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HOME SAFETY CHECKLIST

Client Name
Date
Client Address

SAFETY CRITERIA	YES	NO
ENTRANCE TO HOME
Are there outside lights covering the sidewalks and/or other entrance ways?	yes	no
Are the steps & sidewalks in good repair and free from debris/material?	yes	no
Is a ramp needed?	yes	no
Are the railings on the steps secured?	yes	no
Is there a functional peephole in the front door?	yes	no
Does the door have a deadbolt lock that does not require a key to open it from the inside (unless client has a tendency to wander)?	yes	no
GENERAL
Is there an emergency plan in place?	yes	no
Are working smoke detectors installed?	yes	no
Is there a “ready-to-use” fire extinguisher(s) on the premises?	yes	no
Are inside halls and stairways free of clutter/debris?	yes	no
Are throw rugs removed?	yes	no
Are there sturdy handrails or banisters by all steps and stairs?	yes	no
Are electrical cords non-frayed and placed in a manner to avoid tripping?	yes	no
Are electric outlets/switches overloaded (e.g. warm to the touch)?	yes	no
Are rugs secured around the edges?	yes	no
Are hazardous products labeled and kept in a secure place?	yes	no
Is there a need for a stool to reach high shelves/cupboards?	yes	no
Is smoking paraphernalia handled safely (e.g. cigarettes put out)?	yes	no
Does anybody smoke in homes where oxygen is in use?	yes	no
Are all animals, on site, controlled?	yes	no
Is the home free from bugs, mice and/or animal waste?	yes	no
Are materials stored safely and at a proper height?	yes	no
Does the client wear an emergency response necklace/bracelet?	yes	no
Are polished floors no waxed or waxed-free?	yes	no
MEDICATIONS
Are all medications marked clearly?	yes	no
Are medications named?	yes	no
Are medications dated?	yes	no
Are instructions given as to how medications are to be taken?	yes	no
Are instructions given as to when medications are to be taken?	yes	no
MEDICAL EQUIPMENT/SUPPLIES
Are used needles placed in a sharp container?	yes	no
Is oxygen tubing kept off the walking path?	yes	no
Is medical equipment properly stored?	yes	no
LIVING AREAS
Are doorways wide enough to carry loads through and get a wheelchair/walker through?	yes	no
Are light switches accessible so they can be turned on/off without walking across a dark room?	yes	no
Are sofas & chairs high and firm enough for easy sitting and rising?	yes	no
Is there a telephone in the room that is easily accessible from the bed?	yes	no
Is list of emergency telephone numbers by the telephone?	yes	no
Do telephone cords/electronic wires run across walking areas?	yes	no
Are there castors or wheels on furniture?	yes	no
Does sitting furniture have armrests which are strong enough for getting in and out?	yes	no
Are phone & extension cords out of the foot traffic area?	yes	no
Is the room clutter-free?	yes	no
Are heaters at least 12 inches from furniture and drapes?	yes	no
BATHROOM
Are there glass doors on the bathtub/shower?	yes	no
Is there a non-skid surface/mat in the bathtub/shower?	yes	no
Are there grab-bars on the bathtub/shower and adjacent to the toilet?	yes	no
Is there a raised toilet seat (if client has trouble getting on/off toilet)?	yes	no
Is a hand-held shower spray required?	yes	no
Is the water temperature below scalding (e.g. below 120°?	yes	no
Is there a shower bench/bath seat with a hand-held shower wand available?	yes	no
Does the bathroom have a night light?	yes	no
Are there unsafe loose rugs, carpet or tiles on floor?	yes	no
BEDROOM
Are there any scatter rugs?	yes	no
Is the bed lower than “back-of-the-knee” height?	yes	no
Is there a chair with armrests & firm seat (to reduce falls while dressing)?	yes	no
Does furniture have castors or roll?	yes	no
Is there a telephone in the room that is easily accessible from the bed?	yes	no
Is list of emergency telephone numbers by the telephone?	yes	no
Is there a flashlight, light switch or lamp beside the bed?	yes	no
Is there a night light?	yes	no
KITCHEN
Is the floor waxed or in a slippery condition?	yes	no
Are there any flammable items near the heat source?	yes	no
Do the “ON” buttons work on all appliances?	yes	no
Are stove controls accessible and easy to use?	yes	no
Are items used the most stored between eye and knee level?	yes	no
Is there an uncluttered workspace near the cooking area (to avoid having to carry items)?	yes	no
Are dishcloths, dishtowels & oven mitts away from stove burners/flames?	yes	no
LIGHTING
Is there adequate lighting in all stairways and hallways?	yes	no
Is there a light switch at both the top and bottom of stairs?	yes	no
Is there a night light between bedroom and bathroom?	yes	no
CLIENT’S/RESIDENT’S POTENTIAL FOR VIOLENCE
Is there a history of violence?	yes	no
Are there violence fantasies or plans of violence?	yes	no
Is there a level of support from significant other?	yes	no
Are there signs & symptoms? i.e.: o staring and eye contact; o tone & volume of voice; o pacing o anxiety; o mumbling	yes	no
NEIGHBORHOOD HAZARDS
Is there sufficient lighting?	yes	no
Can individuals be heard if they call for help?	yes	no
Are there people nearby who can help?	yes	no
Are there improvements that can be made to enhance safety?	yes	no
OTHER

