Body: Council Type: Document Meeting: Regular Date: March 7, 2013 Collection: Documents Municipality: Frontenac County
[View Document (PDF)](/docs/frontenac-county/PDF Documents/Fairmount Home - 07 Mar 2013.pdf)
Document Text
Fairmount Home Meeting Agenda Management Team Date: March 7, 2013 Time: 9:30 a.m. Place: Fairmount Boardroom Members:
Julie Shillington Deb Crawford Tom Mercer
Mary Lake Gail Williams Rosemarie Christian Jones
Page 1.
Welcome and Introductions
Adoption of Minutes of the Previous Meeting
Additions to Agenda under Other Business
Delegations
Communications
Business Arising out of Minutes a)
“We Love Your Opinion” Book
b)
Scent Awareness Policy
c)
1North Care Carts (locking doors/curtains)
d)
Update of Fire Drill Report
e)
Snoozelen Policy
f)
Fire Plan Approval
g)
Approval of Updated Emergency Callback List
h)
Update of Emergency Plan (external evacuation sites)
i)
1North Humidity
j)
Garbage Receptacle Lids for Pathways
k)
Bomb Threat Exercise
l)
Spare Doors for Resident Wall Units
m)
Scabies Policy/Checklist
n)
Locking Door for Documentation Room
o)
Storage Unit
p)
Notification to Families during Power/Phone Outage
Page 1 of 29
Page 6.
5
6-13
Business Arising out of Minutes q)
Lift/Repositioning Policy Drafts
r)
Performance Appraisal Trial
s)
Worklife Pulse Staff Survey
t)
Swipe Verification Form Update
u)
11-7 Duty List Policy (weights)
v)
Diet Order Policies
w)
Battery/Pager Protocol (team rooms)
x)
Paid Sitter/Companion Agreement
y)
Website Content
z)
Laundry Labels
aa)
Printer/Scanner for Receptionist
ab)
Ontario LTC Homes Policy and Procedure Management (set-up meeting)
ac)
Restorative Care Policies
ad)
ESA Services
ae)
Eye Wash Spout Caps
af)
Basic Room Lettering
ag)
Hand Hygiene Workshop-March 28
ah)
RFP for Nursing Software
ai)
LED Light Bulb Trial
aj)
Confined Space Ruling (Bio Disc)
ak)
Quotation for Push Plates for Med Room Doors
al)
De-Icing Costs
am)
Euchre Table/Chairs in Veteran’s Area
an)
Restorative Care Measures on Statistical Report
ao)
Electrical Checklist Policy
ap)
Lobby Elevator
aq)
Physician On Call Policy (draft)
ar)
New Year’s Dinner-Financial Figures
as)
Staff Influenza Vaccination Rate Certificate
at)
Church Portering (reminder email)
au)
RN Kit
av)
Fluid Intake (caffeine vs. de-caffeinated)
aw)
Elevator Outage Protocol (signage)
ax)
Quality Life Contract Renewal (July 2013)
Page 2 of 29
Page 6.
Business Arising out of Minutes ay)
2nd Floor Servery Lock Combination
New Business a)
b)
Resident Care – Compliance, Accreditation, Classification i)
Compliance
ii)
Accreditation
iii)
Residents’ Council Update
iv)
Resident/Family Survey
Support Services i)
Tour of Building/Main Kitchen
c)
Treasury
d)
Administration
e)
i)
Concerns
ii)
Risk ID’s
iii)
Work Plan
Human Resources i)
f)
Staffing
Health & Safety i)
Monthly Fire Drill
ii)
Management Inspections Schedule: Julie – June 13, 2013, November 7, 2013 Tom – February 8, 2013, July 11, 2013, December 12, 2013 Rosemarie – March 7, 2013, August 8, 2013, January 11, 2014 Gail – January 11, 2013, April 11, 2013, September 12, 2013 Mary – May 9, 2013, October 10, 2013
14-29
iii)
Inspection Form Draft
g)
Information Technology
h)
Communications
i)
Education Information Sharing (Staff Attendance at Conventions/Workshops)
Page 3 of 29
Page j)
Quality Improvements/Audits i)
Hazard Analysis Report (Quarterly-May)
ii)
Complaint Documentation Report (Quarterly-March)
iii)
Symptoms Report (Monthly-February report due in March)
iv)
Near Misses/Incident Reports (Quarterly-May)
v)
Restraint Audits (Monthly – done the 3rd week, report the 4th week)
Other Business
Confirmation of time, date and location of next meeting
- Adjournment
Page 4 of 29
AgendaItem#6r)
Performance Appraisal Trial Our current performance appraisal document has been in place for many years and we are going to trial a different performance appraisal document. As you have a performance appraisal due in the next six months, we would like to understand your satisfaction with the current performance appraisal document. You will then be asked to make comments on the trial document after your performance review is completed. Please take a few moments to answer the following questions:
- I am a o o
Front-line staff member Manager
- Do you find the current performance appraisal document easy to understand and use? o o
Yes No
If you answer no to question 2, please go to question 3. If you answer yes to question 2, please go straight to question 5 3. What do you find challenging about the current performance appraisal document?
Do these challenges prevent you from completing your performance appraisal document in a timely manner?
Can you recommend any changes to the current performance appraisal document?
Performance Appraisal Trial
Page 5 of 29
AgendaItem#6x)
Policy & Procedure Manual Program:
Administration
Policy:
Paid Companions
Index Number: ADM-23 Page 1 of 3 Effective: July 1, 2011
Approved:
Policy:
Revision Date:
All residents/substitute decision makers wishing to engage the services of a paid companion (who does not provide personal care) must sign a waiver of indemnification and take responsibility for the hiring and payment of same. A paid companion is not an employee of Fairmount Home and may or may not have health care training.
Objective:
To define the relationship between the paid companion, the resident/substitute decision maker and Fairmount Home.
Procedure:
The resident/substitute decision maker will be made aware of this policy upon admission to the Home. Should the resident/substitute decision maker wish to engage the services of a paid companion, he/she shall sign the applicable Release and Indemnification form (Form 10) and introduce the paid companion to the Director of Resident Care/Assistant Director of Care. The paid companion shall then provide all necessary contact information to facilitate ongoing dialogue about this arrangement for the provision of company for their resident. The Executive Assistant will maintain a listing of all paid companions in the home. If the paid companion is retained by the resident/substitute decision-maker through an agency, the contractor orientation package will be provided to the agency. If the paid companion is retained directly by the resident/substitute decision-maker the contractor orientation package will be sent directly to the resident/substitute decision-maker. The Director of Resident Care will ensure that the paid companion has reviewed the contractor orientation package prior to providing service to the resident. The paid companion will be orientated to the Home and the Home area by designated staff. The Director of Resident Care or the Assistant Director of Resident Care will arrange the orientation. The paid companion will not solicit business from other families or clients in the Home. The paid companion will be made aware of any relevant medical/nursing/care issues by the relevant member of the care team. The paid companion will liaise with the Nurse in Charge (RN/RPN) at the Home to establish the visiting schedule as per the resident’s needs. The paid companion will provide companionship to his/her resident exclusively throughout their hours of employment. Services of any type (e.g. bringing in food, drinks, etc.) will not be directed toward any other resident.
