INSPECTION CHECK-LIST



INSPECTION CHECK-LIST

This form is a compilation of topics and areas of focus during a re-inspection. It can be used to perform a “mock” inspection, or to focus on certain areas that require close attention.

By following this checklist and using the state forms (“attachments”), you and/or a designated staff person can effectively take note of concerns in your building, and implement changes to address those concerns.

Be sure to utilize the three forms of data gathering: observation, interview, and record review.

OBSERVATION: Many concerns can be brought to your attention through simply watching and listening. Observe staff-resident interactions, handwashing and personal care, medication assistances/administration, activities, environmental issues, food preparation and handling, etc.

INTERVIEW: Interviews with staff, residents, volunteers, and resident family members can serve as a surfacing agent for many issues. By talking with staff and volunteers about policies, mandatory reporting, disaster preparedness, job duties and expectations, frustrations and general concerns, you can gather ideas to improve work practice, implement training opportunities, or clarify confusion. By talking with residents and their family members about living arrangements, activities, safety, privacy and resident rights, food service, and a host of other topics, you can discover their frustration(s), satisfaction, and ideas for improvement.

RECORD REVIEW: Although record review is not an emphasis of the inspection process, it is important nonetheless. It is imperative that observation and interview information matches recorded data (i.e., if a resident refused his/her medication this morning, the medication administration record should reflect this refusal). Furthermore, dated materials (such as the resident assessment, service agreement, staff training information) must be updated and maintained current in order to ensure accurate and timely information.

METHODS TO DO A “MOCK” INSPECTION:

• It is ideal if you have 2 to 3 participants. Break up the tasks and follow the state licensor’s inspection process. Share issues with the entire team, and plan on methods to correct any “deficiencies.”

• Choose certain areas of the inspection that are of particular concern to you (i.e., if your building was cited particularly heavy in the food service area, focus your efforts there) and follow through. You can “break up” the inspection into bite-size pieces by focusing on one topic per day, per week, etc.

• Swap buildings – have a nearby boarding home conduct a mock inspection on your facility, and vice versa. That way, your staff may be “more on their toes” if they think the inspection is a real one.

• Think like and investigator. If you see something that concerns you, dig deeper. For example, if you observe a resident expressing an aggressive behavior, look at the resident’s service agreement to see if it is addressed there. If it is, did the staff respond to the resident based on information in the service agreement?

