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VA FORM

AUG 2013

10-0361c Page of

VA FORM

AUG 2013

10-0361c Page of Table of Content Guy A. Liedke D:20050418133328- 04'00' D:20050418133358- 04'00'

PLACEMENT OF VETERANS AT THIS PROVIDER'S FACILITY.

PLACEMENT OF VETERANS AT THIS PROVIDER'S FACILITY.

GRANT AND PER DIEM PROGRAM

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

THIS INSPECTION IS FOR:

THIS INSPECTION IS FOR:

INSPECTION TEAM MEMBERS

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.

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

MEDICAL CENTER DIRECTOR - REVIEW & RECOMMENDATION

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs

NAME

NAME

NAME

TITLE

TITLE

FACILITIES MANAGEMENT

FACILITIES MANAGEMENT

CLINICAL REVIEW

CLINICAL REVIEW

SECURITY/ LAW ENFORCEMENT

SECURITY/ LAW ENFORCEMENT

NHC OR DESIGNEE

NHC OR DESIGNEE

MEDICATION REVIEW

MEDICATION REVIEW

NUTRITION

NUTRITION

INSPECTION PACKAGE ASSEMBLY CHECKLIST

INSPECTION PACKAGE ASSEMBLY CHECKLIST

ALL ITEMS MUST BE INCLUDED BEFORE SENDING TO THE GRANT AND PER DIEM PROGRAM OFFICE FOR REVIEW ALL ITEMS MUST BE INCLUDED BEFORE SENDING TO THE GRANT AND PER DIEM PROGRAM OFFICE FOR REVIEW

ITEM

ITEM

RESPONSIBLE

RESPONSIBLE

VAMC DIRECTOR, LIAISON & TEAM MEMBERS

VAMC DIRECTOR, LIAISON & TEAM MEMBERS

VA LIAISON - OVERVIEW & RECOMMENDATION

VA LIAISON - OVERVIEW & RECOMMENDATION

GPD LIAISON SHOULD COMPLETE THIS SECTION ATTACHING ANY OTHER DOCUMENTATION, AS NECESSARY GPD LIAISON SHOULD COMPLETE THIS SECTION ATTACHING ANY OTHER DOCUMENTATION, AS NECESSARY

YES

YES

NO

NO

N/A N/A

VAMC DIRECTOR

VAMC DIRECTOR

VAMC DIRECTOR & PROVIDER

VAMC DIRECTOR & PROVIDER

PROVIDER

PROVIDER

PROVIDER

PROVIDER

PROJECT OPERATES IN ACCORDANCE WITH PROGRAM REGULATIONS

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 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 GRANT APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE HAS DEMONSTRATED ADEQUATE STAFFING AND AN APPROPRIATE SCOPE OF SERVICES TO CARRY OUT THIS PROJECT AS OUTLINED IN THE ORIGINAL GRANT APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE AGENCY SERVES THE POPULATION(S) AS DESCRIBED IN THEIR GRANT APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE AGENCY SERVES THE POPULATION(S) AS DESCRIBED IN THEIR GRANT APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE 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 THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE WITHIN THE SITES COVERED UNDER THIS PROJECT NUMBER:

THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE WITHIN THE SITES COVERED UNDER THIS PROJECT NUMBER:

NUMBER OF GPD BEDS

NUMBER OF GPD BEDS

A. MEN

A. MEN

D. TOTAL NUMBER OF BEDS UNDER THIS PROJECT NUMBER

D. TOTAL NUMBER OF BEDS UNDER THIS PROJECT NUMBER

C. CHILDREN

C. CHILDREN

B. WOMEN

B. WOMEN

TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE FOLLOWING CRITERIA?

TO THE BEST OF YOUR KNOWLEDGE

TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE FOLLOWING CRITERIA?

VA LIAISON INSPECTION OVERVIEW

ALL APPROPRIATE CHECKLIST SECTIONS HAVE BEEN COMPLETED AND ARE ATTACHED. THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS.

