R499--State Veterans Home (SVH) Nursing Homes

CONTINUATION PAGE 36C10G24R0016 Page 98 of 134 Page 1 of 150 Page 1 of 150 SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS ATTACHMENTS SVH Master Survey Schedule Listing Corrective Action Request Procedure and Form Observation Record Table of Survey Component Guide VA Form 10-0143 VA Form 10-0143A VA Form 10-0144 VA Form 10-0144A VA Form 10-3567 Staffing Profile VA Form 10-3567 Staffing Profile Reference VA NFPA Interpretation for the SVH Program SVH NH Life Safety Checklist SVH NH_DOM Combine Life Safety Checklist SVH NH_DOM_ADHC Combine Life Safety Checklist SVH DOM Family Dwellings SVH DOM Large Board and Care Life Safety Checklist SVH DOM Small Board and Care Life Safety Checklist Existing Day Care Occupancy Checklist Scope and Severity Matrix IJ Template Final Survey Report Format Life Safety Code Headings Quick Reference Guide Nursing Home Quick Reference Guide Domiciliary Quick Reference Guide ADHC Survey Deficiency Summary Report Format DOCUMENTS Business Associate Agreement Estimate Quantities and Pricing Sheet Detailed Price / Cost Sheet