CHECKLIST
ADULT COMMUNITY RESIDENTIAL SERVICES
Fourth Edition
COOLIDGE HOUSE
CRJ - Coolidge House 1
4-ACRS-1A-01 (MANDATORY) (Ref. 3-ACRS-4D-05) The facility potable water source and supply are sanitary and are approved by an independent, qualified agency or individual to be in compliance with jurisdictional laws and regulations.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Sanitation and Housekeeping P&P
Letter from Boston Water & Sewer Commission
Information about Boston Water & Sewer
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 2
4-ACRS-1A-02 (MANDATORY) (Ref. 3-ACRS-4D-02) The facility complies with the sanitation and health codes of the jurisdiction having authority.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Sanitation and Housekeeping P&P
Health Permit
Food Services Inspection
Certificate of Compliance for Kitchen Grease Exhaust
House Details List
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 3
4-ACRS-1A-03 (Ref. 3-ACRS-4D-01) Sanitation and safety inspections are conducted weekly, inspection results are reviewed, and deficiencies are corrected.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Sanitation and Housekeeping P&P
Room Search Forms
Daily Inspection Sheets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 4
4-ACRS-1A-04 (MANDATORY) (Ref. 3-ACRS-4D-03) Waste is disposed of properly in accordance with an approved plan by the appropriate regulatory agency.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Sanitation and Housekeeping P&P Site Cleanliness License Daily Inspection Sheets Room Search Forms EZ Disposal Invoices
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 5
4-ACRS-1A-05 (MANDATORY) (Ref. 3-ACRS-4D-04) Vermin and pests are controlled.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Sanitation and Housekeeping P&P
AAA Exterminating Treatment Plan Letter
AAA pink site documents
AAA invoices
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 6
4-ACRS-1A-06 (Ref. 3-ACRS-4D-06) The facility is clean and in good repair, and a housekeeping and maintenance plan is in effect.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Sanitation and Housekeeping P&P
House Details List
Daily Inspection Sheets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 7
4-ACRS-1A-07 (Ref. 3-ACRS-2D-01) (Revised January 2008) Documentation is provided by an independent, qualified source that lighting is at least 20 footcandles at desk level and in personal grooming areas.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Living Environment P&P
Email from Turner Engineers re: foot candles
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 8
4-ACRS-1A-08 (Ref. 3-ACRS-2D-01) (Revised August 2002) (Interpretation August 2002) Air circulation is at least 15 cubic feet of outside or recirculated filtered air per minute per person and should be checked not less than once per accreditation cycle.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Living Environment P&P
Email from Turner Engineers re: ventilation
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 9
4-ACRS-1A-09 (Ref. 3-ACRS-2A-01) The facility conforms to all applicable building codes and applicable federal laws.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Zoning and Building Code Compliance P&P
City of Boston Inspection Certificate
Certificate of Use and Occupancy
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 10
4-ACRS-1A-11 (Ref. 3-ACRS-2E-07) Space is provided for janitorial supplies in one or more locations that are accessible to the living and activity areas.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
Auditor Signature(s)
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Sanitation and Housekeeping P&P
Floor plans
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 11
4-ACRS-1A-12 (Ref. 3-ACRS-2C-07) Offenders have access to operable showers with temperature-controlled hot and cold running water, at a minimum ratio of one shower for every eight offenders, unless national or state building or health codes specify a different ratio. Water for showers is thermostatically controlled to temperatures ranging from 100 degrees Fahrenheit to 120 degrees Fahrenheit to ensure the safety of offenders and to promote hygienic practices.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Living Environment P&P
Shower ratios
Daily Kitchen Temperature Checklist
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 12
4-ACRS-1A-13 (Ref. 3-ACRS-1A-13) Offenders have access to writing and seating space.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Furnishings P&P
Photo of writing/seating areas
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 13
4-ACRS-1A-14 (Ref. 3-ACRS-2C-03) Male and female offenders do not occupy the same sleeping room.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Living Environment P&P
Bedsheets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 14
4-ACRS-1A-15 (Ref. 3-ACRS-2C-11) (Revised January 2007) Offenders are permitted to decorate their living and sleeping quarters with personal possessions. Rules regarding the decorating of living/sleeping quarters are available to all offenders and staff. These rules are reviewed annually and revised, if necessary.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Furnishings P&P
Intake Process P&P
Resident Handbook
Memo
Photo of resident room
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 15
4-ACRS-1B-01 (Ref. 3-ACRS-3B-09) (MANDATORY) (Revised-August 2002) An annual safety inspection of all vehicles is conducted by qualified individuals and in accordance with state statutes for any vehicle that is owned, leased or used in the operation of the facility.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Brooke House does not have a vehicle
