Lead Counselor Name: Site Name

Lead Counselor Checklist

Lead Counselor Name: Site Name:

Staff Schedule:
All Shifts filled for the upcoming week?
Staff changes (vacation or shifts exchanged, noted and approved? / Date Checked / Date Checked
Date Checked / Date Checked
Food Supplies:
Fresh produce fruits and vegetables) available daily
Enough food to cover the week’s menus and snacks plus additional food for at least one week in case of emergency. / Date Checked / Date Checked
Date Checked / Date Checked
Staff Meetings
Staff meeting Dates for this month:
Primary Checklists reviewed during the staff meetings (include staff names below):
1st meeting:
2nd meeting:
Primary staff who did not submit a Primary Checklist for the meetings (include staff names below):
1st meeting:
2nd meeting:
ADT alarm reports need to be checked and reviewed every other week. (list any gaps in time (5 minutes or more) that the alarm was armed, explain follow-up to identified gaps: / Date Checked / Date Checked
Medication Changes:
Name of medication / Nature of Change
(add/discontinue/change dose, etc.) / Date of Change
Use back of form if needed…
Are all medications correct on medication sheet and on side effect sheets? / Date Checked / Date Checked
If a psychiatric PRN was used is there an Actual Use Form Present? / Date Checked / Date Checked
Medication Errors:
(Review med sheets once a week for medication errors)
Date Checked / Date Checked / Date Checked / Date Checked
Resident Counselor Checklist:
(Signed every shift and spot check completed to ensure all duties are carried out)
Date Checked / Date Checked / Date Checked / Date Checked
Miscellaneous Responsibilities
Appointments:
Resident Appointments Scheduled and carried out?
Is the Maintenance Department being informed of upcoming appointments each Sunday? / Date Checked / Date Checked
Date Checked / Date Checked
Activities:
·  Activity schedule is planned weekly and posted?
·  Is there at least one community activity per day?
·  Is there one new outing this week?
·  Are the primary one-to-one’s on the activity schedule.
·  Is room deep cleaning with primary counselors taking place weekly?
·  Activities must vary for each person in the residence. / Date Checked / Date Checked
Date Checked / Date Checked
House Inspections:
Please use the Safety Checklist and submit to the Office at end of month.
Is fresh produce and at least one week supply of food present in the facility?
Maintenance Issues present (please explain):
Were work orders submitted for each? / Date Checked / Date Checked
ADP Staffing Audits / Date Checked / Date Checked
Date Checked / Date Checked
Ledgers (individuals cash and banking, house and gas accounts) review
Cash Counts for each resident / Date Checked / Date Checked
Date Checked / Date Checked

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