The Following Policies Are Required to Be Submitted to the Regional Office

Agency Name:

The following policies are required to be submitted to the Regional Office.

Updated: 05.11.2017

Agency Name:

1-Accounting for Personal Funds

2-Advocacy

3-Crisis Intervention Policy

4-Complaint Resolution

5-Emergency/Urgent Care

6-Fire, Sanitation and Emergency Precautions

7-Health Care Needs (ISP) – HIPAA

8-Incident Management

9-Protection of Rights

10-Quality assessment, assurance, and improvement

11-Records Management

12-Respect to Persons Supported

13-Title VI

14-Transportation to People supported

15-Use of Positive Approaches

16-Well Trained Staff

Updated: 05.11.2017

Agency Name:

For all of the above there are “critical element” review sheets which detail what should be included.

17 -Personnel Policies that at least address:

Updated: 05.11.2017

Agency Name:

• Hiring Procedures, Process and Minimum Qualifications
• Progressive Disciplines
• Employee Grievance Procedure
• Employee Driving Own Vehicle
• Employment Screening

Updated: 05.11.2017

Agency Name:

Policy / Policy Reference / Critical Elements / Complete
Yes No
Accounting for Personal Funds
*If the provider manages or assists in management of personal funds. / A.DIDD Personal Funds Policy #80.4.3
B.QA Organizational Checklist: Domain 10 (10.B.1.)
C.TCA §33-1-302 and 303; §4-3-2708
D.Executive orders of the State of Tennessee #9, 10, 21, and 34
E.DIDD Provider Manual /

1. 1. The person participates in their own finances to the extent of their capabilities.

2. How personal funds will be maintained securely and safeguarded including limitations on staff access to personal funds.
3. Limitations on staff access to personal funds.
4. A separation of duties concerning personal funds (Personal allowance and petty cash in the home).
5. The staff positions authorized to approve disbursements.
6. The staff positions authorized to sign checks drawn on personal accounts.
7. A statement of the agency's liability in the case of loss of personal funds due to staff negligence or theft. The statement needs to include the staff positions covered in the agency's fiduciarybond.
8. Ensure records are kept for each person served.
9. Which fees and costs the individual is responsible for paying and the extent the agency will financially assist the individual in paying these costs, if necessary.
10. The procedure or basis used to determine a person's rent or room and board charges.
11. Personal funds are kept separate from agency funds.
12. Personal funds are not used to supplement agency funds.
13. Staff does not borrow money nor accept personal benefits from people.
14. How direct support and other designated staff are trained on agency policies and procedures
15. Agency’s oversight of the accumulation of personal funds to prevent loss of benefits (SSI, Medicaid eligibility)
16. Advancement of funds on behalf of persons supported if the agency chooses to advance funds.
Comments:
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Advocacy / A.Personal outcome measures: CQL-Factor 3
B.QA Organizational Checklist: Domain 4
C.DIDD Provider Manual /

1. Advocate for the person supported and arrange for external advocacy services as needed.

1. Delineates activities the agency may engage in to assist in advocacy efforts (e.g., participation on work groups, committees, task forces related to advocacy efforts; efforts at encouraging and supporting participation by individuals in advocacy groups).

1. Opportunities available for staff to express their ideas, concerns or complaints which affect people they support (e.g., at regular staff meetings, meetings with supervisors of the agency, meeting with members of the board of directors) without fear of retribution and which ensure such issues will be seriously considered and addressed.

1. Accessing Natural Supports and assisting the person’s supported to build a Natural Support Network. Natural supports are family members and close (constant, stable, steady, long-lasting, and established) friends of the person using services. A natural support can be someone who is relatively new in the life of the person using services.

1. Providers are required to supply information and skills training as necessary to provide safe and effective natural supports. The information and training may be based on the time they are spending together with the person. Consent must be obtained from the person served or their legal representative in writing before any personal information is shared.

