36C24118Q9162-005.docx

Department of Veterans Affairs

Health Care for Homeless Veterans (HCHV)

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

INSPECTION IS FOR: INITIAL INSPECTION RE-INSPECTION PROJECT #:

AGENCY'S ADMINISTRATIVE OFFICE ADDRESS:

LIST ALL PHYSICAL ADDRESSES WHERE VETERANS ARE HOUSED UNDER THIS PROJECT NUMBER:

INSPECTION TEAM MEMBERS

FACILITIES MANAGEMENT

NUTRITION

CLINICAL REVIEW

SECURITY / LAW ENFORCEMENT

MEDICATION REVIEW

NHC OR DESIGNEE

OTHER

MEDICAL CENTER DIRECTOR - REVIEW & RECOMMENDATION

I HAVE REVIEWED THE INSPECTION PACKAGE REGARDING THE ABOVE NAMED PROVIDER AND IT IS COMPLETE BASED ON THE INFORMATION CONTAINED IN THIS INSPECTION PACKAGE AND MEETS THE STANDARDS PRESCRIBED IN VHA HANDBOOK _____. ANY INSPECTION DEFICIENCIES NOTED HAVE BEEN CORRECTED.

I APPROVE I DISAPPROVE PLACEMENT OF VETERANS AT THIS PROVIDER'S FACILITY.

I APPOINT THE FOLLOWING INDIVIDUAL AS LIAISON FOR THIS PROJECT

LIAISON PHONE:

DATE

INSPECTION PACKAGE ASSEMBLY CHECKLIST

ALL ITEMS MUST BE INCLUDED BEFORE SENDING TO THE HCHV PROGRAM OFFICE FOR REVIEW

SITE ADDRESS:

HCHV Staff SHOULD COMPLETE THIS SECTION ATTACHING ANY OTHER DOCUMENTATION, AS NECESSARY

A. MEN

B. WOMEN

D. TOTAL NUMBER OF BEDS UNDER THIS PROJECT NUMBER

TO THE BEST OF YOUR KNOWLEDGE DOES THE PROGRAM MEET THE FOLLOWING CRITERIA?

YES

NO

N/A

MEETS ALL APPLICABLE STATE AND LOCAL LICENSING AND OTHER REQUIREMENTS FOR THE OPERATION OF THE PROJECT IN THE JURISDICTION WHERE THE PROJECT IS LOCATED

HAS DEMONSTRATED ADEQUATE STAFFING AND AN APPROPRIATE

SCOPE OF SERVICES TO CARRY OUT THIS PROJECT AS OUTLINED IN THE ORIGINAL STATEMENT OF WORK OR SUBSEQUENT APPROVED CHANGE OF SCOPE

AGENCY SERVES THE POPULATION(S) AS DESCRIBED IN THEIR APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE

AGENCY OCCUPANCY RATE ROUTINELY MEETS OR EXCEEDS 80 PERCENT OF THE HCHV FUNDED BEDS; OR AGENCY HAS IMPLEMENTED ADEQUATE MEASURES TO EXPAND OUTREACH AND COORDINATION TO IMPROVE PROGRAM UTILIZATION

THE PHYSICAL STRUCTURE OF THE FACILITY, PROGRAM POLICIES AND PROCEDURES ARE APPROPRIATE TO ENSURE THE SAFETY, SECURITY, AND PRIVACY OF ALL INDIVIDUALS IN THE FACILITY

CORRECTIVE ACTION PLANS (CAP) HAVE BEEN IMPLEMENTED

IF APPLICABLE (RE-INSPECTIONS ONLY)

BASED ON THE RESULTS OF THE ATTACHED INSPECTION DOCUMENTS THIS PROJECT IS RECOMMENDED FOR THE PLACEMENT OF VETERANS

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

ANY CHECKLIST ITEMS WHERE “NO” WAS INDICATED MUST HAVE DOCUMENTATION PROVIDED BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND APPROPRIATELY DOCUMENTED WILL RESULT IN AN INCOMPLETE INSPECTION PACKAGE.

