Children’s Licensed Staffed Residential
Quality Assurance Assessment /
DATE / VISIT TYPE (ANNUAL OR BY REQUEST) / DDA REVIEWER’S NAME
DIVISION OF LICENSED RESOURCES (DLR) LICENSOR’S NAME / LICENSOR’S TELEPHONE NUMBER
Assessor should obtain information below from regional Voluntary Placement Services (VPS) Coordinator, Resource Manager, and/or Social Workers prior to conducting QA assessment. See DDA MB D10-016
LICENSED STAFFED RESIDENTIAL AGENCY / HOUSE NAME
AGENCY / PROGRAM ADMINISTRATOR NAME / HOUSE / PROGRAM MANAGER NAME
MAILING ADDRESS / MAILING ADDRESS
CITY STATE ZIP CODE
/ CITY STATE ZIP CODE
TELEPHONE NUMBER / FAX NUMBER / TELEPHONE NUMBER
CURRENT VALID LICENSE
Yes No / TOTAL LICENSED CAPACITY / RESPITE CONTRACT
Yes No / RESPITE CAPACITY
NUMBER OF RESIDENTS / DDA: CA:
INDIVIDUALS RESIDING IN THE HOME / AGENCY PROVIDING
OVERSIGHT (DDA / CA) / SOCIAL WORKER / DATE OF
BIRTH / STAFFING RATIO
(PER CLIENT RATE ASSESSMENT)
PREVIOUS VISIT DATE / TYPE OF PREVIOUS VISIT (ANNUAL OR BY REQUEST)
Summarize review of previous QA Assessment and/or corrective action report to provide a brief summary of identified areas that required corrections:
DSHS 21-059 (REV. 09/2017) Page 1
Social Worker and Supervisor current issues / concernsAssessor should obtain information below from regional Voluntary Placement Services (VPS) Coordinator, Resource Manager, and/or Social Workers prior to conducting QA assessment. See DDA MB D10-016.
If home has DDA residents from other regions, a conference call should be scheduled with the other region. Content should include issues or outstanding compliance concerns with DDA contract, WAC and/or policy.
Has there been any known child / youth support issues this past year?
Is the child / youth receiving the level of supervision per current rate and staffing schedule?
Is the child / youth receiving treatment services (OT, PT, ST) including behavior support?
Is there documentation of family contact and community integration per activity program?
Is the child / youth receiving instruction and support that work towards increased independence and/or maintaining skills and abilities (teaching strategies with ADL / IADLs)?
Is the DDA Worker receiving timely and thorough reports and communication from the agency?
Is the child / youth maintaining a health care schedule (i.e. annual medical and dental checkups, neurologist, medication review, mental health professional, nutritionist, etc.)? If no, provide explanation.
Review any DLR compliance agreements for the past year.
Additional comments:
First Impressions / Yes / No / N/A / Comments (provide specific information on “No” and “N/A” responses only)
DSHS 21-059 (REV. 09/2017) Page 1
Are staff aware of the planned QA visit?Do residents appear clean, with clean clothing, hair brushed, etc.?
(WAC 388-145-1780)
Are residents engaged with staff, visitors, or in activities in or out of the residence?
Is the residence free of unpleasant odors? (WAC 388-145-1555)
Does the residence appear to be personalized by the residents (i.e., looks like their home)?
(WAC 388-145-1555)
Home Environment and Safety / Yes / No / N/A / Comments (provide specific information on “No” and “N/A” responses only)
Exterior
Is the exterior in good repair?
(WAC 388-145-1555)
Yard / lawn maintained and free of debris? (WAC 388-145-1555)
Residence address number visible; residence accessible to emergency vehicles?
(WAC 388-145-1555)
Interior
Interior clean and in good sanitary condition? (WAC 388-145-1555)
Are all utilities operating (i.e., water, sewer, heat, electricity)?
(WAC 388-145-1555)
Is furniture in good repair?
(WAC 388-145-1555)
Are there handrails for steps, stairs, and ramps if required per DLR and/or client support plans?
(WAC 388-145-1555)
Licensed posted in view of public?
(WAC 388-145-1345)
Bedrooms / Shared Areas
Are shared / single bedroom requirements being followed?
(WAC 388-145-1605)
LSR - one child per bedroom?
Medically Intensive Group Home - no more than four residents per room?
Are the bedrooms and shared areas clean and free of odors?
(WAC 388-145-1555)
Individual bedrooms are reflective of the resident’s interest?
Approved use of side bed rails per physician’s order?
(DDA Policy 5.20)
Alarms on doors and/or windows per client support plans?
(WAC 388-145-1625)
Do bedroom windows have appropriate covering?
(WAC 388-145-1555)
Use of approved video / audio monitors (excluding MICP and infants) per client support plans?
(WAC 388-145-1625)
Kitchen
Are appliances in good working order? (WAC 388-145-1555)
Is there a variety of foods and is the amount of food sufficient for residents? (WAC 388-145-1795)
Is there a weekly menu of meals and snacks available?
(WAC 388-145-1790)
Bathroom(s)
Are the bathrooms clean, free of
mold / odors, and in good sanitary condition? (WAC 388-145-1555)
Are secure, adequate grab-bars provided per client support plans?
(WAC 388-145-1560)
Bathroom(s)
Dangerous chemicals inaccessible and stored securely per client support plans? (WAC 388-145-1580)
Are all medications properly labeled and appropriately stored in a locked container? (WAC 388-145-1850)
Exits, corridors, aisles, doorways and other evacuation paths are accessible, unblocked and free of obstacles / barriers / hazards?
(WAC 388-145-1555)
Is there documentation of monthly fire drills and semiannual smoke alarm / detector checks?
(WAC 388-145-1675;
WAC 388-145-1685)
Carbon monoxide alarm on each floor and near bedroom(s)?
(WAC 388-145-1680)
First-aid supplies are stocked and adequate? (WAC 388-145-1640)
Are knives / sharps secured per client support plans? (DDA Policy 5.20)
Posted emergency numbers (including poison control) for both resident and staff access? (WAC 388-145-1555)
Meaningful Activities / Yes / No / N/A / Comments (provide specific information on “No” and “N/A” responses only)
Documentation of an activity program that includes variety of age-related activities to integrate each resident in the community? (WAC 388-145-1735)
Out of the past seven (7) full calendar days, how many days have the residents left their home (defined as going beyond their yard, regardless of where and with whom)?
Residential Name / Days 1 through 7 / Total Days / If resident did not access the community five (5) or more days; what was the primary barrier?
Transportation unavailable Staffing Lack of interest
Physical issues Behavioral issues Other
Transportation unavailable Staffing Lack of interest
Physical issues Behavioral issues Other
Transportation unavailable Staffing Lack of interest
Physical issues Behavioral issues Other
Transportation unavailable Staffing Lack of interest
Physical issues Behavioral issues Other
Transportation unavailable Staffing Lack of interest
Physical issues Behavioral issues Other
Transportation unavailable Staffing Lack of interest
Physical issues Behavioral issues Other
Other (if “Other” checked above, explain):
Support Planning / Mark either “Yes” with date met or reviewed; “No” if not located or incomplete
for each client record reviewed
Client Name (may enter up to four)
Client records system is orderly, consistent, secured and kept confidential? (WAC 388-145-1520; WAC 388-145-1530)
Documentation of data collection and monitoring is consistent and occurring every 30 days?
Approved Functional Analysis (FA) and Positive Behavior Support Plans (PBSP) are current and signed by DDA staff?
Current Individual Education Plan (IEP)? (WAC 388-145-1520)
Current Shared Parenting Plan (SPP) for child/youth under age 18?
Documentation of current treatment plan and up to date Quarterly Reports submitted to DDA?
(WAC 388-145-1725)
Documentation of incident reports including notification to DDA, DLR, CPS, parents, etc., as appropriate?
(WAC 388-145-1535)
Current property inventory (reviewed annually as a best practice)?
(WAC 388-145-1520)
Current Signed DDA / ISP maintained in child records?
(WAC 388-845-3055)
Medical / Medication Records: Mark either “Yes” with date met or reviewed; “No” if not located or incomplete
Documentation that regular, necessary medical and dental appointments are maintained (includes date, reason for visits, and instructions)? (WAC 388-148-1550; WAC 388-145-1840)
Is the administration of medications being documented on the medication log/MAR consistently and in a timely manner? (WAC 388-145-1855)
Does the medication log / MAR and the medications onsite match?
Is there a protocol information sheet for each psychoactive medication? (DDA Policy 5.19)
Documentation for nurse delegation for child / youth age 18-21?
(DDA Policy 6.15; 6.19)
Physician approved restricted diet (signed annually by PCP)?
(WAC 388-145-1800)
Child specific supervision needs (i.e. seizure log, health or safety issues)? (WAC 388-145-1515)
Observations: Briefly discuss interactions that were observed during the time of the visit including child/youth’s appearance, staff engagement, teaching and training strategies, skill development, medication administration, etc.
Client name:
Comments:
Client name:
Comments:
Client name:
Comments:
Client name:
Comments:
Interviews: Conduct a random sample of a minimum of two direct care staff (staff present during the time of the visit), two residents (if able, dependent on the household size), and two parents or family members
Direct Care Staff Interview
Staff Name:
How long have you worked here?
What kind of training have you had in the following areas?
· Supervising children / youth?
· Behavior management / “discipline” / restraining or restrictive procedures?
· Medical treatment / emergency triage?
· Specialized areas i.e. developmental disabilities, mental health, sexual / physical aggression, abuse / neglect, etc.?
What does it mean to be a mandatory reporter?
What training have you had around mandatory reporting?
Do you know how to report incidents of abuse, neglect, exploitation or abandonment of a child / youth (i.e. directly to CPS and law enforcement)?
Do you know the timeline for reporting suspected incidents (i.e., immediately but within 48 hours if related to sexual or physical abuse, neglect or exploitation, etc.; as soon as possible but within 48-hours if related to suicidal / homicidal behavior, medication error, emergency medical care, etc.)?
What are some significant support needs you face here at work (challenging behaviors / medical issues)? How do you typically respond to them?
Do you think there is an adequate number of staff to provide supervision?
Do you feel supported by your agency?
Staff Name:
How long have you worked here?
What kind of training have you had in the following areas?
· Supervising children / youth?
· Behavior management / “discipline” / restraining or restrictive procedures?
· Medical treatment / emergency triage?
· Specialized areas i.e. developmental disabilities, mental health, sexual / physical aggression, abuse / neglect, etc.?
What does it mean to be a mandatory reporter?
What training have you had around mandatory reporting?
Do you know how to report incidents of abuse, neglect, exploitation or abandonment of a child / youth (i.e. directly to CPS and law enforcement)?
Do you know the timeline for reporting suspected incidents (i.e., immediately but within 48 hours if related to sexual or physical abuse, neglect or exploitation, etc.; as soon as possible but within 48-hours if related to suicidal / homicidal behavior, medication error, emergency medical care, etc.)?
What are some significant support needs you face here at work (challenging behaviors / medical issues)? How do you typically respond to them?
Do you think there is an adequate number of staff to provide supervision?
Do you feel supported by your agency?
Child / Youth: Mark “N/A” if child / youth is unable to participate.
Client Name:
What chores do you do on a regular basis? What new skills are you learning?
What activities do you like to participate in during the week? What activities do you like to do on the weekends?
What happens when you get into trouble? What are the consequences?
If you needed help, who would you go to?
Do you go to the store with staff to pick out things you want?
Do you have a DDA Social Worker? What is your Social Worker’s name?
Client Name:
What chores do you do on a regular basis? What new skills are you learning?
What activities do you like to participate in during the week? What activities do you like to do on the weekends?
What happens when you get into trouble? What are the consequences?
If you needed help, who would you go to?
Do you go to the store with staff to pick out things you want?
Do you have a DDA Social Worker? What is your Social Worker’s name?
Parent / Family: Assessor to contact parents/family of child/youth receiving VPS only to get feedback on current issues, questions or concerns pertaining to services to their child/youth)
Parent Name:
How do you stay in touch with your child?
When did you last visit?
Do you have any health and safety concerns regarding your child’s residence? Yes No; if “No,” what are your concerns?
Do you think your child receives adequate supervision? Yes No; if “No,” what are your concerns?
Has your child ever expressed having problems at the home, with staff or other residents? Yes No
If yes, how were the concerns addressed and resolved?
Do you feel your child’s medical needs are being met? Yes No; if “No,” what are your concerns?
Do you feel your child’s educational needs are being met? Yes No; if “No,” what are your concerns?
Have you been included in the IEP conferences? Yes No
Do you feel your child’s behavioral needs are appropriately supported? Yes No; if “No,” what are your concerns?
Is there anything else you would like me to know?
Parent Name:
How do you stay in touch with your child?
When did you last visit?
Do you have any health and safety concerns regarding your child’s residence? Yes No; if “No,” what are your concerns?
Do you think your child receives adequate supervision? Yes No; if “No,” what are your concerns?
Has your child ever expressed having problems at the home, with staff or other residents? Yes No
If yes, how were the concerns addressed and resolved?
Do you feel your child’s medical needs are being met? Yes No; if “No,” what are your concerns?
Do you feel your child’s educational needs are being met? Yes No; if “No,” what are your concerns?
Have you been included in the IEP conferences? Yes No
Do you feel your child’s behavioral needs are appropriately supported? Yes No; if “No,” what are your concerns?
Is there anything else you would like me to know?
Corrections, Consultations, and Follow-Up
Review the assessment and summarize the areas marked “No”. These require follow-up and action by the VPS coordinator, resource manager, and/or social worker(s). Recommendations and suggestions for “best practice” can also be included as they relate to DDA contract and policy, and WACs.
DSHS 21-059 (REV. 09/2017) Page 1