36C24618Q0731-003.pdf

Department of Veterans Affairs

Healthcare for Homeless Veterans (HCHV)

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

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

PROVIDER'S NAME: DATE INSPECTION STARTED: DATE INSPECTION COMPLETED:

AGENCY'S ADMINISTRATIVE OFFICE ADDRESS:

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

VA MEDICAL CENTER AND STATION NUMBER: NAME OF VA LIAISON COMPLETING REPORT:

INSPECTION TEAM MEMBERS

NAME TITLE

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 1162.01. 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

VAMC DIRECTOR (PRINT NAME) SIGNATURE

INSPECTION PACKAGE ASSEMBLY CHECKLIST

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

REVIEW

ITEM RESPONSIBLE

HCHV INSPECTION CHECKLISTS - SIGNED WITH

APPROPRIATE REPORTS ATTACHED

CERTIFICATE OF OCCUPANCY OR LETTER STATING WHY

THE GOVERNING ENTITY (CITY, COUNTY, STATE) DOES NOT

REQURIE ONE (INITIAL INSPECTIONS ONLY)

VAMC DIRECTOR, LIAISON, &

TEAM MEMBERS

VAMC DIRECTOR

VAMC DIRECTOR & PROVIDER

PROVIDER

HCHV LIAISON – OVERVIEW &

RECOMMENDATION

PROJECT NUMBER:

SITE ADDRESS: HCHV Staff SHOULD COMPLETE THIS SECTION

ATTACHING ANY OTHER DOCUMENTATION, AS

NECESSARY

THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO

HOUSE WITHIN THE SITES COVERED UNDER THIS PROJECT NUMBER:

NUMBER OF HCHV

BEDS

A. MEN

B. WOMEN

D. TOTAL NUMBER OF BEDS UNDER THIS PROJECT NUMBER

TO THE BEST OF YOUR KNOWLEDGE DOES THE CONTRACTOR & PROGRAM

MEET THE FOLLOWING CRITERIA?

YES

NO

N/A

1 PROJECT OPERATES IN ACCORDANCE WITH PROGRAM REGULATIONS

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

BASED ON THE RESULTS OF THE ATTACHED INSPECTION DOCUMENTS

THIS PROJECT IS RECOMMENDED FOR THE PLACEMENT OF VETERANS

THE RESULTS OF THE TECHNICAL REPORT HAVE BEEN DISCUSSED AT

LEAST QUARTERLY WITH THE CONTRACTOR (RE-INSPECTIONS ONLY)

CORRECTIVE ACTION PLANS (CAP) HAVE BEEN IMPLEMENTED PER 38 CFR

61.80, IF APPLICABLE (RE-INSPECTIONS ONLY)

THE ANNUAL TECHNICAL REPORT DOES NOT INDICATE A CAP FOR MORE

THAN THREE OBJECTIVES (RE-INSPECTIONS ONLY)

THE ANNUAL TECHNICAL REPORT DOES NOT INDICATE A CAP FOR ANY

SINGLE OBJECTIVE FOR MORE THAN 2 QUARTERS OF THE YEAR (RE-

INSPECTIONS ONLY)

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS

APPROVED FOR PLACEMENT OF VETERANS:

HCHV STAFF SIGNATURE DATE

HCHV LIAISON –

OVERVIEW &

RECOMMENDATION

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

SITE ADDRESS:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CONTRACTED PROVIDERS (ALL INSPECTIONS)

THE CONTRACTED FACILITY YES NO N/A

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, REFERRED

TO AS ARCHITECTURAL BARRIERS ACT COMPLIANT

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

20 PROVIDES A WATER SUPPLY THAT IS FREE FROM CONTAMINATION

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

(REFER TO VHA HANDBOOK 1162.01)

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 INSPECTION TEAM MEMBERS SIGNATURE DATE