DEFICIENCIES AND CORRECTIVE ACTIONS REQUIRED:

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACTOR TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

FACILITIES MANAGEMENT

PROJECT NUMBER:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CONTRACTED PROVIDERS (ALL INSPECTIONS)

IS IN COMPLIANCE WITH THE NFPA LIFE SAFETY CODE (SEE ATTACHED REPORT)

IS STRUCTURALLY SOUND SO AS NOT TO POSE ANY THREAT TO THE HEALTH AND SAFETY OF THE OCCUPANTS AND SO AS TO PROTECT THEM FROM THE ELEMENTS

HAS ENTRIES AND EXIT LOCATIONS THAT ARE CAPABLE OF BEING

UTILIZED WITHOUT UNAUTHORIZED USE OF OTHER PRIVATE PROPERTIES AND PROVIDE ALTERNATE MEANS OF EGRESS IN CASE OF FIRE

IS COMPLIANT WITH THE AMERICAN WITH DISABILITIES ACT AND THE ARCHITECTURAL BARRIERS ACT.

PROVIDES EACH RESIDENT APPROPRIATE SPACE AND SECURITY FOR THEMSELVES AND THEIR BELONGINGS

PROVIDES EACH RESIDENT AN ACCEPTABLE PLACE TO SLEEP THAT IS IN COMPLIANCE WITH APPROPRIATE CODES AND REGULATIONS

PROVIDES EVERY ROOM OR SPACE WITH NATURAL OR MECHANICAL

VENTILATION

IS FREE OF POLLUTANTS IN THE AIR AT LEVELS THAT THREATEN THE HEALTH OF RESIDENTS

PROVIDES SUFFICIENT SANITARY FACILITIES TO RESIDENTS THAT ARE IN

PROPER OPERATIONAL CONDITION, MAY BE USED IN PRIVACY, AND ARE ADEQUATE FOR PERSONAL CLEANLINESS AND THE DISPOSAL OF HUMAN WASTE

PROVIDES ADEQUATE HEATING AND OR COOLING PLANTS THAT ARE IN PROPER OPERATING CONDITION

PROVIDES ADEQUATE NATURAL OR ARTIFICIAL ILLUMINATION TO PERMIT NORMAL INDOOR ACTIVITIES AND TO SUPPORT THE HEALTH AND SAFETY OF RESIDENTS

PROVIDES SUFFICIENT ELECTRICAL SOURCES TO PERMIT USE OF ESSENTIAL ELECTRICAL APPLIANCE WHILE ASSURING SAFETY FROM FIRE

CONTRACTOR HAS A WRITTEN DISASTER PLAN THAT HAS BEEN COORDINATED WITH THE EMERGENCY MANAGEMENT ENTITY RESPONSIBLE FOR THE LOCALITY IN WHICH THE PROJECT RESIDES. THE DISASTER PLAN ENCOMPASSES NATURAL AND MANMADE DISASTERS

PROVIDES THAT HOUSING AND EQUIPMENT ARE MAINTAINED IN A SANITARY MANNER

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

FACILITIES MANAGEMENT

PROJECT NUMBER:

ANY CHECKLIST ITEMS WHERE “NO” WAS INDICATED MUST HAVE DOCUMENTATION PROVIDED BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND APPROPRIATELY DOCUMENTED WILL RESULT IN AN INCOMPLETE INSPECTION PACKAGE.

DEFICIENCIES AND CORRECTIVE ACTIONS REQUIRED:

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACTOR TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

NUTRITION AND FOOD SERVICES

PROJECT NUMBER:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HEALTH CARE for HOMELESS VETERAN PROVIDERS (ALL INSPECTIONS)

HOW DOES THE AGENCY PROVIDE FOR THE NUTRITIONAL NEEDS OF VETERANS IN THE PROGRAM (CHECK ONE):

CENTRALLY PREPARED NUTRITION AND FOOD SERVICES

INDIVIDUAL FOOD PREPARATION FACILITIES

FOR CENTRALLY PREPARED NUTRITION AND FOOD SERVICES THE CONTRACTOR

NO

N/A

AGENCY DEMONSTRATES THE ABILITY TO MEET SPECIAL DIETARY NEEDS (I.E. KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED)

ADEQUATE MEALS AREPROVIDED THREE TIMES PER DAY AS WELL AS NUTRITIOUS SNACKS BETWEEN MEALS AND BEFORE BEDTIME, INCLUDING WEEKENDS

ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION PRACTICES

REFRIGERATION AND DRY FOOD STORAGE AREAS ARE APPROPRIATELY MAINTAINED AND MONITORED

FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A SANITARY CONDITION

FOR INDIVIDUAL FOOD PREPARATION THE CONTRACTOR

NO

N/A

APPLIANCES ARE ADEQUATE TO SAFELY STORE AND PREPARE FOOD AND ARE IN GOOD WORKING CONDITION (I.E. STOVE, REFRIGERATOR, DISHWASHER)

ENSURES THAT ALL FOOD PREPARATION AREAS CONTAIN SUITABLE SPACE AND EQUIPMENT TO STORE, PREPARE, AND SERVE FOOD IN A SANITARY MANNER

SUFFICIENT FOOD STORES ARE AVAILABLE TO ENSURE VETERANS RECEIVE THREE NUTRITIONALLY ADEQUATE MEALS PER DAY AND SNACKS (E.G., VETERANS HAVE ACCESS TO A FOOD PANTRY, LOCAL FOOD BANK, ARE RECEIVING SUPPLEMENTAL NUTRITIONAL ASSISTANCE PROGRAM (SNAP), ETC.)

RESOURCE INFORMATION IS AVAILABLE TO EDUCATE VETERANS WITH SPECIAL DIETARY NEEDS (I.E. DIABETIC, ALLERGIES, MEDICALLY INDICATED). MAY BE ACCOMPLISHED THROUGH NUTRITIONAL EDUCATION PROVIDED DIRECTLY BY THE AGENCY OR A REFERRAL RESOURCE WITHIN THE COMMUNITY

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

ANY CHECKLIST ITEMS WHERE “NO” WAS INDICATED MUST HAVE DOCUMENTATION PROVIDED BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND APPROPRIATELY DOCUMENTED WILL RESULT IN AN INCOMPLETE INSPECTION PACKAGE.

DEFICIENCIES AND CORRECTIVE ACTIONS REQUIRED:

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACTOR TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

CLINICAL REVIEW

PROJECT NUMBER:

THE CLINICAL REVIEW MAY INVOLVE SOCIAL WORK OR MENTAL HEALTH ALONE OR IN ANY COMBINATION AS THE AWARDEES APPLICATION DICTATES. APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV PROVIDERS (ALL INSPECTIONS)

ENSURES THAT PARTICIPANTS IN NEED OF MEDICAL OR SOCIAL DETOX CONDUCTED AT THE SAME SITE ARE CLEARLY SEPARATED FROM THE GENERAL RESIDENT POPULATION

ENSURES THAT THE CONTRACT PROVIDER MEETING THE GOALS, OBJECTIVES, MEASURES, AND SPECIAL NEEDS AS SET FORTH IN THEIR CONTRACT SOW.

WHEN NECESSARY, THE CONTRACTOR INITIATES A CORRECTIVE ACTION PLAN (CAP) WHEN ACCOMPLISHMENTS VARY FOR ANY OF THE GOALS AND OBJECTIVES AS STATED IN THE CONTRACT SOW OR CONTRACT.

ENSURES THAT THE CONSULTATION AND PARTICIPATION OF NOT LESS THAN ONE HOMELESS VETERAN OR FORMERLY HOMELESS VETERAN ON THE BOARD OF DIRECTORS OR THE EQUIVALENT POLICY MAKING ENTITY

ATTEMPTS TO INVOLVE HOMELESS VETERANS THROUGH EMPLOYMENT, VOLUNTEER SERVICES, OR OTHERWISE, IN CONSTRUCTION, REHABILITATION, MAINTAINING, AND OPERATION THE PROGRAM

ENSURES THE RECORDS KEPT ON HOMELESS VETERANS ARE KEPT CONFIDENTIAL, INCLUDING ANY RECORDS OF THE PROVISION OF FAMILY VIOLENCE PREVENTION OR TREATMENT SERVICES

ENSURES THAT ALL HOUSING AND SERVICES PROVIDED TO PARTICIPANTS ARE OF AN ACCEPTABLE QUALITY

ENSURES SUSTAINED EFFORTS ARE MADE THAT ELIGIBLE HARD-TO- REACH PERSONS ARE SERVED IN THE FACILITY. THIS OUTREACH SHOULD BE PRIMARILY TOWARD PERSONS WHO MEET THE DEFINITION OF HOMELESSNESS IN THE REGULATION in 38 U.S.C. 2002(1)

PARTICIPANT RECORD INCLUDES, AT A MINIMUM THE FOLLOWING: FAMILY STATUS, VERIFICATION OF VETERAN STATUS, EDUCATION, EMPLOYMENT HISTORY, AND MARKETABLE SKILLS/LICENSES/CREDENTIALS

ENSURES THAT AN INDIVIDUAL TREATMENT PLAN IS MAINTAINED IN THE CASE MANAGEMENT RECORD FOR EACH INDIVIDUAL PARTICIPANT

THE INDIVIDUAL TREATMENT PLAN CONTAINS AN ASSESSMENT OF BARRIERS, SERVICE NEEDS, STRENGTHS, SPECIFIC SERVICES PROVIDED INCLUDING DURATION AND OUTCOMES, DOCUMENTATION OF REFERRALS, AND BENEFITS TO BE ACHIEVED AS A RESULT OF PROGRAM PARTICIPATION

CONTRACTOR MAINTAINS SYSTEMATIC PARTICIPANT ENROLLMENT INFORMATION AND TRACKING

A. THE CONTRACTOR UTILIZES HMIS FOR PROGRAM PARTICIPANTS

B. THE CONTRACTOR UTILIZES AGENCY INTERNAL TRACKING SYSTEM

C. OTHER. EXPLAIN:

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

CLINICAL REVIEW

PROJECT NUMBER:

ANY CHECKLIST ITEMS WHERE “NO” WAS INDICATED MUST HAVE DOCUMENTATION PROVIDED BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND APPROPRIATELY DOCUMENTED WILL RESULT IN AN INCOMPLETE INSPECTION PACKAGE.

DEFICIENCIES AND CORRECTIVE ACTIONS REQUIRED:

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACTOR TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

CHIEF OF VA POLICE OR DESIGNEE SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HEALTH CARE FOR HOMELESS VETERAN PROVIDERS (ALL INSPECTIONS)

PROJECT IS LOCATED ON VA PROPERTY AND THE CHIEF, POLICE SERVICE OR DESIGNEE HAS CONDUCTED A COMPREHENSIVE RISK ASSESSMENT OF THE PROJECT

PROJECT IS LOCATED ON VA PROPERTY AND A PROCEDURE FOR ON- GOING LAW ENFORCEMENT MONITORING HAS BEEN ESTABLISHED BETWEEN THE PROVIDER AND VA

PROJECT IS LOCATED IN THE COMMUNITY AND THE CHIEF, POLICE SERVICE OR DESIGNEE HAS AS A MEMBER OF THE HEALTH CARE TEAM COORDINATED WITH THE PROVIDER FOR THE PURPOSE OF CONDUCTING A COMPREHENSIVE RISK ASSESSMENT OF THE PROJECT

IS THERE SUFFICIENT LIGHTING AROUND THE PERIMETER OF THE FACILITY BASED ON THE HOUSING SETTING (I.E. RURAL, INDUSTRIAL, OR RESIDENTIAL SETTINGS)

IS THERE SUFFICIENT LIGHTING AROUND THE INTERIOR OF THE FACILITY

ARE LIGHTS CHECKED REGULARLY TO MAKE SURE THEY ARE OPERATING EFFECTIVELY

ARE INTERIOR AND EXTERIOR LOCKS IN GOOD WORKING ORDER; APPROPRIATELY LOCATED; ADEQUATE FOR THE AREA THAT IS BEING SECURED AND POPULATIONS SERVED WITHIN THE FACILITY

ARE COMMON AREAS (E.G., LAUNDRY, COMPUTER LABS, BREAK ROOMS) APPROPRIATELY SECURED, MONITORED, AND LIT

AGENCY HAS APPROPRIATE PROCEDURES REGARDING FACILITY OR UNIT ACCESS WHICH ARE ADEQUATELY CONTROLLED TO ENSURE THE SAFETY OF ALL RESIDENTS

ADEQUATELY ADDRESSES SAFETY AND SECURITY CONCERNS WITH THE FACILITY BASED ON LOCATION, POPULATION(S) SERVED, AND FACILITY STRUCTURE

AGENCY HAS WRITTEN POLICIES AND PROCEDURES REGARDING

SAFETY, SECURITY, AND PRIVACY WHICH ARE REGULARLY COMMUNICATED TO PARTICIPANTS AND STAFF AND ROUTINELY ENFORCED

FACILITY ACCESS IS APPROPRIATELY SEPARATED FOR PRIVACY AND SECURITY GIVEN THE POPULATION(S) SERVED

STAFF OFFICES, TREATMENT, GROUP, PARTICIPANT ROOMS, DORMS, SHOWER, AND RESTROOMS HAVE LOCKS APPROPRIATE FOR THE SETTING AND GENDER MIX

