Health and Safety Plan Form | FamiliesForFamilies

Name of Person Submitting This Form

Relationship to the Client

Home Address

Today's Date required

Encabezado 4

Instructions: This Health and Safety Assessment and Plan is to be maintained current at all times. An assessment and plan shall be completed and/or updated when a consumer enters services and each time the consumer moves. The plan should be completed for individuals in Comprehensive Services as well as Supported Living Services. The IDT may waive the need for an assessment/plan for SLS consumers living with family if the family is responsible for the consumer's health and safety 24 hours a day.

Encabezado 4

Knows names of medication taken

Yes

N/A

Knows what medications are taken for

Yes

N/A

Identifies dosages taken, route and correct times to take medication

Yes

N/A

Identifies appropriate prescription container for each medication

Yes

N/A

Can explain side effects of medication

Yes

N/A

Reports side effects of medication

Yes

N/A

Reports when dosage is not effective--too much or too little

Yes

N/A

States/demonstrates what to do if dosage is missed

Yes

N/A

Explains the risks of not taking medication

Yes

N/A

Knows how to take medications properly (interactions w/food, etc.)

Yes

N/A

Encabezado 4

Chooses correct medication container at the correct time

Yes

N/A

Dispenses medication from container (can open container)

Yes

N/A

Counts or measures correct amount of medication from container

Yes

N/A

Fills seven-day planner from prescription bottles without any assistance

Yes

N/A

Takes medication at appropriate times--does not skip dosages

Yes

N/A

Informs support staff when medication supply is down to five days

Yes

N/A

Reads medication bottle label to identify information for recording

Yes

N/A

Reorders medication without staff assistance

Yes

N/A

Takes medications on outings/day program/visits with family as needed

Yes

N/A

Medication is stored safely (separate from other meds, refrigerated if needed)

Yes

N/A

Can purchase over the counter medications as needed

Yes

N/A

Encabezado 4

Can regulate water temperature without assistance

Yes

N/A

Can bathe/shower without supervision (no seizure, mobility, safety or medical concerns)

Yes

N/A

Can bathe/shower without assistance

Yes

N/A

Can access bath/shower independently

Yes

N/A

Can communicate if the water temperature is not comfortable (too hot/cold)

Yes

N/A

Encabezado 4

Has list of contact and emergency numbers posted by phone (including poison control)

Yes

N/A

Can describe what an emergency is

Yes

N/A

Can demonstrate use of emergency contact information

Yes

N/A

Provides or says name, address, phone number

Yes

N/A

Has identification with current address and emergency number

Yes

N/A

Carries identification with current address and emergency number

Yes

N/A

Demonstrates ability to dial 911 for assistance when necessary

Yes

N/A

Describes appropriate vs. inappropriate use of 911

Yes

N/A

Can access nearest neighbor or phone in case of emergency

Yes

N/A

Has emergency evacuation plan in home

Yes

N/A

Encabezado 4

Demonstrates how to contain stove-top fire

Yes

N/A

Identifies most flammable liquids (i.e. cleaning products)

Yes

N/A

Stores flammable liquids properly--away from heat, not with food

Yes

N/A

Demonstrates what to do if clothes are on fire (stop, drop and roll)

Yes

N/A

Has working smoke detector and back-up batteries (if hearing impaired-flashing alarm)

Yes

N/A

Explains what to do if alarm sounds

Yes

N/A

Responds to smoke alarm, smell of smoke or warning from others

Yes

N/A

Has fire extinguisher in accessible place

Yes

N/A

Demonstrates how to use fire extinguisher

Yes

N/A

Demonstrates when to use fire extinguisher

Yes

N/A

Demonstrates how to avoid starting fires (no smoking in bed, turn off stove, etc.)

