DME Inspection Document.doc
DOC document 118 KB Posted
- Solicitation number
- 36C25521Q0307
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Other files
| File | Type | Posted |
|---|---|---|
| VISN 15 Facilities and Counties Covered - Updated.xls | XLS spreadsheet | |
| 36C25521Q0307 0001.docx | DOCX document | |
| DME Schedule of Costs.xlsx | XLSX spreadsheet | |
| 36C25521Q0307_1.docx | DOCX document | |
| Attachment (C) VA Privacy Language Appendix C.pdf | ||
| WAGE DETERMINATIONS INCORPORATED BY REFERENCE.pdf | ||
| Contractor Confidentiality Agreement (VA Form 0752).pdf | ||
| Quality Assurance Surveillance Plan (QASP) - FINAL.pdf | ||
| VSC Security_Complete Packet.pdf | ||
| Attachment (D) Contractor Rules of Behavior Appendix D.pdf | ||
| VHA 1605.05 BUSINESS ASSOCIATE AGREEMENT - New.docx | DOCX document | |
| Estimated Equipment Quantities.xlsx | XLSX spreadsheet | |
| Areas of Coverage.xls | XLS spreadsheet |
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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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