3 Facilities Managment Template.docx

FACILITIES MANAGEMENT

HOMES PROJECT CODE:

SITE ADDRESS:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

WITHOUT UNAUTHORIZED USE AND PROVIDE ALTERNATE MEANS OF EGRESS IN CASE OF FIRE

PROPER OPERATIONAL CONDITION, MAY BE USED IN PRIVACY, AND ARE

ADEQUATE FOR PERSONAL CLEANLINESS AND THE DISPOSAL OF HUMAN WASTE

NORMAL INDOOR ACTIVITIES AND TO SUPPORT THE HEALTH AND SAFETY OF RESIDENTS

WITH THE GUIDANCE OFFERED BY THE EMERGENCY MANAGEMENT ENTITY

RESPONSIBLE FOR THE LOCALITY IN WHICH THE PROJECT RESIDES. THE

DISASTER PLAN ENCOMPASSES NATURAL AND MANMADE DISASTERS (REFER TO VHA DIRECTIVE 1162.01)

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

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.

Deficiencies were present for items on this checklist during inspection (If Yes list deficiencies and confirm resolution below)

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACT PROVIDER TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

ALL APPROPRIATE CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS

Facilities Management Inspection Team Members Signature Facility Management Inspection Team Members Name ( Print) Date