Yes

N/A

Encabezado 4

Describes when to evacuate

Yes

N/A

Demonstrates ability and willingness to evacuate in the event of fire

Yes

N/A

Describes or demonstrates evacuation routes

Yes

N/A

Knows to leave home to call for help in the event of a fire

Yes

N/A

Knows not to re-enter home until told it is safe

Yes

N/A

Demonstrates ability to crawl on floor if there is smoke

Yes

N/A

Describes how to alert others in the event of danger

Yes

N/A

Demonstrates how to check door before opening and knows not to open if hot

Yes

N/A

Demonstrates how to block space under door if unable to escape

Yes

N/A

Knows not to use elevator in event of fire

Yes

N/A

Is able to call 911 from outside home and give correct information

Yes

N/A

Has knowledge and ability to close but not lock door when leaving home

Yes

N/A

Knows and is able to shout for help when applicable

Yes

N/A

Encabezado 4

Calls if late or unable to make appointment

Yes

N/A

Tells staff/provider when going out

Yes

N/A

Can identify what it would mean to be lost

Yes

N/A

Describes what to do if lost--call staff, asks police, etc. for help, shows I.D.

Yes

N/A

Able to call cab

Yes

N/A

Able to use public transportation

Yes

N/A

Can identify street and community signs

Yes

N/A

Is able to safely cross intersections

Yes

N/A

Encabezado 4

Has primary physician and dentis

Yes

N/A

Can contact physician and dentist when needed

Yes

N/A

Can schedule appointments as needed

Yes

N/A

Can transport self to appointments

Yes

N/A

Recognizes common health hazards (i.e. smoking, drinking, drug use, unprotected sex)

Yes

N/A

Participate in routine health/exercise program

Yes

N/A

Encabezado 4

Describes use of 1st Aid for minor illness/injuries: colds, upset stomach, etc.

Yes

N/A

Alerts staff/provider to health problems

Yes

N/A

Wears/carries emergency medical identification as needed (i.e. seizures, diabetes)

Yes

N/A

Can identify signs and symptoms of illness needing care (i.e. cold, broken bones)

Yes

N/A

Determines if ill enough to require medical care

Yes

N/A

Knows own allergies and describes/demonstrates what to do for them

Yes

N/A

Locate 1st Aid kit, identifies contents and their purpose

Yes

N/A

Knows how to treat minor illness/injuries (abrasions, colds, cough, etc.)

Yes

N/A

Describes/demonstrates when to take over the counter medications (aspirin, etc.)

Yes

N/A

Knows how much over the counter medication to take for minor illness

Yes

N/A

Knows what to do in the event of a serious illness

Yes

N/A

Knows what to do in the event of an accident

Yes

N/A

Encabezado 4

Identifies community warning system and describes/demonstrates what to do

Yes

N/A

Describes what to do in the event of high winds or tornado (stay indoors away from windows, listen to TV or radio, goes to shelter)

Yes

N/A

Describes what to do in the event of a flood (high ground)

Yes

N/A

Describes what to do in heat wave (drink fluids, stay out of sun)

Yes

N/A

Describes what to do in the event of lightning (don't use phone, stay inside)

Yes

N/A

Describes what to do for extreme cold weather

Yes

N/A

Describes what to do in blizzard conditions

Yes

N/A

Describes what to do in hail storm

Yes

N/A

Describes what to do if utilities are out

Yes

N/A

Describes what to do in the event of an earthquake

Yes

N/A

Knows where designated "safe" areas are for emergency evacuations (see plan)

Yes

N/A

Encabezado 4

Keeps doors and windows to home locked

Yes

N/A

Opens door only to known people

Yes

N/A

Describes how to identify potential intruder

Yes

N/A

Describes/demonstrates how to respond to intruder; yell for help, call 911 etc.

Yes

N/A

Is cautious with strangers--doesn't give out personal info, accept rides, etc.

Yes

N/A

Knows basic self-defense tactics--yelling "Back Off!", running away, etc.

Yes

N/A

Encabezado 4

Understands consequences of unprotected sex (HIV, STDs, Pregnancy)

Yes

N/A

Knows how to say "no" and/or prevent unwanted sexual advances (not inviting strangers in, pushing person away, sticking to "no")

Yes

N/A

Demonstrates ability to access condoms and birth control

Yes

N/A

Demonstrates understanding of inappropriate or threatening sexual behavior

Yes

N/A

Demonstrates/understands appropriate public/private sexual behavior

Yes

N/A

Does not associate with people or engage in situations which will jeopardize personal safety

Yes

N/A

Demonstrates an interest in sexual activity

Yes

N/A

Has a history of sexual abuse/exploitation

Yes

N/A

Knows how to avoid sexual abuse/exploitation

Yes

N/A

Can describe when personal safety is in jeopardy

Yes

N/A

Knows not to show money to others

Yes

N/A

Avoids high risk activities and areas (i.e. late night walks, bars)

Yes

N/A

Encabezado 4

HUD checklist completed?

