PA Monthly QAPA Monthly QA Please Fill out This Form: Date * Program Administrator DetailsName * Name First Name First Name Last Name Last Name Facility Program * Phone Number * Email address * General Home SafetyCarbon Detector & Smoke Detectors Working * Met Unmet Comments Fire Extinguisher Charged * Met Unmet Comments Fire Evacuation Map Posted * Met Unmet Comments Fire Drill Log Up To Date * Met Unmet Comments On Call # Posted * Met Unmet Comments Staff Schedule Posted * Met Unmet Comments DRM & Rights Information Posted * Met Unmet Comments No Outstanding Maintenance Requests * Met Unmet Comments Labor Laws Posted in Office * Met Unmet Comments License Posted * Met Unmet Comments Employee handbook signed by all staff * Met Unmet Comments Residential Policy Signed by All Staff * Met Unmet Comments Reportable Event Policy signed by all staff * Met Unmet Comments Grievance Policy signed by all staff * Met Unmet Comments Food QAMeal plan & Activity Posted * Met Unmet Comments Mileage & Activity Log Current * Met Unmet Comments No expired foods in the fridge * Met Unmet Comments Foods not in original containers labeled/dated * Met Unmet Comments No food products on counter * Met Unmet Comments Food separated by resident * Met Unmet Comments Medical QAPerson Name First & Last Name * CRMA Med Policy Signed by all staff * Met Unmet Comments Vital Information Complete & Current * Met Unmet Comments Emergency Data Form is Current * Met Unmet Comments MAR Complete, no blanks * Met Unmet Comments CRMA Signatures on MAR * Met Unmet Comments Previous 2 months MAR * Met Unmet Comments Side Effects for Every Med w/ CRMA Signatures * Met Unmet Comments Current Order for Each Med * Met Unmet Comments Current Consent for Each Med * Met Unmet Comments Current OTC Order * Met Unmet Comments Internal & External Meds Separate * Met Unmet Comments Discontinued & Expired Meds in Destroy Box * Met Unmet Comments Control Book Up To Date * Met Unmet Comments After Visit Summaries for Med Appointments * Met Unmet Comments Doctor appointment * Met Unmet Comments plus1 Add minus1 RemoveHouse QABedroom Person Name * Clean & organized * Met Unmet Comments Lights working * Met Unmet Comments Floor, Windows, Walls in good repair * Met Unmet Comments Door lock * Met Unmet Comments Phones working * Met Unmet Comments Reflect the person personality * Met Unmet Comments plus1 Add Person minus1 Remove PersonBathroomsClean & organized * Met Unmet Comments Lights working * Met Unmet Comments Floor, Windows, Walls in good repair * Met Unmet Comments Tub/shower clean * Met Unmet Comments Hygiene products organized and separated by * Met Unmet Comments Laundry Area & BasementClean & organized * Met Unmet Comments No evidence of water/moisture * Met Unmet Comments Items stored 4 inches off the floor * Met Unmet Comments Living Area & HallwaysClean & organized * Met Unmet Comments Lights working * Met Unmet Comments Floor, Windows, Walls in good repair * Met Unmet Comments Couches and chairs clean * Met Unmet Comments TV working * Met Unmet Comments Internet working * Met Unmet Comments Phones working * Met Unmet Comments KitchenClean & organized * Met Unmet Comments Refrigerator clean and appropriate temperature * Met Unmet Comments Oven/stove clean * Met Unmet Comments Lights working * Met Unmet Comments Fire extinguisher checked and working * Met Unmet Comments Floor, Windows, Walls in good repair * Met Unmet Comments Clinical BookCurrent Rental agreement up to date * Met Unmet Comments Current Authorization to release * Met Unmet Comments Current photo Release * Met Unmet Comments Current permission to administer medication * Met Unmet Comments Current guardianship letter * Met Unmet Comments Current Consent to administration medication * Met Unmet Comments Current Functional Assessment * Met Unmet Comments Current Person Center Plan * Met Unmet Comments Submit If you are human, leave this field blank.