36C25718Q9874-003.pdf

INSPECTION SHEETS

HCHV PROGRAM LIAISON CHECKLIST YES NO

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

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:

MEDICATION MANAGEMENT CHECKLIST YES NO

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

FOR INDIVIDUAL STORAGE YES NO

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:

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

FACILITY MANAGEMENT CHECKLIST YES NO

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 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

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

ONE WEEK OF MENUS AVAILABLE FOR REVIEW

MENUS REPRESENT NUTRITIONALLY ADEQUATE DIET

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

ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER

CURRENT LICENSURES ARE MAINTAINED, IF REQUIRED

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

THE CONTRACTED FACILITY YES NO

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

YES NO

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

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

SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE LIVING) ARE AVAILABLE

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

FACILITY)