PARTICIPANTS HAVE AN APPROPRIATE PLACE TO SECURE PERSONAL VALUABLES AND BELONGINGS

A PROCEDURE FOR ON-GOING LAW ENFORCEMENT MONITORING HAS BEEN ESTABLISHED

EMERGENCY CONTACTS FOR MEDICAL, LAW ENFORCEMENT, FIRE DEPARTMENT AND AGENCY ARE PROMINENTLY POSTED IN THE FACILITY

RESIDENTIAL SUPERVISION WITH SUFFICIENT KNOWLEDGE FOR THE POSITION IS ON DUTY 24 HRS PER DAY, 7 DAYS PER WEEK; IF THIS SUPERVISION IS PROVIDED BY A VOLUNTEER OR SENIOR RESIDENT, A PAID STAFF MEMBER IS ON CALL FOR EMERGENCIES 24 HRS PER DAY, 7

DAYS PER WEEK

PROGRAM HAS ADEQUATE POLICIES AND PROCEDURES WHICH ARE ENFORCED TO ENSURE THAT ILLICIT DRUGS, WEAPONS, AND OTHER SIMILAR ITEMS ARE NOT PERMITTED ON THE PREMISES

AS PART OF THE RISK ASSESSMENT FOR THIS PROJECT, LOCAL CRIME STATISTICS FOR THE AREA HAVE BEEN REVIEWED AND DISCUSSED WITH THE PROVIDER

SCREENING SYSTEM FOR SEX OFFENDERS (MIXED GENDER AND/OR CHILDREN IN FACILITY)

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

ANY CHECKLIST ITEMS WHERE “NO” WAS INDICATED MUST HAVE DOCUMENTATION PROVIDED BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND APPROPRIATELY DOCUMENTED WILL RESULT IN AN INCOMPLETE INSPECTION PACKAGE.

DEFICIENCIES AND CORRECTIVE ACTIONS REQUIRED:

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACTOR TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

MEDICATION REVIEW

PROJECT NUMBER:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S)

TYPE OF MEDICATION CONTROL SYSTEM USED BY AGENCY (CHECK ALL THAT APPLY):

___ MEDICATION MANAGEMENT: PRACTICE OF PRESCRIBING, ADMINISTERING, AND/OR

DISPENSING MEDICATION BY QUALIFIED PERSONNEL, INCLUDING TAKING PILLS OUT OF BOTTLES, MEASURING LIQUIDS, OR GIVING INJECTIONS ___ MEDICATION MONITORING: PRACTICE OF PROVIDING A SECURE STORAGE AREA AND CONTROLLED ACCESS FOR MEDICATIONS THAT ARE BROUGHT INTO A PROGRAM AND USED BY THE VETERAN. THE PERSON TAKES THE MEDICATION WITHOUT ANY ASSISTANCE FROM STAFF

___ INDIVIDUAL STORAGE: PRACTICE OF ALLOWING INDIVIDUALS TO STORE (I.E. LOCK BOX, INDIVIDUAL APARTMENT UNIT) AND SELF-ADMINISTER THEIR MEDICATIONS

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF MEDICATION USE

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT RESOURCES FOR ADVOCACY TO ASSIST THEM IN BEING ACTIVELY INVOLVED IN MAKING DECISIONS RELATED TO THE USE OF MEDICATIONS

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT TRAINING AND EDUCATION REGARDING MEDICATION

ORGANIZATION DOCUMENTS THAT THE USE OF ALL MEDICATIONS BY PERSONS SERVED IS REVIEWED ON AT LEAST AN ANNUAL BASIS BY A PHYSICIAN OR QUALIFIED PROFESSIONAL LICENSED TO PRESCRIBE MEDICATIONS

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS ADMINISTRATION OF MEDICATIONS BY PERSONNEL, INCLUDING STAFF CREDENTIALS AND COMPETENCIES, DOCUMENTATION OF MEDICATION ADMINISTRATION, AND DOCUMENTATION OF THE USE AND BENEFITS, OR LACK THEREOF, OF AS NEEDED DOSES

ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS

THAT PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES

ORGANIZATION HAS DOCUMENTATION OR CONFIRMATION OF INFORMED CONSENT FOR EACH MEDICATION ADMINISTERED, WHEN POSSIBLE

ORGANIZATION HAS WRITTEN PROCEDURES WHICH INTEGRATE ANY

PRESCRIBED MEDICATIONS INTO A PERSON'S OVERALL PLAN, INCLUDING, IF APPLICABLE, SPECIAL DIETARY NEEDS AND RESTRICTIONS ASSOCIATED WITH MEDICATION USE

