Attachment 7 - Site Inspection Checklist.pdf

HCHV Site Inspection Contract Residential Checklist

DOES THE OFFEROR’S PROGRAM MEET THE FOLLOWING

CRITERIA?

YES NO

1 HAS ADEQUATE STAFFING AND AN APPROPRIATE SCOPE OF

THERAPEUTIC AND REHABILITATIVE SERVICES TO CARRY OUT

THIS PROJECT AS OUTLINED IN THE STATEMENT OF WORK

(SOW).

2 IS PHYSICALLY READY TO PROVIDE BASIC SERVICES

OUTLINED IN THE SOW (ROOM AND BOARD, LAUNDRY

FACILTIES, AND MEDICATION STORAGE). NOTE: LIGHTING,

PLUMBING, ELECTRICAL, SPACE, AND SECURITY OF THE

FACILITY WILL BE EVALUATED.

THE FACILITY – (STRUCTURE, SECURITY, LIFE SAFETY) YES NO

3 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.

4 PROVIDES A WATER SUPPLY THAT IS FREE FROM

CONTAMINATION.

5 PROVIDES SUFFICIENT SANITARY FACILITIES TO RESIDENTS

THAT ARE OPERATIONAL, MAY BE USED IN PRIVACY, AND

ARE ADEQUATE FOR PERSONAL CLEANLINESS AND THE

DISPOSAL OF HUMAN WASTE.

6 HAS SUFFICIENT LIGHTING AROUND THE PERIMETER OF THE

FACILITY.

7 HAS INTERIOR AND EXTERIOR LOCKS IN GOOD WORKING

ORDER.

8 HAS PROCEDURES REGARDING FACILITY OR UNIT ACCESS

WHICH ARE ADEQUATELY CONTROLLED TO ENSURE THE

SAFETY OF ALL RESIDENTS.

9 HAS WRITTEN POLICIES AND PROCEDURES REGARDING

SAFETY, SECURITY, AND PRIVACY.

10 STAFF OFFICES, TREATMENT, GROUP, PARTICIPANT ROOMS,

DORMS, SHOWER, AND RESTROOMS HAVE LOCKS

APPROPRIATE FOR THE SETTING AND GENDER MIX.

11 HAS POSTED EMERGENCY CONTACTS FOR MEDICAL, LAW

ENFORCEMENT, FIRE DEPARTMENT, POISON CONTROL, AND

AGENCY.

12 SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE

LIVING).

13 HAS A WRITTEN DISASTER PLAN THAT HAS BEEN

COORDINATED WITH THE EMERGENCY MANAGEMENT ENTITY

RESPONSIBLE FOR THE LOCALITY IN WHICH THE PROJECT

RESIDES. THE DISASTER PLAN ENCOMPASSES NATURAL AND

MANMADE DISASTERS.

Attachment 7: Site Inspection Checklist

MEDICATION MANAGEMENT YES NO

14 ORGANIZATION HAS WRITTEN PROCEDURES THAT

ADDRESSES STORAGE, INVENTORY, AND HANDLING OF

MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF

MEDICATION USE.

15 ORGANIZATION HAS WRITTEN PROCEDURES REGARDING

MEDICATIONS THAT PROVIDE FOR COMPLIANCE WITH ALL

APPLICABLE LAWS AND REGULATIONS PERTAINING TO

MEDICATIONS AND CONTROLLED SUBSTANCES.

16 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.

NUTRITION AND FOOD SERVICES YES NO

17 ONE WEEK OF MENUS AVAILABLE FOR REVIEW.

18 MENUS REPRESENT NUTRITIONALLY ADEQUATE DIET.

19 DEMONSTRATE THE ABILITY TO MEET SPECIAL DIETARY

NEEDS (I.E. KOSHER, DIABETIC, ALLERGIES, MEDICALLY

INDICATED.)

20 REFRIGERATION AND DRY FOOD STORAGE AREAS ARE

MAINTAINED AND MONITORED.

21 ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER.

22 APPLIANCES ARE IN GOOD WORKING CONDITION (I.E. STOVE,

REFRIGERATOR, DISHWASHER).

23 FOOD PREPARATION AREAS CONTAIN SUITABLE SPACE AND

EQUIPMENT TO STORE, PREPARE, AND SERVE FOOD IN A

SANITARY MANNER.

24 RESOURCE INFORMATION IS AVAILABLE TO EDUCATE

VETERANS WITH SPECIAL DIETARY NEEDS (I.E. DIABETIC,

ALLERGIES, MEDICALLY INDICATED). MAY BE

ACCOMPLISHED THROUGH NUTRITIONAL EDUCATION

PROVIDED DIRECTLY BY THE AGENCY OR A REFERRAL

RESOURCE WITHIN THE COMMUNITY.

RECORDS MANAGEMENT YES NO

25 HAS POLICY AND PROCEDURES TO KEEP RESIDENT RECORDS

CONFIDENTIAL AND SECURED.