Horticultural Therapy Safety Screening (Tools, Allergens, or Fall Risk)

Horticultural Therapy Safety Screening and Risk Assessment

Patient/Participant Name: [Name]
MRN/ID: [Identifier]
DOB: [DOB per facility policy]
Date/Time: [Date and time of screening]
Screening Type: [Initial / Update / Session-Specific Addendum]
Setting: [Indoor / Greenhouse / Outdoor Garden / Community Site] Address (if offsite): [Full address]
Clinician: [Name, credentials]
Encounter Context: [Individual / Group] Staff-to-Participant Ratio: [Ratio]
Planned Activities: [Brief description of tasks for this session]

Information Review/Carry-Forward Attestation: [No prior content carried forward / Prior information reviewed and updated today] (If prior content carried forward, note changes: [Summary of updates])

Immediate Exclusion Criteria (Hard-Stop Gate)

(If any item is Yes, document the specific finding and escalation plan. If any domain was Not Assessed, default overall gate to Not Cleared until resolved.)

• Unstable medical condition: [Yes / No / Unknown / Not Assessed] Details/Escalation: [If yes, document finding and plan]
• New fever or symptoms suggesting contagious infection: [Yes / No / Unknown / Not Assessed] Details/Escalation: [If yes, document finding and plan]
• Uncontrolled bleeding risk or inability to protect wounds: [Yes / No / Unknown / Not Assessed] Details/Escalation: [If yes, document finding and plan]
• Severe allergy risk without rescue plan available: [Yes / No / Unknown / Not Assessed] Details/Escalation: [If yes, document finding and plan]
• Inability to follow basic safety instructions with insufficient supervision: [Yes / No / Unknown / Not Assessed] Details/Escalation: [If yes, document finding and plan]
• Environmental conditions exceed program thresholds without mitigation: [Yes / No / Unknown / Not Assessed] Details/Escalation: [If yes, document finding and plan]

Clearance Gate: [Not Cleared Today / Cleared With Restrictions / Cleared Without Restrictions]
Gate Rationale: [Concise rationale; if Not Cleared, document reason and escalation plan]

Participant Risk Profile

(Include only items that change risk management. Use explicit status indicators. For unknown items, document how information will be obtained. Do not infer absence from missing data.)

Medical Conditions Affecting Risk

• Cardiopulmonary limitations: [Present / Absent / Unknown] [Details and controls if present]
• Seizure disorder: [Present / Absent / Unknown] [Last event, triggers, rescue plan]
• Diabetes/hypoglycemia risk: [Present / Absent / Unknown] [Monitoring and snack plan]
• Anticoagulation or bleeding risk: [Present / Absent / Unknown] [Agent, INR target if relevant, controls]
• Immunocompromised state: [Present / Absent / Unknown] [Etiology if known, controls]
• Dermatologic fragility: [Present / Absent / Unknown] [Areas affected, protection plan]
• Cognitive impairment: [Present / Absent / Unknown] [Impact on safety, supervision needs]
• Psychiatric or behavioral concerns: [Present / Absent / Unknown] [Triggers, de-escalation plan]

Mobility and Fall Risk

• Ambulation status: [Independent / With assistive device / Wheelchair user / Non-ambulatory] Device: [None / Cane / Walker / Wheelchair / Other]
• Transfer independence: [Independent / Supervision / Contact guard / Moderate assist / Max assist]
• Standing tolerance: [Duration estimate or Unknown] Bending tolerance: [Tolerates / Limited / Avoid bending / Unknown]
• Fall history: [Yes / No / Unknown] Timeframe and details: [Count, dates, circumstances]
• Dizziness, orthostasis, or neuropathy: [Present / Absent / Unknown] [Details]
• Vision impairment affecting safety: [Present / Absent / Unknown] [Details]
• Sedating or balance-affecting medications: [Present / Absent / Unknown] Medication review considered: [Yes / No]
• Footwear appropriateness: [Appropriate / Not appropriate / Will be provided / Unknown]
• Standardized fall risk tool: Tool: [Name or None used] Score: [Score] Risk category: [Low / Moderate / High] Controls derived: [Specific controls based on score]

Allergy and Hypersensitivity

• Latex allergy or glove material requirement: [Yes / No / Unknown] Required material: [Nitrile / Vinyl / Other]
• Plant, pollen, or mold allergy: [None / Mild / Moderate / Severe / Unknown] [Specific triggers and controls]
• Insect sting allergy: [Yes / No / Unknown] Anaphylaxis history: [Yes / No / Unknown] Rescue medication on site: [Yes / No] Location: [Location]
• Contact dermatitis triggers: [Listed / None known / Unknown] [Specific triggers]

Communication and Comprehension

• Ability to follow multi-step safety commands: [Adequate / Needs cues / Unable / Unknown]
• Sensory deficits affecting safety: Vision: [Yes / No / Unknown] Hearing: [Yes / No / Unknown] [Assistive devices]
• Interpreter needs: [Yes / No] [Language and modality]

Skin Integrity

(Include if soil, tool, or plant contact is planned)

• Open wounds requiring coverage: [Yes / No] Location: [Sites] Occlusive dressing applied: [Yes / No / Not applicable]
• Fragile skin: [Yes / No / Unknown] [Protection plan]
• Ostomies, lines, or tubes: [Yes / No] [Protection plan]

Unknown Items and Information Gathering Plan: [List unknowns and how/when they will be clarified]

Setting and Environmental Hazards

• Terrain features: [Uneven ground / Slopes / Wet surfaces / Thresholds / Raised-bed edges / Stairs / Ramps / Smooth pathways] [Notes on specific hazards]
• Environmental exposures: [Sun/UV / Heat / Cold / Wind / Pollen / Dust / Insect activity] [Notes]
• Materials present: [Soil / Compost / Mulch / Fertilizers / Pesticides / None] SDS accessible: [Yes / No] Location: [Location]
• Equipment and trip hazards: [Hoses / Carts / Irrigation lines / Wheelbarrows / Other] [Controls]
• Current outdoor conditions (if applicable): Temperature: [Value] Heat index: [Value] Wind: [Calm / Light / Moderate / Strong] Precipitation: [None / Drizzle / Rain / Snow]

Infection Control and Exposure Precautions

• Hand hygiene plan: [Before session / After session / After soil contact / After glove removal / Before eating or drinking]
• PPE determination: Gloves: [Required / Not required] Material: [Nitrile / Vinyl / Other] Eye protection: [Required / Not required] Mask/respirator: [None / Surgical / N95] Protective clothing: [Long sleeves / Long pants / Apron / None required] Footwear: [Closed-toe required]
• Wound and skin protection: All open areas covered with occlusive dressing: [Yes / No / Not applicable]
• Immunocompromised or high fungal risk controls: [Avoid direct soil contact / Avoid dusty soil handling / N95 if soil disturbance unavoidable / Relocate to indoor alternatives / Standard precautions only] (Default to more protective controls when immune status is unknown)
• Shared equipment cleaning: [Method and agent] Responsible staff: [Name or role]

Tool Safety Plan

(Include if tools or sharps are planned for use or accessible in the environment. If no tools or sharps involved, document: "No tools or sharps in use; sharps secured" and skip remaining items.)

• Tools present or planned: [Hand tools / Cutting tools / Equipment / None]
• Participant tool eligibility: [Independent use / Use with direct supervision / Use with continuous 1:1 supervision / No tool or sharp handling] Rationale: [Brief rationale]
• Required controls: Pre-use safety briefing: [Completed / Not completed] PPE for tool tasks: [List] Safe handling rules reviewed: [Yes / No] Sharps inventory process: [Check-in/check-out method]
• Adaptive tools authorized: [Yes / No] [Specific tools: ergonomic grips, spring-loaded pruners, seated workstation]
• First aid kit location: [Location] Staff trained in minor injury response: [Yes / No]
• Sharps present but not used by participant: Access control: [Locked storage / Supervised area only / Not applicable]

Environmental Physiologic Tolerance

(Include for outdoor sessions or greenhouse settings with heat exposure. For indoor sessions without temperature concerns, document "Not applicable—indoor climate-controlled session" and skip remaining items.)

• Heat risk factors: [Limited sweating / Dehydration risk / Diuretic use / Cardiac conditions / Impaired thirst recognition / Cognitive impairment / None identified]
• Cold risk factors: [Poor circulation / Wet clothing risk / Inability to report discomfort / None identified / Not applicable]
• Sun protection plan: Sunscreen: [Applied / Offered / Declined / Not applicable] Hat: [Yes / No] Shade break intervals: [Interval] Direct sun time limit: [Duration]
• Hydration plan: Water accessible: [Yes / No] Break frequency: [Interval] Staff prompts needed: [Yes / No]
• Duration and thresholds: Maximum duration outdoors: [Time] Work/rest cycle: [Pattern] Recovery location: [Shaded or climate-controlled location] Stop criteria: [Symptom-based and environmental thresholds]

Clearance Decision and Required Controls

• Clearance status: [Cleared with standard precautions only / Cleared with restrictions required / Not cleared—defer and escalate] Rationale: [Brief rationale]
• Supervision level: [Independent / Intermittent check-ins / Direct supervision / Continuous visual / 1:1 / Enhanced staffing / Other] Rationale: [Brief rationale]
• Required PPE summary: [List all required PPE with task triggers]
• Activity modifications:
  • Allowed activities today: [List]
  • Prohibited activities today: [List specific restrictions]
  • Adaptive setup required: [Raised bed / Seated station / Stable chair with arms / Paved paths only / Frequent rest breaks / Other]
• Allergy and emergency response readiness: Epinephrine location: [Location or Not applicable] Staff awareness confirmed: [Yes / No] Avoidance plan: [Brief plan] Mild reaction response: [Steps] Poison Control: 1-800-222-1222 Escalation triggers: [List]
• Education provided: Safety briefing: [Completed / Not completed] Teach-back: [Yes / No] Comprehension deficits: [None / Noted—specify] Caregiver/staff instructions: [Provided / Not needed]
• Validity: [This session only / Valid until date] Re-screen if: [Fall event / Medication change / New wound / New allergy symptoms / Infectious symptoms / Environmental change / Other]

Emergency Response Plan

(For facility-based settings, reference unit emergency protocol and document garden-specific access details. For offsite/community settings, complete all fields.)

• Setting: [Offsite/Community / Facility-based]
• Emergency activation: [Phone / Radio / Other] Response leader: [Name or role]
• EMS access (offsite/community): Address: [Full address] Location descriptors: [Landmarks, building name] Gate codes: [Codes if applicable] Best entry point: [Directions]
• Garden access (facility-based): Nearest EMS entrance: [Location] Directions to garden: [Directions for responders]
• Emergency equipment locations: First aid kit: [Location] Eyewash/handwashing: [Location] AED: [Location or Not available] Epinephrine: [Location or Not stocked]
• Emergency contacts: [List including Poison Control: 1-800-222-1222]
• Role assignments: Stays with participant: [Name/role] Calls emergency services: [Name/role] Meets responders: [Name/role] Documents: [Name/role]
• Incident reporting: [Form or policy reference]

Attestation

Clinician Signature: [Signature]
Credentials: [Credentials]
Date/Time: [Date and time]

If screening performed by delegate: Delegate: [Name and role] Supervision arrangement: [Description] Finalized by: [Clinician name] Date/Time finalized: [Date and time]