Home Environment and Emergency Preparedness Assessment

PART I

Patient’s Name(Required)

DOB(Required)

Date(Required)

Home Environment Assessment

1.Home environment is safe and sanitary for provision of care.(Required)

2.Bathroom is safe and is accessible for safe bathing and mobility.(Required)

3.Electrical cords and outlets appear to be in good repair in the patient area.(Required)

5.Access to outside exits is free of obstruction and alternate exits are accessible in case of fire.(Required)

6.Walking pathways are level, uncluttered and have non-skid surfaces.(Required)

7.Lighting is adequate for safe ambulation and ADLs.(Required)

8.Temperature and ventilation are adequate.(Required)

9.Medicines and poisonous/toxic substance are clearly labeled and placed where patient can reach and not within reach of children.(Required)

10.Environment is safe for effective oxygen use.(Required)

11.Other(Required)

Emergency Preparedness Assessment

1.Is the patient mobile?(Required)

2. Is the patient dependent on an assistive device?(Required)

2a. If yes, identify the assistive equipment(Required)

3. Does the patient have a caregiver/family (• living in household • living outside the household) able to assist patient with mobility and transportation in case of emergency?(Required)

Emergency Contact Name:(Required)

Relationship(Required)

Phone(Required)

EMail(Required)

Alternate Contact(Required)

4. Does the patient require a life-saving equipment?(Required)

4a. Identify the equipment(Required)

4b. Is the equipment transportable?(Required)

5. Does the patient have special needs and circumstances?(Required)

5a. identify the equipment(Required)

6. Does the patient have a pet at home?(Required)

7. In emergency, patient can sustain for at least three days at a current location as is and without outside services?(Required)

8. In emergency, the patient is likely to require support of a hospital setting?(Required)

PART II

Patient’s Name(Required)

DOB:(Required)

Date(Required)

For items checked “NO” on the assessment, patient/care giver teaching was provided • Yes • No. Specify,(Required)

In the event of emergency that interrupts our services to you, Galaxy Home Health will make every effort to call and/or visit you, as determined by the assigned triage code. However, if you have a medical emergency and are not able to contact us, you should access the nearest emergency medical facility.

Patient Emergency Preparedness Plan

Emergency Contact: Phone #1(Required)

Phone #2(Required)

Local Evacuation address (i.e. friend, family, etc.)(Required)

Nearest Hospital :(Required)

Physician:(Required)

Pharmacy:(Required)

O2 vendor, if applicable:

Police/Fire/EMS: 911(Required)

Local Red Cross: 1-800-733-2767 or (303) 722-7474(Required)

State of Colorado Emergency Operations: (303) 279-8855.(Required)

Radio or TV stations: Know which station will have emergency broadcast announcements and set a TV or radio to that station. Colorado disaster shelter locations will be determined based on type and location of emergency,

Emergency preparedness plan discussed with patient/caregiver? • Yes • No If no, please explain(Required)

Patient or Legal Representative:(Required)

Date(Required)

Agency Representative:(Required)

Title:(Required)

Date(Required)