G099--Healthcare for Homeless Veterans (HCHV) Contract Residential Services (CRS) in Sacramento, Placer, or Yolo County for Substance Use Disorder (SUD) and Mental Health Services for VA Northern California Health Care System (VANCHCS)

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 NHC OR DESIGNEE CONTRACTING OFFICER REPRESENTATIVE 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 -- 1 of 14 -- 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 1 THE FOLLOWING POPULATIONS ARE CLINICALLY APPROPRIATE TO HOUSE WITHIN THE SITES COVERED UNDER THIS PROGRAM NUMBER: A. MEN B. WOMEN C. CHILDREN 2 PROGRAM OPERATES IN ACCORDANCE WITH HCHV PROGRAM REGULATIONS, 38 CFR 63. 3 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. 4 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. 5 CONTRACT PROVIDER SERVES THE POPULATION(S) AS DESCRIBED IN THEIR CONTRACT/SOW/PWS. 6 THE CONTRACT PROVIDER SUBMITS ACCURATE BILLING ON A MONTHLY BASIS AND MAINTAINS DOCUMENTATION TO SUPPORT MONTHLY BILLING. 7 CONTRACT PROVIDER MAINTAINS SYSTEMATIC PARTICIPANT ENROLLMENT AND TRACKING INFORMATION FOR SAFETY AND BILLING PURPOSES. 8 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). 9 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. -- 2 of 14 -- 11 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 12 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. 13 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. B. C. D. E. F. G. H. I. 14 THE CONTRACT PROVIDER IS CURRENTLY PROVIDING ALL SERVICES AS STATED IN THE CONTRACT/SOW/PWS. IF INITIAL INSPECTION, THIS SECTION CAN BE LEFT BLANK. ALL APPROPRIATE CHECKLIST ITEMS HAVE BEEN ADDRESSED AND FACILITY IS APPROVED FOR PLACEMENT OF VETERANS: HCHV LIAISON SIGNATURE HCHV LIAISON NAME (PRINT) DATE I, AS THE HCHV LIAISON'S SUPERVISOR, HAVE REVIEWED THIS INSPECTION PACKET AND DISCUSSED THE FINDINGS WITH THE HCHV LIAISON. I CONCUR WITH THE LIAISON'S FINDINGS AND AFFIRM THAT TO THE BEST OF MY KNOWLEDGE 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) COR SIGNATURE COR NAME (PRINT) DATE -- 3 of 14 -- FACILITIES MANAGEMENT HOMES PROJECT CODE: SITE ADDRESS: APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE THIS SECTION AND ATTACH THEIR RESPECTIVE REPORT FORMAT(S). OPERATING STANDARDS ALL HCHV CRS PROVIDERS (ALL INSPECTIONS) THE CONTRACT PROVIDER FACILITY: YES NO N/A 15 IS COMPLIANT WITH THE AMERICANS WITH DISABILITIES ACT, REFERRED TO AS ARCHITECTURAL BARRIERS ACT. IF NO OR N/A, YOU MUST PROVIDE AN EXPLANATION AND NOTE ANY PROVISIONS MADE OR RSOURCES AVAILABLE FOR VETERANS WITH DISABILITIES ON THE FOLLOWING PAGE 16 IS IN COMPLIANCE WITH THE NFPA LIFE SAFETY CODE (SEE ATTACHED REPORT). 17 IS STRUCTURALLY SOUND SO AS NOT TO POSE ANY THREAT TO THE HEALTH AND SAFETY OF THE OCCUPANTS AND TO PROTECT THEM FROM THE ELEMENTS. 18 HAS ENTRIES AND EXIT LOCATIONS THAT ARE CAPABLE OF BEING UTILIZED WITHOUT UNAUTHORIZED USE AND PROVIDE ALTERNATE MEANS OF EGRESS IN CASE OF FIRE. 19 PROVIDES EACH RESIDENT APPROPRIATE SPACE AND SECURITY FOR THEMSELVES AND THEIR BELONGINGS. 20 PROVIDES EACH RESIDENT AN ACCEPTABLE PLACE TO SLEEP THAT IS IN COMPLIANCE WITH APPROPRIATE CODES AND REGULATIONS. 21 PROVIDES EVERY ROOM OR SPACE WITH NATURAL OR MECHANICAL VENTILATION. 22 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. 23 ON THE DAY OF INSPECTION, THE FACILITY APPEARS UPON VISUAL INSPECTION TO PROVIDE A WATER SUPPLY THAT IS FREE FROM CONTAMINATION. 24 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. 25 PROVIDES …