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 16
4-ACRS-1B-02 (Ref. 3-ACRS-3B-09) Safety repairs are completed immediately. Vehicles are not used again until repairs are made.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Brooke House does not have a vehicle
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 17
4-ACRS-1B-03 (Ref. 3-ACRS-3B-09) Vehicles are operated only by licensed drivers.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Brooke House does not have a vehicle
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 18
4-ACRS-1B-04 (Ref. 3-ACRS-3B-09) Vehicles and drivers are insured in conformance with state statutes.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Brooke House does not have a vehicle
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 19
4-ACRS-1C-01 (Ref. NEW) Emergencies are analyzed and the results used to initiate or revise policy and/or procedure to prevent future occurrences.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Emergency Plans P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 20
4-ACRS-1C-01-1 (Ref. NEW) (Added January 2003) Critical incidents are defined for the facility along with a debriefing to be conducted after each such incident. The debriefing process includes coordination and feedback about the incident with designated staff of the facility as soon as possible after the incident. A debriefing includes, but is not limited to: a review of staff and offender actions during the incident a review of the incident’s impact on staff and offenders a review of corrective actions taken and still needed plans for improvement to avoid another incident
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Emergency Plans P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 21
4-ACRS-1C-02 (MANDATORY) (Ref. 3-ACRS-3B-06) There is a written emergency plan, which includes an evacuation plan, to be used in the event of a major emergency. The plan is reviewed annually, updated if necessary. The plan includes the following:
• location of building/room floor plan • use of exit signs and directional arrows that are easily seen and read • location of publicly posted plan
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Emergency Plans P&P
Memo
Floor plans
Emergency Evacuation Plan in English
Emergency Evacuation Plan in Spanish
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 22
4-ACRS-1C-04 MANDATORY (Ref. 3-ACRS-3B-07) All facility personnel are trained in the implementation of written emergency plans.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Emergency Plans P&P
Employee Orientation Checklist
Training Schedule
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 23
4-ACRS-1C-05 MANDATORY (Ref. 3-ACRS-3B-07) Emergency plans are disseminated to appropriate local authorities.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Emergency Plans P&P
Floor plans
Copies of letters with emergency plans sent to authorities
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 24
4-ACRS-1C-06 (Ref. 3-ACRS-3B-10) There is a written work stoppage or job action plan. Copies of this plan are available to appropriate supervisory personnel who are required to familiarize themselves with its contents.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Work Stoppage P&P
Memo
Training Schedule
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 25
4-ACRS- 1C-07 (Ref. 3-ACRS-3B-10) The facility operates continuously in the event of employee work stoppage or other job action.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Work Stoppage Plans P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 26
4-ACRS-1C-08 MANDATORY (Ref. 3-ACRS-2A-03) Comply with the regulations of the fire authority having jurisdiction.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Boston Fire Inspection
Boston Fire Permit
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 27
4-ACRS-1C-09 MANDATORY (Ref. 3-ACRS-3B-06) (Revised August 2007) There is a written evacuation plan to be used in the event of a fire. The plan is certified by an independent qualified agency or individual trained in the application of national fire safety codes. The plan is reviewed annually, updated if necessary and reissued to the local fire jurisdiction. The plan includes the following:
• location of building/room floor plan • use of exit signs and directional arrows that are easily seen and read • location of publicly posted plan • at least quarterly drills in all facility locations, and on every shift, including administrative areas
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Emergency Plans P&P
Resident Handbook
Fire Drills
Floor Plans
Copy of letter with emergency plans sent to Boston Fire Department
Training Schedule
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 28
4-ACRS-1C-10 MANDATORY (Ref. 3-ACRS-3B-01) A qualified person conducts fire inspections at least quarterly or at intervals approved by the fire authority having jurisdiction, following the procedures stated for variances, exceptions, or equivalences. Equipment is tested as specified by the manufacturer or the fire authority, whichever is more frequent.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Boston Fire Inspection
Boston Fire Permit
Certificate of Compliance for Kitchen Grease Exhaust
Carlysle Sprinkler Systems Inspection
Gorham Fire Extinguisher Inspection
Invoices from Carlysle, Gorham, RE Lyons
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 29
4-ACRS-1C-11 MANDATORY (Ref. 3-ACRS-3B-01) Secure an annual inspection by the authority having jurisdiction or other qualified person(s).
