant Lifestyles |
|Race and Culture, Religious Expression, Sexuality | N | Y | Compliance Requirements and Date | Notes |
|Are tenants’ rights regarding race, culture, religion | | | | |
|and sexuality respected by the Homeowner/Home Staff? | | | | |
|Privacy | N | Y | Compliance Requirements and Date | Notes |
|Are tenants’ rights respected and promoted (i.e. | | | | |
|privacy in bedrooms, to visit with visitors, unopened | | | | |
|mail, and private telephone calls)? | | | | |
|Is the home accessible to tenants on a | | | | |
|24 hour basis? | | | | |
|Are tenants free to enter and leave the Home at their | | | | |
|choosing? | | | | |
|Is there an organized forum available for tenants to | | | | |
|raise concerns (i.e. house meeting)? | | | | |
|Daily Living |
|Life Skills, Social and Recreational Programs |
|In-Home Living Activities | N | Y | Compliance Requirements and Date | Notes |
|Does the Home provide adequate/appropriate in-home | | | | |
|activities? | | | | |
|Do tenants have an opportunity to participate in the | | | | |
|development of life skills within the home? | | | | |
|Activity Programs in the Community | N | Y | Compliance Requirements and Date | Notes |
|Does the Homeowner/Home staff assist the tenant in | | | | |
|participating in community activities (i.e. fitness, | | | | |
|community programs)? | | | | |
|Tenants’ Spending Money | N | Y | Compliance Requirements and Date | Notes |
|Are tenants aware of their financial status and | | | | |
|matters of estate? | | | | |
|Does the Home maintain appropriate books | | | | |
|and records for those tenants who are | | | | |
|assisted with their spending money? | | | | |
| HSC Licence Inspection Report |
|om4e |
|Administration |
|Staffing |
|List the names of Home Staff: |
| |
|Staffing | N | Y | Compliance Requirements and Date | Notes |
|Is there Home Staff on duty 24 hours a day? | | | | |
|Is tenant supervision satisfactory to meet tenant | | | | |
|needs with current staffing level? | | | | |
|Is the local HSC office informed prior to staff | | | | |
|changes and criminal reference checks (CPICs) acquired| | | | |
|for all new staff? | | | | |
|Is there appropriate and satisfactory communication | | | | |
|between the Home Staff and residents and HSC Field | | | | |
|Staff? | | | | |
|Are Home Staff adequately supervised? | | | | |
|Is job orientation and relevant training provided for | | | | |
|all home staff? | | | | |
|Licensing | N | Y | Compliance Requirements and Date | Notes |
|Are fire inspections completed and provided to HSC | | | | |
|Field Office by Nov. 15 of each year? | | | | |
|Does the homeowner report to have adequate insurance | | | | |
|as set out in the Operating Guidelines for HSC? | | | | |
|Does the homeowner report to have CPICs (including | | | | |
|vulnerable sector screening) for him/herself, spouse, | | | | |
|and any person the homeowner has in the home who has | | | | |
|unsupervised access to tenants? Are CPICs updated on | | | | |
|a 3 year cycle? | | | | |
|Records, Confidentiality, Conflicts, Conflict | N | Y | Compliance Requirements and Date | Notes |
|Resolution | | | | |
|Does the Home Owner keep appropriate records as per | | | | |
|the Operating Guidelines for HSC? | | | | |
|Are documents and records pertaining to tenants stored| | | | |
|in a locked and secure cabinet? | | | | |
|Does homeowner/home staff understand confidentiality | | | | |
|requirements and consents? | | | | |
|Are there written/verbal complaint procedures in place| | | | |
|in the home? | | | | |
|Is homeowner/home staff free of conflicts of interest | | | | |
|as set out in the Operating Guidelines for HSC? | | | | |
| HSC Licence Inspection Report |
|om4e |
|Reporting Requirements | N | Y | Compliance Requirements and Date | Notes |
|Does the home have procedures for serious | | | | |
|incidents/occurrences (including notifying police)? | | | | |
|Does the homeowner report all serious incidents in | | | | |
|time (within 24 hours)? | | | | |
|Emergencies |
|Abuse and Neglect | N | Y | Compliance Requirements and Date | Notes |
|Does the homeowner provide a home environment free | | | | |
|from emotional, physical, financial, verbal or sexual | | | | |
|abuse? | | | | |
|Does the homeowner ensure that each tenant is not | | | | |
|subject to neglect and is provided with necessary | | | | |
|food, clothing, services, care and assistance required| | | | |
|for health and safety and well-being? | | | | |
|General |
|Does the homeowner/home staff show an understanding of| | | | |
|the Operating Guidelines for HCS and requirements of | | | | |
|the HSC program? | | | | |
|Does the homeowner have a copy of, or access to, the | | | | |
|Operating Guidelines for HSC, including appendices? | | | | |
| |
|Instructions |
|Once inspection report is completed, it must be signed by the homeowner and HSC field staff. |
|Licence recommendations can only be made once areas of non-compliance have been rectified. |
|This report have been reviewed by: |
|Signature of Homeowner |Print Name of Homeowner |
|x | |
|Date (yyyy/mm/dd) |
| |
|Comments of Homeowner |
| |
|Signature of HSC Field Staff |Print Name of HSC Field Staff |
|x | |
|Signature of HSC Field Staff |Print Name of HSC Field Staff |
|x | |
|Comments of HSC Field Staff |
| |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- school home page elementary
- xfinity home page install
- xfinity home page internet explorer
- fwisd home page for students
- xfinity home page or homepage
- xfinity home page and toolbar
- xfinity home page install for windows 10
- xfinity comcast home page website
- xfinity home page official windows 10
- comcast home page official site
- make xfinity my home page windows 10
- comcast xfinity home page email