GPD LIAISON SIGNATURE

GPD LIAISON SIGNATURE

BASED ON THE RESULTS OF THE ATTACHED INSPECTION DOCUMENTS THIS PROJECT IS RECOMMENDED FOR THE PLACEMENT OF VETERANS THE ANNUAL TECHNICAL REPORT DOES NOT INDICATE A CAP FOR ANY SINGLE OBJECTIVE FOR MORE THAN 2 QUARTERS OF THE YEAR (RE-INSPECTIONS ONLY) THE ANNUAL TECHNICAL REPORT DOES NOT INDICATE A CAP FOR MORE THAN THREE OBJECTIVES (RE-INSPECTIONS ONLY) CORRECTIVE ACTION PLANS (CAP) HAVE BEEN IMPLEMENTED PER 38 CFR 61.80, IF APPLICABLE (RE-INSPECTIONS ONLY) THE RESULTS OF THE TECHNICAL REPORT HAVE BEEN DISCUSSED AT LEAST QUARTERLY WITH THE GRANTEE (RE-INSPECTIONS ONLY) 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.

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

VA LIAISON INSPECTION OVERVIEW

BEST PRACTICE RECOMMENDATIONS:

FACILITIES MANAGEMENT

GRANT COMPLIANCE CAPITAL GRANT PROJECTS (INITIAL INSPECTION ONLY)

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) ACQUIRED, RENOVATED, OR NEWLY CONSTRUCTED THE SITE AS OUTLINED IN THE GRANT APPLICATION

THE AWARDEE HAS

YES

NO

N/A PURCHASED AND INSTALLED EQUIPMENT AS OUTLINED IN THE ORIGINAL GRANT APPLICATION, (E.G., STOVES, REFRIGERATORS, WASHING MACHINES, ETC.)

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

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

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 N/A

NO

YES

THE AWARDEE FACILITY

PROVIDES ADEQUATE NATURAL OR ARTIFICIAL ILLUMINATION TO PERMIT NORMAL INDOOR ACTIVITIES AND TO SUPPORT THE HEALTH AND SAFETY OF RESIDENT PROVIDES SUFFICIENT ELECTRICAL SOURCES TO PERMIT USE OF ESSENTIAL ELECTRICAL APPLIANCE WHILE ASSURING SAFETY FROM FIRE

PROVIDES THAT HOUSING AND EQUIPMENT ARE MAINTAINED IN A SANITARY MANNER

FACILITIES MANAGEMENT INSPECTION TEAM MEMBER SIGNATURE

FACILITIES MANAGEMENT INSPECTION TEAM MEMBER SIGNATURE

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

GRANTEE 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)

FACILITIES MANAGEMENT

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

FACILITIES MANAGMENT

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.

BEST PRACTICE RECOMMENDATIONS:

NUTRITION AND FOOD SERVICES

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

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) N/A

NO

YES

FOR CENTRALLY PREPARED NUTRITION AND FOOD SERVICES THE AWARDEE

ONE WEEK OF MENUS AVAILABLE FOR REVIEW

MENUS REPRESENT NUTRITIONALLY ADEQUATE DIET

NUTRITION AND FOOD SERVICES INSPECTION TEAM MEMBER SIGNATURE

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)

CURRENT LICENSURES ARE MAINTAINED, IF REQUIRED

APPLIANCES ARE ADEQUATE TO SAFELY STORE AND PREPARE FOOD AND ARE IN GOOD WORKING CONDITION (I.E. STOVE, REFRIGERATOR, DISHWASHER) 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 MANNER

FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A SANITARY CONDITION

ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER

REFRIGERATION AND DRY FOOD STORAGE AREAS ARE APPROPRIATELY MAINTAINED AND MONITORED

ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION PRACTICES

THREE MEALS PROVIDED PER DAY, INCLUDING WEEKENDS

HOW DOES THE AGENCY PROVIDE FOR THE NUTRITIONAL NEEDS OF VETERANS IN THE PROGRAM (CHECK ONE):

N/A

NO

YES

FOR INDIVIDUAL FOOD PREPARATION THE AWARDEE

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

NUTRITION AND FOOD SERVICES

BEST PRACTICE RECOMMENDATIONS:

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.

CLINICAL REVIEW

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

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) N/A

NO

YES

THE AWARDEE FACILITY

ENSURES RESIDENTS ARE PROVIDED A CLEAN AND SOBER ENVIRONMENT (FREE FROM ILLICIT DRUGS) 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 GRANTEE INITIATES A CORRECTIVE ACTION PLAN (CAP) AS OUTLINED IN 38 CFR 61.80 14(C)(7) WHEN ACCOMPLISHMENTS VARY BY A MARGIN OF +/- FIFTEEN PERCENT FOR ANY OF THE GOALS AND OBJECTIVES AS STATED IN THE GRANT APPLICATION OR SUBSEQUENT APPROVED CHANGES OF SCOPE 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 ENSURES NO VETERAN REMAINS IN TRANSITIONAL HOUSING LONGER THAN 24 MONTHS WITHOUT A WAIVER 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 AND FAMILIES THOUGH 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 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 ENSURES THAT AN INDIVIDUAL SERVICE PLAN (ISP) IS MAINTAINED IN THE CASE MANAGEMENT RECORD FOR EACH INDIVIDUAL PARTICIPANT PARTICIPANT RECORD INCLUDES, AT A MINIMUM THE FOLLOWING: FAMILY STATUS, VERIFICATION OF VETERAN STATUS, EDUCATION, EMPLOYMENT HISTORY, AND MARKETABLE SKILLS/LICENSES/CREDENTIALS 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

CLINICAL INSPECTION TEAM MEMBER SIGNATURE

CLINICAL INSPECTION TEAM MEMBER SIGNATURE

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

GRANTEE MAINTAINS SYSTEMATIC PARTICIPANT ENROLLMENT INFORMATION AND TRACKING

C. OTHER. EXPLAIN:

B. THE GRANTEE UTILIZES AGENCY INTERNAL TRACKING SYSTEM

A. THE GRANTEE UTILIZES HMIS FOR PROGRAM PARTICIPANTS

QUARTERLY THE GRANTEE VERIFIES SERVICE OUTCOMES WITH THE PARTICIPANT AND INCLUDES DOCUMENTATION IN THE PARTICIPANTS CASE MANAGEMENT FILE

CLINICAL REVIEW

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

CLINICAL REVIEW

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.

BEST PRACTICE RECOMMENDATIONS:

LAW ENFORCEMENT AND PHYSICAL SECURITY

CHIEF OF VA POLICE OR DESIGNEE SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) N/A

NO

YES

THE AWARDEE

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) STAFF OFFICES, TREATMENT, GROUP, PARTICIPANT ROOMS, DORMS, SHOWER, AND RESTROOMS HAVE LOCKS APPROPRIATE FOR THE SETTING AND GENDER MIX FACILITY ACCESS IS APPROPRIATELY SEPARATED FOR PRIVACY AND SECURITY GIVEN THE POPULATION(S) SERVED AGENCY 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 AGENCY HAS APPROPRIATE PROCEDURES REGARDING FACILITY OR UNIT ACCESS WHICH ARE ADEQUATELY CONTROLLED TO ENSURE THE SAFETY OF ALL RESIDENTS ARE COMMON AREAS (I.E. LAUNDRY, COMPUTER LABS, BREAK ROOMS) APPROPRIATELY SECURED, MONITORED, AND LIT 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 LIGHTS CHECKED REGULARLY TO MAKE SURE THEY ARE OPERATING EFFECTIVELY

IS THERE SUFFICIENT LIGHTING AROUND THE INTERIOR OF THE FACILITY

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

LAW ENFORCEMENT AND PHYSICAL SECURITY

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

POLICE INSPECTION TEAM MEMBER SIGNATURE

SECURITY INSPECTION TEAM MEMBER SIGNATURE

PARTICIPANTS HAVE AN APPROPRIATE PLACE TO SECURE PERSONAL VALUABLES AND BELONGINGS

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

SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE LIVING)

AS PART OF THE RISK ASSESSMENT FOR THIS PROJECT, LOCAL CRIME STATISTICS FOR THE AREA HAVE BEEN REVIEWED AND DISCUSSED WITH THE PROVIDER

DOCUMENTATION OF RESIDENTIAL SUPERVISION TRAINING IS PRESENT

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 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 EMERGENCY CONTACTS FOR MEDICAL, LAW ENFORCEMENT, FIRE DEPARTMENT AND AGENCY ARE PROMINENTLY POSTED IN THE FACILITY

A PROCEDURE FOR ON-GOING LAW ENFORCEMENT MONITORING HAS BEEN ESTABLISHED

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

SECURITY & LAW ENFORCEMENT

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.

BEST PRACTICE RECOMMENDATIONS:

MEDICATION REVIEW

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) 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 POSSIBLE 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 MEDICATION 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 REVIEW

N/A

NO

YES

FOR MEDICATION MONITORING THE AWARDEE

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

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 RECOMMENDATIONS

ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES OR DETERIORATION

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE UNDER THE CONTROL OF AUTHORIZED STAFF ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT WHEN UNDER THE DIRECT SUPERVISION OF APPROPRIATE STAFF 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

SECURITY INSPECTION TEAM MEMBER SIGNATURE

BEST PRACTICE RECOMMENDATIONS:

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.

NURSING SERVICES

SERVICE CENTER REQUIREMENTS

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) N/A

NO

YES

THE AWARDEE

PROVIDES SERVICES TO HOMELESS VETERANS FOR A MINIMUM OF 40 HOURS OVER A MINIMUM OF FIVE DAYS PER WEEK, AS WELL AS IN AN AS NEEDED, UNSCHEDULED BASIS. MOBILE SERVICE CENTERS MAY COUNT TRAVEL TIME IN THE 40-HOUR REQUIREMENT HOURS OF OPERATION AND EMERGENCY CONTACTS ARE CLEARLY POSTED. MOBILE SERVICE CENTERS HAVE PROVIDED A REASONABLE TENTATIVE SCHEDULE OF SITE VISITS AND ACTIVITIES, (SEE REGULATIONS FOR SCHEDULE SPECIFICS)

LIAISON OR CLINICAL INSPECTION TEAM MEMBER SIGNATURE

LIAISON OR CLINICAL INSPECTION TEAM MEMBER SIGNATURE

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

SPACE IS MADE AVAILABLE FOR USE BY VA STAFF AND OTHER APPROPRIATE AGENCIES AND ORGANIZATIONS THAT ASSIST HOMELESS VETERANS SERVICE CENTER IS EQUIPPED TO PROVIDE, OR ASSIST IN PROVIDING, HEATH CARE, MENTAL HEALTH SERVICE, HYGIENE FACILITIES, BENEFITS AND EMPLOYMENT COUNSELING, MEALS AND TRANSPORTATION ASSISTANCE PROVIDES OTHER SERVICES AS VA DETERMINES NECESSARY BASE ON THE NEED FOR SERVICES OTHERWISE NOT AVAILABLE IN THE GEOGRAPHIC AREA

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

SERVICE CENTER

BEST PRACTICE RECOMMENDATIONS:

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.

VAN USAGE

GPD LIAISON SHOULD COMPLETE THIS SECTION ATTACHING ANY OTHER DOCUMENTATION, AS NECESSARY N/A

NO

YES

GRANTEE HAS BEEN AWARDED A VAN

VAN IS OPERATIONAL AND BEING USE AS OUTLINED IN THE GRANT APPLICATION FOR THE OUTREACH AND TRANSPORTATION OF VETERANS IN THE PROGRAM

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED

GRANTEE HAS PROOF OF VAN REGISTRATION(S) AND INSURANCE

GRANTEE ENSURES THAT ALL VAN OPERATOR(S) ARE QUALIFIED, APPROPRIATELY TRAINED, AND APPROPRIATELY LICENSED

A COPY OF THE VAN REGISTRATION HAS BEEN INCLUDED IN THE INSPECTION PACKAGE

GPD LIAISON SIGNATURE

GPD LIAISON SIGNATURE

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

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

VAN USAGE

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.

