5 Clinical Review Template.docx

DOCX document 19 KB Posted

Attached to
HCHV Federal contract opportunity
Solicitation number
36C26123Q0196
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

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CLINICAL REVIEW

HOMES PROJECT CODE:

SITE ADDRESS:

THE APPROPRIATE DISCIPLINE(S) (SOCIAL WORK

AND/OR MENTAL HEALTH) SHOULD COMPLETE

THIS SECTION. WHENEVER POSSIBLE, THIS

SECTION SHOULD NOT BE COMPLETED BY THE HCHV LIAISON ASSIGNED TO THIS PROGRAM.

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER:
YES
NO
44
HAS POLICIES AND PROCEDURES TO ADDRESS HOW INTOXICATED OR IMPAIRED PRATICIPANTS WILL BE INDENTIFIED AND MANAGED IN THIS PROGRAM.
45
ENSURES THAT PROGRAM STAFF ARE EDUCATED ON AND FOLLOWING CONTRACT PROVIDERS POLICIES AND PROCEDURES REGARDING HOW INTOXICATED OR IMPAIRED PRATICIPANTS WILL BE INDENTIFIED AND MANAGED.
46
ENSURES RESIDENTS ARE PROVIDED A CLEAN AND SAFE ENVIRONMENT, AS EVIDENCED BY POLICIES AND PROCEDURES THAT ARE COMMUNICATED TO PARTICIPANTS AND THAT ARE CONSISTENTLY FOLLOWED BY STAFF.
47
ENSURES THE RECORDS KEPT ON HOMELESS VETERANS ARE KEPT CONFIDENTIAL AND SECURE, (IF FAMILY VIOLENCE PREVENTION OR TREATMENT SERVICES ARE PROVIDED SEE REGULATIONS PERTAINING TO CONFIDENTIALLY OF RECORDS).
48
ENSURES THAT ALL HOUSING AND SERVICES PROVIDED TO PARTICIPANTS ARE OF AN ACCEPTABLE QUALITY AND ARE CLINICALLY APPROPRIATE TO MEET THE UNIQUE NEEDS OF THE HOMELESS VETERAN POPULATION SERVED.
49
ENSURES SUSTAINED EFFORTS ARE MADE THAT ELIGIBLE HARD-TO-REACH CHRONICALLY HOMELESS VETERANS ARE SERVED IN THE FACILITY
50
ENSURES THAT PARTICIPANT RECORDS ARE MAINTAINED INCLUDING, AT A MINIMUM THE FOLLOWING:

A. VERIFICATION OF VETERAN STATUS

B. FAMILY STATUS

C. EMPLOYMENT HISTORY

D. EDUCATION AND MARKETABLE SKILLS/LICENSES/CREDENTIALS

51
ENSURES THAT AN INDIVIDUAL SERVICE PLAN (ISP) IS MAINTAINED IN THE CASE MANAGEMENT RECORD FOR EACH INDIVIDUAL PARTICIPANT. THE ISP CONTAINS AN ASSESSMENT OF:

A. BARRIERS

B. SERVICE NEEDS

C. STRENGTHS

D. SPECIFIC SERVICES PROVIDED INCLUDING DURATION AND OUTCOMES

E. DOCUMENTATION OF REFERRALS

F. BENEFITS TO BE ACHIEVED AS A RESULT OF PROGRAM PARTICIPATION

52
INCLUDING INDIVIDUALIZED GOALS FOR EACH PARTICIPANTQUARTERLY THE CONTRACT PROVIDER VERIFIES SERVICE OUTCOMES WITH THE

PARTICIPANT AND INCLUDES DOCUMENTATION OF SUCH IN THE PARTICIPANTS

CASE MANAGEMENT FILE IN THE FORM OF AN ISP REVIEW OR UPDATE

CLINICAL REVIEW CHECKLIST
HOMES PROJECT CODE:

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.

YES
NO

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.

YES
NO

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

Clinical Inspection Team Members Signature
Clinical Inspection Team Members Name (

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