Paid Sitter/Companion Agreement
Page 6 of 29
AgendaItem#6x)
Policy & Procedure Manual Program:
Administration
Policy:
Paid Companions
Approved:
Revision Date: Index Number: ADM-23 Page 2 of 3 Effective: July 1, 2011
The paid companion will not have access to resident medical records. The paid companion will provide verbal feedback to the Home’s nursing staff routinely. He/She will notify the Home’s Charge Nurse or unit RPN of arrival and departure from the home area and any resident changes. Outings from the Home area must be discussed in advance with the Home’s Charge Nurse or designate. Outings must not interfere with scheduled appointments, assessments, etc. The paid companion will report any incident to the Home’s Charge Nurse or designate and will assist in completion of an incident report in accordance with Home policy. The paid companion must comply with all relevant Fairmount Home policies and procedures (confidentiality, immunization, health and safety, etc.). The paid companion is not an employee of Fairmount Home and is accordingly not entitled to any benefits, privileges, rights or information to which a Fairmount Home employee may be entitled, except as specifically set out in this policy. Nothing in this policy shall modify, replace or waive the employment relationship that exists between the paid companion and their regular employer, if any. Nothing in this policy shall be construed to create any duty, liability or responsibility whatsoever for Fairmount Home with respect to the paid companion and the Workplace Safety and Insurance Act, 1997 or its successor legislation. The paid companion is required to possess the necessary training, certification and competencies as identified by the Director of Care at Fairmount Home to carry out special activities such as feeding, restorative care, etc. The paid companion will not be permitted to bathe a resident or administer medications to a resident. The Home shall have the ability to deny any paid companion access to the Home on either a temporary or permanent basis. Such denial may arise as a result of, but is not limited to, situations where (1) the paid companion becomes a risk to the resident, the Home or the Home staff; or (2) the Home has had an unsatisfactory experience with the paid companion or their employer in the past and determines that there is a risk of further unsatisfactory experiences in the future. The Home shall not be liable for any damages incurred by the resident or the paid companion, should the Home choose to deny access to the Home. Prior to commencement of services, the paid companion must sign a Release and Indemnification form (Form 11) that also acknowledges and accepts the provisions of this Policy.
Paid Sitter/Companion Agreement
Page 7 of 29
AgendaItem#6x)
Policy & Procedure Manual Program:
Administration
Policy:
Paid Companions
Approved:
Revision Date: Index Number: ADM-23 Page 3 of 3 Effective: July 1, 2011
All references to “Home”, “Fairmount Home” and “Fairmount Home for the Aged” in this Policy and related documents shall be interpreted to include the Corporation of the County of Frontenac, which owns and operates the Home.
Paid Sitter/Companion Agreement
Page 8 of 29
AgendaItem#6x)
Form #10
Resident/Substitute Decision Maker’s Release and Indemnification I, ____________________ (Name of Resident/Substitute Decision Maker), have retained the services of ________________________________(Name of Paid Companion/ Trained Health Care Worker, or “THCW”) to provide the following services (“the Services”):
to ___________________________ (Name of Resident), who resides at Fairmount Home for the Aged (“the Home”). I acknowledge that ___________________________________ (Name of Paid Companion/THCW) is not an employee of the Home or the Corporation of the County of Frontenac (“the County”). I accept full responsibility for the payment of _____________________________________ (Name of Paid Companion/THCW). I hereby release the County, the Home and their directors, officers, employees and agents from all actions, causes of action, suits, claims, liability, damages and demands of any kind, whether direct, indirect, special, exemplary or consequential, including interest thereon (“the Claims”) which may occur as a result of ____________________________ (Name of Paid Companion/THCW) providing the Services to the Resident in the Home. I hereby agree to indemnify and hold harmless the County, the Home and their directors, officers, employees and agents from and against all Claims whatsoever incurred by the County, the Home or such other persons as a result of ____________________________ (Name of Paid Companion/THCW) providing the Services to the Resident in the Home.
Signature of Resident/Substitute Decision Maker
Witness
Date
Relationship of Witness to Resident
Policy ADM-23 July 1, 2011
Paid Sitter/Companion Agreement
Page 9 of 29
AgendaItem#6x)
Form #11
Paid Companion/Trained Health Care Worker Release and Indemnification In the matter of _______________________ (Name of Paid Companion/Trained Health Care Worker), ___________________________(Name of Resident, hereinafter “the Resident”) and the Corporation of the County of Frontenac (hereinafter ”the County”), operator of Fairmount Home for the Aged (hereinafter “the Home”): I hereby release the County, the Home and their directors, officers, employees and agents from all actions, causes of action, suits, claims, liability, damages and demands of any kind, whether direct, indirect, special, exemplary or consequential, including interest thereon (hereinafter “the Claims”) which occur as a result of me providing (or contracting to provide) services to the Resident in the Home. I hereby agree to indemnify and hold harmless the County, the Home, their directors, officers, employees and agents from and against all Claims whatsoever which may occur as a result of me providing (or contracting to provide) services to the Resident in the Home. I acknowledge that in keeping with its responsibility for resident care, the County and/or the Home have the right to intervene in those instances where I may be functioning in a manner considered by the County and/or the Home to be of potential danger to the well-being of the Resident or contrary to the Home’s regulations, rules, policies or procedures. I have reviewed the Home’s contractor package and understand and accept the policies and procedures contained therein. I have received a copy of and understand and accept the Home’s Companion/Trained Health Care Worker Policy and Procedures.
