36C26219R0025-003.pdf

PROJECT #:

I APPOINT THE FOLLOWING INDIVIDUAL AS LIAISON FOR THIS PROJECT:

DATE

___ I APPROVE ___ I DISAPPROVE PLACEMENT OF VETERANS AT THIS PROVIDER'S FACILITY.

VAMC DIRECTOR (PRINT NAME) SIGNATURE

MEDICATION REVIEW

NHC OR DESIGNEE

OTHER

SECURITY / LAW ENFORCEMENT

NAME TITLE

INSPECTION TEAM MEMBERS

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.

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:

FACILITIES MANAGEMENT

NUTRITION

CLINICAL REVIEW

Department of Veterans Affairs Health Care for Homeless Veterans Contracted

Residential Services Programs Inspection Packet

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

DATE INSPECTION COMPLETED:DATE INSPECTION STARTED:PROVIDER'S NAME:

INSPECTION IS FOR: ___ INITIAL INSPECTION ___ RE-INSPECTION

TOTAL BEDS AWARDED

ATTACHMENT B: HCHV Contracted Residential Services Programs Inspection Packet

YES NO N/A

VA LIAISON – OVERVIEW &

RECOMMENDATION

HOMES PROJECT CODE:

SITE ADDRESS:

THE RESULTS OF THE CONTRACT PROVIDER'S PERFORMANCE ON THE

APPLICABLE VA METRICS HAVE BEEN DISCUSSED AT LEAST QUARTERLY

WITH THE CONTRACT PROVIDER (RE-INSPECTIONS ONLY)

HCHV LIAISON SHOULD COMPLETE THIS SECTION

ATTACHING ANY OTHER DOCUMENTATION, AS

NECESSARY

PROGRAM OPERATES IN ACCORDANCE WITH HCHV PROGRAM

REGULATIONS, 38 CFR 63

PROGRAM MEETS ALL APPLICABLE STATE AND LOCAL LICENSING AND

OTHER REQUIREMENTS FOR THE OPERATION OF THE PROGRAM IN THE

JURISDICTION WHERE THE PROGRAM IS LOCATED

CONTRACT PROVIDER HAS DEMONSTRATED ADEQUATE STAFFING AND AN

APPROPRIATE SCOPE OF SERVICES TO CARRY OUT THIS PROGRAM AS

OUTLINED IN THE ORIGINAL SOW/PWS OR SUBSEQUENT APPROVED

CHANGE / CONTRACT MODIFICATION

CONTRACT PROVIDER SERVES/CAN SERVE THE POPULATION(S) AS

DESCRIBED IN THEIR CONTRACT / SOW/PWS.

THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE

WITHIN THE SITES COVERED UNDER THIS PROGRAM NUMBER:

A. MEN

C. CHILDREN

CONTRACT PROVIDER MAINTAINS SYSTEMATIC PARTICIPANT ENROLLMENT

AND TRACKING INFORMATION FOR SAFETY AND BILLING PURPOSES. *If initial inspection this section can be left blank

CONTRACT PROVIDER UTILIZES HMIS FOR PROGRAM PARTICIPANTS

B. WOMEN

THE CONTRACT PROVIDER SUBMITS ACCURATE BILLING ON A MONTHLY

BASIS AND MAINTAINS DOCUMENTATION TO SUPPORT MONTHLY BILLING.

*If initial inspection this section can be left blank

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

MEETS

TARGET

DOES

NOT

MEET

TARGET

PIP IN

PLACE /

REQUIR

ED

YES NO N/A

A.

B.

C.

D.

E.

F.

HCHV LIAISON SIGNATURE

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS

APPROVED FOR PLACEMENT OF VETERANS:

THE CRS PROVIDER MEETS OR EXCEEDS THE MOST CURRENT (YEARLY OR

QUARTERLY) PERFORMANCE DATA BELOW AND IF NOT, THE HCHV LIASION

WORKS WITH THE PROVIDER TO PUT A PLAN IN PLACE FOR IMPROVEMENT

(*If initial inspection this section can be left blank):

A. EXITS TO PERMANENT HOUSING

B. NEGATIVE EXITS

ANNUAL REVIEW OF SERVICES: LIST THE CORE SERVICES INDEPENDENTLY

PERFORMED BY THE CONTRACT PROVIDER AS STATED IN THE SOW/PWS.