Yes

N/A

Has working flashlight and back-up batteries

Yes

N/A

Home is kept clear of clutter and safety hazards

Yes

N/A

Home is stocked with 3-4 days worth of non-perishable food and water

Yes

N/A

Has extra blankets

Yes

N/A

Bathtub has non-slip surfaces (mat or stickers)

Yes

N/A

Uses electricity safely, not too many appliances in one outlet

Yes

N/A

Unplugs/turns off appliances when not in use

Yes

N/A

Uses stove/oven safely

Yes

N/A

Uses cooking utensils safely

Yes

N/A

Uses household appliances safely

Yes

N/A

Uses and stores household products safely (proper use, stores separately from food)

Yes

N/A

Describes how to identify gas leak (smells like rotten eggs)

Yes

N/A

Knows to evacuate home if gas odor noticed

Yes

N/A

Can identify household maintenance needs

Yes

N/A

Knows who to call for repairs or problems in the household

Yes

N/A

Can identify poisonous household products

Yes

N/A

Disposes of trash properly

Yes

N/A

Encabezado 4

Is able to identify physical, verbal or other types of abuse and neglect

Yes

N/A

Can identify if being exploited (being taken advantage of)

Yes

N/A

Is able to say no to exploitation

Yes

N/A

Is able to report assault, abuse, exploitation

Yes

N/A

Is willing to report assault, abuse or exploitation

Yes

N/A

Knows who and when to report to assault, abuse or exploitation

Yes

N/A

Inventory is current with possessions including serial numbers and model numbers

Yes

N/A

Encabezado 4

Describes the components of a well-balanced meal

Yes

N/A

Plans well-balanced meals

Yes

N/A

Prepares well-balanced meals

Yes

N/A

Describes relationship between food, exercise and weight

Yes

N/A

Follows a plan for healthy eating habits and exercise

Yes

N/A

Demonstrates ability to monitor own weight

Yes

N/A

Identifies and disposes of spoiled food

Yes

N/A

Stores food properly (refrigerate as needed, away from hazardous materials, medications)

Yes

N/A

Demonstrates ability to properly prepare foods (clean/cook thoroughly)

Yes

N/A

Demonstrates proper hygiene when preparing food

Yes

N/A

General Instructions: The intent of this health and safety plan is to address the specific actions and steps to be taken by anyone (including staff/providers and consumer) with responsibilities to carry out the plan. This plan should be written to address what staff/providers will do to support this person's health and safety needs. In addition, the plan should address what the individual will do if staff/provider is not available to offer that support in the event of an emergency. This is especially important for people who have a window of unsupervised time as designated by the IDT in the IP. It is strongly recommended that emergency procedures be copied to an emergency procedures sheet for quick reference.

Refer to each section of the Health and Safety Assessment when developing this plan.

Encabezado 4

Name of Pharmacy

Number of Pharmacy

What monitoring is needed to take medication reliably?

How frequently is medication use monitored? (daily, weekly, monthly, quarterly)

How is this documented?

Psychiatrist who reviews person's medication yearly

Date of last review required

Frequency of Human Rights Committee (HRC) review

Date of last HRC review required

Frequency of tardive dyskinesia screens or other longer term side effects

Who completes these screens (i.e. RN, psychiatrist)?

How is this documented?

What steps would be needed in the event of a medication emergency?

Review all responses A-C: support/training needed

Encabezado 4

What level of supervision is needed?

If periodic supervision, indicate the frequency

Describe assistance needed in bathing

What type of adaptive equipment is needed to ensure safety while bathing?

Does the person assisting need to be male or female? Describe why.

Has the water temperature been set safely (below 120 degrees) or scald protector installed?

What measures are needed to protect this person's privacy?

What medical/health concerns need to be addressed/considered while bathing?

Other

Review all responses D: support/training needed

Encabezado 4

What type of support might this person need to communicate in an emergency?

Is this telephone programmed to dial 911?

Who are contacts on the emergency contact sheet in home?

Where would this person go temporarily in the event of an emergency?

Temporary location - Name

Temporary location - Address

Temporary location - Phone

Is any adaptive equipment needed to enhance safety in home/community?