Signature of Paid /Companion/THCW/
Date
Or Representative Agency
Witness
Relationship of Witness to Resident
Policy ADM-23 July 1, 2011
Paid Sitter/Companion Agreement
Page 10 of 29
AgendaItem#6x)
Policy & Procedure Manual Program:
Administration
Policy:
Paid Trained Health Care Workers
Revision Date: Index Number: ADM-25
Approved:
Policy:
Page 1 of 3 Effective: July 1, 2011
All residents/substitute decision makers wishing to engage the services of a paid trained health care worker (“THCW”, who would give direct personal care) must sign a waiver of indemnification and take responsibility for the hiring and payment of same. A THCW is an individual who is an employee of a recognized health care organization (other than Fairmount Home for the Aged, hereinafter “Fairmount Home” or “the Home”) and is employed by the resident/substitute decision maker through that organization.
Objective:
To define the relationship between the paid THCW, the resident/substitute decision maker and Fairmount Home.
Procedure:
The resident/substitute decision maker will be made aware of this policy upon admission to the Home. Should the resident/substitute decision maker wish to engage the services of a paid THCW, he/she shall sign the applicable Release and Indemnification form (Form 10) and introduce the THCW to the Director of Resident Care/Assistant Director of Care. The paid THCW shall then provide all necessary contact information to facilitate ongoing dialogue about this arrangement for the provision of company/care for their resident. A copy of the contractor orientation package will be provided to the agency. The Director of Resident Care will ensure that the paid THCW has reviewed the contractor orientation package prior to providing service to the resident. The Executive Assistant will maintain a listing of all paid companions in the home. The paid THCW will be orientated to the Home and the Home area by designated staff. The Director of Resident Care or the Assistant Director of Resident Care will arrange the orientation. The paid THCW will not solicit business from other families or clients in the Home. The paid THCW will be made aware of any relevant medical/nursing/care issues by the relevant member of the care team. The paid THCW will liaise with the Nurse in Charge (RN/RPN) at the Home to establish the visiting schedule as per the resident’s needs. The paid THCW will provide personal care to his/her resident exclusively throughout their hours of employment. Services of any type (e.g. bringing in food, drinks, providing care, etc.) will not be directed toward any other resident. The paid THCW will not have access to resident medical records.
Paid Sitter/Companion Agreement
Page 11 of 29
AgendaItem#6x)
Policy & Procedure Manual Program:
Administration
Policy:
Paid Trained Health Care Workers
Approved:
Revision Date: Index Number: ADM-25 Page 2 of 3 Effective: July 1, 2011
The paid THCW will provide verbal feedback to the Home’s nursing staff routinely. He/She will notify the Home’s Charge Nurse or delegate of arrival and departure from the home area and any resident changes. The THCW agency will provide their resident progress notes on request from Fairmount Home. Outings from the Home area must be discussed in advance with the Home’s Charge Nurse or designate. Outings must not interfere with scheduled appointments, assessments, etc. The paid THCW will report any incident to the Home’s Charge Nurse or designate and will assist in completion of an incident report in accordance with Home policy. The paid THCW must comply with all relevant Fairmount Home policies and procedures (confidentiality, immunization, health and safety, etc.). The paid THCW is not an employee of Fairmount Home and is accordingly not entitled to any benefits, privileges, rights or information to which a Fairmount Home employee may be entitled, except as specifically set out in this policy. Nothing in this policy shall modify, replace or waive the employment relationship that exists between the paid THCW and their regular employer, if any. Nothing in this policy shall be construed to create any duty, liability or responsibility whatsoever for Fairmount Home with respect to the paid sitter/companion/THCW and the Workplace Safety and Insurance Act, 1997 or its successor legislation. The paid THCW is required to possess the necessary training, certification and competencies as identified by the Director of Care at Fairmount Home to carry out special activities such as feeding, restorative care, etc. The THCW may do personal care for his/her resident within the scope of the THCW’s practice. The Home shall have the ability to deny any THCW access to the Home on either a temporary or permanent basis. Such denial may arise as a result of, but is not limited to, situations where (1) the paid THCW becomes a risk to the resident, the Home or the Home staff; or (2) the Home has had an unsatisfactory experience with the paid THCW or their employer in the past and determines that there is a risk of further unsatisfactory experiences in the future. The Home shall not be liable for any damages incurred by the resident or the paid THCW, should the Home choose to deny access to the Home. The paid THCW will maintain insurance coverage (either personally or through their employer, as the case may be) in a form and amount satisfactory to the Home. The THCW shall provide evidence of such insurance coverage to the Home upon request.
