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HOME SAFETY ASSESSMENT: PREPARING THE HOME FOR HOME CARE Client’s Name(s): _____________________________________________________________________________ Check Completed By: _____________________________________________________ Date: _______________ (Client/Client’s Authorized Legal Representative) Indicate, with a checkmark, the areas that need further evaluation for client or CAREGiver SM safety. If safety hazards are identified, or you require assistance in completing a home safety assessment, consult with a Home Instead Senior Care representative for a follow-up visit by calling our business office at (706) 613-2224. Emergency Procedures Do you know how to summon for emergency assistance? Are emergency numbers posted and visible by the phone? Do you have access to a telephone if you fall (or experience some other emergency which prevents you from standing and reaching a phone)? If not, have you considered a personal medical alert system (i.e. Lifeline)? Fire Hazards & Response Do you have a home fire safety/emergency exit plan and an alternate emergency exit plan? Are exits and passageways kept clear? Are exits available from all locations in the house? Can the windows be opened? Do the following areas have properly working smoke detectors? Hallways Kitchen Bedrooms Attic Basement Do you have a carbon monoxide detector? If fuses are used, are they the correct size for the circuit? Are light bulbs the appropriate size and type for lamps or fixtures? Are gasoline, paints, solvents or other products that give off vapors or fumes stored away from ignition sources? Are containers of volatile liquids tightly capped? Is woodburning equipment installed properly? Does the fireplace have a smoke screen? Is maintenance for the fireplace/wood stove completed regularly (i.e. chimneys cleaned annually and clear from accumulation of leaves or other debris that can clog them)? If your home has space heating equipment, such as a kerosene heater, a gas heater or an LP gas heater, do you understand the installation and operating instructions thoroughly? Are curtains and other flammable items kept away from open flames? Are small stoves and heaters placed where they cannot be knocked over and away from furnishings and flammable materials such as curtains or rugs? Do you refrain from smoking, especially in bed? Are ashtrays, smoking materials or other fire sources (i.e. heaters, hot plates, teapots) located away from beds or bedding? Electric Outlets & Devices Are outlets used properly, avoiding “octopus” plugs and extension cords? Are small electrical appliances such as hair dryers, shavers, curling irons, etc. unplugged when not in use? Are there no outlets or switches that are unusually warm or hot to the touch? Do all outlets and switches have cover plates so that no wiring is exposed? Are electric cords free from fraying or cracking? Are electric cords out from beneath furniture and rugs or carpeting? Do electric plugs fit snugly into their sockets?
Do electric cords run along walls and not across rooms where they are in the flow of traffic? Are electric cords attached to the walls, baseboards, etc. with tape, not nails or staples? Do you know the proper use of heating pads and space heaters? Does the electrical system meet the power requirement for special medical equipment such as ventilators and oxygen concentrators?
Medical Equipment Management Do you know the proper operation of your equipment? Do you understand the mechanical safety requirements? Do you know the proper storage and cleaning of the equipment? Do you understand the hazards of the equipment and how to avoid them? Do you know whom to contact if the equipment malfunctions? Oxygen Safety Are you aware of the dangers of smoking in the presence of oxygen equipment? Is a “No Smoking” sign posted? Do you know the appropriate storage of oxygen cylinders? Do you know the appropriate placement of oxygen concentrators? Floors Is nonskid wax used on floors? Are all small rugs and runners slip-resistant? Are scatter rugs secured at the edges and safe for movement? Are pathways & hallways clear of excess furniture and debris? Stairways Are stairs well lighted? Are light switches located at both the top and bottom of inside stairs? Are there nonskid treads on stairs? Can you clearly see the edges of the steps? Are steps even and of the same size and height? Are different colors used to mark changes in levels? Are sturdy handrails fastened securely on both sides of the stairway? Do the handrails run continuously from the top to the bottom of the entire flight of stairs? Are stairs free of clutter? Is the carpet secure and are the coverings on the steps in good condition to allow secure footing? Lighting Are hallways, passageways between rooms and other heavy traffic areas well lit? Is lighting sufficient and working throughout the house? Are burnt-out light bulbs replaced? Are nightlights used along routes/areas traveled after dark? Can you turn on the lights without first having to walk through a dark area? Are light switches easily visible and within reach throughout the house? Entrances Are the outside entries safe and well lighted? Are streetlights in front of the home working? Is parking available at a safe distance? Are steps safe and the railing secure? Are the walkways uncluttered? Are windows free of broken panes?
Are visitors visible prior to entry? Are the doorways accessible? Are keys and locks easy to access? Are the locks on the door in working order? Are doorbells working and able to be heard?
Kitchen Is the doorway accessible? Is the kitchen free of clutter? Are appliances in working order? Are faucets working? Are the stove burners and oven working? Are towels, curtains and other things that might catch fire located away from the range? Do you avoid wearing clothing with long, loose-fitting sleeves while you are cooking? Do you avoid using a gas range or oven to heat your home? Are kitchen ventilation systems or range exhausts functioning properly and are they in use while you are cooking? Are electrical cords safe for use? Does the refrigerator keep foods cold? Are expired foods thrown away? Does good, even lighting exist over the stove, sink and countertop work areas, especially where food is sliced or cut? Are dishes, pots, silverware and cutlery stored for cleanliness and safety? Are adaptive devices required (i.e. extended graspers or eating devices)? Are sharp objects kept in secure areas out of reach of confused adults? Do you have a step stool which is stable and in good repair? Bedroom Is the doorway accessible? Is access to the bed free of clutter? Is there a need for a hospital bed or trapeze? Is a bedside commode available, if necessary? Is there access to the closet? Are rugs safe for movement? Is lighting accessible from the bed? Is a nightstand available for storage of personal items? Do you make sure that there is nothing covering your electric blanket when in use and do you avoid “tucking in” the sides or ends of your electric blanket? Do you turn off your heating pad before you go to sleep? Is there a telephone close to your bed? Are a flashlight & emergency items within reach? Bathroom Is the doorway accessible? If needed, are raised toilet seats secure? Is there transfer space to the toilet/shower/tub? Are fixtures in working condition? Is the water temperature 120 degrees or lower to prevent tap water scalds? Do bathtubs and showers have at least 1 (preferably 2) handgrips/grab bars? Are bathtubs and showers equipped with non-skid mats, abrasive strips or surfaces that are not slippery? Is there a secure seat or shower bench in the tub/shower? Are floors safe if wet and is the carpet secure?
Are there handgrips/grab bars by the toilet? Is the bathroom conveniently located in the home? Is there a seat by the sink?
Miscellaneous Are medications properly stored in the containers that they came in and are they clearly marked and accessible? Is the house free of bugs, roaches and mice? Is the house free of harmful odors? Is the mailbox safely accessible? Is garbage safely stored and disposed? Are power tools equipped with a 3-prong plug or marked to show that they are double insulated? Are power tool guards in place? Are the grounding features of any 3-prong plugs being properly used (the grounding pin should not be removed and no adapters which allow use in 2-prong outlets should be used)? To Do List/Notes: ____________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
