W.A.S.H. INSPECTION for CERTIFICATION

Quality Standard for Inspection

-All program policy documents should be stored ON GOOGLE DRIVE under Hello@washcommunity.org and share with board members to be easily accessible.

During Inspection, the Program will provide the Inspector with sufficient evidence of the following:

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* 1. NAME OF PROGRAM:

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* 2. NAME OF LOCATION BEING INSPECTED TODAY:

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* 3. ADDRESS OF FACILITY BEING INSPECTED TODAY:

Address:

City:

Zip:

Other:

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* 4. W.A.S.H. Level

Level I

Level II

Level III

Level IV

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* 5. CONTACT PERSON NAME:

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* 6. CONTACT PERSON PHONE NUMBER:

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* 7. EMAIL ADDRESS OF PROGRAM FOR INVOICING

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* 8. DATE, TIME OF INSPECTION:

Date / Time

Date

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* 9. NAME OF INSPECTOR:

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* 10. SIGNATURE OF INSPECTOR DIGITAL

Organizational Documentation Pass Fail Action Item if Fail

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* 11. Proof of Legal Business Entity (Business License, Articles of Incorporation)

Pass

Action Item(s):

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* 12. Marketing Materials (Brochures, Flyers, business cards etc.)

Pass

Action Item(s):

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* 13. Acknowledgement Letter from Property Owner

Pass

Action Item(s):

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* 14. Program is in compliance with the Federal Fair Housing Act

Pass

Action Item(s):

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* 15. Liability Cover Policy and any other insurance policies

Pass

Action Item(s):

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* 16. Mission Statement

Pass

Action Item(s):

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* 17. Vision Statement

Pass

Action Item(s):

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* 18. Code of Ethics Statement

Pass

Action Item(s):

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* 19. Management has signed and abides by a Code of Ethics

Pass

Action Item(s):

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* 20. Confidentiality Policy & Procedure

Pass

Action Item(s):

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* 21. Hardship Scholarship Assessment Policy

Pass

Action Item(s):

Policies

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* 22. Concerning Paid Work to Residents

Pass

Action Item(s):

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* 23. Good Neighbor Policy & Procedure

Pass

Action Item(s):

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* 24. Hazardous Items Search Policy & Procedure

Pass

Action Item(s):

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* 25. Policy of Resident Information to Provide to EMS

Pass

Action Item(s):

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* 26. Emergency/Non-Emergency Policy & Procedure

Pass

Action Item(s):

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* 27. Emergency/Non-Emergency Contact Sheet

Pass

Action Item(s):

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* 28. Medication Storage & Use Policy & Procedure

Pass

Action Item(s):

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* 29. Signed Attestation for Drug Testing

Pass

Action Item(s):

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* 30. Non-discrimination Policy

Pass

Action Item(s):

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* 31. Drug Testing Policy & Procedure including Frequency

Pass

Action Item(s):

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* 32. Recurrence of Use Policy & Procedure

Pass

Action Item(s):

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* 33. Discharge Policy & Procedure

Pass

Action Item(s):

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* 34. Grievance Policy & Procedure, including instructions to file with WASH

Pass

Action Item(s):

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* 35. Grievance Form

Pass

Action Item(s):

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* 36. Maintenance Repair Policy

Pass

Action Item(s):

Health and Safety

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* 37. Smoke alarms installed in every room

Pass

Action Item(s):

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* 38. Evacuation exit maps posted at every doorway

Pass

Action Item(s):

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* 39. Current tagged fire extinguishers in kitchen and dining areas

Pass

Action Item(s):

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* 40. Clean, bedrooms, cosmetically and driveways maintained, and debris free yards, living areas

Pass

Action Item(s):

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* 41. OSHA pool areas, approved as required Extension cords and GFI plugs in bathrooms, kitchen, and laundry area

Pass

Action Item(s):

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* 42. Five maximum per properly operating bathroom, excluding one staff residents member

Pass

Action Item(s):

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* 43. Five maximum per properly operating bathroom, excluding one staff residents member

Pass

Action Item(s):

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* 44. Attic access clear of debris

Pass

Action Item(s):

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* 45. Motor vehicles stored per city code

Pass

Action Item(s):

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* 46. Properly inspected and operational heating and cooling systems

Pass

Action Item(s):

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* 47. Fully functional and clean kitchen and bathrooms

Pass

Action Item(s):

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* 48. Maintenance Repair Request Forms

Pass

Action Item(s):

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* 49. Property address clearly visible on property

Pass

Action Item(s):

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* 50. Proper disposal areas for cigarettes

Pass

Action Item(s):

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* 51. No open flames, no fire hazards, smoke free environment

Pass

Action Item(s):

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* 52. Policy of disposal methods for illegal drugs/medications on property

Pass

Action Item(s):

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* 53. Staff conducts Self-Assessment regular internal Checklist safety and health inspections

Pass

Action Item(s):

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* 54. First aid kit is located on property

Pass

Action Item(s):

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* 55. First aid kit is located on property

Pass

Action Item(s):

Staffing Documentation

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* 56. Employee/Volunteer Background Screening Policy

Pass

Action Item(s):

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* 57. Program staff training .house manager training, narcan, standard safety precautions, medications.

Pass

Action Item(s):

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* 58. Staff/Management Contact Sheet

Pass

Action Item(s):

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* 59. Staffing/Peer Leadership Policy

Pass

Action Item(s):

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* 60. Staff/Peer Leadership Job Descriptions

Pass

Action Item(s):

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* 61. Sample Staffing Weekly Schedule

Pass

Action Item(s):

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* 62. Resident Screening Policy & Procedure

Pass

Action Item(s):

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* 63. Resident Application

Pass

Action Item(s):

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* 64. Program Format (Phases, Stages)

Pass

Action Item(s):

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* 65. Sample Resident Weekly Schedule

Pass

Action Item(s):

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* 66. House Rules & Consequences

Pass

Action Item(s):

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* 67. Resident Rights & Requirements

Pass

Action Item(s):

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* 68. Participants program are required to attend 12 Step or other comparable recovery

Pass

Action Item(s):

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* 69. Program holds, at a minimum, weekly mandatory resident meetings

Pass

Action Item(s):

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* 70. Adequate food storage space for residents

Pass

Action Item(s):

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* 71. Program maintains personal information for each resident

Pass

Action Item(s):

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* 72. Program provides intake orientation and subsequent reviews

Pass

Action Item(s):

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* 73. Program guests has a sign in/out board to track participants and registers all

Pass

Action Item(s):

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* 74. Program orientation tracks and outcome measures for residents, ie location prior to discharge type of housing, length of abstinence

Pass

Action Item(s):

Resident Orientation Policy & Procedure

Recovery Support Documentation

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* 75. All residents forms, participation documents, in and/or the development guides used with their mentor, or RC

Pass

Action Item(s):

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* 76. Recovery resource material is available to participant

Pass

Action Item(s):

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* 77. Community Resource Guide

Pass

Action Item(s):