BEST PRACTICE RECOMMENDATIONS:

TECHNICAL REPORT

OBJECTIVES / EXPECTED RESULTS

% DEVIATION BETWEEN ACTUAL AND EXPECTED RESULTS

NO. IN

SAMPLE SIZE

ACTUAL RESULTS

IS A CORRECTIVE ACTION PLAN (CAP) REQUIRED

ANALYSIS

ANALYSIS AND ACTION PLAN

ACTION PLAN

INCREASED RESIDENTIAL STABILITY

OBJECTIVES / EXPECTED RESULTS

% DEVIATION BETWEEN ACTUAL AND EXPECTED RESULTS

NO. IN

SAMPLE SIZE

ACTUAL RESULTS

IS A CORRECTIVE ACTION PLAN (CAP) REQUIRED

ANALYSIS

ANALYSIS AND ACTION PLAN

ACTION PLAN

TECHNICAL REPORT

INCREASED SKILL AND / OR INCOME

OBJECTIVES / EXPECTED RESULTS

% DEVIATION BETWEEN ACTUAL AND EXPECTED RESULTS

NO. IN

SAMPLE SIZE

ACTUAL RESULTS

IS A CORRECTIVE ACTION PLAN (CAP) REQUIRED

ANALYSIS

ANALYSIS AND ACTION PLAN

ACTION PLAN

OBJECTIVES / EXPECTED RESULTS

% DEVIATION BETWEEN ACTUAL AND EXPECTED RESULTS

NO. IN

SAMPLE SIZE

ACTUAL RESULTS

IS A CORRECTIVE ACTION PLAN (CAP) REQUIRED

ANALYSIS

ANALYSIS AND ACTION PLAN

ACTION PLAN

TECHINCAL REPORT

IMPROVED SELF DETERMINATION

OBJECTIVES / EXPECTED RESULTS

% DEVIATION BETWEEN ACTUAL AND EXPECTED RESULTS

NO. IN

SAMPLE SIZE

ACTUAL RESULTS

IS A CORRECTIVE ACTION PLAN (CAP) REQUIRED

ANALYSIS

ANALYSIS AND ACTION PLAN

ACTION PLAN

OBJECTIVES / EXPECTED RESULTS

% DEVIATION BETWEEN ACTUAL AND EXPECTED RESULTS

NO. IN

SAMPLE SIZE

ACTUAL RESULTS

IS A CORRECTIVE ACTION PLAN (CAP) REQUIRED

ANALYSIS

ANALYSIS AND ACTION PLAN

ACTION PLAN

REVIEW OF HOMES DATA

NOT APPLICABLE FOR INITIAL INSPECTIONS AND SERVICE CENTERS

N/A

NO

YES

HOMES DATA , RELATIVE TO THIS PROJECT NUMBER, HAS BEEN DISCUSSED WITH THE GRANTEE

GPD LIAISON SIGNATURE

GPD LIAISON SIGNATURE

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

ANNUAL REVIEW OF SERVICES

LIST BETWEEN 6-15 CORE SERVICES AS STATED IN THE ORIGINAL GRANT APPLICATION OR SUBSEQUENTLY APPROVED CHANGE OF SCOPE

THE AWARDEE

NO

YES

THE GRANTEE IS CURRENTLY PROVIDING ALL SERVICES AS STATED IN THE ORIGINAL GRANT APPLICATION OR SUBSEQUENTLY APPROVED CHANGE OF SCOPE

SERVICE IS CURRENTLY PROVIDED (Y/N)