36C26018Q9623-004.pdf

VA FORM

MAY 2014

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OTHER:

PLACEMENT OF VETERANS AT THIS PROVIDER'S FACILITY.

HEALTH CARE FOR HOMELESS VETERANS

(HCHV) CONTRACTED PROVIDER INSPECTION

FORMMEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

THIS INSPECTION IS FOR:

INSPECTION TEAM MEMBERS

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.

MEDICAL CENTER DIRECTOR - REVIEW & RECOMMENDATION

INITIAL INSPECTION RE-INSPECTION PROJECT #

PROVIDER'S NAME:

AGENCY'S ADMINISTRATIVE OFFICE ADDRESS:

DATE INSPECTION COMPLETED:

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

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

NAME TITLE

I APPROVE I DISAPPROVE

I APPOINT THE FOLLOWING INDIVIDUAL AS LIAISON FOR THIS PROJECT

DATE

FACILITIES MANAGEMENT

CLINICAL REVIEW

SECURITY/ LAW ENFORCEMENT

NHC OR DESIGNEE

MEDICATION REVIEW

NUTRITION

SIGNATURE VAMC DIRECTOR (PRINT NAME)

DATE INSPECTION STARTED:

LIAISON PHONE:

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INSPECTION PACKAGE ASSEMBLY CHECKLIST

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

ITEM RESPONSIBLE

VAMC DIRECTOR, LIAISON &

TEAM MEMBERS

HCHV LIAISON - OVERVIEW &

RECOMMENDATION

GPD LIAISON SHOULD COMPLETE THIS

SECTION ATTACHING ANY OTHER

DOCUMENTATION, AS NECESSARY

YES NO N/A

HCHV INSPECTION CHECKLIST SIGNED WITH

APPROPRIATE REPORTS ATTACHED

PROVIDER

CERTIFICATE OF OCCUPANCY OR A LETTER STATING

WHY THE GOVERNING ENTITY (CITY, COUNTY, STATE)

DOES NOT REQUIRE ONE. (INITIAL INSPECTIONS ONLY).

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 (SOW) OR SUBSEQUENT APPROVED CHANGE OF SCOPE

AGENCY SERVES THE POPULATION(S) AS DESCRIBED IN THEIR GRANT

APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE4

AGENCY OCCUPANCY RATE ROUTINELY MEETS OR EXCEEDS 75 PERCENT OF

THE GPD 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

PROJECT #

SITE ADDRESS:

THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE

WITHIN THE SITES COVERED:

NUMBER OF HCHV

BEDS

A. MEN

C. TOTAL NUMBER OF BEDS UNDER THIS PROJECT NUMBER

B. WOMEN

TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE

FOLLOWING CRITERIA?

CORRECTIVE ACTION PLANS (CAP) HAVE BEEN IMPLEMENTED PER 38 CFR 61.80,

IF APPLICABLE (RE-INSPECTIONS ONLY)7

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PROJECT #

DATE

ALL APPROPRIATE CHECKLIST SECTIONS HAVE BEEN COMPLETED AND ARE

ATTACHED. THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS.

HCHV STAFF SIGNATURE

BASED ON THE RESULTS OF THE ATTACHED INSPECTION DOCUMENTS THIS

PROJECT IS RECOMMENDED FOR THE PLACEMENT OF VETERANS8

YES NO N/A TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE

FOLLOWING CRITERIA?

HCHV LIAISON - OVERVIEW &

RECOMMENDATION

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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.

