Student Name: _________________________                                                                                 Date of Home Assessment: ______________

Directions: This assignment is worth 4 skills lab hours.

  1. Complete a home safety inspection on a person age 70 or above. Go to their home and complete this template.
  2. As appropriate, make as many corrections during your visit as possible.
  3. ONLY Typed papers will be accepted, and upload completed assessment into the corresponding clinical drop box.
  4. Use as much space as needed to answer the questions thoroughly.  Yes and No answers are NOT acceptable.
  5. Incomplete, late assignments are the same as an unsatisfactory in clinicals so please make sure you turn this in on time and it’s fully completed.
  6. See your Canvas drop box for due date. Incomplete or late documentation will affect the satisfactory progress of your clinical grade, which may result in a course fail.
  7. Follow the legend provided on the next page for the Home Inspection, Teaching and Plan of Correction

General Demographics/Information:

Client Initials: ______       Client Age: ______       Relationship to Student: _____________________    

Who is responsible for upkeep and future corrective actions? _________________________

How long did the physical assessment of the residence take you? _______                           

How many risk factors were you able to correct while you were there?  _____

Learning Assessment:

Barriers to Learning Yes/No Describe any barriers identified and how you might be able to overcome this barrier
Client Caregiver
Willing to learn      
Able to learn      
Adequate vision/hearing      
Able to write      
Language barriers (specify language)      

Home Inspection, Teaching and Plan of Correction


  1. Each element must be addressed identifying that all questions were reviewed and answered.
  2. If there is no smoking in the home, or no public transportation is used, then you can simply put Non-smokers in the household in the Findings column and N/A in the Teaching and Plan of Correction Column. The same ideas with public transportation. (These are the only exceptions)


  1. Element: Do not just ask questions, look around the home/yard to determine if these items are pertinent.
  2. Findings: Describe your finding which either shows there is a risk (deficiency) or not.Identify how they meet or do not meet that element. Every number in the finding column needs to be addressed.Place an N/A only if ALL of any given element is not applicable. Yes and No only answers only are not acceptable, you need to explain what you saw.
  3. Teaching: Identify teaching you did related to your deficiency findings during your visit (DO NOT provide theoretical teaching, add only what you taught. Address interest or willingness (or lack of) to learn that subject matter. If there is no teaching for a specific number (due to no risk/deficiency), put the number and an N/A next to it. There is no reason to teach on something that you did not find to be an “at risk” concern.
  4. Plan of Correction: Make corrections at the time of your visit if possible and state how you made that correction. Be sure you clearly state if you corrected it at the time of your visit. If you are unable to make a correction at that time, develop a plan to correct each at risk/deficiency (specific deficiencies you identified in the findings column). Be sure each plan has; 1) tracking methods if needed, 2) estimated completion dates and 3) responsible person for follow-up with plan. Be sure and make the plan realistic to time and expense. If the risk factor/deficiency is not correctable, such as an uneven sidewalk in an apartment complex, then state that it is not correctable and why. You do not have to restate your findings or teaching elements in the plan, you only need to address the deficiencies found. If you did reinforcement teaching of something they are already doing, that goes in the teaching column NOT IN THE PLAN section.
Element Findings Teaching Plan of Correction
Electrical HazardsAppliances checked periodically for good operating conditionsExtension cords are NOT under rugsWhen using extension cords for appliances, does the gauge of both cords matchAre electrical outlets overloaded      
House KeepingRubbish cleaned out of attics, garages and yardsPaint kept in tightly closed metal containersFlammable liquids stored in safety cans and kept away from heat and childrenNEVER uses flammable liquids for cleaning clothes or starting firesOily rags kept in a tightly sealed containerClothes dryer vent clean and properly installed      
Heating and CookingIf a fireplace, is a screen always placed in front of itIs the filter for a forced air heater changed yearly and the venting cleaned?Combustibles are not stored near the stove, heater or fireplaceMaintain safe distance from flame and heat sources      
Smoking HabitsMatches and lighters kept out of children’s reachIs “NO SMOKING IN BED” a rule of the houseAwareness that ash trays should NEVER be emptied into waste basketsPlenty of large, safe ash trays throughout the houseRoutine check for smoldering cigarette butts in the furniture      
Smoke Alarms Smoke alarm on each floor and in every bedroomTest smoke alarm(s) every monthReplace the battery of battery operated smoke alarm every yearSmoke alarms less than 10 years old                      
Fire Escape Fire escape plan prepared.Is the escape plan posted and regularly practiced?Does each bedroom have TWO exits?Is there a meeting place so you will know everyone is outside and safe?Are emergency response numbers posted on all telephones?Is the home address on or near a telephone and adequately visible? Do all family members know how to dial 9-1-1 for fire, police or medical emergencies?Awareness of the first rule in fire emergencies: (Get everyone out fast and don’t go back inside)      
Fire ExtinguishersIs there a UL or FM approved fire extinguisher in the home?Is there easy access to the fire extinguisher Is it checked two times a year and shaken it to keep the powder from packing?Dexterity and strength to use appropriately      
Outside Have all dried grass cuttings, tree trimmings and weeds been removed from the propertyCan the house number be seen from the street?          
Psycho-SocialWorried about fallingOften feels sad or depressed        
Assistive DevicesUses or has been advised to use a cane or walker to get around safely      
Steadiness and Walking Has fallen in the past yearSometimes feels unsteady when walkingHolds onto furniture when walking at homeNeeds to push with my hands to stand up from a chairUses a rocker or swivel chair Trouble stepping up onto curbsOften has to rush to the toiletLost some feeling in one or both feet      
Trip/fall FactorsCluttered rooms/hallsSmall furniturePets around legsElectrical cordsThrow rugsSlippery floors Lack of lighting/adequate light at nightOutdoor walkways are smooth and free of puddles or holesHow is laundry moved to the wash area? laundry detergent box/bottle too heavy to lift Laundry detergent on floors      
Safety ToolsGrab cane within reach Grab bars inside and outside of bathtub or shower and next to the toilet  Railings on both sides of the stairsToilet high riser or bedside commode Non-skid bath/shower matsStep stools with grab handle Easy to see and dial phone availability Uses no skid rubber sole shoes                                                          
Administration Takes medicine that sometimes that can cause feeling of light-headed, to help with sleep or to improve moodSets up daily medication in an easy-to-use system (e.g. pill box)Medicines are clearly labeled.Read medicine labels in good light to ensure you have the right medicine and always take the correct dose.Dispose of any old or used medicines.Never borrows prescription drugs from others.      
Doctor/PharmacistReviews medicines frequently with doctor or pharmacist and Informs doctor of all over the counter medicines taken, including vitaminsCheck with doctor or pharmacist before mixing alcohol with meds.Check with doctor or pharmacist before mixing non-prescription drugs and prescription drugs.        
Disposal Knows how to Identify expired medications Disposes old medication appropriately 1. 2. 1. 2. 1. 2.
Private TransportationEasy to get in and out of vehicles (seating height)Is assistance needed to transfer to and from vehicle? Is there room in the vehicle to place correct assistive devices if needed        
Public Transportation Handicap accessible transportationw/c ramp if neededlow steps to enter bususes specialty transportation services