36C25718Q0155-002.docx

ATTACHMENT FOUR: INSPECTION SHEETS

INSPECTION SHEETS

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:

FACILITY MANAGEMENT CHECKLIST

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

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

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:

NUTRITION SERVICES CHECKLIST

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

YES

NO

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

YES

NO

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:

SOCIAL WORK SERVICES CHECKLIST

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

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

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

LAW ENFORCEMENT CHECKLIST

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: