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Quarterly Monitoring Report
Review Date
*
ISSP Goal
Is the current ISSP plan still effective?
*
Yes
No
Explain how the plan continues to be effective.
Was it necessary to develop a new ISSP?
*
Yes
No
If yes, were IDT notified?
Yes
No
Home Monitoring
Rate the overall appearance of the home.
*
Is there a fire extinguisher accessible/in date?
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Yes
No
Where is the fire extinguisher located?
*
Is there a first aid kit accessible/in date?
*
Yes
No
Where is the first aid kit located?
*
Are the CO detectors/smoke alarms working?
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Yes
No
Where is the CO detector located?
*
Are all major appliances in good working order?
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Yes
No
Does the home have adequate food supply, stored properly?
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Yes
No
Are medication stored securely?
*
Yes
No
Does the home have adequate bathing facilities?
*
Yes
No
Does the home have adequate heating and cooling?
*
Yes
No
Are living areas/walkways free of obstructions?
*
Yes
No
Are exits free from blockages?
*
Yes
No
Are cameras present in the home?
*
Yes
No
If yes, rights modification in place?
Yes
No
Does the client have a keyed bedroom lock w/ outside access?
*
Yes
No
If no, is a rights modification in place?
Yes
No
Does the bathroom door have a lock?
*
Yes
No
Is the front door secured via key or door code?
*
Yes
No
If no, is a rights modification in place?
Yes
No
Does the client have access to food anytime?
*
Yes
No
If no, is a rights modification in place?
Yes
No
Does the client have freedom to furnish and decorate their room?
*
Yes
No
Does the client have freedom/support to control their schedule and/or activities?
*
Yes
No
Does the client have freedom to accept visitors at any time?
*
Yes
No
Is the home physically accessible?
*
Yes
No
If the client shares a room, do they have choice of roommate?
Yes
No
N/A
Are there any specific needs preventing client rights not otherwise mentioned?
*
Has the client had any medical visits in the last 3 months?
*
Yes
No
Do we have all visit summaries/orders?
*
Yes
No
Signature of Families for Families Representative Completing the Form
*
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