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
City of Boston Inspection Certificate
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 30
4-ACRS-1C-12 MANDATORY (Ref. 3-ACRS-3B-01) A fire prevention plan provides for fire protection service.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Carlysle Sprinkler Systems Inspection
Gorham Fire Extinguisher Inspection
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 31
4-ACRS-1C-13 MANDATORY (Ref. 3-ACRS-3B-02) The facility has a fire protection alarm system and an automatic detection system.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Carlysle Sprinkler Systems Inspection
Gorham Fire Extinguisher Inspection
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 32
4-ACRS-1C-14 MANDATORY (Ref. 3-ACRS-3B-01) Provide fire protection equipment at locations throughout the facility approved by the fire authority that has jurisdiction.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Boston Fire Inspection
Boston Fire Permit
Certificate of Compliance for Kitchen Grease Exhaust
Gorham Fire Extinguishers Inspection
Carlysle Sprinkler Systems Inspection
City of Boston Inspection Certificate
Floor plans
Invoices (Carlysle, Gorham RE Lyons)
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 33
4-ACRS-1C-15 MANDATORY (Ref. 3-ACRS-3B-04) Furnishings comply with fire safety performance requirements.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Bob Barker Invoices
Bob Barker Flammability Ratings
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 34
4-ACRS- 1C-16 MANDATORY (Ref. 3-ACRS-3B-05) Handle and store all flammable materials safely.
• Where smoking is permitted, provide noncombustible receptacles for smoking materials and separate containers for other combustible refuse at accessible locations throughout living quarters.
• Provide special containers for flammable liquids and for rags used with flammable liquids.
• Empty and clean all receptacles and containers daily.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Resident Handbook
Employee Orientation Checklist
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 35
4-ACRS-1C-17 MANDATORY (Ref. 3-ACRS-3B-03) Control the use and storage of all toxic and caustic materials.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Memo
MSDS
Photo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 36
4-ACRS-1C-18 (Ref. NEW) Train staff and offenders in the proper use and safe handling of toxic and caustic materials.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Fire Safety Plans P&P
Resident Handbook
Resident Handbook Acknowledgment Forms
Training Schedule
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 37
4-ACRS-2A-01 (Ref. 3-ACRS-3A-10) Access to and egress from the facility are controlled.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Accountability P&P
Vendor/Contractor Supervision P&P
Resident Handbook
Itineraries
Visitor’s Log
Photos
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 38
4-ACRS-2A-02 (Ref. 3-ACRS-5C-09) Movement of visitors is monitored and controlled.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Visitation P&P
Vendor/Contractor Supervision P&P
Resident Handbook
Visitor’s Log
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 39
4-ACRS-2A-03 (Ref. 3-ACRS-1C-19 and 3A-03) The facility administrator and/or governing authority systematically determine and review staffing requirements at least annually. Staffing plans are implemented.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Adult Services Budget
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 40
4-ACRS-2A-04 (Ref. 3-ACRS-3A-02) Staff members are available in the facility 24 hours a day to respond to offender needs.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Staff Availability P&P
Desk Staff Schedule/WEDO Schedule
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 41
4-ACRS-2A-05 (Ref. 3-ACRS-3A-02) When both males and females are housed in the facility, at least one male and one female staff member are on duty at all times.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
No females housed at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 42
4-ACRS-2A-06 (Ref. 3-ACRS-1C-18) If employee’s contracts are governed by civil service or unions, procedures provide for provisional appointments to ensure that short-term personnel, both full-time and part-time, can be available during emergencies.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Community Resources for Justice is not governed by civil service unions
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 43
4-ACRS-2A-07 (Ref. NEW) A risk assessment is conducted for each offender either prior to admission or within 48 hours of admission.
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Admission Criteria P&P
LSIs
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 44
4-ACRS-2A-08 (Ref. 3-ACRS-4A-05) The program advises the referring authority when a prospective offender is not accepted into the program, stating specific reasons.
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Admission Criteria P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 45
4-ACRS-2A-09 (Ref. 3-ACRS-3A-04) Information about routine operations and unusual incidents that occur at all locations in the facility are consistently recorded.
(a) Offender careworker staff maintain a permanent log. (b) Offender careworker staff prepare shift reports.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Shift summaries from general log
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 46
4-ACRS-2A-10 MANDATORY (Ref. 3-ACRS-3A-07) Possession and use of weapons is prohibited in the facility except in case of an emergency.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Weapons P&P
Resident Handbook
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 47
4-ACRS-2A-11 (Ref. 3-ACRS-3A-11) The facility has a system of accountability for offenders assigned to work and educational release, furloughs, and other temporary absences from the facility. The facility has a system for physically counting offenders. There are at least three offender counts daily. Staff monitor the movement of offenders into and out of the facility.
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Accountability P&P
Bedsheets
Headcounts
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 48
4-ACRS-2A-12 (Ref. 3-ACRS-3A-12) Absconders are detected and promptly reported. Timely notification is made to the facility with jurisdiction over the offender and others as appropriate.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Accountability P&P
General log documentation of escapes
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 49
4-ACRS-2A-13 (Ref. 3-ACRS-4H-01) The electronic monitoring program has a system of accounting for an offender at all times, including verification of activities, reporting of tardiness and/or absence from required services or activities, as well as other program violations.
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: There is no electronic monitoring at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 50
4-ACRS-2A-14 (Ref. 3-ACRS-4H-02 and 4H-03) Access to computer equipment is limited to authorized personnel with security codes. Adequate power and communication backup systems provide continuous, uninterrupted operations.
