Emergency Plan Manual

AHCA Form 3110-1022, Rev March 2013 Rule 59A-8.027, Florida Administrative Code http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Home_Care/HHA/index.shtml#other . Page 25 of 54 PATIENT SAFETY CHECKLIST/ Chequeo sobre Seguridad del Paciente To the nurse or other personnel to whom this may apply: You are requested to conduct a physical check of this patient's home condition and check off items that are satisfactory. Please then sign your name at the bottom of the page and return this list to the agency office within 12 hours of the inspection. (La enfermera conducirá un chequeo físico de la condición de su casa.) (This form may be replaced by the Safety Assessment in the OASIS) Condition Condition Items to Check / A chequear Satisfactory Unsatisfactory Satisfactorio No-Satisfactorio 1. Fire alarm/smoke detector / Alarma de fuego _________ _________ 2. Fire extinguish / Extinguidor de fuego _________ _________ 3. First aid box/Emergency Equipment or Supplies _________ _________ Caja de primeros auxilios, equipos o suministros 4. Telephone / teléfono _________ __________ 5. Lights / Luces _________ __________ 6. Doors/locks /Puertas-cierres _________ __________ 7. Ventilation / Ventilación _________ __________ 8. Beds/Chairs / Camas y sillas _________ __________ 9. Bedding / Protectores de la cama _________ __________ 10. Kitchen / Cocina _________ __________ 12. Electrical appliances / Equipos eléctricos _________ __________ 13. Floors / Pisos _________ __________ 14. Relevant medical appliances, if applicable (e.g. wheelchair, O 2 , Monitors, etc.) _________ __________ Equipos médicos, sillas ruedas, Oxygeno, etc. 15. Ashtrays (if a smoker) / Cenicero _________ __________ 16. Check Flashlights Every 2 wks, Notify Patient to have Replacement Batteries. (if necessary) _________ __________ Linternas, baterías 17. Hurricane Shutter /Protectores de Huracán __________ __________ Signature: ________________________________ Angel Home Care Services, Inc.