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SURVEILLANCE CHECKLIST
Mortuary Services – VA Salt Lake City Health Care System (VHSLCHCS) Quality Assurance Surveillance Plan (QASP) Tool Contract Title: Mortuary Services for Unclaimed or Indigent Veterans Contract Number: ____________________ Contractor: __________________________
COR: _________________________________
Inspection Period/Year: _________________ Date of Inspection: ____________________
1. REMOVAL & TRANSPORT OF REMAINS
| Surveillance Item |
| Yes/No |
| Comments |
| Contractor responded to notification within 1 business day for removal of remains. |
| ☐ Yes ☐ No |
| Proper funeral‑industry vehicle used for transport. |
| ☐ Yes ☐ No |
| Remains loaded professionally and respectfully. |
| ☐ Yes ☐ No |
| Transport completed to designated facility/cemetery without incident. |
| ☐ Yes ☐ No |
2. STORAGE OF REMAINS
| Surveillance Item |
| Yes/No |
| Comments |
| Refrigerated storage functioning and adequate. |
| ☐ Yes ☐ No |
| Storage area clean, sanitary, and compliant with health regulations. |
| ☐ Yes ☐ No |
| Remains secured and properly identified. |
| ☐ Yes ☐ No |
3. CREMATION SERVICES
| Surveillance Item |
| Yes/No |
| Comments |
| Cremation arranged per COR/DR instructions. |
| ☐ Yes ☐ No |
| Durable, sealed, non‑leaking urn provided. |
| ☐ Yes ☐ No |
| Correct labeling and documentation provided. |
| ☐ Yes ☐ No |
4. EMBALMING OF REMAINS (when applicable)
| Surveillance Item |
| Yes/No |
| Comments |
| Embalming resulted in uniform preservation and odor elimination. |
| ☐ Yes ☐ No |
5. PREPARATION OF VIEWABLE REMAINS
| Surveillance Item |
| Yes/No |
| Comments |
| Remains prepared and presented per industry standard and applicable state/local law, suitable for positive identification viewing if conducted |
| ☐ Yes ☐ No |
6. CASKETING
| Surveillance Item |
| Yes/No |
| Comments |
| Casket meets minimum standards (20‑gauge metal, standard size, no cardboard). |
| ☐ Yes ☐ No |
| Remains positioned respectfully and securely for transport. |
| ☐ Yes ☐ No |
| U.S. Flag properly and respectfully draped by Contractor (if burial). |
| ☐ Yes ☐ No |
7. FACILITY & LICENSING COMPLIANCE
| Surveillance Item |
| Yes/No |
| Comments |
| Facility meets NEPA Fire & Life Safety Codes. |
| ☐ Yes ☐ No |
| VA accessibility standards met. |
| ☐ Yes ☐ No |
| All licenses (funeral establishment, embalmers) verified and current. |
| ☐ Yes ☐ No |
| Proper permits obtained (transit, cremation, burial). |
| ☐ Yes ☐ No |
8. DOCUMENTATION & QUALITY CONTROL
| Surveillance Item |
| Yes/No |
| Comments |
| Contractor’s Quality Control Program (QCP) current and followed. |
| ☐ Yes ☐ No |
| Semi‑annual QC reports submitted on time. |
| ☐ Yes ☐ No |
| Inspection checklist completed prior to release of remains (10-2068a (1)). |
| ☐ Yes ☐ No |
| All corrective actions are documented and addressed promptly. |
| ☐ Yes ☐ No |
9. SENSITIVE INFORMATION HANDLING
| Surveillance Item |
| Yes/No |
| Comments |
| Contractor complied with VA privacy requirements (PII/PHI protection). |
| ☐ Yes ☐ No |
| No unauthorized disclosures identified. |
| ☐ Yes ☐ No |
| Contractor staff completed annual privacy/security training. |
| ☐ Yes ☐ No |
| Rules of Behavior signed by all applicable contractor staff. |
| ☐ Yes ☐ No |
10. OVERALL PERFORMANCE
| Performance Area |
| Rating (1–5) |
| Notes |
| Documentation Accuracy |
| 1–5 |
11. DEFICIENCIES & CORRECTIVE ACTIONS
· Issues Identified:
· Corrective Action Required:
· Contractor Response Date: __________________
· Follow‑up Inspection Date: __________________
12. COR SIGNATURE
COR Name: __________________________________ Signature: __________________________________ Date: _______________________________________