SAFETY CRITERIA

YES

ENTRANCE TO HOME

Are there outside lights covering the sidewalks and/or other entrance ways?

yes

Are the steps & sidewalks in good repair and free from debris/material?

yes

Is a ramp needed?

yes

Are the railings on the steps secured?

yes

Is there a functional peephole in the front door?

yes

Does the door have a deadbolt lock that does not require a key to open it from the inside (unless client has a tendency to wander)?

yes

GENERAL

Is there an emergency plan in place?

yes

Are working smoke detectors installed?

yes

Is there a “ready-to-use” fire extinguisher(s) on the premises?

yes

Are inside halls and stairways free of clutter/debris?

yes

Are throw rugs removed?

yes

Are there sturdy handrails or banisters by all steps and stairs?

yes

Are electrical cords non-frayed and placed in a manner to avoid tripping?

yes

Are electric outlets/switches overloaded (e.g. warm to the touch)?

yes

Are rugs secured around the edges?

yes

Are hazardous products labeled and kept in a secure place?

yes

Is there a need for a stool to reach high shelves/cupboards?

yes

Is smoking paraphernalia handled safely (e.g. cigarettes put out)?

yes

Does anybody smoke in homes where oxygen is in use?

yes

Are all animals, on site, controlled?

yes

Is the home free from bugs, mice and/or animal waste?

yes

Are materials stored safely and at a proper height?

yes

Does the client wear an emergency response necklace/bracelet?

yes

Are polished floors no waxed or waxed-free?

yes

MEDICATIONS

Are all medications marked clearly?

yes

Are medications named?

yes

Are medications dated?

yes

Are instructions given as to how medications are to be taken?

yes

Are instructions given as to when medications are to be taken?

yes

MEDICAL EQUIPMENT/SUPPLIES

Are used needles placed in a sharp container?

yes

Is oxygen tubing kept off the walking path?

yes

Is medical equipment properly stored?

yes

LIVING AREAS

Are doorways wide enough to carry loads through and get a wheelchair/walker through?

yes

Are light switches accessible so they can be turned on/off without walking across a dark room?

yes

Are sofas & chairs high and firm enough for easy sitting and rising?

yes

Is there a telephone in the room that is easily accessible from the bed?

yes

Is list of emergency telephone numbers by the telephone?

yes

Do telephone cords/electronic wires run across walking areas?

yes

Are there castors or wheels on furniture?

yes

Does sitting furniture have armrests which are strong enough for getting in and out?

yes

Are phone & extension cords out of the foot traffic area?

yes

Is the room clutter-free?

yes

Are heaters at least 12 inches from furniture and drapes?

yes

BATHROOM

Are there glass doors on the bathtub/shower?

yes

Is there a non-skid surface/mat in the bathtub/shower?

yes

Are there grab-bars on the bathtub/shower and adjacent to the toilet?

yes

Is there a raised toilet seat (if client has trouble getting on/off toilet)?

yes

Is a hand-held shower spray required?

yes

Is the water temperature below scalding (e.g. below 120°?

yes

Is there a shower bench/bath seat with a hand-held shower wand available?

yes

Does the bathroom have a night light?

yes

Are there unsafe loose rugs, carpet or tiles on floor?

yes

BEDROOM

Are there any scatter rugs?

yes

Is the bed lower than “back-of-the-knee” height?

yes

Is there a chair with armrests & firm seat (to reduce falls while dressing)?

yes

Does furniture have castors or roll?

yes

Is there a telephone in the room that is easily accessible from the bed?

yes

Is list of emergency telephone numbers by the telephone?

yes

Is there a flashlight, light switch or lamp beside the bed?

yes

Is there a night light?

yes

KITCHEN

Is the floor waxed or in a slippery condition?

yes

Are there any flammable items near the heat source?

yes

Do the “ON” buttons work on all appliances?

yes

Are stove controls accessible and easy to use?

yes

Are items used the most stored between eye and knee level?

yes

Is there an uncluttered workspace near the cooking area (to avoid having to carry items)?

yes

Are dishcloths, dishtowels & oven mitts away from stove burners/flames?

yes

LIGHTING

Is there adequate lighting in all stairways and hallways?

yes

Is there a light switch at both the top and bottom of stairs?

yes

Is there a night light between bedroom and bathroom?

yes

CLIENT’S/RESIDENT’S POTENTIAL FOR VIOLENCE

Is there a history of violence?

yes

Are there violence fantasies or plans of violence?

yes

Is there a level of support from significant other?

yes

Are there signs & symptoms? i.e.:

o staring and eye contact;

o tone & volume of voice;

o pacing

o anxiety;

o mumbling

yes

NEIGHBORHOOD HAZARDS

Is there sufficient lighting?

yes

Can individuals be heard if they call for help?

yes

Are there people nearby who can help?

yes

Are there improvements that can be made to enhance safety?

yes

OTHER

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December 20, 2023 5:30 pm GMT

HOME SAFETY CHECKLIST Uploaded by John Smith - smitch@chsfl.co IP 202.47.33.79