PWS ADDENDUM 2 COPY OF BLANK INSPECTION FORM.docx

Department of Veterans Affairs Health Care for Homeless Veterans Contracted Residential Services Programs Inspection Packet

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

INSPECTION IS FOR: ___ INITIAL INSPECTION _x__ RE-INSPECTION

PROJECT #:

TOTAL BEDS AWARDED

AGENCY'S ADMINISTRATIVE OFFICE ADDRESS:

LIST ALL PHYSICAL ADDRESSES WHERE VETERANS ARE HOUSED UNDER THIS PROJECT NUMBER:

INSPECTION TEAM MEMBERS

FACILITIES MANAGEMENT

NUTRITION

CLINICAL REVIEW

SECURITY / LAW ENFORCEMENT

MEDICATION REVIEW

NHC OR DESIGNEE

OTHER

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 HANDBOOK 1162.09. 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:

SITE ADDRESS:

HCHV LIAISON SHOULD COMPLETE THIS SECTION

ATTACHING ANY OTHER DOCUMENTATION, AS NECESSARY

A. MEN

B. WOMEN

C. CHILDREN

OTHER REQUIREMENTS FOR THE OPERATION OF THE PROGRAM IN THE

JURISDICTION WHERE THE PROGRAM IS LOCATED

APPROPRIATE SCOPE OF SERVICES TO CARRY OUT THIS PROGRAM AS

OUTLINED IN THE ORIGINAL SOW/PWS OR SUBSEQUENT APPROVED CHANGE / CONTRACT MODIFICATION

*If initial inspection this section can be left blank

APPLICABLE VA METRICS HAVE BEEN DISCUSSED AT LEAST QUARTERLY WITH THE CONTRACT PROVIDER (RE-INSPECTIONS ONLY)

PROCEDURES ARE APPROPRIATE TO ENSURE THE SAFETY, SECURITY, AND PRIVACY OF ALL INDIVIDUALS IN THE FACILITY

QUARTERLY) PERFORMANCE DATA BELOW AND IF NOT, THE HCHV LIASION WORKS WITH THE PROVIDER TO PUT A PLAN IN PLACE FOR IMPROVEMENT (*If initial inspection this section can be left blank):

NOT

MEET

TARGET

PIP IN

PLACE /

REQUIR ED

A. EXITS TO PERMANENT HOUSING

B. NEGATIVE EXITS

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.

PLEASE INDICATE IF THE SERVICE IS CURRENTLY PROVIDED.

A.

B.

C.

D.

E.

F.

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

HCHV LIAISON SIGNATURE

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.

DATE

HCHV LIAISON SUPERVISOR'S SIGNATURE

HCHV LIAISON SUPERVISOR'S NAME (PRINT)

SITE ADDRESS:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS)

WITHOUT UNAUTHORIZED USE AND PROVIDE ALTERNATE MEANS OF EGRESS IN CASE OF FIRE

PROPER OPERATIONAL CONDITION, MAY BE USED IN PRIVACY, AND ARE

ADEQUATE FOR PERSONAL CLEANLINESS AND THE DISPOSAL OF HUMAN WASTE

NORMAL INDOOR ACTIVITIES AND TO SUPPORT THE HEALTH AND SAFETY OF RESIDENTS

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)

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.

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.

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 Members Name ( Print) Date

SITE ADDRESS:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

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

AND ARE IN GOOD WORKING CONDITION (I.E. STOVE, REFRIGERATOR, DISHWASHER)

EQUIPMENT TO STORE, PREPARE, AND SERVE FOOD IN A SANITARY

MANNER INCLUDING PROVIDING APPROPRIATE CLEANING SUPPLIES AS NEEDED

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

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.

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.

ALL APPROPRIATE CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS

Team Members Name ( Print) Date

SITE ADDRESS:

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)

A. VERIFICATION OF VETERAN STATUS

B. FAMILY STATUS

C. EMPLOYMENT HISTORY

D. EDUCATION AND MARKETABLE SKILLS/LICENSES/CREDENTIALS

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

PARTICIPANT AND INCLUDES DOCUMENTATION OF SUCH IN THE PARTICIPANTS

CASE MANAGEMENT FILE IN THE FORM OF AN ISP REVIEW OR UPDATE

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.

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.

ALL APPROPRIATE CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS

Print) Date

SITE ADDRESS:

CHIEF OF VA POLICE OR DESIGNEE SHOULD

COMPLETE THIS SECTION ATTACHING THEIR

RESPECTIVE REPORT FORMAT(S)

OPERATING STANDARDS ALL HCHV CONTRACT PROVIDERS (ALL INSPECTIONS)

HAS CONDUCTED A COMPREHENSIVE RISK ASSESSMENT OF THE PROGRAM. (IF NOT ON VA PROPERTY "N/A")

ENFORCEMENT MONITORING HAS BEEN ESTABLISHED BETWEEN THE PROVIDER AND VA

HAS AS A MEMBER OF THE HEALTH CARE TEAM COORDINATED WITH THE

PROVIDER FOR THE PURPOSE OF CONDUCTING A COMPREHENSIVE RISK ASSESSMENT OF THE PROGRAM

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)

THAT ILLICIT DRUGS, WEAPONS, AND OTHER SIMILAR ITEMS ARE NOT PERMITTED ON THE PREMISES

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

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.

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.

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.

ALL APPROPRIATE CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS

Date

SITE ADDRESS:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

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 _x__ 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

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF MEDICATION USE

RESOURCES FOR ADVOCACY TO ASSIST THEM IN BEING ACTIVELY

INVOLVED IN MAKING DECISIONS RELATED TO THE USE OF MEDICATIONS

PERSONS SERVED IS REVIEWED ON AT LEAST AN ANNUAL BASIS BY A

PHYSICIAN OR QUALIFIED PROFESSIONAL LICENSED TO PRESCRIBE MEDICATIONS

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

THAT PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND

REGULATIONS PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES

PRESCRIBED MEDICATIONS INTO A PERSON'S OVERALL PLAN,

INCLUDING, IF APPLICABLE, SPECIAL DIETARY NEEDS AND RESTRICTIONS ASSOCIATED WITH MEDICATION USE

DOCUMENTATION, AND REQUIRED REPORTING, INCLUDING TO THE

PRESCRIBING PROFESSIONAL, ANY MEDICATION REACTIONS OR

MEDICATION ERRORS, AS APPROPRIATE

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

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF MEDICATION USE

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.

ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

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

FACILITY (I.E. LOCK BOX IS SECURED TO A LARGE DRESSER OR THE STRUCTURE OF THE BUILDING)

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.

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.

ALL APPROPRIATE CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS

Date