Form AAS-5 "Facility Inspection Worksheet (Resident Rights, Physical Plant and Environment, Safety, Dietary Services)" - New Jersey

What Is Form AAS-5?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AAS-5 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form AAS-5 "Facility Inspection Worksheet (Resident Rights, Physical Plant and Environment, Safety, Dietary Services)" - New Jersey

Download PDF

Fill PDF online

Rate (4.7 / 5) 41 votes
New Jersey Department of Health
Division of Health Facility Survey and Field Operations
FACILITY INSPECTION WORKSHEET
Resident Rights, Physical Plant and Environment, Safety, Dietary Services
(ALL REFERENCES ARE TO N.J.A.C. 8:36)
License Name
Facility ID No.
Date of Survey
Address
Bed Capacity
Facility Representative
Telephone Number
Subchapter 16
PHYSICAL PLANT AND ENVIRONMENT
VENTILATION
Does every habitable room have means of ventilation (window or
8.36
mechanical ventilation? ...........................................................................................
Yes
No
N/A
16.3
8.36
Small passageways, aisles and corridors maintain an unobstructed
minimum of 44 inches. ..........................................................................................
Yes
No
N/A
16.4
Are all exits unobstructed? ......................................................................................
Yes
No
N/A
AUTOMATIC FIRE DETECTION SYSTEM
Do all residents’ bedrooms, living rooms, and studio apartments
8.36
have smoke detectors? ...........................................................................................
Yes
No
N/A
16.5
INTERIOR FINISH REQUIREMENT
Are interior walls, ceiling and floor finishes free of any major
8.36
damage? .................................................................................................................
Yes
No
N/A
16.7
Are stairs and hallways free from hazards and obstructions? .................................
Yes
No
N/A
Are ceiling tiles in place and free from stains? ........................................................
Yes
No
N/A
GENERAL RESIDENTIAL UNIT REQUIREMENTS
8.36
Is the Residential Unit lockable? .............................................................................
Yes
No
N/A
16.8
TOILETS, BATH, AND HAND WASHING SINK
Does the unit have a bathroom with a toilet, bathtub and a
8.36
shower?...................................................................................................................
Yes
No
N/A
16.9
Are additional toilets in areas other than residents' units? ......................................
Yes
No
N/A
COMMUNITY SPACE
Adequate space for Common Areas? .....................................................................
Yes
No
N/A
8.36
16.11
AAS-5
AUG 15
Page 1 of 5 Pages.
New Jersey Department of Health
Division of Health Facility Survey and Field Operations
FACILITY INSPECTION WORKSHEET
Resident Rights, Physical Plant and Environment, Safety, Dietary Services
(ALL REFERENCES ARE TO N.J.A.C. 8:36)
License Name
Facility ID No.
Date of Survey
Address
Bed Capacity
Facility Representative
Telephone Number
Subchapter 16
PHYSICAL PLANT AND ENVIRONMENT
VENTILATION
Does every habitable room have means of ventilation (window or
8.36
mechanical ventilation? ...........................................................................................
Yes
No
N/A
16.3
8.36
Small passageways, aisles and corridors maintain an unobstructed
minimum of 44 inches. ..........................................................................................
Yes
No
N/A
16.4
Are all exits unobstructed? ......................................................................................
Yes
No
N/A
AUTOMATIC FIRE DETECTION SYSTEM
Do all residents’ bedrooms, living rooms, and studio apartments
8.36
have smoke detectors? ...........................................................................................
Yes
No
N/A
16.5
INTERIOR FINISH REQUIREMENT
Are interior walls, ceiling and floor finishes free of any major
8.36
damage? .................................................................................................................
Yes
No
N/A
16.7
Are stairs and hallways free from hazards and obstructions? .................................
Yes
No
N/A
Are ceiling tiles in place and free from stains? ........................................................
Yes
No
N/A
GENERAL RESIDENTIAL UNIT REQUIREMENTS
8.36
Is the Residential Unit lockable? .............................................................................
Yes
No
N/A
16.8
TOILETS, BATH, AND HAND WASHING SINK
Does the unit have a bathroom with a toilet, bathtub and a
8.36
shower?...................................................................................................................