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: There is no electronic monitoring at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 51
4-ACRS-2A-15 (Ref. 3-ACRS-4H-05) Any interruption in service is documented and reported to the authority having jurisdiction.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: There is no electronic monitoring at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 52
4-ACRS-2A-16 (Ref. 3-ACRS-4H-08) A detailed written offender schedule is developed and signed by a staff member and the offender.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: There is no electronic monitoring at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 53
4-ACRS-2A-17 (Ref. 3-ACRS-4H-10) Provisions are made for those who are unable to pay program costs.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: There is no electronic monitoring at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 54
4-ACRS-2B-01 (Ref. 3-ACRS-3A-05) MANDATORY (Revised August 2000) Physical force is used only in instances of self-protection, protection of the offender or others, prevention of property damage, prevention of escape, or to maintain or regain control.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Use of Force P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 55
4-ACRS-2B-02 (Ref. 3-ACRS-3A-06) Persons injured in an incident immediately receive a medical examination and treatment.
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Use of Force P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 56
4-ACRS-2B-03 (Ref. NEW) Use of force incidents are investigated; findings are aggregated and analyzed.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Use of Force P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 57
4-ACRS-2C-01 (Ref. 3-ACRS-3A-13) The contraband policy is provided to staff and offenders.
SELF-EVALUATION
Agency Personnel STANDARDS COMPLIANCE AUDIT
Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Searches P&P
Resident Handbook
Resident Handbook Acknowledgment Forms
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 58
4-ACRS-2C-02 (Ref. 3-ACRS-3A-13) Searches are conducted to control contraband.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Searches P&P
Resident Handbook
U/A sheets
Weekly Safety and Sanitation Checklists
Room searches
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 59
4-ACRS-2C-03 (Ref. 3-ACRS-3A-15) All physical evidence obtained in connection with a violation of law and/or facility regulation is preserved, controlled, and disposition made. At a minimum, procedures address the following:
• chain of custody • evidence handling • location & storage requirements
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Searches P&P
Resident Handbook
Contraband Incident Reports
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 60
4-ACRS-2C-04 (Ref. 3-ACRS-4E-09) Manual or instrument inspection of body cavities is conducted only when there is reason to do so and when authorized by the facility administrator or designee.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Brooke House does not conduct body cavity searches
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 61
4-ACRS- 2C-05 (Ref. 3-ACRS-4E-09) Inspection of body cavities is conducted in private by health-care personnel.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Brooke House does not conduct body cavity searches
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 62
4-ACRS-2C-06 (Ref. NEW) Only staff of the same sex as the offender participate in strip searches.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: Brooke House does not conduct strip searches
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 63
4-ACRS-2D-01 MANDATORY (Ref. 3-ACRS-3A-14)(Revised January 2001) A control plan(s) for keys, tools and utensils addresses access, use and storage.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Control and Use of Keys, Tools, and Equipment P&P
Key Inventory
Tool Control Plan
Utensil Control Plan
Tool Inventory
Tool sign in/sign out
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 64
4-ACRS-2D-02 MANDATORY (Ref. 3-ACRS-3A-14)(Revised 2001) Tools and utensils are used in accordance with the prescribed system.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Control and Use of Keys, Tools, and Equipment P&P
Tool Inventory
Tool Control Plan
Utensil Control Plan
Tool sign in/sign out
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 65
4-ACRS-2D-03 MANDATORY (Ref. 3-ACRS-3A-14)(Revised 2001) Keys are used in accordance with the prescribed system.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Control and Use of Keys, Tools, and Equipment P&P
Staff Key Inventory
Key Return Form for staff
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 66
4-ACRS- 3A-01 (Ref. 3-ACRS-3C-01) Offender rules and disciplinary regulations describe violations, sanctions and penalties.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Rules and Sanctions P&P
Resident Handbook
Incident Reports
Discipline Guidelines
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 67
4-ACRS-3A-02 (Ref. 3-ACRS-3C-01) Facility rules and regulations are reviewed at least annually and updated, if necessary.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Rules and Sanctions P&P
Resident Handbook
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 68
4-ACRS-3A-03 (Ref. 3-ACRS-3C-02) All program rules and regulations pertaining to offenders are conspicuously posted in the facility or included in a handbook that is accessible to all offenders and staff.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Rules and Sanctions P&P
Resident Handbook
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 69
4-ACRS-3A-04 (Ref. 3-ACRS-3C-02 and 4A-05 and 4H-06) At the time of admission, facility staff discuss program goals, service(s) available, rules governing conduct, access to health care, and program rules with the offender. Orientation is completed with five working days and is documented by a statement signed and dated by the offender and staff. When a literacy or communication problem exists, a staff member assists the offender.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Rules and Sanctions P&P
Intake P&P
Resident Handbook
Brooke House intake sheets
Resident Handbook Acknowledgment forms
Individual Service Plans (ISP)
Case notes
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 70