If yes, what types?

If seizure disorder, is a seizure protocol in place?

Review all responses E: support/training needed

Encabezado 4

How often are fire safety skills to be practiced with this person?

How frequently does staff check smoke alarms/fire extinguishers?

Does the person's home need to be flagged by the local fire department?

Under what circumstances should fire suppression be attempted?

Review all responses F: support/training needed

Encabezado 4

Describe what the person will do in the event of a fire

What are the evacuation routes to be used to exit the home?

Is the person capable of evacuation?

Has the person practiced using these exits?

Where should this person go in the event of evacuation? (name/address/phone)

Does the person know the location/person designated to go to in evacuation?

If assistance needed to evacuate, what will staff need to do?

Does the individual's home have two exits from the sleeping floor?

What are the two exits from the sleeping floor?

Has the person practiced using these exits?

How quickly does this person respond to a smoke alarm or warning?

How quickly can this person evacuate from the home?

Based on ability, how often does fire evacuation need to be practiced?

How frequently are specific fire procedures (other than evacuation) practiced?

Review all responses G: support/training needed

Encabezado 4

At what point is this person determined missing?

What steps would need to be followed if the person was determined missing?

What assistance does this person need to ensure safety while in the community?

Review all responses H: support/training needed

Encabezado 4

Describe this person's most significant health and safety issues which require support

How are the health and medical needs for this person supported?

In a medical emergency, who should be contacted?

Where should this person be taken in the event of a medical emergency?

Hospital location

If adaptive equipment is used, how frequently is it checked for maintenance?

Who is contacted to perform maintenance?

Maintenance contact - Company/Name

Maintenance contact - Address

Maintenance contact - Phone

Review all responses I: support/training needed

Encabezado 4

Where is a first aid kit kept in the home?

How frequently is the kit checked and restocked?

What level of assistance is needed to use first aid supplies for minor injuries?

What support is needed to get/store/check/discard OTC medication?

What support would be needed in the event of a serious illness?

What support would be needed in the event of an accident?

Review all responses J: support/training needed

Encabezado 4

High Wind/Tornado plan

Flood plan

Heatwave plan

Extreme Cold plan

Lightning plan

Blizzard plan

Hail plan

Power/Utility Outage plan

What supports would staff need to provide in severe weather/disaster?

How frequently are emergency procedures for severe weather practiced?

Review all responses K: support/training needed

Encabezado 4

In an assault/intruder emergency, what should this person do?

What should staff do?

Review all responses L: support/training needed

Encabezado 4

Describe specific issues which may jeopardize this person's personal health and safety

Review all responses M: support/training needed

Encabezado 4

Who is to be contacted if repairs/maintenance are needed - Name

Who is to be contacted if repairs/maintenance are needed - Phone

Household hazards notes

Need household repairs notes

Review all responses N: support/training needed

Encabezado 4

What signs would staff look for if this person were unable/unwilling to indicate M/A/N/E?

What support would staff provide in the event of M/A/N/E?

Review all responses O: support/training needed

Encabezado 4

Does this person have a special diet? If yes, what are the dietary restrictions?

If yes, who is the prescribing physician?

What is the diet prescribed for?

What types of supports does this person need to follow this diet?

How is this person's diet and nutrition monitored?

Review all responses P: support/training needed

Encabezado 4

Discuss any historic health/safety issues which may become a concern if support network changes

Encabezado 4

Doors and windows have locks

Yes

N/A

Windows are free from broken glass

Yes

N/A

Doors close securely

Yes

N/A

Doors and windows are not blocked

Yes

N/A

The home is free of electrical hazards (no frayed cords, no overloaded outlets)

Yes

N/A

The home is free of heating hazards

Yes

N/A

Hazardous materials are stored safely

Yes

N/A

All flooring (boards, carpeting, rugs, etc.) is secure

Yes

N/A

Stairs and railings inside and out of the home are safe

Yes

N/A

The person's home has adequate lighting (inside and outside)

Yes

N/A

Encabezado 4

I have read the health and safety assessment and plan. I am aware of the supports this person needs from me to maintain health and to be safe. I understand how to respond to an emergency for this consumer and how to assist the consumer to evacuate the residence in the event of an emergency.

Your Signature