Comments:
CQL Factor 3: Natural Support Networks
•3a Policies and practices facilitate continuity of natural support systems.
•3b The organization recognizes emerging support networks.
•3c Communication occurs among people, their support staff and their families.
•3d The organization facilitates each person’s desire for natural supports.
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Complaint Resolution /

1. Provider Manual
2. Performance Measures

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1. Complaint resolution procedures for persons supported, family members, and legal representatives.

1. Complaint Resolution Tracking.

1. Complaint data is utilized to monitor compliance with the federally mandated health and welfare assurance and related CMS-approved performance measures.

1. Providers are required to establish a complaint resolution process to address complaints submitted by persons using services and families.

1. Providers are also required to have an identified complaints contact person and to maintain documentation of all complaints filed.

1. Complaint procedures and pertaining to alleged Title VI violations for persons supported.

Comments:
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Crisis Intervention
Policy / A.DIDD Provider Manual
B.CQL Factor 1a, 1b, 1c, 1d, 1e
C.CQL Factor 3c
D.CQL Factor 5f
E.CQL Factor 6a, 6c
F.CQL, Factor 8a, 8c,8d, 8e
G.QA Organizational Checklist: Domain 4 / 1. Instructions for use of PRN psychotropic medications and behavioral safety interventions as applicable.
2. Assurance that procedures are only used in response to behaviors which present risk of harm.
3. Assurance that procedures is in alignment with DIDD procedural definitions.
4. References to de-escalation and redirection techniques which are used prior to behavioral safety interventions.
5. Assurance that behavioral safety interventions are only used when they are in the safest most appropriate response.
6. Safeguards to prevent misuse of behavioral safety interventions.
7. Mechanisms for recording the agency’s use of behavioral safety interventions.
8 Mechanisms for reviewing the agency’s use of behavioral safety interventions.
9. Mechanisms for ensuring a behavior assessment is requested when a person has 3 uses of behavioral safety intervention of PRN medication within a 6 month period.
10. General procedures for managing crisis situations involving outside entities including staff monitoring of a person’s status until it is clear the person has been admitted to a facility.
11. Policy is approved by HRC.
Comments:
CQL Factor 1: Rights Protection and Promotion: Indicators 1a, 1b, 1c, 1d, 1e

• 1a The Organization implements policies and procedures that promote people’s rights.
• 1b The organization supports people to exercise their rights and responsibilities
• 1c Staff recognizes and honors people’s rights.
• 1d The organization upholds due process requirements,
• 1e Decision-making supports are provided to people as needed.

CQL Factor 3: Natural Support Networks: Indicator 3c

• Communication occurs among people, their support staff and their families.

CQL Factor 5: Best Possible Health: Indicator 5f

• 5f Staff immediately recognizes and responds to medical emergencies.

CQL Factor 6: Safe Environments: Indicators 6a, 6c

• 6a The organization provides individualized safety supports.
• 6c The organization has individualized emergency plans.

CQL Factor 8: Positive Services and Supports: Indicators: 8a, 8c, 8d, 8e

• 8a People’s individual plans lead to person-centered and person-directed services and supports.
• 8c The organization provides positive behavioral supports to people.
• 8d The organization treats people with psychoactive medications for mental health needs consistent with national care standards of care.
• 8e People are free from unnecessary, intrusive interventions.

Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Emergency/
Urgent Care /

1. Personal Outcome Measures: CQL, Factor 5-Best Possible Health.
2. QA Organizational Checklist: Domain 5

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1. The nature and the involvement of the support coordinator and provider.

2. Notification requirements
3. Documentation requirements
4. Instructions on what an emergency looks like, as well as, what to do and who to contact in an emergency for people identified as having high medical and/or behavioral or mental health needs.
5. Instructs staff 911 calls must not be delayed.
6. Indicates information regarding initiation of emergency first aid procedures.
7. Indicates requirements for provision of information to emergency medical staff.
8. Indicates requirements for notification of designated provider supervisory staff.