Yes
No
N/A
16.9
Are additional toilets in areas other than residents' units? ......................................
Yes
No
N/A
COMMUNITY SPACE
Adequate space for Common Areas? .....................................................................
Yes
No
N/A
8.36
16.11
AAS-5
AUG 15
Page 1 of 5 Pages.
FACILITY INSPECTION WORKSHEET
(Continued)
Subchapter 16
PHYSICAL PLANT AND ENVIRONMENT
LAUNDRY EQUIPMENT – ALR
(CPCH)
8.36
When commercial type laundry equipment is utilized:
16.12
Is the laundry room protected by a fire separation assembly of at
least one-hour rated construction? ..........................................................................
Yes
No
N/A
Does the facility have at least one washer and dryer for residents'
use? ........................................................................................................................
Yes
No
N/A
Are all dryers vented to the outside of the building?................................................
Yes
No
N/A
ADMINISTRATION AND PUBLIC
Wheelchair access ..................................................................................................
Yes
No
N/A
8.36
16.14
Interview space .......................................................................................................
Yes
No
N/A
Mailboxes ................................................................................................................
Yes
No
N/A
Offices for records and staff possessions................................................................
Yes
No
N/A
FIRE EXTINGUISHER SPECIFICATIONS
Are all fire extinguishers unobstructed, properly labeled and
8.36
secure? ...................................................................................................................
Yes
No
N/A
16.15
Adequate number and type? ...................................................................................
Yes
No
N/A
SOUNDING DEVICES
Sounding device Alarm or self-locking doors? ........................................................
Yes
No
N/A
8.36
16.16
Subchapter 14
EMERGENCY SERVICES AND PROCEDURE
EMERGENCY PLANS AND PROCEDURE
8.36
AED Onsite? ...........................................................................................................
Yes
No
14.1 (d)
Location:
DRILLS
*Does all staff participate at least annually? ...........................................................
Yes
No
N/A
8.36
14.3
* Interviews
AAS-5
AUG 15
Page 2 of 5 Pages.
FACILITY INSPECTION WORKSHEET
(Continued)
Subchapter 17
PROVISION OF SERVICE GENERAL SAFETY, BUILDING AND GROUND
HOUSEKEEPING
Are all furnishings clean and in good repair? ..........................................................
Yes
No
N/A
8:36
17.1-17.2
Are thermometers located within refrigerator and freezers?....................................
Yes
No
N/A
Are Residential Units clean to sight and smell, clutter free?....................................
Yes
No
N/A
Adequate pest control? ...........................................................................................
Yes
No
N/A
Does facility utilize a “call bell system?”............................................................
Yes
No
If Yes:
Does facility have a policy on responding to “call bells”?................................
Yes
No
On interview, are there any complaints about slow response time?................
Yes
No
RESIDENT ENVIRONMENT
8:36
Are articles in storage elevated from the floor? .......................................................
Yes
No
N/A
17.3 (a) (8)
8:36
Are all poisonous and toxic materials identified, labeled and stored
in a locked cabinet or room? ...................................................................................
Yes
No
N/A
17.3 (b) (4)
Are combustible materials stored in accordance with Fire Safety
8:36
requirements specified in the NJ Uniform Code N.J.A.C. 5:70?..............................
Yes
No
N/A
17.3 (b) (5)
8:36
Are electrical outlets free from damage?.................................................................
Yes
No
N/A
17.3 (b) (8)
Are electrical cords used? .......................................................................................
Yes
No
N/A
(i – ii)
HEATING AND AIR CONDITION
Resident areas fully air-conditioned and heated? ...................................................
Yes
No
N/A
8:36
17.5
Are portable heaters in use? ...................................................................................
Yes
No
N/A
8:36
17.5 (a) (2)
8:36
Is the domestic hot water temperature range between 105 F and
120 F?....................................................................................................................
Yes
No
17.6 (b)
Is the water temperature monitored?.......................................................................
Yes
No
Are discrepancies in the log addressed by maintenance? ...............................
Yes
No
If Yes, how?
AAS-5
AUG 15
Page 3 of 5 Pages.
FACILITY INSPECTION WORKSHEET
(Continued)
Subchapter 17
PROVISION OF SERVICE GENERAL SAFETY, BUILDING AND GROUND
BUILDING AND GROUNDS MAINTENANCE
Are handrails present and secure?..........................................................................
Yes
No
N/A
8:36
17.7
Are ventilation grills clean and unobstructed? .........................................................
Yes
No
N/A
Exit lights are unobstructed and lit?.........................................................................
Yes
No
N/A
Do emergency lights work when tested?.................................................................
Yes
No
N/A
Self-closing doors are not obstructed or held open with wedge,
chairs, etc.?.............................................................................................................
Yes
No
N/A
When fire doors are closed, do they close all the way into the
frame and latch shut?..............................................................................................
Yes
No
N/A
Do double smoke doors have a gap less then 1/8 inch when
closed?....................................................................................................................
Yes
No
N/A
Are cylinders secured in carts, stands or chained to the wall? ................................
Yes
No
N/A
Is there an 18" clearance under sprinkler heads? ...................................................
Yes
No
N/A
LAUNDRY SERVICE
Soiled and clean laundry shall be kept separated. ..................................................
Yes
No
N/A
8:36
17.8
If laundry services provided on-site, is there an area for receiving,
sorting and folding with a hand washing sink? ........................................................
Yes
No
N/A
Subchapter 10
DIETARY SERVICES
REQUIREMENTS FOR DINING SERVICES
The facility and personnel shall comply with the provisions of N.J.A.C. 8:24, Retail Food
8:36
Establishments and Food and Beverage Vending Machines Chapter XII of the New Jersey
10.5(a)
Sanitary Code.
Does facility kitchen have a commercial dishwashing machine? ............................
Yes
No
If yes: Sanitizing Solution used:
Does it reach maximum hot water temperature?..................................................
Yes
No
Does facility use a 3-compartment sink?.................................................................
Yes
No
If yes: Are they using the 3 compartments appropriately?....................................
Yes
No
Sanitizing Solution used:
Does the facility have a food temperature log in the kitchen? .................................
Yes
No
Are staff taking food temperatures prior to serving?................................................
Yes
No
On interview, do the residents complain about food temperatures? ...............
Yes
No
If yes: Review log and take food temperatures with digital thermometer:
Hot = at least 140 degrees F; Cold = 45 degrees F. or below.
AAS-5
AUG 15
Page 4 of 5 Pages.
FACILITY INSPECTION WORKSHEET
(Continued)
Subchapter 10
DIETARY SERVICES
Are menus posted in kitchen? .................................................................................
Yes
No
8:36
10.5(c)
If not, does facility give menu to each resident daily/weekly? .................................
Yes
No
Does the kitchen staff use appropriate measured utensils, i.e.,
spoodles, cups, etc. to portion the food onto the plates? ........................................
Yes
No
Subchapter 2
LICENSURE PROCEDURES AND RESIDENT RIGHTS
and
Subchapter 4
POSTING AND DISTRIBUTION OF STATEMENT OF RESIDENT RIGHTS
Are these posted in conspicuous places in the facility?
8:36
2.5(c)
Facility’s current license? ...............................................................................
Yes
No
4.1(a)(38)
Resident Rights?............................................................................................
Yes
No
(40)
Phone numbers for the Ombudsman, NJDOH and County
Agencies? ......................................................................................................
Yes
No
Subchapter 5
GENERAL REQUIREMENTS
Is notice posted that the following are available for review
8:36
during normal business hours? ..........................................................................
Yes
No
5.11(a)1-7
Waivers;
Copy of last inspection report;
Policies regarding Resident Rights;
Business Hours of facility;
Policies and Procedures regarding maintaining security of the facility;
Toll-free hot line number of the Department;
Telephone numbers of county agencies;
Telephone numbers of the State of NJ, Office of the Ombudsman; and
The names of, and a means to formally contact, the owner and/or
members of the governing authority.
Name of Surveyor Completing Form
Date Completed
AAS-5
AUG 15
Page 5 of 5 Pages.