Paid Sitter/Companion Agreement
Page 12 of 29
AgendaItem#6x)
Policy & Procedure Manual Program:
Administration
Policy:
Paid Trained Health Care Workers
Approved:
Revision Date: Index Number: ADM-25 Page 3 of 3 Effective: July 1, 2011
Prior to commencement of services, the paid THCW must sign a Release and Indemnification form (Form 11) that also acknowledges and accepts the provisions of this Policy. All references to “Home”, “Fairmount Home” and “Fairmount Home for the Aged” in this Policy and related documents shall be interpreted to include the Corporation of the County of Frontenac, which owns and operates the Home.
Paid Sitter/Companion Agreement
Page 13 of 29
Inspection Form Draft
Fairmount Home Monthly Management Safety Inspection Guide PG
Inspection performed by:
Resident room
1
Date:
Care station and med room
3
Areas inspected:
Corridors
4
Lounges and activity rooms
5
Staff practice
6
Tub and shower rooms
8
Utility, janitor, & storage rooms (all departments)
9
Laundry room
11
Dietary (MAIN Kitchen; Servery; Support Kitchen; Dining Room)
12
Mechanical room
14
Fire, first aid & protective equipment
15
Last updated: [date]
Types of action class: A – Critical Immediate action required. B – Urgent Action required within one week. C – Important Action required before next inspection.
AgendaItem#7fiii)
Page 14 of 29
AREA
Inspection Form Draft
RESIDENT ROOM Room(s) inspected: Item Description
1.1 Resident’s bed and furniture in good condition 1.2 1.3 1.4 1.5 1.6
Y
N
If No, Describe Issue and Action Needed
Action Class
Call bells at bedside and in bathroom are clean and in good condition Lights in room and bathroom are in good condition Room is free of small appliances such as toasters, coffee makers, etc. (small fridge permitted) Chairs are clean
1.8
Door handles on wardrobe and door secure
1.9
Window screens in place and in good repair
1.10
Window blinds move freely and in good condition
1.11
Thresholds are distinct
1.12
Bars in bathroom are secure
1.13
No signs of leaks or spills in resident or bathroom
1.14
Floors, walls and ceilings are clean and in good repair
1.15
Sinks and taps are clean and in good repair
1.16
High level dusting in complete 1
Fairmount Home Monthly Inspection Guide
AgendaItem#7fiii)
Page 15 of 29
1.7
Privacy curtain free of tears and functioning properly (if applicable) Bed rails are working properly
Inspection Form Draft
1.17
Area free of pests e.g. ants, mice
1.18
1.20
Garbage containers are not overflowing and have lids (where appropriate) Furniture in room arranged as not to pose safety risk to resident or staff Nurse call system working (test resident and staff assist buttons)
1.21
Electrical appliances have been inspected by maintenance
1.22
Electrical cords are tied back and not laying across access areas
1.23
Electrical cords are in good condition
1.24
Lift ceiling track in good repair
1.25
Ceiling lift is left on a firm, flat surface when not in use
1.26
Electrical cover plates and switches are in good condition
1.27
Electrical outlets are not overloaded
1.28
Ceiling pole is compliant with equipment guidelines
1.29
Linen is in good condition, with no stains and not in disrepair
1.19
OTHER ISSUES NOT LISTED Action Class
2 Fairmount Home Monthly Inspection Guide
AgendaItem#7fiii)
Page 16 of 29
Describe Issue and Action Needed
Inspection Form Draft
CARE STATION AND MED ROOM Item Description
