DME Contractor Inspection Sheet.doc
DOC document 118 KB Posted
- Attached to
- Durable Medical Equipment – VISN 15 Federal contract opportunity
- Solicitation number
- 36C25525MC0001
About this file
This is a contractor inspection sheet template for Durable Medical Equipment (DME) providers serving VA facilities. The form is designed to evaluate DME contractors across multiple operational areas including facility conditions, cleaning/storage areas, vehicles, delivery personnel, documentation, and equipment records.
The inspection sheet contains detailed checkboxes and evaluation criteria covering: building characteristics and condition; JCAHO certification status; cleaning and storage protocols; vehicle safety equipment and maintenance; staff appearance and knowledge requirements; patient record documentation; equipment maintenance records; and quality assurance measures. Key areas of focus include infection control procedures, safety protocols, emergency response readiness, staff training, and proper equipment handling. The form requires signature by an inspecting official and must be faxed to the Contracting Officer Representative (COR) upon completion.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Q and A - DME SSN VISN 15.pdf | ||
| DRAFT - Estimated Equipment Quantities - VISN 15 DME.xlsx | XLSX spreadsheet | |
| Sources sought response form.docx | DOCX document | |
| VISN 15 Facilities and Counties Covered.xls | XLS spreadsheet | |
| PWS - DME VISN 15 - draft.docx | DOCX document |
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Text version
Attachment A
Contractor Inspection Sheet
NAME AND LOCATION OFCOMPANY
MILES FROM LOCAL VA FACILITY
| FACILITY |
| TYPE OF BUILDING (CHECK TWO) |
FORMCHECKBOX
BRICK FORMCHECKBOX
FRAME FORMCHECKBOX
RESIDENCE FORMCHECKBOX
BUSINESS BUILDING
BUSINESS/OCCUPATIONAL LICENSE CURRENT?
FORMCHECKBOX
YES FORMCHECKBOX
NO
CONDITION O F BUILDING (CHECK TWO)
FORMCHECKBOX
NEW FORMCHECKBOX
OLD FORMCHECKBOX
GOOD FORMCHECKBOX
POOR
JCAHO CERTIFIED IN GOOD STANDING?
FORMCHECKBOX
YES FORMCHECKBOX
NO
GENERAL CONDITION AND APPREARANCE (CHECK TWO)
FORMCHECKBOX
CLEAN FORMCHECKBOX
DIRTY FORMCHECKBOX
NEAT FORMCHECKBOX
CLUTTERED
FIRE EXTINGUSHER CHECKED MONTHLY?
FORMCHECKBOX
YES FORMCHECKBOX
NO
| CLEANING & STORAGE AREA |
| GENERAL OVERALL APPEARANCE – CLEAN/NEAT |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| CLEAN AREAS PROVIDES FOR SAFETY OF STAFF |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| BAGGED ITEMS TAGGED |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| SUPPLIES FOR CLEANING READILY AVAILABLE |
| FORMCHECKBOX |
| CLEAN/DIRTY SEPARATED |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| EYE WASH SYSTEM AVAILABLE |
| FORMCHECKBOX |
COMMENTS:
| VEHICLES |
| FIRE EXTINQUISHER IN EACH VEHICLE |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| SAFE DISPOSAL OF HAZARDOUS WASTE |
| FORMCHECKBOX |
| FIRE EXTINQUISHER CHECKED MONTHLY |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| SAFETY FLARES/TRIANGLES IN EACH VEHICLE |
| FORMCHECKBOX |
| MAINTENANCE RECORDS |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| LICENSE, REGISTRATION - CURRENT/ACCURATE |
| FORMCHECKBOX |
| VEHICLE CLEARLY IDENTIFIED, INCLUDING REQUIRED TAGS |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| MEANS FOR SEPARATING CLEAN/DIRTY EQUIPMENT |
| FORMCHECKBOX |
| MEANS TO WASH HANDS IN VEHICLE |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| NO SMOKING SIGN IN VEHICLE |
| FORMCHECKBOX |
| DISPOSABLE GLOVES IN EACH VEHICLE |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| FIRST AID KIT IN VEHICLE |
| FORMCHECKBOX |
| PROTECTIVE GARMENTS IN EACH VEHICLE |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| EYEWASH IN VEHICLE |
| FORMCHECKBOX |
| DOT, IF APPLICABLE |
| FORMCHECKBOX |
COMMENTS:
| DELIVERY PERSONNEL |
| APPEARANCE – NEAT AND PROFESSIONAL |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| COMMUNICATION SKILLS DEMONSTRATED |
| FORMCHECKBOX |
| a. PROFESSIONAL |
| FORMCHECKBOX |
Yes FORMCHECKBOX
STAFF ADEQUATELY DESCRIBES PROCEDURES
| b. ID BADGES |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| a. INSTRUCTION TO PATIENTS |
| FORMCHECKBOX |
| c. UNIFORMS |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| b. CLEANING PROCEDURES |
| FORMCHECKBOX |
| d. SAFETY WEAR (IE: STEEL TOE SHOES) |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
FORMCHECKBOX
KNOWLEDGABLE ABOUT:
KNOWLEDGABLE ABOUT:
| a. ENVIRONMENT OF CARE |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| j. ELECTRICAL SAFETY |
| FORMCHECKBOX |
| b. PATIENT RIGHTS/RESPONSIBILITIES |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| 1) EXPOSURE TO LIQUID |
| FORMCHECKBOX |
| c. UNIVERSAL SAFETY PRECAUTIONS |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| 2) AMPERAGE |
| FORMCHECKBOX |
| d. INFECTIOUN CONTROL |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| 3) GROUNDING |
| FORMCHECKBOX |
| e. GENERAL – STAIRS, THROW RUGS |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| 4) USE OF EXTENSION CORD |
| FORMCHECKBOX |
| f. FIRE HAZARDS (SMOKING, OPEN FLAME) |
| FORMCHECKBOX |
Yes FORMCHECKBOX
k. EQUIPMENT SAFETY
| g. SMOKE ALARMS |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| 1) USE OF GLOVES |
| FORMCHECKBOX |
| h. EMERGENCY EXITS IN CASE OF FIRE. |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| 2) BAGGING OF EQUIPMENT |
| FORMCHECKBOX |
| i. ROUTINE AND EMERGENCY RESPONSE PROCEDURES |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
3) DISPOSAL OF GLOVES AND OTHER
HAZARDOUS MATERIALS
FORMCHECKBOX
COMMENTS:
RECORD REVIEW
DOCUMENTATION FOUND
5% OR A MINIMUM OF 5 PT. RECORDS WILL BE REVIEWED FOR DOCUMENTATION OF:
EQUIPMENT RECORDS ON FILE
| a. EMERGENCY/DISASTER EDUCATION |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| a. MANUFACTURER |
| FORMCHECKBOX |
| b. PATIENTS RIGHTS/RESPONSIBILITIES |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| b. MODEL |
| FORMCHECKBOX |
| c. INSTRUCTIONS IN USE/CARE OF EQUIPMENT |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| c. SERIAL NUMBER |
| FORMCHECKBOX |
| d. HOME VISITS |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| d. MAINTENANCE INSTRUCTIONS |
| FORMCHECKBOX |
| e. CONTINUING EDUCATION FOR PATIENTS & CAREGIVER |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| e. ROUTINE MAINTENANCE DOCUMENTATION |
| FORMCHECKBOX |
| f. HOME SAFETY/ENVIRONMENTAL INSPECTION |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| RECALL PROCESS WITH NOTIFICATION OF PATIENT/VA |
| FORMCHECKBOX |
| ON-GOING STAFF EDUCATION |
| FORMCHECKBOX |
Yes FORMCHECKBOX No
| EQUIPMENT IS CLEAN AND TAGGED APPROPRIATELY |
| FORMCHECKBOX |
| QA PLAN - STAFF KNOWS OF QA PLAN/PROCESS |
| FORMCHECKBOX |
| INCIDENT REPORTING |
| FORMCHECKBOX |
COMMENTS:
ADDITIONAL COMMENTS MAY BE ADDED TO BACK
FAX COPY OF COMPLETED FORM TO COR
SIGNATURE OF INSPECTING OFFICIAL DATE
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