|FOCUS |YES |NO |COMMENTS |

| | | | |

|TOUR | | | |

|Quality of Life | | | |

| Residents appropriately groomed and | | | |

|dressed? | | | |

| Staff-to-resident interactions appropriate, | | | |

|Including eye contact, touch, verbal | | | |

|communication | | | |

|Appropriate delivery of care and services | | | |

| General appearance of residents | | | |

| General appearance of resident care | | | |

|needs and level of assistance | | | |

|Impact of environment & safety issues | | | |

| Infection control practices | | | |

| Maintenance of facility equipment | | | |

| Homelike setting | | | |

| Safety practices | | | |

|Observe the following for cleanliness, neatness, safety: | | | |

|Common areas | | | |

|Resident furnishings, walls, floors | | | |

|Activity room(s) | | | |

|Laundry room(s) | | | |

|Storage area(s) | | | |

|Restrooms | | | |

|Nursing areas, including: | | | |

|Clean and dirty equipment handling | | | |

|Medication storage areas | | | |

|Exterior grounds | | | |

|Posters/notices: | | | |

|Complaint Resolution Unit | | | |

|Ombudsman’s office | | | |

|Current BH license | | | |

|Most recent inspection (including cover letter | | | |

|and POC) | | | |

|FOCUS |YES |NO |COMMENTS |

| | | | |

|INTERVIEW: RESIDENT (Attachment G) | | | |

|Resident Interview: | | | |

|Services and needs | | | |

|Preferences and choice | | | |

|Safety and well-being | | | |

|Environment | | | |

|Meals and food service | | | |

|Healthcare services | | | |

|Resident rights | | | |

|Activities | | | |

|Abilities | | | |

|Resident observation during interview: | | | |

|Water temperature in room/apartment | | | |

|Cleanliness of room/clutter | | | |

|Cleanliness of resident/clothing | | | |

|Any safety issues | | | |

|Medication storage | | | |

|Personal care items (if state contract) | | | |

| | | | |

|INTERVIEW: STAFF, ADMINISTRATOR | | | |

|Discuss the following topics: | | | |

|What constitutes abuse | | | |

|Facility procedures regarding abuse | | | |

|Prevention of abuse | | | |

|Reporting | | | |

|Emergencies, including: | | | |

|Emergency lighting | | | |

|Location of first aid supplies | | | |

|Location of disaster plan | | | |

|Staff responsibilities in an emergency | | | |

|Provisions for essential resident needs, | | | |

|Including food, water, and medications | | | |

|FOCUS |YES |NO |COMMENTS |

| | | | |

|MEDICATION SERVICES | | | |

|Medication storage | | | |

|Medication delivery, including | | | |

|Documentation | | | |

|Assistance/administration | | | |

|Medication alterations | | | |

|Appropriate for resident needs | | | |

|Respect of resident rights, including | | | |

|Right to refuse | | | |

|Individual choice and preference | | | |

|Medication storage, including: | | | |

|Secure | | | |

|Properly labeled | | | |

|Each resident medications separate from | | | |

|other resident medication, toxic substances | | | |

|Stored according to label directions | | | |

|Storage area locked and accessible only to | | | |

|designated staff | | | |

|Medication observation, including: | | | |

|Staff to resident interaction | | | |

|Appropriate level of assistance | | | |

|Infection control | | | |

|Safety and security of medications and | | | |

|documents | | | |

|Interviews, including: | | | |

|Staff knowledge and techniques | | | |

|FOCUS |YES |NO |COMMENTS |

| | | | |

|ENVIRONMENTAL OBSERVATION (ATTACHMENT I) | | | |

|Common areas for general appearance | | | |

|Pets, including cleanliness and demeanor | | | |

|Communication system | | | |

|* FOR AL CONTRACT: | | | |

|Homelike smoke-free common areas | | | |

|Access to outdoor area | | | |

|Meeting space outside of apartment | | | |

|Laundry room accessible to residents | | | |

|* FOR EARC-SPECIALIZED DEMENTIA CARE: | | | |

|Multiple common areas | | | |

|Opportunities for privacy, socialization, | | | |

|Wandering | | | |

|Outdoor area, accessible by residents without | | | |

|staff assistance | | | |

|Personal items/furnishings | | | |

|Use of communication/intercom system | | | |

|Activities | | | |

|Access to room at all times without assistance | | | |

|Restricted egress | | | |

|INFORMATION POSTED | | | |

|CRU | | | |

|Ombudsman | | | |

|Boarding home license | | | |

|Last full inspection (cover letter and POC, too) | | | |