2.1 Care station free from unnecessary clutter and trash 2.2
Team room free from unnecessary clutter and trash
2.3
Alcohol hand wash available at care station
2.4
Garbage cans not overflowing
2.5
Staff food/drink is not kept in med fridge
2.6
Med fridge temperatures are taken as required by policy
2.7
Electrical cords tied back and not laying across access areas
2.8
Emergency phone numbers are posted at telephone
2.9
Sharps containers not overflowing
2.10
Sharps have not been recapped
2.11
Resident information is kept confidential at care station
Y
N
If No, Describe Issue and Action Needed
Action Class
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 17 of 29 3 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
CORRIDORS Item Description
3.1 Corridors are clean 3.2
Corridors are in good repair and free of tripping/slipping hazards
3.3 3.4
Corridors are free of equipment, housekeeping and care carts (or at one side) Handrails are clean, in good repair and secure
3.5
Carpet is clean and in good repair
3.6 3.7
Electrical cords, if in use, are tied back and not posing a trip hazard Lighting is adequate
3.8
Exit lights are lit
3.9
Emergency plan at each designated exit
3.10
Emergency exits are marked and illuminated
3.11
Emergency exits are unobstructed and unlocked
Y
N
If No, Describe Issue and Action Needed
Action Class
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 18 of 29 4 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
LOUNGES & ACTIVITY ROOMS Item Description
4.1 Furniture and equipment clean and in good repair 4.2
Window blinds move freely and in good repair
4.3
Furniture arranged as to not pose risk to staff or residents
4.4
Carpet and flooring are clean and in good repair
4.5
Electrical cords out of the way of traffic
4.6
Electrical cords are in good condition
4.7
Food in refrigerator does not belong to staff and is not outdated
4.8
Hazardous chemicals are locked up
Y
N
If No, Describe Issue and Action Needed
Action Class
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 19 of 29 5 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
STAFF PRACTICE Item Description
5.1 Employees know how to report a fire Employees know the purpose of and where to locate MSDS sheets
5.3
Staff are wearing their nametags
5.4
Staff know the purpose of any chemicals on the unit
5.5
5.7
Staff are aware of Infection Prevention and Control Policies and Procedures including where to locate them, use of PPE, how to clean resident equipment, etc. Staff are aware of where to locate eyewash stations & how to operate Staff are using equipment safely
5.8
Staff are practicing good hand hygiene
5.9 5.10
Housekeeping carts are locked when not in use (or stored in janitor rooms) RPN does not leave med cart unattended when unlocked
5.11
Staff are wearing appropriate footwear
5.12
Staff are engaging residents
5.13 5.14
Staff are speaking at an appropriate volume, i.e not yelling out to each other Staff are respecting resident confidentiality
5.15
Staff are speaking to residents respectfully
5.6
N
If No, Describe Issue and Action Needed
Action Class
Page 20 of 29
6 Fairmount Home Monthly Inspection Guide
AgendaItem#7fiii)
5.2
Y
Inspection Form Draft
5.16
Incontinent briefs kept out of sight
5.17
Are there any offensive odors?
5.18
Dirty linen carts are not left in hallways with lids open
5.19
Used attends are bagged and tied
5.20
Are there any issues with care carts?