THESE ARE ITEMS THAT WOULD NOT CAUSE THE GRANTEE TO BE DEFICIENT IN ANY PROGRAM

REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

HCHV LIAISON - OVERVIEW &

RECOMMENDATION

PROJECT NUMBER #:

DEFICIENCIENCIES AND CORRECTIVE ACTIONS REQUIRED

BEST PRACTICE RECOMMENDATIONS:

DELETE PAGEDUPLICATE PAGE

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FACILITIES MANAGEMENT

OPERATING STANDARDS ALL HCHV CONTRACTED PROVIDERS (ALL INSPECTIONS)

PROJECT NUMBER

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS

SECTION ATTACHING THEIR RESPECTIVE REPORT

FORMAT(S)

SITE ADDRESS

IS IN COMPLIANCE WITH THE NFPA LIFE SAFETY CODE (SEE ATTACHED REPORT)9

THE CONTRACTED FACILITY YES NO N/A

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

IS COMPLIANT WITH THE AMERICANS WITH DISABILITIES ACT AND THE

ARCHITECTURAL BARRIERS ACT12

PROVIDES EACH RESIDENT APPROPRIATE SPACE AND SECURITY FOR

THEMSELVES AND THEIR BELONGINGS13

PROVIDES EACH RESIDENT AN ACCEPTABLE PLACE TO SLEEP THAT IS IN

COMPLIANCE WITH APPLICABLE CODES AND REGULATIONS14

PROVIDES EVERY ROOM OR SPACE WITH NATURAL OR MECHANICAL VENTILATION15

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

RESIDENTS16

PROVIDES A WATER SUPPLY THAT IS FREE FROM CONTAMINATION17

PROVIDES ADEQUATE HEATING AND OR COOLING PLANTS THAT ARE IN PROPER

OPERATING CONDITION19

PROVIDES ADEQUATE NATURAL OR ARTIFICIAL ILLUMINATION TO PERMIT NORMAL

INDOOR ACTIVITIES AND TO SUPPORT THE HEALTH AND SAFETY OF RESIDENTS20

PROVIDES SUFFICIENT ELECTRICAL SOURCES TO PERMIT USE OF ESSENTIAL

ELECTRICAL APPLIANCE WHILE ENSURING SAFETY FROM FIRE21

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

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

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

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PROVIDES THAT HOUSING AND EQUIPMENT ARE MAINTAINED IN A SANITARY

MANNER28

FACILITIES MANAGEMENT INSPECTION TEAM MEMBER SIGNATURE DATE

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY

IS APPROVED FOR PLACEMENT OF VETERANS:

PROJECT NUMBERFACILITIES MANAGEMENT

THE CONTRACTED FACILITY YES NO N/A

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INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

FACILITIES MANAGMENT

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.

THESE ARE ITEMS THAT WOULD NOT CAUSE THE GRANTEE TO BE DEFICIENT IN ANY PROGRAM

REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

BEST PRACTICE RECOMMENDATIONS:

DEFICIENCIENCIES AND CORRECTIVE ACTIONS REQUIRED

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NUTRITION AND FOOD SERVICES

OPERATING STANDARDS ALL GRANT & PER DIEM PROVIDERS (ALL INSPECTIONS)

PROJECT NUMBER

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

SITE ADDRESS

N/A NO YES FOR CENTRALLY PREPARED NUTRITION AND FOOD SERVICES

ONE WEEK OF MENUS AVAILABLE FOR REVIEW24

MENUS REPRESENT NUTRITIONALLY ADEQUATE DIET25

NUTRITION AND FOOD SERVICES INSPECTION TEAM MEMBER SIGNATURE DATE

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS

APPROVED FOR PLACEMENT OF VETERANS:

AGENCY DEMONSTRATES THE ABILITY TO MEET SPECIAL DIETARY NEEDS (I.E.

KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED)26

CURRENT LICENSURES ARE MAINTAINED, IF REQUIRED31

APPLIANCES ARE ADEQUATE TO SAFELY STORE AND PREPARE FOOD AND ARE

IN GOOD WORKING CONDITION (I.E. STOVE, REFRIGERATOR, DISHWASHER)33

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

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)

