PRE-ASSESSMENT AND COMPLIANCE FORM
PRE-ASSESSMENT AND COMPLIANCE FORM | ||||||
SECTION 1- DEMOGRAPHIC DATA Name of Facility: | ||||||
Address: | Phone Number: | |||||
Key Provider's Name: | Service Area: | |||||
QUALIFICATIONS OF PROVIDERS/OWNERS | ||||||
A written statement of interest in not more than 300 words why do you want to join ACSPOPIN | ||||||
SPECIFY PARTNER ORGANISATIONS (IF ANY) | ||||||
COMPANY DETAILS | ||||||
CAC Registration documents | ||||||
Certificate of registration | ||||||
Certificate of registration with Federal / State | ||||||
Copy of constitution | ||||||
SELECT APPLICABLE SERVICES/ORGANISATION | DATE OF COMMENCEMENT OF SERVICES | COMMENT |
HOME NURSING | ||
RESIDENTIAL FACILITY | ||
REHABILITATION CENTRE | ||
TRAINING CENTRE | ||
NGO | ||
DEMENTIA CARE HOME | ||
DAYCARE CENTRE | ||
LONG CARE FACILITY | ||
NURSING HOME | ||
RETIREMENT HOMES | ||
DEPENDENT LIVING FACILITY | ||
INDEPENDENT LIVING FACILITY | ||
ADVOCACY ORGANISATION | ||
COMMUNITY CENTERS |
SECTION 2
OTHERS | ||
Specify the type of Clients: (Check as appropriate)
Capacity Comment
Frail | ||
Sick | ||
Homeless | ||
Sick | ||
Others |
SECTION 3
SELF ASSESSMENT TOOL
Standard | Self-assessment questions to the state where you are currently | Descriptive questions: | Evaluation and Quality Assessment Scores. | Identify areas for improvement |
QS 1. Access to Care | Does your organization offer sufficient and accurate information to empower clients’ choice of a care home/service? | List the information sources. | ||
QS 2. Infrastructure/ Facility | Does your organization have an age-friendly, fit-for-purpose and well-maintained structure? | How will you describe your facility in relation to your service? -How often do you maintain and update the facility and processes? Describe the location of your facility in relation to accessibility. -List your mobility and security equipment | ||
QS 3. Staffing | List out the staff mix in your organization and the job description of each staff. | Assess the quality of care and service delivery |
-What healthcare system defines your culture? - | ||||
QS 4. Training and Certification | Specify the staff qualification Does the organization have the skill and qualification to impact the needed skill? | Do you have in-house training? In your own word, specify the focus, curriculum and expected staff development goals of your organization. | ||
QS 5. Management and Governance | Company details: Business name? Business registration? Taxpayer ID? List of Directors Company Organogram. | What are the company’s vision and mission? Specify your risk assessment programs What is the medication policy? What infection control measures are in your organisation? | ||
QS 6. Health, Wellbeing and care | State your organization’s policy and programs in the following areas; -Privacy and dignity -Person-centred care -Deprivation and liberty | What activities and facilities for rehabilitation and occupational therapy of the elderly? |
-Restraints | ||||
QS 7. SUPPORT AND LIFESTYLE | What services do your organisations provide for optimising the health and well-being of the elderly in your care? | Specify policies on the following? Meals Social activities Arts, games and hobbies | ||
QS 8. Compliant and Reporting | What is your policy on complaints and disclosure? State the legal rights of the elderly applicable to your services. What is your policy on abuse? What is your policy on neglect? How does your organization support your staff | Does your staff have knowledge of the care quality standards applicable to their Job description? What type of documentation and record keeping does your organization maintain for care audits? | ||
Please click on the download link to access the pre-assessment form. Complete the form appropriately and email to nacspopin@gmail.com.
Please be aware that you will be required to input a password before being able to download the form. Members should send a request to nacspopin@gmail.com..
Requester will be provided with a password to access the pre-assessment form. Please do not hesitate to contact the office via email for more information information if required.