|MAINTENANCE AND HOUSEKEEPING: INTERIOR | | | |

|Cleanliness | | | |

|Odors | | | |

|Housekeeping supply area: | | | |

|Storage of wet mops | | | |

|Storage of cleaning supplies | | | |

|Adequate ventilation | | | |

|Clean and soiled nursing equipment storage | | | |

|Handwashing areas | | | |

|Adequate lighting | | | |

|Stairs, ramps, handrails in good repair | | | |

| QUALITY OF LIFE | | | |

|Shades in resident rooms | | | |

|Staff knocking prior to entering resident room | | | |

|SAFETY | | | |

|Resident access to: | | | |

|Cleaning supplies | | | |

|Hazardous and toxic chemicals | | | |

|Medications | | | |

|Water temperature (105-120 degrees) | | | |

|FOCUS |YES |NO |COMMENTS |

| | | | |

|ENVIRONMENTAL OBSERVATION (continued) | | | |

|EXTERIOR ENVIRONMENT | | | |

|Safe, sanitary, in good repair | | | |

|Garbage/refuse area | | | |

|Pests | | | |

|Ramps, stairs, handrails for appropriate | | | |

|placement and repair | | | |

|* FOR EARC-SPECIALIZED DEMENTIA CARE: | | | |

|At least one outdoor area | | | |

|Accessible to residents without staff assistance | | | |

|Walls/fence at least 72 inches high | | | |

|Protected from direct sunshine/rain throughout | | | |

|Day | | | |

|Firm, stable, slip-resistant walking surfaces | | | |

|Suitable outdoor furniture | | | |

|No poisonous or toxic plants | | | |

|FOCUS |YES |NO |COMMENTS |

| | | | |

|FOOD SERVICES (ATTACHMENT I) | | | |

|Dining observation, including | | | |

|Staff interaction with residents | | | |

|Assistance available and provided | | | |

|Quantities eaten by residents | | | |

|Time offered to complete meal | | | |

|Consideration of resident needs, including: | | | |

|Preferences | | | |

|Alternate choices | | | |

|A system so residents can voice comments | | | |

|Prescribed diets | | | |

|Prescribed nutrient supplements | | | |

|Variety of daily food choices | | | |

|Assistance with eating | | | |

|Food preparation area: | | | |

|Cleanliness | | | |

|Personal hygiene practices by staff | | | |

|Condition of equipment | | | |

|Handwashing facilities | | | |

|Handling of food by staff | | | |

|Food storage areas, including: | | | |

|Cleanliness | | | |

|Storage to prevent contamination | | | |

|Menus, including: | | | |

|Variety and nutritious content of food | | | |

|Times of meals and snacks | | | |

|Availability of menus to residents | | | |

|Interviews with staff regarding food service: | | | |

|Sanitation practices: temperature control, | | | |

|dishwasher method, handwashing sinks and | | | |

|practices | | | |

|Prescribed diets/supplements for specific | | | |

|residents | | | |

|Communication between nursing and food | | | |

|service | | | |

|Review food handler cards | | | |

|FOCUS |YES |NO |COMMENTS |

|RESIDENT RECORD REVIEW | | | |

|(ATTACHMENT J) | | | |

|Pre-admission assessment | | | |

|Full assessment | | | |

|Limited assessment if change in condition | | | |

|Qualified assessor | | | |

|Negotiated Service Agreement | | | |

|Updated as needed | | | |

|Plan to meet resident’s needs and preferences | | | |

|Roles and responsibilities of: | | | |

|Staff | | | |

|Resident | | | |

|Family/representative | | | |

|Resident preferences are identified | | | |

|ID medication assistance or administration | | | |

|Family involvement, alternate plan | | | |

|Progress notes | | | |

|Medication record: | | | |

|Appropriate for resident abilities/needs | | | |

|Include: | | | |

|Name of resident | | | |

|Name of medication | | | |

|Dosage and dosage frequency | | | |

|Name of prescriber | | | |

|Documentation of refusal and further actions | | | |

|Physician orders: | | | |

|Therapeutic/modified diet | | | |

|Treatments | | | |

|Incident reports, if indicated | | | |

|FOCUS |YES |NO |COMMENTS |

|FACILITY RECORD REVIEW | | | |

|Policies and procedures | | | |

|QA Committee notes | | | |

|Incident/accident reports | | | |

|Financial records (only if resident services or care not being met) | | | |

|STAFF RECORD REVIEW | | | |

|(ATTACHMENT K) | | | |

|Staff meet all requirements | | | |

|Administrator meets all requirements | | | |

|10 hours of CE completed | | | |

|*FOR EARC-SPECIALIZED DEMENTIA CARE: | | | |

|6 of the 10 hours must be focused on | | | |

|dementia care | | | |

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