Skip to content
717-747-1159
info@rachealhhc.com
1600 Sixth Avenue, suite 116B, York, PA, 17403
Facebook
Google
Linkedin
Instagram
Home
About Us
Services
Pediatrics
Companionship
Personal Care
Skilled Nursing
Careers
Resources
Forms
Service Areas
Contact Us
Blog
Home
About Us
Services
Pediatrics
Companionship
Personal Care
Skilled Nursing
Careers
Resources
Forms
Service Areas
Contact Us
Blog
Schedule Consultation
Home
About Us
Services
Pediatrics
Companionship
Personal Care
Skilled Nursing
Careers
Resources
Forms
Service Areas
Contact Us
Blog
Schedule Consultation
HOME SAFETY ASSESSMENT
Home safety assessment
Patient Name:
Patient Name
MR#
MR#
Address:
Address
Patient Lives with:
Patient lives with
Evaluation Completed By (PRINT):
Evaluation Completed By (PRINT):
Date:
SOC
Item No.
Description
(ENVIRONMENT)
Yes
No
NA
1
Safe and Adequate food and water supplies
Safe and Adequate food and water supplies
Yes
Safe and Adequate food and water supplies
Yes
Safe and Adequate food and water supplies
Yes
2
Stove and means for refrigeration present
Stove and means for refrigeration present
Yes
Stove and means for refrigeration present
Yes
Stove and means for refrigeration present
Yes
3
Adequate heat and ventilation
Adequate heat and ventilation
Yes
Adequate heat and ventilation
Yes
Adequate heat and ventilation
Yes
4
Free from infestation
Free from infestation
Yes
Free from infestation
Yes
Free from infestation
Yes
5
Pathways free of obstacles such as loose rugs, furniture, etc
Pathways free of obstacles such as loose rugs, furniture, etc
Yes
Pathways free of obstacles such as loose rugs, furniture, etc
Yes
Pathways free of obstacles such as loose rugs, furniture, etc
Yes
6
Clean area exists in which to store medical supplies
Clean area exists in which to store medical supplies
Yes
Clean area exists in which to store medical supplies
Yes
Clean area exists in which to store medical supplies
Yes
7
Is cautious with heating pads
Is cautious with heating pads
Yes
Is cautious with heating pads
Yes
Is cautious with heating pads
Yes
8
Has a working smoke detector
Has a working smoke detector
Yes
Has a working smoke detector
Yes
Has a working smoke detector
Yes
9
If uses oxygen, appropriate signs posted
If uses oxygen, appropriate signs posted
Yes
If uses oxygen, appropriate signs posted
Yes
If uses oxygen, appropriate signs posted
Yes
FIRE/ELECTRICAL
1
Fire exits available; warning devices installed
Fire exits available; warning devices installed
Yes
Fire exits available; warning devices installed
Yes
Fire exits available; warning devices installed
Yes
2
No overuse of extension cords / adequate electrical outlets available
No overuse of extension cords / adequate electrical outlets available
Yes
No overuse of extension cords / adequate electrical outlets available
Yes
No overuse of extension cords / adequate electrical outlets available
Yes
3
Turns off oven and stove burners
Turns off oven and stove burners
Yes
Turns off oven and stove burners
Yes
Turns off oven and stove burners
Yes
4
Emergency telephone numbers posted by phone
Emergency telephone numbers posted by phone
Yes
Emergency telephone numbers posted by phone
Yes
Emergency telephone numbers posted by phone
Yes
5
Turns pot handles to back of stove
Turns pot handles to back of stove
Yes
Turns pot handles to back of stove
Yes
Turns pot handles to back of stove
Yes
6
Uses space heaters cautiously
Uses space heaters cautiously
Yes
Uses space heaters cautiously
Yes
Uses space heaters cautiously
Yes
7
Does not smoke in bed
Does not smoke in bed
Yes
Does not smoke in bed
Yes
Does not smoke in bed
Yes
8
Oxygen precautions used
Oxygen precautions used
Yes
Oxygen precautions used
Yes
Oxygen precautions used
Yes
BATHROOM SAFETY
1
No throw rugs
No throw rugs
Yes
No throw rugs
Yes
No throw rugs
Yes
2
Safety bars present and in good condition
Safety bars present and in good condition
Yes
Safety bars present and in good condition
Yes
Safety bars present and in good condition
Yes
3
Lighting is adequate
Lighting is adequate
Yes
Lighting is adequate
Yes
Lighting is adequate
Yes
4
Shower chair is sturdy and in good working condition
Shower chair is sturdy and in good working condition
Yes
Shower chair is sturdy and in good working condition
Yes
Shower chair is sturdy and in good working condition
Yes
MEDICATION USE
1
Keeps all medications in original bottle or med box
Keeps all medications in original bottle or med box
Keeps all medications in original bottle or med box
Yes
Keeps all medications in original bottle or med box
Yes
2
Has a medication schedule
Has a medication schedule
Yes
Has a medication schedule
Yes
Has a medication schedule
Yes
3
Home Safety Instructions Given
Home Safety Instructions Given
Yes
Home Safety Instructions Given
Yes
Home Safety Instructions Given
Yes
Primary Physician:
Primary Physician
As of the date of this evaluation, I attest that this home is sade environment for nursing care.
Clear
Agency Representative Signature
Date
Schedule An Appointment today!
Name
Email
Phone Number
Message
Submit
