Assisted Living And Independent Living Facilities Application Page 5
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8If "Wander Guard" or similar alert system is used:
The system is checked for defaults on what basis?
Daily
Weekly
Monthly
Daily
Weekly
Monthly
A "dummy" bracelet is used by staff to check the system on what basis?
Yes
No
A system is in place to report malfunctioning bracelets and alarm defects
Alternate methods are in place in the event of system failures
Yes
No
Daily
Weekly
On what basis are arm / ankle bands are checked for accuracy proper fit and damage?
Daily
Weekly
Monthly
Door alarms are checked for proper operation on what basis?
PART VII - STAFFING
Staff On Duty
1st Shift
2nd Shift
3rd Shift
RN
LPN
CNA's
RESIDENT ASSISTANTS
MEDICATION AIDE
ADMINISTRATOR
OTHER (Specify)
Is any of the staff listed above required to carry their own professional coverage?
Yes
No
If yes, how is coverage verified?
What are the minimum limits?
Yes
No
Is the facility a drug and alcohol free workplace?
Yes
No
Is 24 hour supervision of all employees provided?
Are prior employment histories of all employees checked?
By what method?
Are criminal background checks performed on all employees?
Yes
No
Do you have a written procedure for reporting resident abuse?
Yes
No
No
Are pre-employment physicals, including mobility screening and drug screening, required of all employees?
Yes
Is drug testing performed on all employees?
Yes
No
Are volunteers utilized?
Yes
No
If yes, describe selection process and training provided:
Assisted Living Application-Uni-Ter Underwriting Management Corp (ed. 07-11)
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