PLEASE INDICATE IF THE SERVICE IS CURRENTLY PROVIDED.

THIS INSPECTION INVOLVED INVERVIEWS BY THE INSPECTION TEAM

MEMBERS WITH VETERANS PARTICIPATING IN THIS PROGRAM; ANY

COMPLAINTS OR ALLEGATIONS MADE BY VETERANS REGARDING

DEFICENCIES IN THE PROGRAM HAVE BEEN EITHER FULLY RESOLVED OR

INVESTIGATED AND DETERMINED TO BE UNFOUNDED.

THE CONTRACT PROVIDER IS CURRENTLY PROVIDING ALL SERVICES AS

STATED IN THE CONTRACT / SOW/PWS . *If initial inspection this section can be left blank

DATE

DATE

HCHV LIAISON SUPERVISOR'S NAME (PRINT)

HCHV LIAISON SUPERVISOR'S SIGNATURE

I, AS THE HCHV LIAISONS SUPERVISOR HAVE REVIEWED THIS INSPECTION PACKET AND DISCUSSED THE

FINDINGS WITH THE HCHV LIAISON. I CONCUR WITH THE LIAISONS FINDINGS AND AFFIRM THAT TO THE

BEST OF MY KNOWLEDGE THAT THIS HCHV PROGRAM OPERATES IN ACCORDANCE WITH HCHV

PROGRAM REGULATIONS AND IS CURRENTLY PROVIDING ALL SERVICES AS STATED IN THE ORIGINAL

SOW/PWSOR SUBSEQUENTLY APPROVED CHANGE OF SCOPE.

HCHV LIAISON NAME (PRINT)

PROVIDES THAT HOUSING AND EQUIPMENT ARE MAINTAINED IN A SANITARY

MANNER

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

CONTRACT PROVIDER HAS A WRITTEN DISASTER PLAN THAT IS CONSISTENT

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)

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

HOMES PROJECT CODE:

FACILITIES MANAGEMENT

SITE ADDRESS:

PROVIDES SUFFICIENT ELECTRICAL SOURCES TO PERMIT USE OF ESSENTIAL

ELECTRICAL APPLIANCES WHILE ASSURING SAFETY FROM FIRE

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER FACILITY

PROVIDES ADEQUATE HEATING AND OR COOLING PLANTS THAT ARE IN

PROPER OPERATING CONDITION

PROVIDES ADEQUATE NATURAL OR ARTIFICIAL ILLUMINATION TO PERMIT

NORMAL INDOOR ACTIVITIES AND TO SUPPORT THE HEALTH AND SAFETY OF

RESIDENTS

IS COMPLIANT WITH THE AMERICAN WITH DISABILITIES ACT, REFERRED TO AS

ARCHITECTURAL BARRIERS ACT * If NO or N/A is chosen you must provide an explanation and note any provisions made or resources available for Veterans with disabilities on the following page.

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 AND PROVIDE ALTERNATE MEANS OF EGRESS

IN CASE OF FIRE

YES NO

Facilities Management Inspection Team Members

Signature

Facility Management Inspection Team

Members Name ( Print)

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

PLACEMENT OF VETERANS

Date

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.

FACILITIES MANAGEMENT

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.

