D.4 HCHV INSPECTION FORM.pdf

HEALTH CARE FOR HOMELESS VETERANS CRS

PROGRAMS INSPECTION PACKET

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

INSPECTION IS FOR: INITIAL INSPECTION RE-INSPECTION

PROJECT #: TOTAL BEDS AWARDED:

PROVIDER'S NAME: DATE INSPECTION STARTED

(MM/DD/YYYY):

DATE INSPECTION

COMPLETED (MM/DD/YYYY):

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:

INSPECTION TEAM MEMBERS

NAME TITLE

FACILITIES MANAGEMENT

NUTRITION

CLINICAL REVIEW

SECURITY / LAW ENFORCEMENT

MEDICATION REVIEW

NHC OR DESIGNEE

CONTRACTING OFFICER

REPRESENTATIVE

OTHER

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 Directive 1162.04. Any inspection deficiencies noted have been corrected.

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

I APPOINT THE FOLLOWING INDIVIDUAL AS LIAISON FOR THIS PROJECT:

SIGNATURE: VAMC DIRECTOR (PRINT NAME): DATE (MM/DD/YYYY):

VA FORM

DEC 2024 10-10116a Page 1 of 13

VA LIAISON – OVERVIEW &

RECOMMENDATION

HCHV liaison should complete this section attaching any other documentation, as necessary.

HOMES PROJECT CODE:

SITE ADDRESS:

THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE WITHIN THE SITES COVERED UNDER THIS

PROGRAM NUMBER:

A. MEN

YES NO

B. WOMEN

C. CHILDREN

2 PROGRAM OPERATES IN ACCORDANCE WITH HCHV PROGRAM REGULATIONS, 38 CFR 63.

3 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.

5 CONTRACT PROVIDER SERVES THE POPULATION(S) AS DESCRIBED IN THEIR CONTRACT / SOW/PWS.

6 THE CONTRACT PROVIDER SUBMITS ACCURATE BILLING ON A MONTHLY BASIS AND MAINTAINS DOCUMENTATION TO

SUPPORT MONTHLY BILLING.

7 CONTRACT PROVIDER MAINTAINS SYSTEMATIC PARTICIPANT ENROLLMENT AND TRACKING INFORMATION FOR SAFETY

AND BILLING PURPOSES.

8 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).

9 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.

10 CONTRACT PROVIDER UTILIZES HMIS FOR PROGRAM PARTICIPANTS.

YES NO N/A

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:

A. EXITS TO PERMANENT HOUSING

MEETS

TARGET

DOES

NOT

MEET

TARGET

PIP IN

PLACE /

REQUIR

ED

B. NEGATIVE EXITS

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.

YES NO

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.

A.

B.

C.

D.

E.

F.

G.

H.

I.

14 THE CONTRACT PROVIDER IS CURRENTLY PROVIDING ALL SERVICES AS STATED IN THE CONTRACT / SOW/PWS.

ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR THE PLACEMENT OF

VETERANS.

VA FORM 10-10116a, DEC 2024 Page 2 of 13

VA LIAISON – OVERVIEW &

RECOMMENDATION

HCHV liaison should complete this section attaching any other documentation, as necessary.

HOMES PROJECT CODE:

SITE ADDRESS:

HCHV LIAISON SIGNATURE: HCHV LIAISON NAME (PRINT): DATE (MM/DD/YYYY):

COR SIGNATURE: COR NAME (PRINT): DATE (MM/DD/YYYY):

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 SUPERVISOR'S SIGNATURE: HCHV LIAISON SUPERVISOR'S NAME (PRINT): DATE (MM/DD/YYYY):

VA FORM 10-10116a, DEC 2024 Page 3 of 13

FACILITIES MANAGEMENT

Appropriate discipline(s) should complete this section attaching their respective report format(s).

HOMES PROJECT CODE:

SITE ADDRESS:

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER FACILITY:

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.

YES NO N/A

16 IS IN COMPLIANCE WITH THE NFPA LIFE SAFETY CODE (SEE ATTACHED REPORT).

17 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.

18 HAS ENTRIES AND EXIT LOCATIONS THAT ARE CAPABLE OF BEING UTILIZED WITHOUT UNAUTHORIZED USE AND

PROVIDE ALTERNATE MEANS OF EGRESS IN CASE OF FIRE.

19 PROVIDES EACH RESIDENT APPROPRIATE SPACE AND SECURITY FOR THEMSELVES AND THEIR BELONGINGS.

20 PROVIDES EACH RESIDENT AN ACCEPTABLE PLACE TO SLEEP THAT IS IN COMPLIANCE WITH APPROPRIATE CODES AND

REGULATIONS.

21 PROVIDES EVERY ROOM OR SPACE WITH NATURAL OR MECHANICAL VENTILATION.

22 ON THE DAY OF INSPECTION, THE FACILITY APPEARS UPON VISUAL INSPECTION TO BE FREE OF POLLUTANTS IN THE

AIR AT LEVELS THAT THREATEN THE HEALTH OF RESIDENTS.

23 ON THE DAY OF INSPECTION, THE FACILITY APPEARS UPON VISUAL INSPECTION TO PROVIDE A WATER SUPPLY THAT IS

FREE FROM CONTAMINATION.

24 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.

25 PROVIDES ADEQUATE HEATING AND OR COOLING PLANTS THAT ARE IN PROPER OPERATING CONDITION.

26 PROVIDES ADEQUATE NATURAL OR ARTIFICIAL ILLUMINATION TO PERMIT NORMAL INDOOR ACTIVITIES AND TO

SUPPORT THE HEALTH AND SAFETY OF RESIDENTS.

27 PROVIDES SUFFICIENT ELECTRICAL SOURCES TO PERMIT USE OF ESSENTIAL ELECTRICAL APPLIANCES WHILE

ASSURING SAFETY FROM FIRE.

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 1162.04.

29 PROVIDES THAT HOUSING AND EQUIPMENT ARE MAINTAINED IN A SANITARY MANNER.

VA FORM 10-10116a, DEC 2024 Page 4 of 13

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 packet.

DEFICIENCIES WERE PRESENT FOR ITEMS ON THIS CHECKLIST DURING INSPECTION. IF YES, LIST DEFICIENCIES AND CONFIRM

RESOLUTION BELOW:

YES NO

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 CHECKLIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

YES NO

FACILITIES MANAGEMENT INSPECTION TEAM MEMBER

SIGNATURE:

FACILITIES MANAGEMENT INSPECTION TEAM MEMBER

NAME (PRINT):

DATE (MM/DD/YYYY):

VA FORM 10-10116a, DEC 2024 Page 5 of 13

NUTRITION AND FOOD

SERVICES

Appropriate discipline(s) should complete this section attaching their respective report format(s).

HOMES PROJECT CODE:

SITE ADDRESS:

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

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

CENTRALLY PREPARED NUTRITION AND FOOD SERVICES INDIVIDUAL FOOD PREPARATION FACILITIES

FOR CENTRALLY PREPARED NUTRITION AND FOOD SERVICES THE CONTRACT PROVIDER:

30 PROVIDES ONE WEEK OF MENUS FOR REVIEW.

YES NO N/A

31 THE MENUS REPRESENT A NUTRITIONALLY ADEQUATE DIET.

32 DEMONSTRATES THE ABILITY TO MEET SPECIAL DIETARY NEEDS (E.G. KOSHER, DIABETIC, ALLERGIES, MEDICALLY

INDICATED).

33 PROVIDES THREE MEALS AND AN EVENING SNACK PER DAY, INCLUDING WEEKENDS.

34 ENSURES ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION PRACTICES.

35 ENSURES REFRIGERATION AND DRY FOOD STORAGE AREAS ARE APPROPRIATELY MAINTAINED AND MONITORED.

36 ENSURES ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER.

37 ENSURES CURRENT LICENSURES AND PERMITS ARE MAINTAINED IF REQUIRED BY LOCAL OR OTHER AUTHORITIES.

38 ENSURES FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A SANITARY CONDITION.

FOR INDIVIDUAL FOOD PREPARATION THE CONTRACT PROVIDER ENSURES:

39 APPLIANCES ARE ADEQUATE TO SAFELY STORE AND PREPARE FOOD AND ARE IN GOOD WORKING CONDITION (I.E.

STOVE, REFRIGERATOR, DISHWASHER).

YES NO N/A

40 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.

41 THE ABILITY TO MEET SPECIAL DIETARY NEEDS (E.G. KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED).

42 SUFFICIENT FOOD STORES ARE AVAILABLE TO ENSURE VETERANS RECEIVE THREE NUTRITIONALLY ADEQUATE MEALS

PER DAY.

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.

VA FORM 10-10116a, DEC 2024 Page 6 of 13

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 packet.