4-ACRS-3A-05 (Ref. 3-ACRS-4A-07) (Revised August 2013) Offenders receive written orientation materials and/or translations in their language, if they do not understand English. When a literacy problem exists, a staff member assists the offender in understanding the material.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Rules and Sanctions P&P
Resident Handbook in Spanish
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 71
4-ACRS-3A-06 (Ref. 3-ACRS-4A-08) If fees are collected, there is documentation that the offender has been informed of the policies and procedures regarding nonpayment of fees.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Intake Process P&P
Resident Rules and Sanctions P&P
Resident Handbook
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 72
4-ACRS-3A-07 (Ref. NEW) Staff model desired behaviors in accordance with a facility code of ethics. Staff members reinforce proper offender behavior and correct offender misbehavior.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Rules and Sanctions P&P
Employee Handbook
Employee Checklist
Standards of Employee Conduct
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 73
4-ACRS-4A-01 MANDATORY (Ref. 3-ACRS-4C-02) [Applicable only to facilities that prepare OR serve food to offenders.] (Revised August 2010) If the facility prepares and serves food to offenders, dietary allowances are reviewed at least annually by a qualified nutritionist, dietician or physician to ensure that they meet the nationally recommended allowances for basic nutrition for the types of offenders housed in the facility.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P
Dietician’s License
Letter from Pine Street Inn
Menus
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 74
4-ACRS-4A-02 MANDATORY (Ref. 3-ACRS-4C-03) [Applicable only to facilities that prepare and serve food to offenders.] (Revised August 2004) Written policy, procedure, and practice provide for special diets as prescribed by appropriate medical or dental personnel. Prescriptions for therapeutic diets should be specific and complete, furnished in writing to the food service manager, and rewritten annually, or more often as clinically indicated.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P
Documentation of special medical diets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 75
4-ACRS-4A-03 (Ref. 3-ACRS-4C-04) Special diets are provided for offenders whose religious beliefs require the adherence to religious dietary laws.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P
Receipts from purchase of Kosher food
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 76
4-ACRS-4A-04 Revised August 2010 (MANDATORY). (Ref. 3-ACRS-4C-05) [Applicable only to facilities that prepare OR serve food to offenders.] Food service staff members comply with all sanitation and health codes enacted by state or local authorities.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P
Health Permit
City of Boston Inspection Certificate
Certificate of Compliance for Kitchen Grease Exhaust
Servsafe Certificates
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 77
4-ACRS-4A-04-1 (Ref. 3-ACRS-4C-05) Added August 2011. All staff, contractors, and inmate workers who work in the food service department are trained in the use of food service equipment and in the safety procedures to be followed in the food service department.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P (re: licensing and certification & inspections)
Chore Checklist Resident Handbook Acknowledgement
Form House Meeting Agenda Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, foot candles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 78
4-ACRS-4A-05 (Ref. 3-ACRS-2E-04) [Applicable only to facilities that prepare OR serve food to offenders.] (Revised August 2010) Adequate space is provided for food preparation and service, and for an eating area and seating for all who dine at the same time.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P
Resident Handbook
Floor plans
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 79
4-ACRS-4A-06 (Ref. 3-ACRS-2E-05) [Applicable only to facilities that prepare OR serve food to offenders.] (Revised August 2010) When the facility has a kitchen, the kitchen, dining, and food storage areas are properly ventilated, properly furnished, and clean.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P
Floor plans
Daily Inspection sheets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 80
4-ACRS-4A-07 (Ref. 3-ACRS-4C-07) [Applicable only to facilities that prepare OR serve food to offenders.] (Revised August 2010)
Food service practices provide for the following: • Weekly inspection of all food service areas, including dining and food
preparation areas and equipment; • Sanitary, temperature-controlled storage facilities for all foods; • Daily checks of refrigerator and water temperatures.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Services P&P
Floor plans
Daily Inspection sheets
Daily kitchen temperature checklist
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 81
4-ACRS-4A-08 (Ref. 3-ACRS-2E-06) [Applicable only to facilities that prepare OR serve food to offenders.] (Revised August 2010) Toilet and wash basin facilities are available to food service personnel and offenders in close proximity to the food preparation area.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Food Service P&P
Photograph of bathroom closest to kitchen
Floor Plans
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 82
4-ACRS-4B-01 (Ref. 3-ACRS-4D-10) Articles necessary for maintaining proper personal hygiene are provided and are readily available to offenders. Articles include at least the following:
• soap • shampoo • toothbrush • toothpaste or powder • a comb • toilet paper • special hygiene items for female offenders
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Personal Hygiene Articles P&P
Photograph of hygiene kit
Photograph of a resident’s personal hygiene items
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 83
4-ACRS-4B-02 (Ref. 3-ACRS-4D-07) Offenders have access to laundry facilities.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Living Environment P&P
Resident Handbook
Resident Laundry sign out sheets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 84
4-ACRS- 4B-03 (Ref. 3-ACRS-2C-02) Offenders have access to the following facilities and conditions:
sanitation facilities, including access to toilets for use without staff assistance 24 hours a day
a washbasin with hot and cold running water a bed, and adequate storage space for clothes and personal belongings natural light from a source within 20 feet of the sleeping room temperatures that are appropriate to the summer and winter comfort zones
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Living Environment P&P
Photograph of resident room and bathroom
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 85
4-ACRS-4B-04 (Ref. 3-ACRS-4D-09)(Revised January 2001) Offenders are issued suitable, clean bedding and linen, including two sheets, a pillow and pillowcase, one mattress, not to exclude a mattress with integrated pillow, and sufficient blankets to provide comfort under existing temperature controls. There is provision for linen exchange, including towels, at least weekly.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Furnishings P&P
Resident Handbook
Photograph of linen closet
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 86
4-ACRS-4B-05 (Ref. 3-ACRS-2E-08) Space is provided in the facility to store and issue clothing, bedding, and other items required for personal hygiene.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Personal Hygiene Articles P&P
Photograph of linen closet
Photograph of hygiene kit
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 87
4-ACRS- 4C-01 MANDATORY (Ref. 3-ACRS-4E-03) Offenders have unimpeded access to health care and to a system for processing complaints regarding health care.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Resident Handbook
Medical visits with itineraries
General log notes of ambulance rides
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 88
4-ACRS-4C-02 MANDATORY (Ref. 3-ACRS-4E-01) The facility has a designated health authority with responsibility for health care pursuant to a written agreement, contract, or job description. The health authority may be a physician, health administrator, or health agency.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Resident Handbook
Letters from medical providers
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 89
4-ACRS-4C-03 MANDATORY (Ref. 3-ACRS-4E-02) Twenty four hour emergency medical, dental, and mental health care is provided for offenders, which includes arrangements for the following:
on-site emergency first aid and crisis intervention
emergency evacuation of the offender from the facility
use of an emergency medical vehicle
use of one or more designated hospital emergency rooms or other appropriate health facilities
emergency on-call physician, dentist, and mental health professional services when the emergency health facility is not located in a nearby community
security procedures providing for the immediate transfer of offenders, when appropriate
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
General log notes for ambulance rides
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 90
4-ACRS-4C-04 MANDATORY (Ref. 3-ACRS-4E-18) A training program for careworker staff and other personnel is established by a recognized health authority in cooperation with the facility administrator that includes the following:
• signs, symptoms, and action required in potential emergency situations • administration of first aid and cardiopulmonary resuscitation (CPR) • methods of obtaining assistance • signs and symptoms of mental illness, retardation, and chemical dependency • procedures for patient transfers to appropriate medical facilities or health-care
providers
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Floor plans
CPR cards
CPR curriculum
Signs & Symptoms Training staff attendance roster
Signs & Symptoms Training curriculum
Training schedule
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 91
4-ACRS-4C-05 (Ref. 3-ACRS-4E-19) (Revised August 2002) First aid kits are available in designated areas of the facility. Contents and locations are approved by the health authority. An automatic external defibrillator is available for use at the facility.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Floor plans
List of contents in first aid kits
Photograph of AED
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 92
4-ACRS-4C-06 MANDATORY (Ref. 3-ACRS-4E-08) Medical, dental and mental health screening is performed by health-trained or qualified health-care personnel on all offenders upon arrival at the facility. The screening includes the following: Inquiry into:
• current illness and health problems, including venereal diseases and other infectious diseases; • dental problems; • mental health problems including suicide attempts or ideation; • use of alcohol and other drugs, which includes types of drugs used, mode of use, amounts used,
frequency of use, date or time of last use, and a history of problems that may have occurred after ceasing use (e.g., convulsions);
• other health problems designated by the responsible physician Observation of: • behavior, which includes state of consciousness, mental status, appearance, conduct, tremor, and
sweating; • body deformities, ease of movement, etc.; • condition of skin, including trauma markings, bruises, lesions, jaundice, rashes and infestations,
and needle marks or other indications of drug abuse.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Institution medical exams and CRJ medical intakes
Intake sheets with medical appointment sheets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 93
4-ACRS-4C-07 (Ref. NEW) Each newly admitted resident who was not transferred from a correctional facility undergoes a medical examination within 14 days of admission.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 94
4-ACRS-4C-08 (Ref. 3-ACRS-4E-12) Medical examinations are conducted for any employee or offender suspected of having a communicable disease.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Communicable Disease List
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 95
4-ACRS-4C-09 (Ref. 3-ACRS-4E-13) The facility provides for the management of serious and infectious diseases.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Serious and Infectious Diseases P&P
Memo
Hepatitis A & C brochures
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 96
4-ACRS-4C-10 (Ref. 3-ACRS-4E-14) Revised January 2008. Policies direct actions to be taken by employees concerning offenders who have been diagnosed with HIV, including, at a minimum, the following:
• appropriate safeguards for staff and offenders • when and under what conditions offenders are to be separated • staff and offender training procedures • issues of confidentiality • counseling and support services