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

YES NO N/A

YES NO N/A

RESOURCE INFORMATION IS AVAILABLE TO EDUCATE VETERANS WITH

SPECIAL DIETARY NEEDS (e.g. DIABETIC, ALLERGIES, MEDICALLY

INDICATED). MAY BE ACCOMPLISHED THROUGH NUTRITIONAL

EDUCATION PROVIDED DIRECTLY BY THE AGENCY OR A REFERRAL

RESOURCE WITHIN THE COMMUNITY

ENSURES CURRENT LICENSURES AND PERMITS ARE MAINTAINED IF

REQUIRED BY LOCAL OR OTHER AUTHORITIES

HOMES PROJECT CODE:

SITE ADDRESS:

NUTRITION AND FOOD SERVICES

ENSURES ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION

PRACTICES

ENSURES REFRIGERATION AND DRY FOOD STORAGE AREAS ARE

APPROPRIATELY MAINTAINED AND MONITORED

PROVIDES THREE MEALS AND AN EVENING SNACK PER DAY, INCLUDING

WEEKENDS

FOR INDIVIDUAL FOOD PREPARATION THE CONTRACT PROVIDER ENSURES:

APPLIANCES ARE ADEQUATE TO SAFELY STORE AND PREPARE FOOD

AND ARE IN GOOD WORKING CONDITION (I.E. STOVE, REFRIGERATOR,

DISHWASHER)

THAT ALL FOOD PREPARATION AREAS CONTAIN SUITABLE SPACE AND

EQUIPMENT TO STORE, PREPARE, AND SERVE FOOD IN A SANITARY

MANNER INCLUDING PROVIDING APPROPRIATE CLEANING SUPPLIES AS

NEEDED

SUFFICIENT FOOD STORES ARE AVAILABLE TO ENSURE VETERANS

RECEIVE THREE NUTRITIONALLY ADEQUATE MEALS PER DAY.

THE ABILITY TO MEET SPECIAL DIETARY NEEDS (e.g. KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED)

THE MENUS REPRESENT A NUTRITIONALLY ADEQUATE DIET

DEMONSTRATES THE ABILITY TO MEET SPECIAL DIETARY NEEDS (I.E.

KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED)

CENTRALLY PREPARED NUTRITION AND FOOD SERVICES

INDIVIDUAL FOOD PREPARATION FACILITIES

ENSURES FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A

SANITARY CONDITION

ENSURES ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

FOR CENTRALLY PREPARED NUTRITION AND FOOD SERVICES THE CONTRACT

PROVIDER :

HOW DOES THE AGENCY PROVIDE FOR THE NUTRITIONAL NEEDS OF VETERANS IN THE PROGRAM, AT LEAST ONE ITEM MUST BE CHECKED, IF AN ITEM IS CHECKED THEN N/A MAY NOT BE SELECTED

FOR ANY ITEMS IN THAT SECTION

PROVIDES ONE WEEK OF MENUS FOR REVIEW

Nutrition/Food Mangement Inspection Team Members

Signature

Facility Food Management Inspection

Team Members Name ( Print) Date

NUTRITION AND FOOD SERVICES

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.

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

B. SERVICE NEEDS

C. STRENGTHS

D. SPECIFIC SERVICES PROVIDED INCLUDING DURATION AND OUTCOMES

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.

E. DOCUMENTATION OF REFERRALS

B. FAMILY STATUS

D. EDUCATION AND MARKETABLE SKILLS/LICENSES/CREDENTIALS

C. EMPLOYMENT HISTORY

A. BARRIERS

QUARTERLY 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

HAS POLICIES AND PROCEDURES TO ADDRESS HOW INTOXICATED OR IMPAIRED

PRATICIPANTS WILL BE INDENTIFIED AND MANAGED IN THIS PROGRAM.

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.

HOMES PROJECT CODE:

CLINICAL REVIEW

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.

THE CONTRACT PROVIDER:

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

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).

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.

ENSURES SUSTAINED EFFORTS ARE MADE THAT ELIGIBLE HARD-TO-REACH

CHRONICALLY HOMELESS VETERANS ARE SERVED IN THE FACILITY

ENSURES THAT AN INDIVIDUAL SERVICE PLAN (ISP) IS MAINTAINED IN THE CASE

MANAGEMENT RECORD FOR EACH INDIVIDUAL PARTICIPANT. THE ISP CONTAINS AN

ASSESSMENT OF:

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

INCLUDING INDIVIDUALIZED GOALS FOR EACH PARTICIPANT

ENSURES THAT PARTICIPANT RECORDS ARE MAINTAINED INCLUDING, AT A

MINIMUM THE FOLLOWING:

A. VERIFICATION OF VETERAN STATUS

Clinical Inspection Team Members Signature Clinical Inspection Team Members Name (

Print) Date

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.

