D.7 INSPECTION PACKET

ATTACHMENT D.7- INSPECTION PACKET

Department of Veterans Affairs

RFQ 36C24226Q0118

Health Care for Homeless Veterans Contracted
Residential Services Programs Inspection Packet

MEDICAL CENTER DIRECTOR REVIEW AND APPROVAL SHEET

INSPECTION IS FOR: ___ INITIAL INSPECTION

___ RE-INSPECTION

TOTAL BEDS AWARDED

PROJECT #:

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

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 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:

VAMC DIRECTOR (PRINT NAME)

SIGNATURE

DATE

ATTACHMENT D.7- INSPECTION PACKET

VA LIAISON – OVERVIEW &

RECOMMENDATION

HCHV LIAISON SHOULD COMPLETE THIS SECTION

ATTACHING ANY OTHER DOCUMENTATION, AS

NECESSARY

RFQ 36C24226Q0118

HOMES PROJECT CODE:

SITE ADDRESS:

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