1. Addresses first aid kits to include the following:
2. accessibility
3. locations
4. contents
5. security
6. periodic review and restocking

Comments:
CQL Factor 5-Best Possible Health
•5a People have supports to manage their own health care.
•5b People access quality health care.
•5c Data and documentation support evaluation of health care objectives and promote continuity of services and supports.
•5d Acute health needs are addressed in a timely manner.
•5e People receive medications and treatments safely and effectively.
•5f Staff immediately recognize and respond to medical emergencies.
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Fire, Sanitation and Emergency Precautions / A.DIDD Licensure Rules, Chapter 0940-5-5.02, General environmental requirements for all facilities.
B.Personal Outcome Measures: CQL, Factor 6-Safe Environments
C.QA Organizational Checklist: Domain 3 (3.A.3.; 3.A.5.; 3.A.6.; 3.A.7.; 3.B.2.) / 1. Agencies have emergency plan in effect in the event of fire, severe weather, or health crisis (includes an evacuation plan and documented regular drills).
2. Agencies have approved compliance record from fire, health and environmental safety authorities.
3. Persons served are not put at risk for safety hazards (i.e.; people serving more than one person in a wheelchair have adequate staff for evacuation procedures.
4. Homes/facilities must be maintained in a safe manner and continuing effort made to eliminate potential hazards.
5. Homes/facilities must be maintained in a sanitary and clean condition, free from all accumulation of dirt and rubbish, well ventilated, and free from foul, stale, or musty odors.
6. Homes/facilities must be kept free of mice, rats, and other rodents.
7. Housekeeping practices and standards must be maintained which will ensure the eradication of flies, roaches, and other vermin.
Comments:
CQL Factor 6 Safe Environments
•6a The organization provides individuals safety supports.
•6b The physical environment promotes people’s health, safety and independence.
•6c The organization has individualized emergency plans.
•6d Routine inspections ensure that environments are sanitary and hazard free.
Reviewers: Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Health Care Needs /

1. Personal Outcome Measures: CQL, Factor 5-Best Possible Health
2. Provider Manual
3. QA Organizational Checklist: Domain 5
4. T.C.A. §33-3-103
5. HIIPAA standards

/ 1. Name of current MCO/BHO and ID# are in the person’s file. (include additional insurances).
2. Name of contact people and their phone numbers are in the person’s file.
3. Current names of PCP including phone numbers are in the person’s file.
4. All medical specialists and their phone numbers are listed in the person’s file.
5. Description of individual’s overall health and specific issues or conditions is listed in the person’s file as specified in the individual transition plan (ITP) or ISP
6. Name and contact information or specific requirements:
a). For medical specialists, dentist, therapies, home health services, medical supplies, transportation, outpatient services, diagnostic/labs, hospitalizations, and emergencies.
b). Information regarding medications
c). Individual medical history
d). Information regarding equipment (assistive, durable medical, durable supplies, and communication devices)
e). Information regarding any special medical condition and the treatment required.
7. Includes compliance with confidentiality requirements (HIPAA Standards)
Comments:
CQL Factor 5-Best Possible Health
•5a People have supports to manage their own health care.
•5b People access quality health care.
•5c Data and documentation support evaluation of health care objectives and promote continuity of services and supports.
•5d Acute health needs are addressed in a timely manner.
•5e People receive medications and treatments safely and effectively.
•5f Staff immediately recognizes and responds to medical emergencies.
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Incident Management /

1. DIDD Provider Manual
2. Personal Outcome Measures: CQL, Factor 4-Protection from Abuse, Neglect, Mistreatment and Exploitation
3. TCA §37-1-403, §37-1-605, §71-6-103 (b) (1) & §71-6-103 (2) (c)
4. Quality Assurance Checklist, Domain 3 (3.C.4., 3.C.5., 3.C.7., 3.C.10. and 3.C.12.)