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

ENSURES THE FACILITY IS SAFE AND SECURE BASED ON LOCATION,

POPULATIONS(S) SERVED, AND FACILITY STRUCTURE (THIS INCLUDES ENSURING

LOCKS ARE IN WORKING ORDER WHERE APPROPRIATE). NOTE: ADEQUATE

CONSDERATIONS SHOULD BE GIVEN TO SEPARATION AND SAFETY IN FACILITIES

WHERE MULTIPLE GENDERS AND/OR CHILDREN ARE SERVED.

PROVIDES ADEQUATE LIGHTING TO PERMIT NORMAL INDOOR ACTIVITIES AND TO

SUPPORT THE HEALTH AND SAFETY OF RESIDENTS

PROVIDES EACH RESIDENT APPROPRIATE SPACE AND SECURITY FOR

THEMSELVES AND THEIR BELONGINGS, INCLUDING VALUABLES

HAS ADEQUATE POLICIES AND PROCEDURES WHICH ARE COMMUNCATED AND

ENFORCED TO ENSURE SAFETY, SECURITY, AND PRIVACY BASED ON LOCATION,

POPULATION(S) SERVED, AND FACILITY STRUCTURE.

ENSURES 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, (FOR HCHV

LDSH PROGRAMS PAID 24/7 STAFF MUST BE USED TO MEET THIS REQUIREMENT)

ENSURES DOCUMENTATION OF RESIDENTIAL SUPERVISION TRAINING IS PRESENT

HAS A SYSTEM TO IDENTIFY PARTICIPANTS WHO ARE SUBJECT TO RESIDENCY

RESTRICTIONS ( E.G., THOSE REQUIRED TO REGISTER FOLLOWING CONVICTION

FOR A SEXUAL OFFENSE), AND, WHEN APPROPRIATE, TO COMMUNICATE WITH

PAROLE OR PROBATION AUTHORITIES TO CONFIRM THAT THE PLACEMENT MEETS

ANY COURT-IMPOSED REQUIREMENTS

HAS ADEQUATE POLICIES AND PROCEDURES WHICH ARE ENFORCED TO ENSURE

THAT ILLICIT DRUGS, WEAPONS, AND OTHER SIMILAR ITEMS ARE NOT PERMITTED

ON THE PREMISES

ENSURES EMERGENCY CONTACTS FOR MEDICAL, LAW ENFORCEMENT, FIRE

DEPARTMENT AND AGENCY ARE PROMINENTLY POSTED IN THE FACILITY

ENSURES COMMON AREAS (I.E. LAUNDRY, COMPUTER LABS, BREAK ROOMS) ARE

APPROPRIATELY SECURED, MONITORED, AND LIT

ENSURES THERE IS SUFFICIENT LIGHTING AROUND THE PERIMETER OF THE

FACILITY BASED ON THE HOUSING SETTING

HOMES PROJECT CODE:LAW ENFORCEMENT AND

PHYSICAL SECURITY

SITE ADDRESS:

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 PROGRAM

CHIEF OF VA POLICE OR DESIGNEE SHOULD

COMPLETE THIS SECTION ATTACHING THEIR

RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CONTRACT PROVIDERS (ALL INSPECTIONS)

IS LOCATED ON VA PROPERTY AND THE CHIEF, POLICE SERVICE OR DESIGNEE

HAS CONDUCTED A COMPREHENSIVE RISK ASSESSMENT OF THE PROGRAM. (IF

NOT ON VA PROPERTY "N/A")

IS LOCATED ON VA PROPERTY AND A PROCEDURE FOR ON-GOING LAW

ENFORCEMENT MONITORING HAS BEEN ESTABLISHED BETWEEN THE PROVIDER

AND VA

THE CONTRACT PROVIDER:

Law Enforcement Inspection Team Members Signature Law Enforcement Inspection Team

Members Name ( Print) Date

LAW ENFORCEMENT AND PHYSCIAL

SECURITY 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.