ENSURES THAT ALL FOOD PREPARATION AREAS CONTAIN SUITABLE SPACE AND

EQUIPMENT TO STORE, PREPARE, AND SERVE FOOD IN A SANITARY MANNER34

FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A SANITARY

CONDITION32

ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER30

REFRIGERATION AND DRY FOOD STORAGE AREAS ARE APPROPRIATELY

MAINTAINED AND MONITORED29

ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION PRACTICES28

THREE MEALS PROVIDED PER DAY, INCLUDING WEEKENDS27

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

N/A NO YES FOR INDIVIDUAL FOOD PREPARATION

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INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

NUTRITION AND FOOD SERVICES

PROJECT NUMBER #

THESE ARE ITEMS THAT WOULD NOT CAUSE THE GRANTEE TO BE DEFICIENT IN ANY PROGRAM

REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

BEST PRACTICE RECOMMENDATIONS:

DEFICIENCIENCIES AND CORRECTIVE ACTIONS REQUIRED

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.

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CLINICAL REVIEW

OPERATING STANDARDS ALL GRANT & PER DIEM PROVIDERS (ALL INSPECTIONS)

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)

SITE ADDRESS

N/A NO YES THE CONTRACTED FACILITY

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

ENSURES THAT PARTICIPANTS IN NEED OF MEDICAL OR SOCIAL DETOX

CONDUCTED AT THE SAME SITE ARE CLEARLY SEPARATED FROM THE GENERAL

RESIDENT POPULATION

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 A QUARTERLY TECHNICAL PERFORMANCE REPORT ADDRESSING

THEIR ABILITY TO MEET THE GOALS, OBJECTIVES, MEASURES, AND SPECIAL

NEEDS AS SET FORTH IN THEIR APPLICATION IS COMPLETED BY THE PROVIDER;

SUBMITTED TO THE GPD LIAISON; AND REVIEWED QUARTERLY

ATTEMPTS TO INVOLVE HOMELESS VETERANS THROUGH EMPLOYMENT,

VOLUNTEER SERVICES, OR OTHERWISE, IN CONSTRUCTION, REHABILITATION,

MAINTENANCE, AND OPERATION OF 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

43 ENSURES THAT ALL HOUSING AND SERVICES PROVIDED TO PARTICIPANTS MEET

THE QUALITY STANDARDS OUTLINED IN THE HCHV HANDBOOK.

ENSURES SUSTAINED EFFORTS ARE MADE THAT ELIGIBLE HARD-TO- REACH

PERSONS ARE SERVED IN THE FACILITY. THIS OUTREACH SHOULD BE TARGETED

TOWARD PERSONS WHO MEET THE DEFINITION OF HOMELESSNESS 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

46 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

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LIAISON OR CLINICAL INSPECTION TEAM MEMBER SIGNATURE DATE

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS

APPROVED FOR PLACEMENT OF VETERANS:

CONTRACTOR MAINTAINS SYSTEMATIC PARTICIPANT ENROLLMENT INFORMATION

AND TRACKING56

C. OTHER. EXPLAIN:

B. THE CONTRACTOR UTILIZES AGENCY INTERNAL TRACKING SYSTEM

A. THE CONTRACTOR UTILIZES HMIS FOR PROGRAM

PROJECT NUMBER #CLINICAL REVIEW

N/A NO YES THE CONTRACTED FACILITY

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INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

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.

DEFICIENCIENCIES AND CORRECTIVE ACTIONS REQUIRED

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE GRANTEE TO BE DEFICIENT IN ANY PROGRAM

REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

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LAW ENFORCEMENT AND PHYSICAL

SECURITY

PROJECT NUMBER

CHIEF OF VA POLICE OR DESIGNEE SHOULD COMPLETE THIS

SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT

(S)

SITE ADDRESS

N/A NO YES THE CONTRACTOR

IS OPERATING A PROJECT LOCATED ON VA PROPERTY, AND THE CHIEF,

POLICE SERVICE OR DESIGNEE HAS CONDUCTED A COMPREHENSIVE RISK

ASSESSMENT OF THE PROJECT

IS OPERATING A PROJECT LOCATED ON VA PROPERTY AND A PROCEDURE FOR

ONGOING LAW ENFORCEMENT MONITORING HAS BEEN ESTABLISHED BETWEEN

THE PROVIDER AND VA

IS OPERATING A PROJECT 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

HAS ENSURED THERE IS SUFFICIENT LIGHTING AROUND THE PERIMETER OF THE

FACILITY BASED ON THE HOUSING SETTING (E.G., RURAL, INDUSTRIAL, OR

RESIDENTIAL SETTINGS)