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Serious and Infectious Diseases P&P
Healthcare Services P&P
HIV Brochure
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 97
4-ACRS-4C-11 (Ref. 3-ACRS-4E-17) Access to dental care is made available to each offender.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Medical appointment sheets
Itineraries
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 98
4-ACRS-4C-12 (Ref. 3-ACRS-4E-20) Policy and procedure direct the possession and use of controlled substances, prescribed medications, supplies, and over-the-counter drugs. Prescribed medications are administered according to the directions of the prescribing physician.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Prescription/Medication Control P&P
Healthcare Services P&P
Resident Handbook
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STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 99
4-ACRS-4C-13 (Ref. NEW) If medications are distributed by facility staff, records are maintained and audited monthly, and include the date, time and name of the resident receiving the medication, and the name of the staff distributing it.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
Auditor Signature(s)
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Prescription/Medication Control P&P
Healthcare Services P&P
Medication audits
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STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 100
4-ACRS-4C-14 (Ref. 3-ACRS-4E-23) If female offenders are housed, access to pregnancy management services is made available.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
Auditor Signature(s)
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not Applicable: No females at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 101
4-ACRS-4C-14-1 (Added January 2003) When nursing infants are allowed to remain with their mothers, provisions are made for a nursery, staffed by qualified persons, where infants are placed when they are not in the care of their mothers.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not Applicable: No females at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 102
4-ACRS-4C-15 (Ref. 3-ACRS-4E-15) Access to mental health services is made available to offenders.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Healthcare Services P&P
Resident Handbook
Itineraries
Appointment sheets
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STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 103
4-ACRS-4C-16 MANDATORY (Ref. 3-ACRS-4E-16) There is a written suicide prevention and intervention program that is reviewed and approved by a qualified medical or mental health professional. All staff with offender supervision responsibilities are trained in the implementation of the suicide prevention program.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Suicide Prevention Policy signed off by CSMA Senior Clinician
Memo
Training schedule
Samaritans curriculum
CRJ Intake Sheet
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 104
4-ACRS-4C-17 (Ref. 3-ACRS-4E-06) If treatment is provided by health-care personnel other than a physician, dentist, psychologist, optometrist, podiatrist, or other independent provider is performed pursuant to written standing or direct orders by personnel authorized by law to give such orders.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: No medical services are provided at Brooke House
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 105
4-ACRS-4C-18 (Ref. 3-ACRS-4E-05) If the facility provides medical treatment, personnel who provide health-care services to offenders are qualified. Duties and responsibilities of such personnel are governed by written job descriptions approved by the health authority. Verification of current credentials and job descriptions are on file in the facility. Appropriate state and federal licensure, certification or registration requirements, and restrictions apply.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: No medical services are provided at Brooke House
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 106
4-ACRS-4C-19 (Ref. 3-ACRS-4E-24) If the facility provides medical treatment, offenders make medical decisions with informed consent. All informed consent standards in the jurisdiction are observed and documented for offender care.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: No medical services are provided at Brooke House
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 107
4-ACRS-4C-20 MANDATORY (Ref. 3-ACRS-4E-25) Offenders do not participate in medical, pharmaceutical, or cosmetic experiments. This does not preclude individual treatment of an offender based on his or her need for a specific medical procedure that is not generally available.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Handbook
Memo
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 108
4-ACRS-4C-21 (Ref. 3-ACRS-4E-26) Individuals designated by the offender are notified in case of serious illness or injury.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Emergency Contact Notification P&P
Intake sheets
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STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 109
4-ACRS-4C-22 (Ref. NEW) If medical treatment is provided by the facility, accurate health records for offenders are maintained separately and confidentially.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: No medical services are provided at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 110
4-ACRS-4C-23 (Ref. 3-ACRS-4E-28) If medical treatment is provided by the facility, the method of recording entries in the records, the form and format of the records, and the procedures for their maintenance and safekeeping are approved by the health authority.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: No medical services are provided at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 111
4-ACRS-4C-24 (Ref. 3-ACRS-4E-29) If medical treatment is provided by the facility, for offenders being transferred to other facilities, summaries or copies of the medical history record are forwarded to the receiving facility prior to or at arrival.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Not applicable: No medical services are provided at Brooke House
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 112
