D7 - INSPECTION CHECKLIST (1).pdf

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VA FORM

MAY 2014

10-10116a Page of Table of Content Guy A. Liedke D:20050418133328- 04'00' D:20050418133358- 04'00'

PLACEMENT OF VETERANS AT THIS PROVIDER'S FACILITY.

HEALTH CARE FOR HOMELESS VETERANS (HCHV) CONTTRACTED PROVIDER INSPECTION FORM

HEALTH CARE FOR HOMELESS VETERANS (HCHV)

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

THIS INSPECTION IS FOR:

THIS INSPECTION IS FOR:

INSPECTION TEAM MEMBERS

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 1162.01. ANY INSPECTION DEFICIENCIES NOTED HAVE BEEN CORRECTED.

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 1162.01. ANY INSPECTION DEFICIENCIES NOTED HAVE BEEN CORRECTED.

MEDICAL CENTER DIRECTOR - REVIEW & RECOMMENDATION

MEDICAL CENTER DIRECTOR - REVIEW & RECOMMENDATION

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs

NAME

NAME

TITLE

FACILITIES MANAGEMENT

FACILITIES MANAGEMENT

CLINICAL REVIEW

CLINICAL REVIEW

SECURITY/ LAW ENFORCEMENT

SECURITY/ LAW ENFORCEMENT

NHC OR DESIGNEE

NHC OR DESIGNEE

MEDICATION REVIEW

MEDICATION REVIEW

NUTRITION

NUTRITION

INSPECTION PACKAGE ASSEMBLY CHECKLIST

ALL ITEMS MUST BE INCLUDED BEFORE SENDING TO THE HCHV PROGRAM OFFICE FOR REVIEW

ITEM

ITEM

RESPONSIBLE

RESPONSIBLE

VAMC DIRECTOR, LIAISON & TEAM MEMBERS

VAMC DIRECTOR, LIAISON & TEAM MEMBERS

HCHV LIAISON - OVERVIEW & RECOMMENDATION

HCHV LIAISON - OVERVIEW & RECOMMENDATION

GPD LIAISON SHOULD COMPLETE THIS SECTION ATTACHING ANY OTHER DOCUMENTATION, AS NECESSARY GPD LIAISON SHOULD COMPLETE THIS SECTION ATTACHING ANY OTHER DOCUMENTATION, AS NECESSARY

YES

YES

NO

NO

N/A N/A

PROVIDER

PROVIDER

PROJECT OPERATES IN ACCORDANCE WITH PROGRAM REGULATIONS

1. PROJECT OPERATES IN ACCORDANCE WITH PROGRAM REGULATIONS

MEETS ALL APPLICABLE STATE AND LOCAL LICENSING AND OTHER REQUIREMENTS FOR THE OPERATION OF THE PROJECT IN THE JURISDICTION WHERE THE PROJECT IS LOCATED

2. MEETS ALL APPLICABLE STATE AND LOCAL LICENSING AND OTHER REQUIREMENTS FOR THE OPERATION OF THE PROJECT IN THE JURISDICTION WHERE THE PROJECT IS LOCATED HAS DEMONSTRATED ADEQUATE STAFFING AND AN APPROPRIATE SCOPE OF SERVICES TO CARRY OUT THIS PROJECT AS OUTLINED IN THE ORIGINAL STATEMENT OF WORK (SOW) OR SUBSEQUENT APPROVED CHANGE OF SCOPE

3. HAS DEMONSTRATED ADEQUATE STAFFING AND AN APPROPRIATE SCOPE OF SERVICES TO CARRY OUT THIS PROJECT AS OUTLINED IN THE ORIGINAL STATEMENT OF WORK (SOW) OR SUBSEQUENT APPROVED CHANGE OF SCOPE AGENCY SERVES THE POPULATION(S) AS DESCRIBED IN THEIR GRANT APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE

4. AGENCY SERVES THE POPULATION(S) AS DESCRIBED IN THEIR GRANT APPLICATION OR SUBSEQUENT APPROVED CHANGE OF SCOPE AGENCY OCCUPANCY RATE ROUTINELY MEETS OR EXCEEDS 75 PERCENT OF THE GPD FUNDED BEDS; OR AGENCY HAS IMPLEMENTED ADEQUATE MEASURES TO EXPAND OUTREACH AND COORDINATION TO IMPROVE PROGRAM UTILIZATION

5. AGENCY OCCUPANCY RATE ROUTINELY MEETS OR EXCEEDS 75 PERCENT OF THE GPD FUNDED BEDS; OR AGENCY HAS IMPLEMENTED ADEQUATE MEASURES TO EXPAND OUTREACH AND COORDINATION TO IMPROVE PROGRAM UTILIZATION 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

6. 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 THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE WITHIN THE SITES COVERED:

1. THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE WITHIN THE SITES COVERED:

NUMBER OF HCHV BEDS

NUMBER OF HCHV BEDS

A. MEN

A. MEN

C. TOTAL NUMBER OF BEDS UNDER THIS PROJECT NUMBER

B. WOMEN

TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE FOLLOWING CRITERIA?

TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE FOLLOWING CRITERIA?

CORRECTIVE ACTION PLANS (CAP) HAVE BEEN IMPLEMENTED PER 38 CFR 61.80, IF APPLICABLE (RE-INSPECTIONS ONLY)

7. CORRECTIVE ACTION PLANS (CAP) HAVE BEEN IMPLEMENTED PER 38 CFR 61.80, IF APPLICABLE (RE-INSPECTIONS ONLY) ALL APPROPRIATE CHECKLIST SECTIONS HAVE BEEN COMPLETED AND ARE ATTACHED. THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS.

ALL APPROPRIATE CHECKLIST SECTIONS HAVE BEEN COMPLETED AND ARE ATTACHED. THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS.

HCHV STAFF SIGNATURE

HCHV STAFF SIGNATURE

HCHV STAFF SIGNATURE

HCHV STAFF SIGNATURE

BASED ON THE RESULTS OF THE ATTACHED INSPECTION DOCUMENTS THIS PROJECT IS RECOMMENDED FOR THE PLACEMENT OF VETERANS

8. BASED ON THE RESULTS OF THE ATTACHED INSPECTION DOCUMENTS THIS PROJECT IS RECOMMENDED FOR THE PLACEMENT OF VETERANS

YES

NO

N/A TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE FOLLOWING CRITERIA?

TO THE BEST OF YOUR KNOWLEDGE DOES THE AWARDEE & PROGRAM MEET THE FOLLOWING CRITERIA?

HCHV LIAISON - OVERVIEW & RECOMMENDATION

HCHV LIAISON - OVERVIEW & RECOMMENDATION

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.

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

HCHV LIAISON - OVERVIEW & RECOMMENDATION

BEST PRACTICE RECOMMENDATIONS:

FACILITIES MANAGEMENT

OPERATING STANDARDS ALL HCHV CONTRACTED PROVIDERS (ALL INSPECTIONS)

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S)

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

THE CONTRACTED FACILITY

YES

NO

N/A 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 IS COMPLIANT WITH THE AMERICANS WITH DISABILITIES ACT AND THE ARCHITECTURAL BARRIERS ACT 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 APPLICABLE 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 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 PROVIDES SUFFICIENT ELECTRICAL SOURCES TO PERMIT USE OF ESSENTIAL ELECTRICAL APPLIANCE WHILE ENSURING SAFETY FROM FIRE CONTRACTOR 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 HAS ENTRIES AND EXIT LOCATIONS THAT ARE CAPABLE OF BEING UTILIZED WITHOUT UNAUTHORIZED USE OF OTHER PRIVATE PROPERTIES AND PROVIDE ALTERNATE MEANS OF EGRESS IN CASE OF FIRE 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

PROVIDES THAT HOUSING AND EQUIPMENT ARE MAINTAINED IN A SANITARY MANNER

FACILITIES MANAGEMENT INSPECTION TEAM MEMBER SIGNATURE

FACILITIES MANAGEMENT INSPECTION TEAM MEMBER SIGNATURE

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

FACILITIES MANAGEMENT

THE CONTRACTED FACILITY

YES

NO

N/A

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

FACILITIES MANAGMENT

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.

BEST PRACTICE RECOMMENDATIONS:

NUTRITION AND FOOD SERVICES

OPERATING STANDARDS ALL GRANT & PER DIEM PROVIDERS (ALL INSPECTIONS)

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) N/A

NO

YES

FOR CENTRALLY PREPARED NUTRITION AND FOOD SERVICES

ONE WEEK OF MENUS AVAILABLE FOR REVIEW

MENUS REPRESENT NUTRITIONALLY ADEQUATE DIET

NUTRITION AND FOOD SERVICES INSPECTION TEAM MEMBER SIGNATURE

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

AGENCY DEMONSTRATES THE ABILITY TO MEET SPECIAL DIETARY NEEDS (I.E. KOSHER, DIABETIC, ALLERGIES, MEDICALLY INDICATED)