HAS INSTALLED STAFF OFFICES, TREATMENT, GROUP, PARTICIPANT ROOMS,

DORMS, SHOWER, AND RESTROOMS HAVE LOCKS APPROPRIATE FOR THE

SETTING AND GENDER MIX

APPROPRIATELY SEPARATED FACILITY ACCESS FOR PRIVACY AND SECURITY

GIVEN THE POPULATION(S) SERVED60

HAS WRITTEN POLICIES AND PROCEDURES REGARDING SAFETY, SECURITY, AND

PRIVACY WHICH ARE REGULARLY COMMUNICATED TO PARTICIPANTS AND

STAFF AND ROUTINELY ENFORCED

ADEQUATELY ADDRESSES SAFETY AND SECURITY CONCERNS WITH THE

FACILITY BASED ON LOCATION, POPULATION(S) SERVED, AND FACILITY

STRUCTURE

HAS APPROPRIATE PROCEDURES REGARDING FACILITY OR UNIT ACCESS WHICH

ARE ADEQUATELY CONTROLLED TO ENSURE THE SAFETY OF ALL RESIDENTS57

HAS ENSURED COMMON AREAS (E.G., LAUNDRY, COMPUTER LABS, BREAK

ROOMS) ARE APPROPRIATELY SECURED, MONITORED, AND LIT56

HAS ENSURED INTERIOR AND EXTERIOR LOCKS ARE IN GOOD WORKING ORDER;

APPROPRIATELY LOCATED; ADEQUATE FOR THE AREA THAT IS BEING SECURED

AND POPULATIONS SERVED WITHIN THE FACILITY

REGULARLY CHECKS LIGHTS TO MAKE SURE THEY ARE OPERATING

EFFECTIVELY54

HAS DETERMINED THERE IS SUFFICIENT LIGHTING AROUND THE INTERIOR OF

THE FACILITY53

OPERATING STANDARDS ALL GRANT & PER DIEM PROVIDERS (ALL INSPECTIONS)

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PROJECT NUMBERLAW ENFORCEMENT AND PHYSICAL

SECURITY

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY

IS APPROVED FOR PLACEMENT OF VETERANS.

POLICE INSPECTION TEAM MEMBER SIGNATURE DATE

HAS ENSURED PARTICIPANTS HAVE AN APPROPRIATE PLACE TO SECURE

PERSONAL VALUABLES AND BELONGINGS62

HAS MADE SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE LIVING)

AVAILABLE69

SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE LIVING)68

MAINTAINS DOCUMENTATION OF RESIDENTIAL SUPERVISION TRAINING IS

PRESENT67

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

ENSURES 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

HAS POSTED EMERGENCY CONTACTS FOR MEDICAL, LAW ENFORCEMENT, FIRE

DEPARTMENT, AND AGENCY 64

HAS ESTABLISHED A PROCEDURE FOR ONGOING LAW ENFORCEMENT

MONITORING63

USES A SCREENING SYSTEM FOR SEX OFFENDERS (MIXED GENDER AND/OR

CHILDREN IN FACILITY)70

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INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

SECURITY & LAW

ENFORCEMENT

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.

DEFICIENCIENCIES AND CORRECTIVE ACTIONS REQUIRED

BEST PRACTICE RECOMMENDATIONS:

THESE ARE ITEMS THAT WOULD NOT CAUSE THE GRANTEE TO BE DEFICIENT IN ANY PROGRAM

REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

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MEDICATION REVIEW

PROJECT NUMBER

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS

SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S)

SITE ADDRESS

N/A NO YES FOR MEDICATION MANAGEMENT THE AWARDEE

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 HAS DOCUMENTATION OR CONFIRMATION OF INFORMED

CONSENT FOR EACH MEDICATION ADMINISTERED, WHEN POSSIBLE78

ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS THAT

PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS

PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES

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 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

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT

TRAINING AND EDUCATION REGARDING MEDICATION74

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

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND

HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF

MEDICATION USE

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS

SERVED

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

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PROJECT NUMBER

MEDICATION REVIEW

N/A NO YES FOR MEDICATION MONITORING THE AWARDEE

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED

ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE 89

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE FAMILIAR WITH ALL

MEDICATIONS STOCKED INCLUDING INDICATIONS, SIDE EFFECTS, TOXIC

EFFECTS, INTERACTIONS, AND POTENTIAL ALLERGIC REACTIONS

ALL MEDICATIONS ARE STORED ACCORDING TO MANUFACTURER'S

RECOMMENDATIONS87

ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES OR

DETERIORATION86

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE UNDER

THE CONTROL OF AUTHORIZED STAFF85

ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT WHEN

UNDER THE DIRECT SUPERVISION OF APPROPRIATE STAFF84

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND

HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF

MEDICATION USE

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS

SERVED

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

ORGANIZATION PROCEDURES ENSURE THE IDENTIFICATION, DOCUMENTATION,

AND REQUIRED REPORTING, INCLUDING TO THE PRESCRIBING PROFESSIONAL,

ANY MEDICATION REACTIONS OR MEDICATION ERRORS, AS APPROPRIATE

N/A NO YES FOR INDIVIDUAL STORAGE THE AWARDEE

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 MEMBER SIGNATURE DATE

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THESE ARE ITEMS THAT WOULD NOT CAUSE THE GRANTEE TO BE DEFICIENT IN ANY PROGRAM

REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

BEST PRACTICE RECOMMENDATIONS:

DEFICIENCIENCIES AND CORRECTIVE ACTIONS REQUIRED

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.

PROJECT NUMBER #

NURSING SERVICES

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REVIEW OF HOMES DATA

PROJECT NUMBER

NOT APPLICABLE FOR INITIAL INSPECTIONS AND SERVICE CENTERS

DATE OF DISCUSSION:

N/A NO YES

HOMES DATA , RELATIVE TO THIS PROJECT NUMBER, HAS BEEN DISCUSSED

WITH THE CONTRACTOR91

HCHV LIAISON SIGNATURE DATE

92 PROVIDE THE MOST CURRENT (YEARLY OR QUARTERLY) HOMES DATA (PERCENTAGES FOR THIS

PROJECT NUMBER):

A. INDEPENDENTLY HOUSED AT DISCHARGE

D. RECEIVING VA BENEFITS AT DISCHARGE

C. EMPLOYED PART-TIME AT DISCHARGE

B. EMPLOYED FULL-TIME AT DISCHARGE

E. RECEIVING NON-VA BENEFITS AT DISCHARGE

10-10116a Page 20 of 20

ANNUAL REVIEW OF SERVICES PROJECT NUMBER #

LIST BETWEEN 6-15 CORE SERVICES AS STATED IN THE ORIGINAL GRANT

APPLICATION OR SUBSEQUENTLY APPROVED CHANGE OF SCOPE

EXAMPLES: SERVICES RELATED TO CASE MANAGEMENT, ADL'S, MEALS, EMPLOYMENT,

BENEFITS, SUBSTANCE USE DISORDER SERVICES, ETC

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

IMPLEMENTATION PLAN AND CORRESPONDING TIMELINE

THE CONTRACTOR NO YES

THE CONTRACTOR IS CURRENTLY PROVIDING ALL SERVICES AS STATED IN THE

IN THE ORIGINAL STATEMENT OF WORK OR SUBSEQUENTLY APPROVED CHANGE

OF SCOPE

SERVICE IS

CURRENTLY

PROVIDED (Y/N)