1 Inspection Cover Sheet Template.docx
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Text version
Department of Veterans Affairs Health Care for Homeless Veterans Contracted Residential Services Programs Inspection Packet
MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET
INSPECTION IS FOR: ___ INITIAL INSPECTION __ __ RE-INSPECTION
PROJECT #:
TOTAL BEDS AWARDED
| 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 1162.09. 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: Iisha Toombs, LCSW
| VAMC DIRECTOR (PRINT NAME) |
| SIGNATURE |
| DATE |
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