CDDP Site Visit File Review Document
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IndividualCDDP Date of Review
DOB SE: Service Coord. Reviewer
Requirement / Yes / No / NA / Date Noted in File / Comments/NotesI / Case File Information - General
1 / Summary Sheet - OAR411-320-0070(3)(b)-(c)
- Is there a summary sheet in the file?
- Is it complete?
- Is it current?
2 / In the event of change in service coordinators (w/in the past 12 months) there is documentation of notification of change in file & that individual/ family are notified. – OAR411-320-0100(2)(a)(b) / Would expect to see copy of letter sent to individual/family in file and case note stating change. Must include name, phone # and address of new SC. / 0016
Requirement / Yes / No / NA / Date Noted
in File / Comments/Notes
II / Case File Information – General (cont)
1 / Current Enrollment Forms (CPMS, eXPRS, DHS-0337) / 0017
2 / Legal Papers (Guardianship, Probation/Parole, PSRB, Commitment, etc.) OAR 411-320-0070(3)(a)(P) / 0018
3 / Copy of completed Initial Title XIX Waiver in file
OAR 411-320-0070(3)(a)(N) / 0059
4 / Title XIX Waiver Annual Level of Care Review is complete OAR 411-320-0070(3)(a)(N) / 0019
5 / Notice of Right to Admin Review & Title XIX Medicaid Fair Hearing / 0060
Requirement / Yes / No / NA / Date Noted in File / Comments/Notes
III / Monitoring Activities for DD50, DD58, & DD51 (DD51 One time a year monitoring)
(OAR 411-320-0130)
SITE MONITORING
1 / The following documentation is found in file:
- Evidence that the monitoring occurred
- Monitoring occurred within timelines identified in OARs (including 1x per year to employment site)
- Needed changes are identified
- If a needed change is identified, is there evidence of follow up?
- Did follow up lead to improvement of support or services?
SERVICE MONITORING
2 / The following documentation is found in the file:
- Evidence that services are being monitored
- Monitoring occurred within timelines per OARs
- Is the checklist complete?
- Do the services or supports identified in the plan continue to meet needs? (i.e., important to/for, goals are still relevant, supported and met)
- If a needed change is identified, is there evidence of follow up?
- Did follow up lead to improvement of support or services?
3 / For SE 58 Plans: If consultation funds are included in the rate, is there evidence that the use of consultation funds has been monitored? / 0067
4 / Evidence of consideration of serious events and unusual incident report resulting from monitoring visits / 0027
5 / Semi-annual review conducted for individual’s funds / 0025
Schedule for minimum monitoring visits:
Monitoring is required ¼, and ISP services; health and safety, behavior; and facility must be monitored a minimum of 1x per year
Requirement / Yes / No / NA / Date Noted in File / Comments/NotesIV / Incident Reports/SERT/PSI Services
OAR 411-320-0070(3)(a)(L) & (M) and 411-320-0140
1 / Copies of IRs are kept in accordance with OARs / 0068
2 / Documentation of review of Unusual Incidents received from Service Provider by CDDP staff / 0029
- Is there a progress note of the Unusual Incident?
- Copy of Unusual Incident IR is in the client file
- If IR meets SERT criteria, is it entered into the SERT system?
3 / Documentation of report of SERT events & appropriate Follow-up / 0030
- Documentation of appropriate follow-up
4 / Documentation of notice to guardian of initiation of PSI investigation / 0031
5 / Documentation of PSI investigation outcome and required follow-up / 0032
Requirement / Yes / No / NA / Date Noted in File / Comments/Notes
V / Case Notes
OAR 411-320-0070(4)(a)-(f)
1 / Case Note Integrity:
- Date service provided
- Date entry made if different from the date of service
- Late entries noted appropriately
- Chronologically organized
- Errors corrected promptly
2 / Case Note Quality:
- Linked to plan (whenever possible)
- Sufficiently documents specific services provided, action taken
3 / Targeted Case Management:
- Is there a corresponding case note for each TCM encounter?
- Does the date for each encounter match the date on the case note?
Requirement / Number / Comments/Notes
V / Case Notes (continued)
OAR 411-320-0070(4)(a)-(f)
3 / Targeted Case Management (continued)
- How many submitted encounters met the TCM Criteria?
- How many submitted encounters were reviewed?
OTHER COMMENTS/FEEDBACK:
Form:Main Checklist Version:7 Next Record Key: 0076 Load Date-Time
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