FACILITIES MANAGEMENT

BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE

DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND

NUTRITION AND FOOD SERVICES

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

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

27 ONE WEEK OF MENUS AVAILABLE FOR REVIEW

28 MENUS REPRESENT NUTRITIONALLY ADEQUATE DIET

AGENCY DEMONSTRATES THE ABILITY TO MEET SPECIAL DIETARY

NEEDS (I.E. KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED)

THREE MEALS PROVIDED PER DAY, INCLUDING WEEKENDS

ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION

PRACTICES

REFRIGERATION AND DRY FOOD STORAGE AREAS ARE

APPROPRIATELY MAINTAINED AND MONITORED

33 ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER

34 CURRENT LICENSURES ARE MAINTAINED, IF REQUIRED

FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A

SANITARY CONDITION

FOR INDIVIDUAL FOOD PREPARATION THE CONTRACTOR

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 (I.E.

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:

NUTRITION INSPECTION TEAM MEMBERS SIGNATURE DATE

NUTRITION AND FOOD

SERVICES

BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE

DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND

PROGRAM REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM

IMPROVEMENT.

CLINICAL REVIEW

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)

THE CONTRACTED FACILITY YES NO N/A

ENSURES THAT PARTICIPANTS IN NEED OF MEDICAL OR SOCIAL

DETOX CONDUCTED AT THE SAME SITE ARE CLEARLY SEPARATED

FROM THE GENERAL RESIDENT POPULATION

ENSURES A QUARTERLY TECHNICAL PERFORMANCE REPORT

ADDRESSING THEIR ABILITY TO MEET THE GOALS, OBJECTIVES,

MEASURES, AND SPECIAL NEEDS AS SET FORTH IN THEIR CONTRACT

SOW IS COMPLETED BY THE PROVIDER; SUBMITTED TO THE HCHV

LIAISON; AND REVIEWED QUARTERLY

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, (IF FAMILY VIOLENCE PREVENTION OR TREATMENT

SERVICES ARE PROVIDED SEE REGULATIONS PERTAINING TO

CONFIDENTIALLY OF RECORDS)

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

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 SERVICE PLAN (ISP) IS MAINTAINED IN

THE CASE MANAGEMENT RECORD FOR EACH INDIVIDUAL

PARTICIPANT

THE ISP 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:

LIAISON OR CLINICAL INSPECTION TEAM MEMBERS SIGNATURE DATE

CLINICAL REVIEW

BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE

DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND

LAW ENFORCEMENT AND

PHYSICAL SECURITY

SITE ADDRESS: 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) THE CONTRACTOR YES NO N/A

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 (I.E. 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

70 DOCUMENTATION OF RESIDENTIAL SUPERVISION TRAINING IS PRESENT

AS PART OF THE RISK ASSESSMENT FOR THIS PROJECT, LOCAL CRIME

STATISTICS FOR THE AREA HAVE BEEN REVIEWED AND DISCUSSED

WITH THE PROVIDER

72 SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE LIVING)

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:

POLICE INSPECTION TEAM MEMBERS SIGNATURE DATE

LAW ENFORCEMENT AND

PHYSICAL SECURITY

BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE

DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND

MEDICATION REVIEW

SITE ADDRESS: APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

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

FOR MEDICATION MANAGEMENT THE AWARDEE YES NO N/A

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

FOR MEDICATION MONITORING THE AWARDEE YES NO N/A

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

FOR INDIVIDUAL STORAGE THE AWARDEE YES NO N/A

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:

MEDICATION REVIEW INSPECTION TEAM MEMBERS SIGNATURE DATE

NURSING SERVICE

BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE

DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND

PROGRAM REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM

IMPROVEMENT.

REVIEW OF HOMES DATA

DATE OF DISCUSSION:

NOT APPLICABLE FOR INITIAL INSPECTIONS

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

HCHV LIAISON SIGNATURE DATE

ANNUAL REVIEW OF SERVICES

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 YES NO

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