5.21
Staff are carrying pages and phones that are in working order
5.22
Work area/stations are clean and orderly
5.23
Filing cabinets and drawers are not left open when not in use
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 21 of 29 7 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
TUB AND SHOWER ROOMS Item Description
6.1 Door code access working 6.2
Floors are clean, dry and in good repair
6.3
No signs of water damage or mold growth
6.4
Sinks, countertops and taps clean and in good repair
6.5
Hazardous chemicals are away in cupboards
6.6
Cupboards are clean, secure to the wall and in good repair
6.7
Tub clean and in good repair
6.8
Ceiling lift clean and in good repair
Y
N
If No, Describe Issue and Action Needed
Action Class
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 22 of 29 8 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
UTILITY, JANITOR, & STORAGE ROOMS (all departments) Item Description
6.1 Door code access working (if applicable) Floor is clean and in good repair with no tripping/slipping hazards
6.3
Shelves and racks are of adequate strength and are secured
6.4
6.7
Heavy items are stored on shelves between knee and shoulder height No goods over 30lbs stored at more than five feet above floor height Goods have been removed from cartons prior to being placed on shelves Cartons cross-stacked to avoid tipping or tumbling
6.8
Stool/ladder available and in good condition
6.9
Stool/ladder has non-slip safety feet
6.10
Falling object hazards are eliminated
6.11
Hazardous chemicals are stored and labeled properly
6.12
Items on shelves are a minimum 15’’ from ceiling
6.13
MSDS current
6.14
Containers are clearly marked as to contents
6.5 6.6
N
If No, Describe Issue and Action Needed
Action Class
Page 23 of 29
9 Fairmount Home Monthly Inspection Guide
AgendaItem#7fiii)
6.2
Y
Inspection Form Draft
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 24 of 29 10 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
LAUNDRY ROOM Item Description
7.1 Staff are wearing PPE while handling dirty laundry 7.2
Washers and dryers are not overfilled
7.3
Equipment is clean and in good repair
7.4
There are no leaks from automatic chemical systems
7.5
Laundry chute door is closed when not in use
7.6
Staff are not picking clean linen up from floor when dropped
7.7
There is no food in work area
7.8
All chemicals are in appropriate containers and properly labeled
7.9
Laundry room door is locked when staff are not in work area
Y
N
If No, Describe Issue and Action Needed
Action Class
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 25 of 29 11 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
DIETARY (MAIN Kitchen; Servery; Support Kitchen; Dining Room) Item Description
8.1 Floor mats, non-slip material or strips properly placed and in good condition 8.2 Dish machine final rinse about 180 degrees Dishes stacked properly
8.4
Mops and pails clean and available to clean up spills
8.5 8.6
Broken glass is swept up promptly and placed in special, clearly marked containers No standing water where people stand
8.7
Countertops clean, free of clutter and in good repair
8.8
Equipment clean and in good repair
8.9
Staff are not wearing jewelry on hands (wedding bands excepted)
8.10
Staff are wearing proper footwear
8.11
Staff are following dress code
8.12
Emergency shut off accessible (if applicable)
8.13
Proper scoop provided in ice machine
8.14
Floors in walk-ins are clean, dry and not slippery (in main kitchen)
8.15
Refrigerator & freezer temperatures are taken as required by staff
8.16
Diets are posted in the servery
N
If No, Describe Issue and Action Needed
Action Class
12 Fairmount Home Monthly Inspection Guide
AgendaItem#7fiii)
Page 26 of 29
8.3
Y
Inspection Form Draft
8.17
Diet list on the nourishment cart
8.18
Changes in diet communicated effectively
8.19
No Styrofoam cups being used on nourishment cart
8.20
Dirty linen cart is removed from dining room when not in use
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 27 of 29 13 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
MECHANICAL ROOM Item Description
9.1 Floors are free from slip and trip hazards 9.2 9.3
Inspect all systems for leaks (boilers, pumps, fire suppression, water softening, etc.) Tools and parts are properly stored
9.4
Fresh air intake vents are unobstructed
9.5
No obvious fire hazards exists (oily rags, improperly stored paint, etc.) Equipment under repair has been locked out as per Fairmount policy All lights are functioning and exit signs are lit
9.6 9.7 9.8 9.9
Do you small/hear anything unusual? Identify and report immediately. Chemicals are labeled and safely stored
9.10
Electrical cords are in good condition
Y
N
If No, Describe Issue and Action Needed
Action Class
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 28 of 29 14 Fairmount Home Monthly Inspection Guide
Inspection Form Draft
FIRE, FIRST AID & PROTECTIVE EQUIPMENT Item Description
10.1 Fire extinguishers are secured, easily accessible and conspicuously marked 10.2 Fire extinguishers have up-to-date servicing 10.3 Location of first aid stations is clearly marked 10.4 Eye wash station is clearly marked 10.5 There is appropriate signage for hazards in the work area 10.6 Staff are using personal protective equipment where appropriate
Y
N
If No, Describe Issue and Action Needed
Action Class
OTHER ISSUES NOT LISTED Describe Issue and Action Needed
Action Class
AgendaItem#7fiii)
Page 29 of 29 15 Fairmount Home Monthly Inspection Guide