CURRENT LICENSURES ARE MAINTAINED, IF REQUIRED

APPLIANCES ARE ADEQUATE TO SAFELY STORE AND PREPARE FOOD AND ARE IN GOOD WORKING CONDITION (I.E. STOVE, REFRIGERATOR, DISHWASHER) 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 SUFFICIENT FOOD STORES ARE AVAILABLE TO ENSURE VETERANS RECEIVE THREE NUTRITIONALLY ADEQUATE MEALS PER DAY (I.E. VETERANS HAVE ACCESS TO A FOOD PANTRY, LOCAL FOOD BANK, ARE RECEIVING SUPPLEMENTAL NUTRITIONAL ASSISTANCE PROGRAM (SNAP), ETC) ENSURES THAT ALL FOOD PREPARATION AREAS CONTAIN SUITABLE SPACE AND EQUIPMENT TO STORE, PREPARE, AND SERVE FOOD IN A SANITARY MANNER

FACILITY FOOD PREPARATION AREAS ARE MAINTAINED IN A SANITARY CONDITION

ALL FOOD AREAS ARE CLEAN AND FREE OF LITTER

REFRIGERATION AND DRY FOOD STORAGE AREAS ARE APPROPRIATELY MAINTAINED AND MONITORED

ALL FOOD SERVICE PERSONNEL OBSERVE SAFE SANITATION PRACTICES

THREE MEALS PROVIDED PER DAY, INCLUDING WEEKENDS

HOW DOES THE AGENCY PROVIDE FOR THE NUTRITIONAL NEEDS OF VETERANS IN THE PROGRAM (CHECK ONE):

N/A

NO

YES

FOR INDIVIDUAL FOOD PREPARATION

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

NUTRITION AND FOOD SERVICES

BEST PRACTICE RECOMMENDATIONS:

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.

CLINICAL REVIEW

OPERATING STANDARDS ALL GRANT & PER DIEM PROVIDERS (ALL INSPECTIONS)

THE CLINICAL REVIEW MAY INVOLVE SOCIAL WORK OR MENTAL HEALTH ALONE OR IN ANY COMBINATION AS THE AWARDEES APPLICATION DICTATES. APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) N/A

NO

YES

THE CONTRACTED FACILITY

ENSURES THAT THE CONSULTATION AND PARTICIPATION OF NOT LESS THAN ONE HOMELESS VETERAN OR FORMERLY HOMELESS VETERAN ON THE BOARD OF DIRECTORS OR THE EQUIVALENT POLICY MAKING ENTITY ENSURES THAT PARTICIPANTS IN NEED OF MEDICAL OR SOCIAL DETOX CONDUCTED AT THE SAME SITE ARE CLEARLY SEPARATED FROM THE GENERAL RESIDENT POPULATION WHEN NECESSARY, THE CONTRACTOR INITIATES A CORRECTIVE ACTION PLAN (CAP) WHEN ACCOMPLISHMENTS VARY FOR ANY OF THE GOALS AND OBJECTIVES AS STATED IN THE CONTRACT SOW OR CONTRACT ENSURES A QUARTERLY TECHNICAL PERFORMANCE REPORT ADDRESSING THEIR ABILITY TO MEET THE GOALS, OBJECTIVES, MEASURES, AND SPECIAL NEEDS AS SET FORTH IN THEIR APPLICATION IS COMPLETED BY THE PROVIDER; SUBMITTED TO THE GPD LIAISON; AND REVIEWED QUARTERLY ATTEMPTS TO INVOLVE HOMELESS VETERANS THROUGH EMPLOYMENT, VOLUNTEER SERVICES, OR OTHERWISE, IN CONSTRUCTION, REHABILITATION, MAINTENANCE, AND OPERATION OF THE PROGRAM ENSURES THE RECORDS KEPT ON HOMELESS VETERANS ARE KEPT CONFIDENTIAL, INCLUDING ANY RECORDS OF THE PROVISION OF FAMILY VIOLENCE PREVENTION OR TREATMENT SERVICES ENSURES THAT ALL HOUSING AND SERVICES PROVIDED TO PARTICIPANTS MEET THE QUALITY STANDARDS OUTLINED IN THE HCHV HANDBOOK.

