Inspection Checklist.pdf

Department of Veterans Affairs 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: DATE INSPECTION COMPLETED:

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

SOCIAL WORK LIAISON

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 1162.01. 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:

MHA

FACHE VAMC DIRECTOR CTXVHCS

SIGNATURE DATE

VA LIAISON – OVERVIEW &

RECOMMENDATION

HOMES PROJECT CODE:

SITE ADDRESS:

HCHV LIAISON SHOULD COMPLETE THIS

SECTION ATTACHING ANY OTHER

DOCUMENTATION, AS NECESSARY

YES NO N/A

THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO

HOUSE WITHIN THE SITES COVERED UNDER THIS PROGRAM NUMBER:

A. MEN

B. WOMEN

C. CHILDREN

PROGRAM OPERATES IN ACCORDANCE WITH HCHV PROGRAM

REGULATIONS, 38 CFR 63

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

CONTRACT PROVIDER SERVES THE POPULATION(S) AS DESCRIBED IN

THEIR CONTRACT / SOW/PWS.

THE CONTRACT PROVIDER SUBMITS ACCURATE BILLING ON A MONTHLY

BASIS AND MAINTAINS DOCUMENTATION TO SUPPORT MONTHLY BILLING.

CONTRACT PROVIDER MAINTAINS SYSTEMATIC PARTICIPANT

ENROLLMENT AND TRACKING INFORMATION FOR SAFETY AND BILLING

PURPOSES

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)

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

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:

MEETS

TARGET

DOES

NOT

MEET

TARGET

PIP IN

PLACE /

REQUIRED

A. EXITS TO PERMANENT HOUSING

B. NEGATIVE EXITS

YES NO N/A

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.

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. Therapeutic and Rehabilitative Services

B. Residential Room and Board

C. Medical and Mental Health Stabilization

D. Dietetic Services

E. Transportation

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 PLACEMENT OF VETERANS:

HCHV LIAISON SIGNATURE

LCSW

HCHV LIAISON NAME DATE

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

LCSW

HCHV LIAISON SUPERVISOR DATE

FACILITIES MANAGEMENT

APPROPRIATE DISCIPLINE(S) SHOULD

COMPLETE THIS SECTION ATTACHING THEIR

RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER FACILITY YES NO N/A

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.

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

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

HAS ENTRIES AND EXIT LOCATIONS THAT ARE CAPABLE OF BEING UTILIZED

WITHOUT UNAUTHORIZED USE AND PROVIDE ALTERNATE MEANS OF EGRESS IN

CASE OF FIRE

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 APPROPRIATE CODES AND REGULATIONS

PROVIDES EVERY ROOM OR SPACE WITH NATURAL OR MECHANICAL

VENTILATION

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

ON THE DAY OF INSPECTION, THE FACILITY APPEARS UPON VISUAL INSPECTION

TO PROVIDE A WATER SUPPLY THAT IS FREE FROM CONTAMINATION

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 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 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 1162.01)

PROVIDES THAT HOUSING AND EQUIPMENT ARE MAINTAINED IN A SANITARY

MANNER

FACILITIES MANAGEMENT

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 CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS

APPROVED FOR PLACEMENT OF VETERANS

Facilities Management Inspection Team Members Signature

Facility Management Inspection Team Member Date

NUTRITION AND FOOD SERVICES

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING 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 (I.E. 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 (I.E. STOVE, REFRIGERATOR, DISHWASHER)

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

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). 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

Nutrition/Food Management Inspection Team Members Signature

Facility Food Management Inspection Team Member

Date

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.

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER: YES NO

44 HAS POLICIES AND PROCEDURES TO ADDRESS HOW INTOXICATED OR IMPAIRED

PRATICIPANTS WILL BE INDENTIFIED AND MANAGED IN THIS PROGRAM.

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 AND OUTCOMES

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

CLINICAL 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 PACKAGE.

YES NO

Deficiencies were present for items on this checklist during inspection (If Yes list deficiencies and confirm

Clinical Inspection Team Members Signature Clinical Inspection Team Member Date

LAW ENFORCEMENT AND

PHYSICAL SECURITY

HOMES PROJECT CODE:

CHIEF OF VA POLICE OR DESIGNEE SHOULD

COMPLETE THIS SECTION ATTACHING THEIR

RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CONTRACT PROVIDERS (ALL INSPECTIONS)

THE CONTRACT PROVIDER: YES NO N/A

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 "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 "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

ENSURES COMMON AREAS (I.E. 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

ENSURES EMERGENCY CONTACTS FOR MEDICAL, LAW ENFORCEMENT, FIRE DEPARTMENT

AND AGENCY ARE PROMINENTLY POSTED IN THE FACILITY

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 CONSDERATIONS SHOULD BE GIVEN TO

SEPARATION AND SAFETY IN FACILITIES WHERE MULTIPLE GENDERS AND/OR CHILDREN

ARE SERVED.

HAS ADEQUATE POLICIES AND PROCEDURES WHICH ARE COMMUNCATED AND ENFORCED

TO ENSURE SAFETY, SECURITY, AND PRIVACY BASED ON LOCATION, POPULATION(S)

SERVED, AND FACILITY STRUCTURE.

LAW ENFORCEMENT AND

PHYSCIAL 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 PACKAGE.

YES NO

Deficiencies were present for items on this checklist during inspection (If Yes list deficiencies and confirm resolution below)

Law Enforcement Inspection Team Member Signature

Law Enforcement Inspection Team Member Date

APPROPRIATE DISCIPLINE(S) SHOULD

COMPLETE THIS SECTION ATTACHING THEIR

RESPECTIVE REPORT FORMAT(S)

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 MAYNOT 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: YES NO N/A

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND

HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF MEDICATION

USE

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

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT TRAINING

AND EDUCATION REGARDING MEDICATION

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

ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS THAT

PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS

PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES

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

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: YES NO N/A

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND

HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF

MEDICATION USE

ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT WHEN UNDER

THE DIRECT SUPERVISION OF APPROPRIATE STAFF

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE UNDER THE

CONTROL OF AUTHORIZED STAFF

ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES OR

DETERIORATION

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.

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED ORIENTATION,

CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

FOR INDIVIDUAL STORAGE: YES NO N/A

SELF-ADMINISTERED MEDICATIONS ARE STORED IN A SAFE AND SECURE MANNER

IN THE RESIDENT'S ROOM ACCORDING TO THE FACILITY'S POLICIES AND

PROCEDURES

METHOD OF STORAGE CAN NOT BE EASILY REMOVED FROM THE FACILITY (I.E. LOCK

BOX IS SECURED TO A LARGE DRESSER OR THE STRUCTURE OF THE BUILDING)

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 PACKAGE.

YES NO

Deficiencies were present for items on this checklist during inspection (If Yes list deficiencies and confirm resolution below)

Medication Inspection Team Members Signature

Medication Management Inspection Team Member Date