There is signage alerting those entering the home that oxygen is in use and no smoking a   Oxygen concentrator is plugged into a grounded outlet with no other electrical appliances, lamps, etc. plugged into the same outlet

The patient/family were advised to let the Fire Department know that there is oxygen in the home

There is a fully charged or hard wired smoke detector in appropriate places throughout the home

Exits are free from any obstacles

An emergency exit plan has been discussed with the patient/family

□   There is a working fully charged fire extinguisher easily accessible
If the patient or others smoke:

o   Patient and family were instructed not to smoke while oxygen is in use o   Patient and family were instructed in the dangers of smoking with oxygen in use o   There is documentation that the M.D., fire department, and police were notified if the patient and family are not compliant with the above instructions

□   There are no combustible products near the oxygen tanks or concentrator

Oxygen tanks are secure in a stand or lying down in a well-ventilated area (not in the closet or under a bed with a skirt)

□   The patient or caregiver demonstrated how to set-up and apply the back-up oxygen in
case there is a power failure or the patient has to leave the home

There is an adequate supply of tanks to use in an emergency if the patient is on

continuous oxygen therapy and there is a power failure a   There are no portable space heaters near the oxygen a   The tubing from the concentrator is adequate for ambulation or transferring needs, but not

so long that the patient is not getting enough oxygen

□   The patient/family can explain:o How to clean the oxygen concentrator's filter (a least once a week or whenever


there is signs of dust on the outside) o   How to clean the humidifier bottle, if applicable (white vinegar and water)o   How to fill the humidifier bottle o   How often to change the nasal cannula (every two weeks unless the patient is


having excessive nasal secretions, then prn) o   How to contact the DME/HME company

□   The patient/family understands not to go near the stove or open the oven with the nasal
cannula on

The patient/family know that the liter flow per min must be within the range that was ordered by the doctor and are compliant with these orders

There are no frayed wires or cords on lamps or other appliances that are in use and that could cause a spark in the room with the oxygen

The concentrator is located in a well ventilated area with nothing obstructing the air intake(s)

The filter(s) is dust-free