ENSURES SUSTAINED EFFORTS ARE MADE THAT ELIGIBLE HARD-TO- REACH PERSONS ARE SERVED IN THE FACILITY. THIS OUTREACH SHOULD BE TARGETED TOWARD PERSONS WHO MEET THE DEFINITION OF HOMELESSNESS IN 38 U.S.C. 2002(1) PARTICIPANT RECORD INCLUDES, AT A MINIMUM, THE FOLLOWING: FAMILY STATUS, VERIFICATION OF VETERAN STATUS, EDUCATION, EMPLOYMENT HISTORY, AND MARKETABLE SKILLS/LICENSES/CREDENTIALS ENSURES THAT AN INDIVIDUAL TREATMENT PLAN IS MAINTAINED IN THE CASE MANAGEMENT RECORD FOR EACH INDIVIDUAL PARTICIPANT THE INDIVIDUAL TREATMENT PLAN CONTAINS AN ASSESSMENT OF BARRIERS, SERVICE NEEDS, STRENGTHS, SPECIFIC SERVICES PROVIDED INCLUDING DURATION AND OUTCOMES, DOCUMENTATION OF REFERRALS, AND BENEFITS TO BE ACHIEVED AS A RESULT OF PROGRAM PARTICIPATION

LIAISON OR CLINICAL INSPECTION TEAM MEMBER SIGNATURE

CLINICAL INSPECTION TEAM MEMBER SIGNATURE

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

CONTRACTOR MAINTAINS SYSTEMATIC PARTICIPANT ENROLLMENT INFORMATION AND TRACKING

C. OTHER. EXPLAIN:

B. THE CONTRACTOR UTILIZES AGENCY INTERNAL TRACKING SYSTEM

A. THE CONTRACTOR UTILIZES HMIS FOR PROGRAM

CLINICAL REVIEW

N/A

NO

YES

THE CONTRACTED FACILITY

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

CLINICAL REVIEW

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.

BEST PRACTICE RECOMMENDATIONS:

LAW ENFORCEMENT AND PHYSICAL SECURITY

CHIEF OF VA POLICE OR DESIGNEE SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) N/A

NO

YES

THE CONTRACTOR

S OPERATING A PROJECT LOCATED ON VA PROPERTY, AND THE CHIEF, POLICE SERVICE OR DESIGNEE HAS CONDUCTED A COMPREHENSIVE RISK ASSESSMENT OF THE PROJECT IS OPERATING A PROJECT LOCATED ON VA PROPERTY AND A PROCEDURE FOR ONGOING LAW ENFORCEMENT MONITORING HAS BEEN ESTABLISHED BETWEEN THE PROVIDER AND VA IS OPERATING A PROJECT 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 PROJECT HAS ENSURED THERE IS SUFFICIENT LIGHTING AROUND THE PERIMETER OF THE FACILITY BASED ON THE HOUSING SETTING (E.G., RURAL, INDUSTRIAL, OR RESIDENTIAL SETTINGS) HAS INSTALLED STAFF OFFICES, TREATMENT, GROUP, PARTICIPANT ROOMS, DORMS, SHOWER, AND RESTROOMS HAVE LOCKS APPROPRIATE FOR THE SETTING AND GENDER MIX APPROPRIATELY SEPARATED FACILITY ACCESS FOR PRIVACY AND SECURITY GIVEN THE POPULATION(S) SERVED HAS WRITTEN POLICIES AND PROCEDURES REGARDING SAFETY, SECURITY, AND PRIVACY WHICH ARE REGULARLY COMMUNICATED TO PARTICIPANTS AND STAFF AND ROUTINELY ENFORCED ADEQUATELY ADDRESSES SAFETY AND SECURITY CONCERNS WITH THE FACILITY BASED ON LOCATION, POPULATION(S) SERVED, AND FACILITY STRUCTURE HAS APPROPRIATE PROCEDURES REGARDING FACILITY OR UNIT ACCESS WHICH ARE ADEQUATELY CONTROLLED TO ENSURE THE SAFETY OF ALL RESIDENTS HAS ENSURED COMMON AREAS (E.G., LAUNDRY, COMPUTER LABS, BREAK ROOMS) ARE APPROPRIATELY SECURED, MONITORED, AND LIT HAS ENSURED INTERIOR AND EXTERIOR LOCKS ARE IN GOOD WORKING ORDER; APPROPRIATELY LOCATED; ADEQUATE FOR THE AREA THAT IS BEING SECURED AND POPULATIONS SERVED WITHIN THE FACILITY

REGULARLY CHECKS LIGHTS TO MAKE SURE THEY ARE OPERATING EFFECTIVELY

HAS DETERMINED THERE IS SUFFICIENT LIGHTING AROUND THE INTERIOR OF THE FACILITY

OPERATING STANDARDS ALL GRANT & PER DIEM PROVIDERS (ALL INSPECTIONS)

LAW ENFORCEMENT AND PHYSICAL SECURITY

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

POLICE INSPECTION TEAM MEMBER SIGNATURE

SECURITY INSPECTION TEAM MEMBER SIGNATURE

HAS ENSURED PARTICIPANTS HAVE AN APPROPRIATE PLACE TO SECURE PERSONAL VALUABLES AND BELONGINGS

HAS MADE SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE LIVING) AVAILABLE

SEPARATE MALE AND FEMALE BATHROOMS (CONGREGATE LIVING)

MAINTAINS DOCUMENTATION OF RESIDENTIAL SUPERVISION TRAINING IS PRESENT

PROGRAM 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 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 HAS POSTED EMERGENCY CONTACTS FOR MEDICAL, LAW ENFORCEMENT, FIRE DEPARTMENT, AND AGENCY

HAS ESTABLISHED A PROCEDURE FOR ONGOING LAW ENFORCEMENT MONITORING

USES A SCREENING SYSTEM FOR SEX OFFENDERS (MIXED GENDER AND/OR CHILDREN IN FACILITY)

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

SECURITY & LAW ENFORCEMENT

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.

BEST PRACTICE RECOMMENDATIONS:

MEDICATION REVIEW

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION ATTACHING THEIR RESPECTIVE REPORT FORMAT(S) N/A

NO

YES

FOR MEDICATION MANAGEMENT THE AWARDEE

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 DOCUMENTATION OR CONFIRMATION OF INFORMED CONSENT FOR EACH MEDICATION ADMINISTERED, WHEN POSSIBLE ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS THAT PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES 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 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 AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT TRAINING AND EDUCATION REGARDING MEDICATION 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 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

TYPE OF MEDICATION CONTROL SYSTEM USED BY AGENCY (CHECK ALL THAT APPLY):

MEDICATION REVIEW

N/A

NO

YES

FOR MEDICATION MONITORING THE AWARDEE

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE FAMILIAR WITH ALL MEDICATIONS STOCKED INCLUDING INDICATIONS, SIDE EFFECTS, TOXIC EFFECTS, INTERACTIONS, AND POTENTIAL ALLERGIC REACTIONS

ALL MEDICATIONS ARE STORED ACCORDING TO MANUFACTURER'S RECOMMENDATIONS

ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES OR DETERIORATION

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE UNDER THE CONTROL OF AUTHORIZED STAFF ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT WHEN UNDER THE DIRECT SUPERVISION OF APPROPRIATE STAFF 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 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 ORGANIZATION PROCEDURES ENSURE THE IDENTIFICATION, DOCUMENTATION, AND REQUIRED REPORTING, INCLUDING TO THE PRESCRIBING PROFESSIONAL, ANY MEDICATION REACTIONS OR MEDICATION ERRORS, AS APPROPRIATE N/A

NO

YES

FOR INDIVIDUAL STORAGE THE AWARDEE

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 APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS.

MEDICATION REVIEW INSPECTION TEAM MEMBER SIGNATURE

SECURITY INSPECTION TEAM MEMBER SIGNATURE

BEST PRACTICE RECOMMENDATIONS:

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.

NURSING SERVICES

REVIEW OF HOMES DATA

NOT APPLICABLE FOR INITIAL INSPECTIONS AND SERVICE CENTERS

N/A

NO

YES

HOMES DATA , RELATIVE TO THIS PROJECT NUMBER, HAS BEEN DISCUSSED WITH THE CONTRACTOR

HCHV LIAISON SIGNATURE

GPD LIAISON SIGNATURE

PROVIDE THE MOST CURRENT (YEARLY OR QUARTERLY) HOMES DATA (PERCENTAGES FOR THIS PROJECT NUMBER):

A. INDEPENDENTLY HOUSED AT DISCHARGE

D. RECEIVING VA BENEFITS AT DISCHARGE

C. EMPLOYED PART-TIME AT DISCHARGE

B. EMPLOYED FULL-TIME AT DISCHARGE

E. RECEIVING NON-VA BENEFITS AT DISCHARGE

ANNUAL REVIEW OF SERVICES

LIST BETWEEN 6-15 CORE SERVICES AS STATED IN THE ORIGINAL GRANT APPLICATION OR SUBSEQUENTLY APPROVED CHANGE OF SCOPE

THE CONTRACTOR

NO

YES

THE CONTRACTOR IS CURRENTLY PROVIDING ALL SERVICES AS STATED IN THE IN THE ORIGINAL STATEMENT OF WORK OR SUBSEQUENTLY APPROVED CHANGE OF SCOPE

SERVICE IS CURRENTLY PROVIDED (Y/N)