36C24218R0185-003.pdf

PDF 188 KB Posted Mar 2, 2018

Attached to: 2018 VISN 2 CNH SOLICITATION Federal contract opportunity
Solicitation number: 36C24218R0185
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 2

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36C24218R0185 D4 - INSPECTION CRITERIA.pdf

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36C24218R0185-0002000.docx	DOCX document	Nov 20, 2018
36C24218R0185-001.docx	DOCX document	Mar 2, 2018
36C24218R0185-005.pdf	PDF	Mar 2, 2018
36C24218R0185-004.pdf	PDF	Mar 2, 2018
36C24218R0185-002.pdf	PDF	Mar 2, 2018
36C24218R0185-000.docx	DOCX document	Mar 1, 2018

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INSPECTION CRITERIA

NURSING HOME:

INSPECTION DATE: NUMBER OF BEDS:

VA/VETERAN PATIENT RECORD MET NOT MET NA

Identifying information

Interdisciplinary patient assessment

Interdisciplinary patient care plan

Progress notes reflect patient goals

Patient care plan for each Veteran patient

Patient care plan updated quarterly

Patient goals identified and updated

History & physical

Ongoing MD review

EVIDENCE OF ADEQUATE PATIENT CARE WITHIN FACILITY MET NOT MET NA

Adequate personal hygiene and dress

Program to reduce immobility

Program to reduce incontinence

Safety/Risk Management Program

Call light accessible

Comfort/Pain Management adequate

Adequate nutrition/hydration

Restorative nursing program

Medication documentation reflects effectiveness

QUALITY OF LIFE MET NOT MET NA

Privacy provided for each patient

Innovative patient activity programs

Access to outside grounds (if appropriate)

Diversion activities involving community interaction

Resident council and patient/family advocacy

Staff/patient interaction

Adequate space per patient

Restraint-free environment promoted

Patient satisfaction program

D.10 ATTACHMENT

QUALITY IMPROVEMENT MET NOT MET NA

Quality Improvement Plan is available that include Clinical Indicators (i.e.

development of decubitus ulcers, falls, medications etc.)

Quality Improvement data is routinely forwarded to CNH Coordinator for the site

Quality Improvement Data is shared with Leadership at the CNH facility Quality Care issues are documented/evaluated on VA/Veteran patients re-admitted to VHA from the CNH

CLINICAL STAFF MET NOT MET NA

Current licenses available

Policies and procedures are available

Ongoing training and education provided

Job descriptions and competencies available

Age-specific orientation program

Adequate staffing pattern

DAY EVENING NIGHT

LPN

N/A

COMMENTS:

UPON CONCLUSION OF THE SITE INSPECTION AND EXCLUSIONARY REVIEW FORM, THIS FACILITY

PASSES INSPECTION/ACCEPTABLE DOES NOT PASS INSPECTION/UNACCEPTABLE

SITE INSPECTION CONDUCTED BY:

NAME TITLE

SIGNED BY:

*In addition to the above, the facility must also meet all National Fire Protection Agency (NFPA) inspection criteria in order to be eligible for award.*

INSPECTION CRITERIA

METIdentifying information:

NOT METIdentifying information:

NAIdentifying information:

METInterdisciplinary patient assessment:

NOT METInterdisciplinary patient assessment:

NAInterdisciplinary patient assessment:

METInterdisciplinary patient care plan:

NOT METInterdisciplinary patient care plan:

NAInterdisciplinary patient care plan:

METProgress notes reflect patient goals:

NOT METProgress notes reflect patient goals:

NAProgress notes reflect patient goals:

METPatient care plan for each Veteran patient:

NOT METPatient care plan for each Veteran patient:

NAPatient care plan for each Veteran patient:

METPatient care plan updated quarterly:

NOT METPatient care plan updated quarterly:

NAPatient care plan updated quarterly:

METPatient goals identified and updated:

NOT METPatient goals identified and updated:

NAPatient goals identified and updated:

METHistory physical:

NOT METHistory physical:

NAHistory physical:

METOngoing MD review:

NOT METOngoing MD review:

NAOngoing MD review:

METAdequate personal hygiene and dress:

NOT METAdequate personal hygiene and dress:

NAAdequate personal hygiene and dress:

METProgram to reduce immobility:

NOT METProgram to reduce immobility:

NAProgram to reduce immobility:

METProgram to reduce incontinence:

NOT METProgram to reduce incontinence:

NAProgram to reduce incontinence:

METSafetyRisk Management Program:

NOT METSafetyRisk Management Program:

NASafetyRisk Management Program:

METCall light accessible:

NOT METCall light accessible:

NACall light accessible:

METComfortPain Management adequate:

NOT METComfortPain Management adequate:

NAComfortPain Management adequate:

METAdequate nutritionhydration:

NOT METAdequate nutritionhydration:

NAAdequate nutritionhydration:

METRestorative nursing program:

NOT METRestorative nursing program:

NARestorative nursing program:

METMedication documentation reflects effectiveness:

NOT METMedication documentation reflects effectiveness:

NAMedication documentation reflects effectiveness:

METPrivacy provided for each patient:

NOT METPrivacy provided for each patient:

NAPrivacy provided for each patient:

METInnovative patient activity programs:

NOT METInnovative patient activity programs:

NAInnovative patient activity programs:

METAccess to outside grounds if appropriate:

NOT METAccess to outside grounds if appropriate:

NAAccess to outside grounds if appropriate:

METDiversion activities involving community interaction:

NOT METDiversion activities involving community interaction:

NADiversion activities involving community interaction:

METResident council and patientfamily advocacy:

NOT METResident council and patientfamily advocacy:

NAResident council and patientfamily advocacy:

METStaffpatient interaction:

NOT METStaffpatient interaction:

NAStaffpatient interaction:

METAdequate space per patient:

NOT METAdequate space per patient:

NAAdequate space per patient:

METRestraintfree environment promoted:

NOT METRestraintfree environment promoted:

NARestraintfree environment promoted:

METPatient satisfaction program:

NOT METPatient satisfaction program:

NAPatient satisfaction program:

METQuality Improvement Plan is available that include Clinical Indicators ie development of decubitus ulcers falls medications etc:

NOT METQuality Improvement Plan is available that include Clinical Indicators ie development of decubitus ulcers falls medications etc:

NAQuality Improvement Plan is available that include Clinical Indicators ie development of decubitus ulcers falls medications etc:

METQuality Improvement data is routinely forwarded to CNH Coordinator for the site:

NOT METQuality Improvement data is routinely forwarded to CNH Coordinator for the site:

NAQuality Improvement data is routinely forwarded to CNH Coordinator for the site:

METQuality Improvement Data is shared with Leadership at the CNH facility:

NOT METQuality Improvement Data is shared with Leadership at the CNH facility:

NAQuality Improvement Data is shared with Leadership at the CNH facility:

METQuality Care issues are documentedevaluated on VAVeteran patients re admitted to VHA from the CNH:

NOT METQuality Care issues are documentedevaluated on VAVeteran patients re admitted to VHA from the CNH:

NAQuality Care issues are documentedevaluated on VAVeteran patients re admitted to VHA from the CNH:

METCurrent licenses available:

NOT METCurrent licenses available:

NACurrent licenses available:

METPolicies and procedures are available:

NOT METPolicies and procedures are available:

NAPolicies and procedures are available:

METOngoing training and education provided:

NOT METOngoing training and education provided:

NAOngoing training and education provided:

METJob descriptions and competencies available:

NOT METJob descriptions and competencies available:

NAJob descriptions and competencies available:

METAgespecific orientation program:

NOT METAgespecific orientation program:

NAAgespecific orientation program:

DAYRN:

EVENINGRN:

NIGHTRN:

DAYLPN:

EVENINGLPN:

NIGHTLPN:

DAYNA:

EVENINGNA:

NIGHTNA:

METAdequate staffing pattern:

NOT METAdequate staffing pattern:

NAAdequate staffing pattern:

NAMERow1:

TITLERow1:

NAMERow2:

TITLERow2:

NAMERow3:

TITLERow3:

NAMERow4:

TITLERow4:

NAMERow5:

TITLERow5:

NAMERow6:

TITLERow6:

NAMERow7:

TITLERow7:

NAMERow8:

TITLERow8:

NAMERow9:

TITLERow9:

NAMERow10:

TITLERow10:

NAMERow11:

TITLERow11:

NAMERow12:

TITLERow12:

Text1:

Text2:

Text3:

Text4:

Group5: Off

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