1 Inspection Cover Sheet Template.docx
DOCX document 15 KB Posted
- Attached to
- HCHV Federal contract opportunity
- Solicitation number
- 36C26123Q0196
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| S02 36C26123Q0196 0004.pdf | ||
| S02 36C26123Q0196 0003.pdf | ||
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| 4 Nutrition and Food Template.docx | DOCX document | |
| ZIP CODE CATCHMENT LIST - EXCEL VERSION.xlsx | XLSX spreadsheet | |
| S02 36C26123Q0196 0002.pdf | ||
| S02 36C26123Q0196 0001.pdf | ||
| PERFORMANCE WORK STATEMENT.pdf | ||
| Attachment 1 - Wage Determination 1995-0573 Rev 52 12.27.22.pdf | ||
| S02 36C26123Q0196.pdf |
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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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