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 N/A

HOMES PROJECT CODE:

MEDICATION REVIEW

SITE ADDRESS:

ORGANIZATION HAS DOCUMENTATION OR CONFIRMATION OF INFORMED

CONSENT FOR EACH MEDICATION ADMINISTERED, WHEN POSSIBLE

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

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

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

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

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

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT

TRAINING AND EDUCATION REGARDING MEDICATION

ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS

THAT PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND

REGULATIONS PERTAINING TO MEDICATIONS AND CONTROLLED

SUBSTANCES

TYPE OF MEDICATION CONTROL SYSTEM USED BY AGENCY (CHECK ALL THAT APPLY, AT LEAST ONE

ITEM MUST BE CHECKED, IF AN ITEM IS CHECKED THEN N/A MAYNOT BE SELECTED FOR ANY ITEMS

IN THAT SECTION):

MEDICATION MANAGEMENT: PRACTICE OF PRESCRIBING, ADMINISTERING, AND/OR

DISPENSING MEDICATION BY QUALIFIED PERSONNEL, INCLUDING TAKING PILLS OUT OF

BOTTLES, MEASURING LIQUIDS, OR GIVING INJECTIONS

MEDICATION MONITORING: PRACTICE OF PROVIDING A COMBINED SECURE STORAGE AREA

AND CONTROLLED ACCESS FOR MEDICATIONS THAT ARE BROUGHT INTO A PROGRAM AND

USED BY THE VETERAN. THE PERSON TAKES THE MEDICATION WITHOUT ANY ASSISTANCE

FROM STAFF

INDIVIDUAL STORAGE: PRACTICE OF ALLOWING INDIVIDUALS TO STORE (I.E. LOCK BOX,

INDIVIDUAL APARTMENT UNIT) AND SELF-ADMINISTER THEIR MEDICATIONS

FOR MEDICATION MANAGEMENT:

YES NO N/A

YES NO N/A

METHOD OF STORAGE CAN NOT BE EASILY REMOVED FROM THE

FACILITY (I.E. LOCK BOX IS SECURED TO A LARGE DRESSER OR THE

STRUCTURE OF THE BUILDING)

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE

AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION

OF MEDICATION USE

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 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

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY

PERSONS SERVED

ORGANIZATION PROCEDURES ENSURE THE IDENTIFICATION,

DOCUMENTATION, AND REQUIRED REPORTING, INCLUDING TO THE

PRESCRIBING PROFESSIONAL, ANY MEDICATION REACTIONS OR

MEDICATION ERRORS, AS APPROPRIATE

FOR MEDICATION MONITORING:

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 MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT

WHEN UNDER THE DIRECT SUPERVISION OF APPROPRIATE STAFF

ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES

OR DETERIORATION

ALL MEDICATIONS ARE STORED ACCORDING TO MANUFACTURER’S

RECOMMENDATIONS

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE FAMILIAR WITH

ALL MEDICATIONS STOCKED. THEY HAVE KNOWLEDGE OF/OR ACCESS

TO INFORMATION (e.g. CURRENT PHYSICIANS DESK REFERENCE OR

OTHER RESOURCE) THAT INCLUDES INDICATIONS, SIDE EFFECTS, TOXIC

EFFECTS, INTERACTIONS, AND POTENTIAL ALLERGIC REACTIONS.

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED

ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE

UNDER THE CONTROL OF AUTHORIZED STAFF

FOR INDIVIDUAL STORAGE:

Medication Inspection Team Members Signature Medication Management Inspection Team

Members Name ( Print) Date

MEDICATION 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.

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.