07/11/2003

APPENDIX C

FORMS A & B

QUALITY ASSURANCE CHECKLIST (FORM A)

Agency: Period of Review: ______

Consumer reviews list initials and date of verification: ______

______

IP’s / Indiv. / Indiv. / Indiv. / Indiv. / Indiv. / Comments
Consumer/Family surveys
IP documents available to all staff
IPP’s and objectives implemented as specified
IPP and objective data collected
IPP and objective data internally monitored
Self Medication objectives
Rights Restrictions
IP’s (at case manage-ment) / IP Checklist
IP addresses specific needs of the individual
IP based on Assessments
Quarterlies
Incident Reports, issues addressed in IP
Behavior Support needs addressed in IP
Functional Analysis, needed/completed
Freedom from Aversive Procedures

* It is the responsibility of the QIS to refer issues noted with Individual Plans through the IP Team process. Areas of concern that involve case management are to be referred to the case management supervisor by the QIS*

QUALITY ASSURANCE CHECKLIST (FORM A)PAGE 2

Agency: Period of Review: ______

Date(s) of Review: QIS: ______

Can be completed by Desk Review at DDP office: / Comments
Accreditation
Fiscal - Audit, cost plans, invoices
Quality Assurance Observation Sheets Trends from the past year
Medication Errors
Quarterly reviews from the past year / Q1 / Q2 / Q3 / Q4

Rights Restrictions/violations

Incident Reports/Reporting: Abuse/Neglect/Exploitation &
Trends from the past year
Can be completed at main office of agency (complete staff file review with Human Resource Manager or Training Coordinator
Licensing (completed; follow up / trends from report)
Criminal Background Checks (Sample 3-5 staff files for verification of DOJ check)
Fire Drills/Demonstration of ability to exit (*Cross check drill data with IP Team records for GH residents home alone)
Orientation Training review packet & documentation of staff attendance (Sample 3-5 training files of new hires)
Staff enrolled in DDCPT/equivalent (intensive services only)
Review Policies, Procedures and Processes to ensure supervision of staff & staff satisfaction surveys
Review Policies and procedures to ensure individuals or families have choice of supported living staff

QUALITY ASSURANCE CHECKLIST (FORM B)

Agency: Period of Review: ______

Date(s) of Review: QIS: ______

Bold indicates standards that best apply to facility-based sites or provider-owned services. Health / safety concerns for community employment sites or services delivered in the individual’s own or family home should (minimally) be addressed through the IP Team process and Documentation of Choice Form. Supported Living Health and Safety Requirements apply regardless of where the service is delivered.

Site / Site / Site / Site / Site / Comments
Health
/ Safety: /

Bathing Procedures addressed in IP’s for individuals with seizures

Clean/sanitary environment
Egress
Hot water temperature in bathing areas
Emergency assistance/back-up
Fire extinguishers/ smoke detectors
PRN Medications
Medication procedures
Medications locked/storage
Medication Administration Records
Staff Ratios

Awake overnight staff

Adequate supplies
Storage of supplies

QUALITY ASSURANCE CHECKLIST (FORM B)PAGE 2

Agency: Period of Review: ______

Date(s) of Review: QIS: ______

*Bold indicates standards that apply to facility-based sites or provider-owned services only. Health / safety concerns for community employment sites or services delivered in the individual’s own or family home should (minimally) be addressed through the IP Team process and Documentation of Choice Form. Supported Living Health and Safety Requirements apply regardless of where the service is delivered.

Site specifics/Self-
Deter-mination/Active Treat-ment/ Staff training/Daily routines / Site / Site / Site / Site / Site / Comments
Weekly opportunities for integrated community activities
House Rules/Site Rules
Opportunities to make choices / self determination

Meal prep/ Mealtime

Involvement / Engagement in daily life

Participation in Daily Living Skills
Daily opportunities for a variety of leisure activities
Staff trained in individual specifics
Staff Questionnaires

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