ORGANIZATION PROCEDURES ENSURE THE IDENTIFICATION, DOCUMENTATION, AND REQUIRED REPORTING, INCLUDING TO THE PRESCRIBING PROFESSIONAL, ANY MEDICATION REACTIONS OR MEDICATION ERRORS, AS APPROPRIATE

ORGANIZATION HAS WRITTEN PROCEDURES WHICH INCLUDE ACTIONS TO FOLLOW IN CASE OF EMERGENCIES RELATED TO THE USE OF MEDICATIONS, INCLUDING READY ACCESS TO THE TELEPHONE NUMBER OF A POISON CONTROL CENTER BY BOTH PROGRAM PERSONNEL AND PARTICIPANTS

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF MEDICATION USE

ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT WHEN UNDER THE DIRECT SUPERVISION OF APPROPRIATE STAFF

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE UNDER THE CONTROL OF AUTHORIZED STAFF

ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES OR DETERIORATION

ALL MEDICATIONS ARE STORED ACCORDING TO MANUFACTURER’S RECOMMENDATIONS

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE FAMILIAR WITH ALL MEDICATIONS STOCKED INCLUDING INDICATIONS, SIDE EFFECTS, TOXIC EFFECTS, INTERACTIONS, AND POTENTIAL ALLERGIC REACTIONS

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

SELF-ADMINISTERED MEDICATIONS ARE STORED IN A SAFE AND SECURE MANNER IN THE RESIDENT'S ROOM ACCORDING TO THE FACILITY'S POLICIES AND PROCEDURES

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

NURSING SERVICE

PROJECT NUMBER:

ANY CHECKLIST ITEMS WHERE “NO” WAS INDICATED MUST HAVE DOCUMENTATION PROVIDED BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND APPROPRIATELY DOCUMENTED WILL RESULT IN AN INCOMPLETE INSPECTION PACKAGE.

DEFICIENCIES AND CORRECTIVE ACTIONS REQUIRED:

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACTOR TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

* THE TRIGGER FOR A CORRECTIVE ACTION PLAN (CAP) IS DEFINED IN PROGRAM REGULATIONS 38 CFR 61.80.

NOTE: COPY THIS FORM AS MANY TIMES AS NECESSARY FOR APPLICATIONS WITH MULTIPLE OBJECTIVES.

REVIEW OF HOMES DATA

PROJECT NUMBER:

DATE OF DISCUSSION:

NOT APPLICABLE FOR INITIAL INSPECTIONS

NO

N/A

HOMES DATA , RELATIVE TO THIS PROJECT NUMBER, HAS BEEN DISCUSSED WITH THE CONTRACTOR

PROVIDE THE MOST CURRENT (YEARLY OR QUARTERLY) HOMES DATA (PERCENTAGES FOR THIS PROJECT NUMBER):

A. INDEPENDENTLY HOUSED AT DISCHARGE

B. EMPLOYED FULL-TIME AT DISCHARGE

C. EMPLOYED PART-TIME AT DISCHARGE

D. RECEIVING VA BENEFITS AT DISCHARGE

E. RECEIVING NON-VA BENEFITS AT DISCHARGE

ANNUAL REVIEW OF SERVICES

PROJECT NUMBER:

LIST BETWEEN 6-15 CORE SERVICES AS STATED IN THE ORIGINAL CONTRACT OR SUBSEQUENTLY APPROVED CHANGE OF SCOPE

SERVICE IS CURRENTLY PROVIDED (Y/N)

EXAMPLES: SERVICES RELATED TO CASE MANAGEMENT, ADL'S, MEALS, EMPLOYMENT, BENEFITS, SUBSTANCE USE DISORDER SERVICES, ETC

THE CONTRACTOR IS CURRENTLY PROVIDING ALL SERVICES AS STATED IN THE ORIGINAL STATEMENT OF WORK OR SUBSEQUENTLY APPROVED CHANGE OF SCOPE

IF NO, DESCRIBE WHICH SERVICES ARE NOT PRESENTLY BEING PROVIDED AND OUTLINE THE AGENCY'S IMPLEMENTATION PLAN AND CORRESPONDING TIMELINE