D.6 NUTRITION INSPECTION FORM.pdf

NUTRITION AND FOOD SERVICES

HOMES PROJECT CODE:

SITE ADDRESS: APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION AND ATTACH THEIR RESPECTIVE

REPORT FORMAT(S).

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 :

YES NO N/A

30 PROVIDES ONE WEEK OF MENUS FOR REVIEW .

31 THE MENUS REPRESENT A NUTRITIONALLY ADEQUATE DIET.

DEMONSTRATES THE ABILITY TO MEET SPECIAL DIETARY NEEDS (E.G.,

KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED).

PROVIDES THREE MEALS AND AN EVENING SNACK PER DAY, INCLUDING

WEEKENDS.

ENSURES ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION

PRACTICES.

ENSURES REFRIGERATION AND DRY FOOD STORAGE AREAS ARE

APPROPRIATELY MAINTAINED AND MONITORED.

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

ENSURES CURRENT LICENSURES AND PERMITS ARE MAINTAINED IF REQUIRED

BY LOCAL OR OTHER AUTHORITIES.

ENSURES FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A SANITARY

CONDITION.

FOR INDIVIDUAL FOOD PREPARATION, THE CONTRACT PROVIDER ENSURES: YES NO N/A

APPLIANCES ARE ADEQUATE TO SAFELY STORE AND PREPARE FOOD AND ARE

IN GOOD WORKING CONDITION (E.G., STOVE, REFRIGERATOR, DISHWASHER).

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 .

THE ABILITY TO MEET SPECIAL DIETARY NEEDS (E.G., KOSHER,

DIABETIC, ALLERGIES, MEDICALLY INDICATED).

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). THIS MAY

BE ACCOMPLISHED THROUGH NUTRITIONAL EDUCATION PROVIDED DIRECTLY

BY THE AGENCY OR A REFERRAL RESOURCE WITHIN THE COMMUNITY.

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.

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 CHECKLIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS

APPROVED FOR PLACEMENT OF VETERANS.

Nutrition/Food Management Inspection Team Member Signature

Facility Food Management Inspection Team Member Name (Print)

Date