Attachment B - Vendor Inspection Form.pdf

Attachment 2 36C25525R0054

NAME AND LOCATION OF COMPANY

MILES FROM

LOCAL VA

FACILITY

FA

C

IL

IT

Y

TYPE OF BUILDING (CHECK TWO)

BRICK FRAME RESIDENCE BUSINESS BUILDING

BUSINESS/OCCUPATIONAL LICENSE CURRENT?

YES NO

CONDITION O F BUILDING (CHECK TWO)

NEW OLD GOOD POOR

ACCREDITATION IN GOOD STANDING?

YES NO

GENERAL CONDITION AND APPREARANCE (CHECK TWO)

CLEAN DIRTY NEAT CLUTTERED

FIRE EXTINGUSHER CHECKED MONTHLY?

YES NO

C

LE

A N

IN

G

ST

O

R A

G E

A R

EA

GENERAL OVERALL APPEARANCE – CLEAN/NEAT Yes No CLEAN AREAS PROVIDES FOR SAFETY OF STAFF Yes No

BAGGED ITEMS TAGGED Yes No SUPPLIES FOR CLEANING READILY AVAILABLE Yes No

CLEAN/DIRTY SEPARATED Yes No EYE WASH SYSTEM AVAILABLE Yes No

COMMENTS:

V E

H

IC

L E

S

FIRE EXTINQUISHER IN EACH VEHICLE Yes No SAFE DISPOSAL OF HAZARDOUS WASTE Yes No

FIRE EXTINQUISHER CHECKED MONTHLY Yes No SAFETY FLARES/TRIANGLES IN EACH VEHICLE Yes No

MAINTENANCE RECORDS Yes No LICENSE, REGISTRATION - CURRENT/ACCURATE Yes No

VEHICLE CLEARLY IDENTIFIED, INCLUDING REQUIRED TAGS Yes No MEANS FOR SEPARATING CLEAN/DIRTY EQUIPMENT Yes No

MEANS TO WASH HANDS IN VEHICLE Yes No NO SMOKING SIGN IN VEHICLE Yes No

DISPOSABLE GLOVES IN EACH VEHICLE Yes No FIRST AID KIT IN VEHICLE Yes No

PROTECTIVE GARMENTS IN EACH VEHICLE Yes No EYEWASH IN VEHICLE Yes No

DOT, IF APPLICABLE Yes No

COMMENTS:

D

EL

IV

ER

Y

PE

R

SO

N N

EL

APPEARANCE – NEAT AND PROFESSIONAL Yes No COMMUNICATION SKILLS DEMONSTRATED Yes No

a. PROFESSIONAL Yes No STAFF ADEQUATELY DESCRIBES PROCEDURES

b. ID BADGES Yes No a. INSTRUCTION TO PATIENTS Yes No

c. UNIFORMS Yes No b. CLEANING PROCEDURES Yes No

d. SAFETY WEAR (IE: STEEL TOE SHOES) Yes No Yes No

TRAINING RECORDS (COMPENTENCIES): TRAINING RECORDS (COMPETENCIES):

a. ENVIRONMENT OF CARE Yes No j. ELECTRICAL SAFETY Yes No

b. PATIENT RIGHTS/RESPONSIBILITIES Yes No 1) EXPOSURE TO LIQUID Yes No

c. UNIVERSAL SAFETY PRECAUTIONS Yes No 2) AMPERAGE Yes No

d. INFECTION CONTROL Yes No 3) GROUNDING Yes No

e. GENERAL – STAIRS, THROW RUGS Yes No 4) USE OF EXTENSION CORD Yes No

f. SMOKE ALARMS Yes No k. EQUIPMENT SAFETY

g. EMERGENCY EXITS IN CASE OF FIRE. Yes No 1) USE OF GLOVES Yes No

h. ROUTINE AND EMERGENCY RESPONSE PROCEDURES Yes No 2) BAGGING OF EQUIPMENT Yes No

Yes No 3) DISPOSAL OF GLOVES AND OTHER HAZARDOUS MATERIALS Yes No

COMMENTS:

R

EC

O R

D R

EV

IE

W

D O

C U

M

EN

TA

TI

O N

F O

U N

D

5% OR A MINIMUM OF 5 PT. RECORDS WILL BE REVIEWED

FOR DOCUMENTATION OF: EQUIPMENT RECORDS ON FILE

a. EMERGENCY/DISASTER EDUCATION Yes No a. MANUFACTURER Yes No

b. PATIENTS RIGHTS/RESPONSIBILITIES Yes No b. MODEL Yes No

c. INSTRUCTIONS IN USE/CARE OF EQUIPMENT Yes No c. SERIAL NUMBER Yes No

d. HOME VISITS Yes No d. MAINTENANCE INSTRUCTIONS Yes No

e. CONTINUING EDUCATION FOR PATIENTS & CAREGIVER Yes No e. ROUTINE MAINTENANCE DOCUMENTATION Yes No

f. HOME SAFETY/ENVIRONMENTAL INSPECTION Yes No RECALL PROCESS WITH NOTIFICATION OF PATIENT/VA Yes No

g. ON-GOING STAFF EDUCATION Yes No EQUIPMENT IS CLEAN AND TAGGED APPROPRIATELY Yes No

h. QA PLAN - STAFF KNOWS OF QA PLAN/PROCESS Yes No

INCIDENT REPORTING Yes No

COMMENTS:

ADDITIONAL COMMENTS MAY BE ADDED TO BACK

SIGNATURE OF INSPECTING OFFICIAL DATE