4-ACRS-5A-01 (Ref. 3-ACRS-4B-02) An objective assessment of each offender's risk and need, specifies the type of program needed and provides for regular review.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Program Plans P&P
Individual Service Plans (ISPs)
Level of Service Inventory (LSIs)
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STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 113
4-ACRS-5A-02 (Ref. 3-ACRS-4F-01) Offenders are provided with interventions targeted to factors that relate to their individual criminal behavior.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Program Plans P&P
ISPs
Itineraries
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 114
4-ACRS-5A-03 (Ref. 3-ACRS-4B-01 and 4B-03 and 4H-07) Staff design and complete an offender's personalized program plan within 14 days of admission. The plan includes measurable criteria of expected behavior and accomplishments, a time schedule for achieving specific goals, and scheduled progress reviews. The plan is documented with staff and offender signatures. Offenders have input into planning, problem solving, and decision making related to their participation in the program.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Program Plans P&P
ISP
Intake sheets
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 115
4-ACRS-5A-04 (Ref. 3-ACRS-4B-04) Any change in a personalized program plan is reviewed and discussed with the offender. This review is dated and documented by staff and offender signatures.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Program Plans P&P
Case notes showing level changes
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 116
4-ACRS-5A-05 (Ref. 3-ACRS-4B-05) Offender progress in the program is measured through objective assessment at least every six months and at discharge. The outcome of each review is documented.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Program Plans P&P
LSIs
Closing summaries
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 117
4-ACRS-5A-06 (Ref. 3-ACRS-4B-07) The facility administrator has the authority to remove or transfer an offender from the program.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Admission Criteria P&P
Closing summaries
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STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 118
4-ACRS-5A-07 (Ref. 3-ACRS-4F-02 and 4F-03) Each offender is assigned a facility staff member who meets with and counsels that offender as necessary, consistent with his/her individual treatment plan.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resident Program Plans P&P
Intake Process P&P
Comprehensive Case Management P&P
Case notes
Case load assignment
Resident Handbook
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 119
4-ACRS-5A-08 (Ref. 3-ACRS-4E-08-1)(Revised January 2001) Provide for early identification and treatment of inmates with alcohol and drug abuse problems through a standardized battery assessment. This battery shall be documented and include, at a minimum, the following:
• screening and sorting • clinical assessment and reassessment; • medical assessment for appropriate drug and alcohol program assignment based
on the needs of the individual offenders (if not done within the past six months); • referrals
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
TDAT Referrals?
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 120
4-ACRS- 5A-09 (Ref. 3-ACRS-4F-12) If the facility operates a urine surveillance program, procedures provide instructions for the collection and processing of samples, the interpretation of results and the response to violations.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Urine Collection P&P
Resident Handbook
Alco-Sensor Test Logs
Kroll Urine Sample Test form
Kroll Urine Results form
Incident report
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 121
4-ACRS-5A-10 (Ref. NEW) Health education is provided to offenders. Health education includes information on medical services and immunizations, personal hygiene, dental hygiene, nutrition, venereal disease, HIV and AIDS, tuberculosis and other communicable diseases.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resource Manual and Access to Community Services P&P
Resident Handbook
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 122
4-ACRS-5A-11 (Ref. 3-ACRS-4F-06) Staff use community resources, either through referrals for service or by contractual agreement, to provide offenders with the services to meet their program needs.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Treatment Services P&P
Resource Manual and Access to Community Services P&P
Itineraries
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 123
4-ACRS-5A-12 (Ref. 3-ACRS-4F-05) The agency maintains and periodically updates a directory of functioning community agencies, or uses a directory that is maintained and updated by another agency.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resource Manual and Access to Community Services P&P
Resident Handbook
Coming Home Directory
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 124
4-ACRS-5A-13 (Ref. 3-ACRS-4G-02) Offenders are aided with their transition to the community, including referrals to assist offenders in locating suitable housing.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Resource Manual and Access to Community Services P&P
Housing and Transitional Assistance P&P
Housing Searches
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!
STANDARDS COMPLIANCE CHECKLIST
CRJ - Coolidge House 125
4-ACRS-5A-14 (Ref. 3-ACRS-4G-04) Each offender should be given gradual increased responsibility in the community prior to release, dependent upon his/her ability to accept responsibility.
SELF-EVALUATION Agency Personnel
STANDARDS COMPLIANCE AUDIT Visiting Committee
Staff Signature(s)
________________________________
________________________________
Auditor Signature(s)
________________________________
________________________________
Compliance Noncompliance Not Applicable
Compliance Noncompliance Not Applicable
List documentation to support compliance or explain non-applicability of standard
Pass Program/Program Related Activties P&P
Home passes
List reasons for noncompliance or non-applicability. Note: List all deficiencies if standard is in noncompliance. Include the square footage, ratios, footcandles, dBA=s, etc. Make your complete comments on this page with attachments, if necessary. BE VERY SPECIFIC!