Policy Manual sample

MDT Home Health Care Agency, Inc. PATIENT SAFETY CHECKLIST 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 48 hours of the inspection. (This Formmay be replaced for the Safety Assessment in theOASIS/Adult Comprehensive assessment form) Condition Condition Items to Check Satisfactory Unsatisfactory 1. Fire alarm/smoke detectors 2. Fire extinguisher 3. First aid box/Emergency Equipment or Supplies 4. Telephone 5. Lights 6. Doors/locks 7. Ventilation 8. Beds/Chairs 9. Bedding 10. Telephone 11. Kitchen 12. Electrical appliances 13. Floors 14. Relevant medical appliances, if applicable (e.g. wheelchair, O 2 , Monitors, etc.) 15. Ashtrays (if a smoker) 16. Check Flashlights Every 2 wks, Notify Patient to Have Replacement Batteries. (if necessary) 17. Hurricane Shutters ____________________________________________________________ Signature: _____________________________________ Home Health Agency. - - Personnel/Operations Policies B-23