Environmental QR2000

1. All areas in and outside the site are accessible to the individual (except areas such as storage areas for medication and harmful chemicals). If applicable there are modifications or assistive devices available to increase accessibility. The site policies allow the individual to move about the inside and outside of the setting.
(Applies to selected review individual(s) only - record detailed notes regarding any modifications or assistive devices available to increase accessibility.)

Comments:

2. Does the site offer privacy in the bedrooms/ private living areas?

Comments:

3. Can the bedrooms/private living areas be locked? Are staff and others observed to knock or announce before entering bedrooms or other private living areas? (If an individual's bedroom cannot be locked, is there documentation present in their Personal Plan/Implementation Strategy identifying the modification and giving justification for it? Applies to selected review individual(s) only - record detailed observations.)

Comments:

4. Is the means of exit suitable for and physically accessible to the individual(s) served in the setting?

Comments:

5. Are sufficient smoke detectors present and working? (There must be one smoke detector within 15 feet of every room used for sleeping purposes, as well as one on every level of the dwelling.)

Comments:

6. Is there a properly inspected and charged fire extinguisher(s)? (A minimum of one extinguisher is required per residence with an annual inspection tag.)

Date of fire extinguisher inspection:

Comments:

7. Does the site appear to be a clean and safe environment?

• Are the stairs and halls free of obstacles and in good repair?
• Are all interior and exterior areas in good repair?
• Is building clean, free of foul odors, and free from observable mold?
• Is building free from evidence of roaches, rodents, flies, fleas, bedbugs, or other vermin? (All must be answered in the affirmative to be a 'yes'.)

Comments:

8. Do individuals have access to a phone?

Comments:

9. CILA Only - Are there no more than 8 individuals residing in the home?

Comments:

10. CILA Only - Are there no more than 2 individuals per bedroom?

Comments:

11. CILA Only - Do traffic patterns avoid going through individuals' bedrooms?

Comments:

12. CILA Only - Does the individual's bedroom have (at a minimum) a mattress, box spring/platform frame, and storage space for clothing and other belongings? (All must be present to be 'yes'.)

Comments:

13. CILA Only - Does it appear that the individuals have the freedom to furnish and decorate their bedroom/private living area to their personal preference?

Comments:

14. Is the water at a safe temperature (between 100'-110'F for CILA and CDS/100'-115' for CRW)? Tub/Shower temp is _ _ F

Comments:

15. CILA and CRW Only - Is there at least one working bathroom for every 4 individuals in the home?

Comments:

16. Is the bathroom located and equipped to facilitate independence of use? (Applies to selected review individual(s) only - record detailed notes regarding any modifications or equipment available to increase independence of use.)

Comments:

17. Are food items closed, labeled, properly stored, and within their expiration/useby dates? (All must be answered in the affirmative to be 'yes'.)

Comments:

18. Are the Abuse/Neglect (OIG or DCFS as applicable) reporting number, Poison Control, agency on-call staff, and emergency numbers posted in an accessible area?

Comments:

19. Does the site have a properly functioning carbon monoxide detector? As of January 1, 2007, homeowners, landlords, and building owners are required to install carbon monoxide (CO) detectors within 15 feet of rooms used for sleeping. The carbon monoxide alarm may be combined with smoke detecting devices, providing the unit emits an alarm that clearly differentiates the hazard.

Comments:

20. Is there a supplied and unexpired first aid kit available?

Comments:

21. Are all areas of the building, exits, and emergency areas physically accessible to all individuals? If needed, are modifications/assistive devices present to facilitate accessibility?

(Applies to selected review individual(s) only - record detailed observations regarding physical accessibility and any modifications present.)

Comments:

22. Does the individual follow a prescribed special diet? (Diabetic diet, Cardiac diet, Pureed/Mechanical Soft/Nectar-thick liquids, etc.)

(Applies to selected review individual(s) only - record detailed notes regarding prescribed diet and observation of appropriate foods and preparation equipment available.)

Comments

23. Does the individual have the appropriate assistive devices in good working condition (if applicable)?

(Applies to selected review individual(s) only - record detailed observations.)

Comments:

24. Are all prescribed assistive technology and/or adaptive equipment clean, in good repair, and available to the individuals at appropriate times? (Applies to selected review individual(s) only - record detailed observations.)

Comments:

25. Do staff demonstrate competency in the proper use of all assistive technology and/or adaptive equipment techniques and devices (if applicable)? (Applies to selected review individual(s) only - record detailed observations.)

Comments:

26. Are there observation cameras in the setting? (If No, mark N/A) If so, are there both an individual approval and an HRC approval in file? (Must be verified in an individual's Discovery Tool/Personal Plan - applies to selected review individual(s) only - record detailed observations.)

Comments

27. Are there alarms on the doors or windows for the purpose of restricting an individual's movement? (If No, mark N/A) If so, is the restriction approved by the HRC and verified to be addressed in an individual's Discovery Tool/Personal Plan? (Applies to selected review individual(s) only - record detailed observations.)

Comments:

28. Is the site free from any unapproved and undocumented right's restrictions? (Applies to selected review individual(s) only - record detailed observations.)

Comments:

29. Are meaningful recreational/training activities available to individuals either in their home or accessible in the community?

Comments:

30. Is there sufficient privacy provided during personal care activities?

Comments:

31. Did staff talk to and treat the individuals, co-workers, and others with dignity and respect?

Comments:

32. Did staff perform duties in a way to support the individuals' right to choose and support the individuals' personal choices?

Comments:

33. Did staff demonstrate competency in person-specific training needed to support the individuals served?

Comments:

34. Were staff knowledgeable of individuals' goals and the programs or interventions to assist in progression towards the individuals' goals?

Comments:

35. Is a copy of the current Implementation Strategy available to staff at the setting (applies to CILA and CDS only) as outlined in the Guidelines?

Comments:

(For Provider Agency Guidance: Per Rule 115 effective 5/31/23, a copy of both the current Personal Plan and the current Implementation Strategy are required to be kept in the CILA/CDS.)

1. Does the site appear to be safe and appropriate to the needs of the individual(s) living in the home? (All items must be present to answer yes.)
   • Does the site appear to afford safety and basic comfort for the individual(s) living in the home?
   • Are there appropriate safety devices present and in working order (smoke detector, carbon monoxide detector, access to a phone, first aid kit, door locks, etc.)?
   • Does the site appear to comply with applicable building and safety codes?