1
07/11/2003
QIS FORM D STAFF SURVEY
Agency/Site:______Date:______
Name of Staff:______How long employed?______
Ask one staff from each service area any two questions under each heading. Staff will need to answer both questions correctly in order to get the section “MET.” If a staff member misses one or both questions, the staff survey area will be considered NOT MET; the QIS will fill out a QAOS. When doing the survey, the QIS will circle “+” if the staff answered correctly or circle
“-“ if the staff answered incorrectly.
ABUSE/NEGLECT REPORTING:METNOT MET
(ARM 37.34.1501 & .1506, MCA 41-3-201 and 52-3-811)
*review June 11, 2002 letter from Jeff Sturm regarding Incident Report Procedures and agency policy.
+ -Q: When ABUSE/NEGLECT/EXPLOITATION is witnessed or suspected, direct service staff are MANDATORY REPORTERS. Allegations are reported to......
A:
+ -Q: If you witness or suspect ABUSE/NEGLECT/EXPLOITATION and want to report it to APS, do you have to first notify your supervisor?
A:
+ -Q: If there is imminent risk to a consumer, is a report to APS adequate:
A:
+ -Q: If you discovered a consumer being physically abused by a staff person, what should be your first course of action?
A:
+ -Q: Describe your agencys internal reporting procedure for allegations of ABUSE/NEGLECT/EXPLOITATION.
A:
CLIENT RIGHTS:MET NOT MET
(DD Policy 411.5, ARM 37.34.701, ARM 37.34.1418, 37.34.1501 & .1506,
GH ARM 37.100.330)
+ -Q: You have a consumer with a history of stealing. You suspect he has taken another consumer’s gloves. What would you do?
A:
+ -Q: A doctor appointment has been requested by the individual’s IP team. The symptoms which prompted the request have not been seen in 3 weeks. You think the appointment is no longer necessary? What do you do?
A:
+ -Q: You and a new staff are working together with an individual. The individuals bumps his/her elbow and lets out a curse word. You ask the individual if he/she are okay and remind him/her of other words he/she can use. The new staff asks you why you don’t punish the person (i.e. go to his/her room, leave work, not let him/her go on an outing). What is your response?
A:
+ -Q: An individual wants to walk to the store. She has no jacket and it is –25 degree outside. What can you do?
A:
+ -Q: Do any of the consumers have rights restrictions here? Who? What is the restriction?
What is being done to allow that consumer to get his/her rights reinstated?
A:
BEHAVIOR SUPPORT PLANS & PROTOCOLS:MET NOT MET
(Only applies if a person at that site has a behavior support plan/protocol)
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM 2101, et seq.)
Review the plan first. Make sure you are using the same terms as written in the plan.
+ -Q: Ask staff to label and define at least one of the target behaviors.
A:
+ -Q: Ask staff to describe the Reactive Strategies.
A:
+ -Q: Ask staff to list 2 or 3 of the Proactive or Environmental Strategies.
A:
+ -Q: What can happen if the Behavior Plan is not implemented with consistency?
A:
1
07/11/2003
+ -Q: Describe the training you received in the implementation of the plan? How often? Who does the training?
A:
ORIENTATION TRAINING:MET NOT MET
(GH - ARM 37.100.322, SL - ARM 37.34.712, ARM 37.34.2102 & .2107)
+ -Q: You run into Mike (who you used to work with at the day program) at the local grocery store. He says he heard that Joe’s (a consumer) health is not good and he would like to visit Joe. He asks how to reach Joe. What do you tell him?
A:
+ -Q: Explain what confidential information is? Who has access to the consumer’s information.
A:
+ -Q: What type of orientation training did you receive when you started working here? When did you receive it? (ask this question if hired within the past 1 year).
A:
+ -Q: How were you trained to meet the health and safety needs of the individuals? (this question can be for staff who have been employed longer than one year).
A:
+ -Q: Describe the emergency evacuation procedure? How do you document an emergency evacuation? What happens if problems are identified?
A:
SUPERVISING MEDICATIONS:MET NOT MET
(ARM 37.34.114)
+ -Q: Role-play or describe the procedure for supervising medications.
A:
+ -Q: What would you do if a medication was unavailable (bottle/bubble-pack empty), missing, etc.
A:
+ -Q: What would you do if you erroneously gave someone a different persons medications?
A:
+ -Q: If someone were capable of taking his/her own medications and they move to a new living situation or started taking a new medication, what do you need to do?
A:
+ -Q: What is required for staff to assist consumers in taking their medications?
A.
+ -Q: Does anyone here receive PRN or OTC medications? How is it decided when to administer a PRN or OTC medication?
A:
+ -Q: What constitutes a medication error? How do you document a medication error?
A:
BEHAVIOR INTERACTIONS WITH CONSUMERS:METNOT MET
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM 2101, et seq.)
+ -Q: If a consumer were destroying things, what would you do?
A:
+ -Q: If a consumer were to pinch a staff and you observe the staff pinching back, what do you do?
A:
+ -Q: If a consumer was hurting himself or others and you have tried a number of non-aversive techniques such things as talking to him, redirection, stimulus change, yet the individual is still causing or about to cause significant injury to another person (tipping an individual’s wheelchair over) what emergency procedures can be used?
A:
+ -Q: If a consumer frequently becomes out of control and endangers themselves or others and they surpassed the 3 times in a 6 month time period for the use of emergency procedures, what do you do?
A:
+ -Q: What sorts of things would lead you to believe that someone needed a behavior support plan? What would you do?
A:
EMOTIONALLY RESPONSIBLE CAREGIVING:METYESN0
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM 2101, et seq.)
+ -Q: An indicator of abuse in a caregiving environment is a power struggle. If during your shift, a consumer refused to get onto the van what steps would you take to avoid a power struggle?
A:
+ - Q: Another indicator of abuse in a caregiving environment is the response to
an upset person. If you observed an individual becoming agitated because he/she couldn’t find his/her lunchbox, how can you assist the individual?
A:
+ -Q: What can you do if you feel youre beginning to lose control?
A:
INDIVIDUAL PLANS (IPS)METNOT MET
(ARM 37.34.701 & .702, ARM 37.34.1101, et seq., ARM 37.34.2107)
+ -Q: What are Individual Plans based on?
A:
+ -Q: If you have an idea for a training objective or suggestions for changing a current objective, who do you talk to?
A:
+ -Q: What is an assessment? What is the purpose of doing assessments?
A:
+ -Q: How do you find out what a person would like to have happen or would like to do?
A:
INCIDENT REPORTING:METNOT MET
(ARM 37.34.1501, et seq.)
+ -Q: When would you fill out an incident report?
A:
+ -Q: What is the notification procedure if an individual goes to the emergency room?
A:
1
07/11/2003
+ -Q: If two consumers are involved in an incident, how do you document?
A:
+ -Q: Who writes the incident report?
A:
+ -Q: Do you fill out an incident report for alleged abuse/neglect/exploitation? What do you do with that IR.
A: