2009 OMRDD ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY by ypw20158

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									                       2009 OMRDD ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY

Camp Name:
Camp Address/Location:


Camp Telephone Number:
Camp Director:
Camp Agency/Operator:
Agency/Operator Address:
Agency/Operator Telephone:                                                      Date(s) of Camp Operation:
Agency/Operator E-Mail:


Please include the following for the 2009 Summer Camp season:
Total Number of Campers:                                          Age Range of Campers:
Total Number of MR/DD Campers:                                    Number of Non-Ambulatory Campers:
Dates of Operation:
Name and Title of Person Completing Checklist:


Submit Completed Checklist to:          Karisa Kacensky
                                        Division of Quality Management/OMRDD
                                        Program Support Unit 4th, Floor
                                        44 Holland Ave.
                                        Albany, NY 12229
                                        Tel: (518) 473-7032 Fax: (518) 486-1108
                                        E-Mail: Karisa.Kacensky@omr.state.ny.us




                                                          Page 1 of 7                                        3/23/09
Adult Overnight Summer Camp Self-Survey                                 REVISED 2009                                                               03/09
Core Indicators are bolded and in CAPITAL LETTERS. These questions must be answered “YES” for inclusion on the OMRDD Directory of Summer Camps.
NOTE: Revisions are italicized.
                                       ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY
     RATING                                        ADMINISTRATION & SUPERVISION
   Y   N   N/A                                                     QUESTIONS                                                            COMMENTS
                        1.   DOES THE CAMP HAVE ALL PERMITS IN EFFECT AS REQUIRED
                             FROM ANY GOVERNMENTAL BODY OR AGENCY HAVING
                             JURISDICTION OVER THE CAMP?
                        2.   IS THE CAMP’S HEALTH DIRECTOR A PHYSICIAN (MD), PHYSICIAN’S
                             ASSISTANT (PA), REGISTERED NURSE (RN)?
                        3.   DOES THE CAMP HAVE STAFF WITH CURRENT FIRST
                             AID/CARDIOPULMONARY RESUSCITATION (CPR) CERTIFICATION
                             ON-DUTY AT ALL TIMES?
                        4.   Does the camp have documentation that they notified the local hospital/clinic of their
                             intent to utilize the facility to provide medical services to campers in the event of illness
                             and/or emergency?
                        5.   Does the camp’s policy and procedures manual include guidelines, as well as
                             requirements for staff training in the following areas:
                             a) Emergency procedures, including emergency medical procedures?
                             b) Reporting of injuries/illness?
                             c) Fire safety procedures?
                             d) Handling/reporting abuse/neglect?
                             e) Staff training?
                             f) Water activities?
                             g) Storage of hazardous materials?
                             h) Health/medical care plan procedures?




                                                                     Page 2 of 7                                                                   3/23/09
Adult Overnight Summer Camp Self-Survey                                 REVISED 2009                                                               03/09
Core Indicators are bolded and in CAPITAL LETTERS. These questions must be answered “YES” for inclusion on the OMRDD Directory of Summer Camps.
NOTE: Revisions are italicized.
                                       ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY
     RATING                                     ADMINISTRATION & SUPERVISION
   Y   N   N/A                                                QUESTIONS                                                                 COMMENTS
                             i) Consumer behavioral needs procedures, including training on specific camper needs
                                (when applicable)?
                             j) Consumer mobility procedures?
                             k) Universal precautions?
                             l) Camp evacuation procedure?
                             m) Missing camper procedures?
                             n) Medication administration?
                             o) Van safety (if applicable)?
                             p) Adaptive equipment (including orthotics if applicable) (i.e. Hoyer lift, eating
                                equipment, AFO, etc.)?
                        6.   Does the camp safety plan address the following areas:
                             a) Camper illness/injury?
                             b) Seizures management?
                             c) Choking precautions?
                             d) Hydration?
                             e) Constipation/bowel management?
                             f) Summer precautions?
                             g) Camp evacuation?
                             h) Emergency communication?
                             i) Notification of agencies/police/hospital?
                             j) Notification of parents?
                        7.   CAN THE CAMP STAFF DEMONSTRATE COMPETENCY IN THE AREAS
                              NOTED IN QUESTIONS #5 AND #6?




                                                                     Page 3 of 7                                                                   3/23/09
Adult Overnight Summer Camp Self-Survey                                 REVISED 2009                                                               03/09
Core Indicators are bolded and in CAPITAL LETTERS. These questions must be answered “YES” for inclusion on the OMRDD Directory of Summer Camps.
NOTE: Revisions are italicized.
                                       ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY
     RATING                                        PERSONNEL/STAFF TRAINING
   Y   N   N/A                                                  QUESTIONS                                                               COMMENTS
                        8. Does the camp have specific staffing ratios in the following areas/activities:
                            a) general population campers who do not have specific needs; i.e., seizures, PICA,
                                wheelchair?
                            b) special needs campers; i.e., seizures, behavioral, PICA, wheelchairs, etc.?
                            c) waterfront activities?
                            d) overnight staffing; i.e., awake or asleep staff?
                            e) bathing/shaving activities?
                            f) medication administration?
                        9. Does the camp have a system to ensure that all campers are present and accounted for
                            during different types of activities; i.e., swimming, hiking, etc.?
                        10. DOES THE CAMP HAVE WRITTEN INSTRUCTIONS INFORMING
                            SUPERVISORY/PROFESSIONAL STAFF AND CAMP COUNSELORS OF
                            THE SPECIALIZED NEEDS OF CAMPERS IN THE FOLLOWING AREAS
                            (IF APPLICABLE)?
                            a) BOWEL MANAGEMENT?
                            b) SEIZURE MANAGEMENT?
                            c) MALADAPTIVE BEHAVIOR MANAGEMENT, PICA, WANDERING, ETC.?
                            d) USE OF ADAPTIVE EQUIPMENT; I.E., HOYER LIFT, ADAPTIVE-
                                EATING EQUIPMENT, ETC.?
                            e) POSITIONING TECHNIQUES?
     RATING                              HEALTH/NURSING/SPECIALIZED PROGRAMS
   Y   N   N/A                                                  QUESTIONS                                                               COMMENTS
                        11. DOES THE CAMP HAVE AN RN AVAILABLE, ON-CALL 24 HOURS A
                            DAY, WHEN CAMP IS IN SESSION?




                                                                     Page 4 of 7                                                                   3/23/09
Adult Overnight Summer Camp Self-Survey                                 REVISED 2009                                                               03/09
Core Indicators are bolded and in CAPITAL LETTERS. These questions must be answered “YES” for inclusion on the OMRDD Directory of Summer Camps.
NOTE: Revisions are italicized.
                                       ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY
     RATING                                HEALTH/NURSING/SPECIALIZED PROGRAMS
   Y   N   N/A                                                  QUESTIONS                                                               COMMENTS
                        12.   EACH CAMPER’S CURRENT PHYSICAL IS ON-SITE AND DOES IT
                              CONTAIN THE FOLLOWING:
                              a) NAME OF PHYSICIAN AND TELEPHONE NUMBERS (REGULAR AND
                                   EMERGENCY)?
                              b) CONFIDENTIAL MEDICAL HISTORY?
                              c) IDENTIFICATION OF SPECIAL HEALTH CARE NEEDS; I.E., SEIZURE
                                   DISORDER (IF APPLICABLE)?
                              d) IDENTIFICATION OF ALLERGIES/COMMUNICABLE DISEASE (IF
                                   APPLICABLE)?
                              e) IMMUNIZATION RECORD?
                        13.   ARE ONLY LICENSED PERSONNEL (MD, PA, NP, RN, or LPN)
                              ADMINISTERING MEDICATIONS?
                        14.   DOES THE CAMP HAVE A MEDICATION ADMINISTRATION RECORD
                              (MAR) ON-SITE FOR EACH CAMPER WHO IS NOT CAPABLE OF SELF-
                              ADMINISTRATION OF MEDICATION AND FOR EACH MEDICATION
                              ADMINISTERED?
                        15.   DOES THE CAMP HAVE CURRENT COPIES OF CAMPERS’
                              MEDICATIONS AND TREATMENTS VIA A CURRENT PHYSICAL,
                              PHYSICIAN’S ORDERS, OR PRESCRIPTIONS (INCLUDING OTC, PRN
                              VITAMINS AND ALTERNATIVE MEDICATIONS) THAT ARE CAMPER-
                              SPECIFIC?
                        16.   Are all medications kept locked at all times, except during administration?
                        17.   Are all controlled medications kept double-locked?
                        18.   Does the camp limit access of medication to only authorized personnel?
                        19.   Do all medications have accurate and legible pharmacy labels?
                        20.   Is the medication storage area free of discontinued/expired medication?
                        21.   DO NURSING PERSONNEL MAINTAIN A HEALTH LOG OR OTHER

                                                                     Page 5 of 7                                                                   3/23/09
Adult Overnight Summer Camp Self-Survey                                 REVISED 2009                                                               03/09
Core Indicators are bolded and in CAPITAL LETTERS. These questions must be answered “YES” for inclusion on the OMRDD Directory of Summer Camps.
NOTE: Revisions are italicized.
                                       ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY
     RATING                                 HEALTH/NURSING/SPECIALIZED PROGRAMS
   Y   N   N/A                                                    QUESTIONS                                                             COMMENTS
                              WRITTEN DOCUMENTATION OF CONSUMER HEALTH CARE THAT
                              DOCUMENT NURSING ASSESSMENT, SUPERVISION AND TRIAGE FOR
                              ILLNESS, INJURIES, MEDICATION ERROR AND/OR MEDICATION
                              REFUSALS?
                        22.   DOES THE CAMP IMPLEMENT INFECTION CONTROL PRACTICES TO
                              MINIMIZE THE RISK OF INFECTIOUS DISEASE TRANSMISSION?
                        23.   Is the health center adequately stocked with medical supplies such as blood pressure
                              equipment, thermometers (non-glass), etc.?
                        24.   ARE MODIFIED DIETS REVIEWED BY THE CAMP’S HEALTH DIRECTOR
                              OR DIETICIAN, IDENTIFIED PRIOR TO THE CAMPERS’ ARRIVAL,
                              PROVIDED PER DIRECTION?
                        25.   Are special needs identified; i.e., ADLs, dining, behavioral and are specialized
                              instructions available for staff review (as appropriate)?
                        26.   Does the camp have areas on-site that are air-conditioned and heated to meet the
                              temperature control needs of campers? (INFORMATIONAL ONLY)
                        27.   Does the camp have a telephone/communication system available to personnel in all
                              areas of camp?
     RATING                                                   DINING SERVICES
   Y   N   N/A                                                    QUESTIONS                                                             COMMENTS
                        28.   Are choking precautions posted?
                        29.   Are fluids offered at meals and readily available throughout the day?
     RATING                                                  COMMUNICATION                                                              COMMENTS
   Y   N                                                          QUESTIONS
                        30.   Does the camp have a process for identifying when and why to contact an
                              individual’s residence/family/care-giver/medical professional?
                        31.   Does the camp have a satisfaction survey?


                                                                     Page 6 of 7                                                                   3/23/09
Adult Overnight Summer Camp Self-Survey                                 REVISED 2009                                                               03/09
Core Indicators are bolded and in CAPITAL LETTERS. These questions must be answered “YES” for inclusion on the OMRDD Directory of Summer Camps.
NOTE: Revisions are italicized.
                                       ADULT OVERNIGHT SUMMER CAMP SELF-SURVEY
     RATING                                                 PHYSICAL PLANT
   Y   N   N/A                                                  QUESTIONS                                                               COMMENTS
                        32.   DOES THE CAMP HAVE AN ADEQUATE PLUMBING SYSTEM AND IS
                              THIS SYSTEM IN GOOD WORKING ORDER?
                        33.   Are there systems in place to ensure the maintenance of the plumbing system and
                              prompt repair?
                        34.   IS THE MAXIMUM WATER TEMPERATURE AT EACH SHOWER, TUB,
                              OR SINK LIMITED TO 110º F OR LESS?
                        35.   DOES THE CAMP HAVE A SYSTEM IN PLACE TO MONITOR AND
                              MAINTAIN SAFE WATER TEMPERATURE?
                        36.   Are bathrooms equipped with appropriate fixtures, grab bars and controls, if
                              applicable?
                        37.   Are the camp’s buildings clean, in good repair, hazard-free, well-ventilated and odor-
                              free?
                        38.   Is the camp reasonably barrier-free and designed to meet the needs of the campers?
                        39.   IS THE CAMP FREE OF SERIOUS HAZARDS THAT ENDANGER THE
                              HEALTH AND SAFETY OF CAMPERS?
                        40.   Is the entire camp fenced in and are there gates? (INFORMATIONAL ONLY)
     RATING                                                WATER ACTIVITIES
   Y   N   N/A                                                  QUESTIONS                                                               COMMENTS
                        41.   IS THERE A QUALIFIED LIFEGUARD ON-DUTY DURING ALL
                              ACTIVITIES INVOLVING A STANDING BODY OF WATER (I.E.
                              WADING/SWIMMING POOL, POND, LAKE, AND RIVER) AND ARE ALL
                              THE LIFEGUARDS CURRENTLY CERTIFIED IN CPR AND FIRST AID?
                        42.   IS ACCESS TO THE AREA CONTROLLED WHEN LIFEGUARDS ARE
                              UNAVAILABLE?
                        43.   Are counts taken of campers in the swimming areas? How often?



                                                                     Page 7 of 7                                                                   3/23/09

								
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