DEFICIENCIES WERE PRESENT FOR ITEMS ON THIS CHECKLIST DURING INSPECTION. IF YES, LIST DEFICIENCIES AND CONFIRM

RESOLUTION BELOW:

YES NO

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 CHECKLIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

YES NO

NUTRITION/FOOD MANAGEMENT INSPECTION TEAM MEMBER

SIGNATURE:

NUTRITION/FOOD MANAGEMENT INSPECTION TEAM

MEMBER NAME (PRINT):

VA FORM 10-10116a, DEC 2024 Page 7 of 13

CLINICAL REVIEW

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.

HOMES PROJECT CODE:

SITE ADDRESS:

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER:

44 HAS HARM REDUCTION POLICIES AND PROCEDURES TO ADDRESS HOW INTOXICATED OR IMPAIRED PARTICIPANTS WILL BE

INDENTIFIED AND MANAGED IN THIS PROGRAM.

YES NO

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.

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

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 & OUTCOME

E. DOCUMENTATION OF REFERRALS

F. BENEFITS TO BE ACHIEVED AS A RESULT OF PROGRAM PARTICIPATION INCLUDING INDIVIDUALIZED GOALS FOR EACH

PARTICIPANT.

52 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.

VA FORM 10-10116a, DEC 2024 Page 8 of 13

CLINICAL REVIEW

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 packet.

DEFICIENCIES WERE PRESENT FOR ITEMS ON THIS CHECKLIST DURING INSPECTION. IF YES, LIST DEFICIENCIES AND CONFIRM

RESOLUTION BELOW:

YES NO

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 CHECKLIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

YES NO

CLINICAL INSPECTION TEAM MEMBER SIGNATURE: CLINICAL INSPECTION TEAM MEMBER NAME (PRINT): DATE (MM/DD/YYYY):

VA FORM 10-10116a, DEC 2024 Page 9 of 13

LAW ENFORCEMENT AND

PHYSICAL SECURITY

Chief of VA police or designee should complete this section attaching their respective report format(s).

HOMES PROJECT CODE:

SITE ADDRESS:

OPERATING STANDARDS ALL HCHV CONTRACT PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER:

53 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, SELECT N/A.

YES NO N/A

54 IS LOCATED ON VA PROPERTY AND A PROCEDURE FOR ON-GOING LAW ENFORCEMENT MONITORING HAS BEEN

ESTABLISHED BETWEEN THE PROVIDER AND VA.

IS LOCATED IN THE COMMUNITY AND THE CHIEF, POLICE SERVICE OR DESIGNEE HAS COORDINATED WITH THE CONTRACT PROVIDER AND LOCAL LAW ENFORCEMENT FOR THE PURPOSE OF CONDUCTING A COMPREHENSIVE RISK ASSESSMENT OF THE PROJECT INCLUDING A REVIEW AND DISCUSSION OF LOCAL CRIME STATISTICS FOR THE AREA WHERE POSSIBLE THE VA CHIEF, POLICE SERVICE MAY ELECT TO ESTABLISH AN MOU WITH THE LAW ENFORCEMENT AGENCY OF JURISDICTION TO ENSURE CONTINUED COMMUNICATION AND AGENCY AWARENESS. IF ON VA PROPERTY, SELECT N/A.

56 ENSURES THERE IS SUFFICIENT LIGHTING AROUND THE PERIMETER OF THE FACILITY BASED ON THE HOUSING SETTING.

57 PROVIDES ADEQUATE LIGHTING TO PERMIT NORMAL INDOOR ACTIVITIES AND TO SUPPORT THE HEALTH AND SAFETY

OF RESIDENTS.

58 PROVIDES EACH RESIDENT APPROPRIATE SPACE AND SECURITY FOR THEMSELVES AND THEIR BELONGINGS, INCLUDING VALUABLES.

59 ENSURES COMMON AREAS (E.G. LAUNDRY, COMPUTER LABS, BREAK ROOMS) ARE APPROPRIATELY SECURED, MONITORED, AND LIT.

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.

61 ENSURES DOCUMENTATION OF RESIDENTIAL SUPERVISION TRAINING IS PRESENT.

62 ENSURES EMERGENCY CONTACTS FOR MEDICAL, LAW ENFORCEMENT, FIRE DEPARTMENT AND AGENCY ARE

PROMINENTLY POSTED IN THE FACILITY.

63 HAS ADEQUATE POLICIES AND PROCEDURES WHICH ARE ENFORCED TO ENSURE THAT ILLICIT DRUGS, WEAPONS, AND

OTHER SIMILAR ITEMS ARE NOT PERMITTED ON THE PREMISES.

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.

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 CONSIDERATIONS SHOULD BE GIVEN TO SEPARATION AND SAFETY IN FACILITIES WHERE MULTIPLE GENDERS AND/OR

CHILDREN ARE SERVED.

66 HAS ADEQUATE POLICIES AND PROCEDURES WHICH ARE COMMUNICATED AND ENFORCED TO ENSURE SAFETY, SECURITY, AND PRIVACY BASED ON LOCATION, POPULATION(S) SERVED, AND FACILITY STRUCTURE.

VA FORM 10-10116a, DEC 2024 Page 10 of 13

LAW ENFORCEMENT AND

PHYSICAL 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 packet.

DEFICIENCIES WERE PRESENT FOR ITEMS ON THIS CHECKLIST DURING INSPECTION. IF YES, LIST DEFICIENCIES AND CONFIRM

RESOLUTION BELOW:

YES NO

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 CHECKLIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

YES NO

LAW ENFORCEMENT INSPECTION TEAM MEMBER SIGNATURE: LAW ENFORCEMENT INSPECTION TEAM MEMBER NAME

(PRINT):

VA FORM 10-10116a, DEC 2024 Page 11 of 13

MEDICATION REVIEW

Appropriate discipline(s) should complete this section and attach their respective report format(s).

HOMES PROJECT CODE:

SITE ADDRESS:

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 may not 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:

67 AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING PRESCRIPTION AND NON-PRESCRIPTION

MEDICATIONS, USED BY PERSONS SERVED.

YES NO N/A

68 ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND HANDLING OF MEDICATIONS, SAFE

DISPOSAL, AND DOCUMENTATION OF MEDICATION USE.

69 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.

70 AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT TRAINING AND EDUCATION REGARDING

MEDICATION.

71 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.

73 ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS THAT PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES.

74 ORGANIZATION HAS DOCUMENTATION OR CONFIRMATION OF INFORMED CONSENT FOR EACH MEDICATION

ADMINISTERED, WHEN POSSIBLE.

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.

76 ORGANIZATION PROCEDURES ENSURE THE IDENTIFICATION, DOCUMENTATION, AND REQUIRED REPORTING, INCLUDING TO THE PRESCRIBING PROFESSIONAL, ANY MEDICATION REACTIONS OR MEDICATION ERRORS, AS APPROPRIATE.

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.

FOR MEDICATION MONITORING:

78 AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING PRESCRIPTION AND NON-PRESCRIPTION

MEDICATIONS, USED BY PERSONS SERVED.

YES NO N/A

79 ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND HANDLING OF MEDICATIONS, SAFE

DISPOSAL, AND DOCUMENTATION OF MEDICATION USE.

80 ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT WHEN UNDER THE DIRECT SUPERVISION OF

APPROPRIATE STAFF.

81 KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE UNDER THE CONTROL OF AUTHORIZED STAFF.

82 ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES OR DETERIORATION.

83 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.

85 PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED ORIENTATION, CONTINUING EDUCATION AND

TRAINING, AS APPROPRIATE.

FOR INDIVIDUAL STORAGE:

86 SELF-ADMINISTERED MEDICATIONS ARE STORED IN A SAFE AND SECURE MANNER IN THE RESIDENT'S ROOM

ACCORDING TO THE FACILITY'S POLICIES AND PROCEDURES.

YES NO N/A

87 METHOD OF STORAGE CAN NOT BE EASILY REMOVED FROM THE FACILITY (E.G. LOCK BOX IS SECURED TO A LARGE

DRESSER OR THE STRUCTURE OF THE BUILDING).

VA FORM 10-10116a, DEC 2024 Page 12 of 13

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 packet.

DEFICIENCIES WERE PRESENT FOR ITEMS ON THIS CHECKLIST DURING INSPECTION. IF YES, LIST DEFICIENCIES AND CONFIRM

RESOLUTION BELOW:

YES NO

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 CHECKLIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS:

YES NO

MEDICATION INSPECTION TEAM MEMBER SIGNATURE: MEDICATION INSPECTION TEAM MEMBER NAME (PRINT): DATE (MM/DD/YYYY):

VA FORM 10-10116a, DEC 2024 Page 13 of 13