/ 1. Incidents that are defined as Reportable Incidents which must be reported to the DIDD Central Office.
2. Reportable Incidents which must be reported immediately (within four hours) to the DIDD Investigation Hotline.
3. Review, follow-up and closure of Reportable Incidents.
4. Requirements for notification of entities external to the provider organization and DIDD of the occurrence of Reportable Incidents and of pending DIDD investigations.
5. Timely response to Reportable Incidents and DIDD investigations.
6. Trend studies of Reportable Incidents and substantiated reports of abuse, neglect, and exploitation.
7. Risk assessments/reviews of persons supported, community homes/programs or other situations/circumstances which trend studies identify as presenting high protection and safety risks.
8. Immediate response to Safety and Health risks associated with Reportable Incidents.
9. Policy addresses 15 types of incidents: death, abuse, neglect, exploitation, injuries, accidents, elopement, choking/aspiration, seizures, swallowing inedible/harmful matter, non-consensual sexual activity, medication error, physical aggression, self-injurious behavior, and behavioral interventions.
10. All Reportable Incident Forms (RIF) must be accurately completed.
11. An Incident Management Coordinator (IMC) is designated.
12. IMC produces an annual written analysis of the trends and patterns related to Reportable Incidents, including substantiated reports of abuse, neglect and exploitation.
13. Incident Review Committee (IRC) is established.
14. IRC meets bi-weekly to review individual RIFs.
15. IMC documents recommendations, actions implemented, and effects of actions taken to reduce and prevent incidents.
16. Procedures are in place for accepting abuse allegations.
17. Results of falsification of incident reports and misleading or withholding information during an investigation.
18. Responsibilities of all staff in regard to reporting incidents timely and accurately.

1. Must specifically state: “Any person subject to this policy who retaliates against another person for his or her involvement as a reports, witness or in any other capacity related to incident management and/or investigations of abuse, neglect and exploitation shall be subject to disciplinary action, including possible termination. Such actions may also result in legal or other administrative measures as appropriate.”

20. How administrative staffing actions are handled with regard to investigations.

1. Ensures confidentiality of the following:
2. DIDD reportable incident form
3. Incident follow-up and review documentation
4. DIDD investigation reports

Comments:
CQL Factor 4-Protection from Abuse, Neglect, Mistreatment and Exploitation

• 4a The organization implements policies and procedures that define, prohibit and prevent abuse, neglect, mistreatment and exploitation.
• 4b People are free from abuse, neglect, mistreatment and exploitation.
• 4c The organization implements systems for reviewing and analyzing trends, potential risks and sentinel events including allegations of abuse, neglect, mistreatment and exploitation, and injuries of unknown origin and deaths.
• 4e The organization ensures objective, prompt and thorough investigations of each allegation of abuse, neglect, mistreatment and exploitation, and of each injury, particularly injuries of unknown origin.

4f The organization ensure thorough, appropriate and prompt responses to substantiated cases of abuse, neglect, mistreatment and exploitation, and to other associated issues identified in the investigation.
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Protection of Rights /

1. QA Organization Checklist: Domain 4 (4C2, 4C3, 4C7, 4D2, 4D3, 4D4,
2. DIDD Provider Manual
3. Personal Outcome Measures: CQL, Factor 1-Rights Protection and Promotion
4. HCBS Settings Rule

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1. Are provider policies outlining rights of people supported made available to the people the agency supports?

1. Are the policies regularly reassessed for compliance and effectiveness and amended as necessary?

3. People served will be entitled to their rights and must be assisted in understanding the responsibilities associated with certain rights. Any restrictions must be reviewed by the Human Rights Committee.
4. The agency will have the Behavior Analyst take BSPs inclusive of restrictive interventions through an approved Human Rights Committee for review.
5. A local Human Rights Committee will be constituted according to DIDD requirements.
6. The agency Incident Management Coordinator will, within established time frames, review all serious incidents that involve emergency use of restrictive procedures.
7. If there is any rights restriction, restricted intervention or psychotropic medication being used by the person, the person and his/her family and/or legal representative have received information about risks, benefits, side effects and alternatives, and have given voluntary, informed, documented consent for the use of the intervention or medication.
Comments:
CQL Factor 1- Rights Protection and Promotion
•1a The organization implements policiesand procedures that promote people’s rights.
•1b The organization supports people to exercise their rights and responsibilities.
•1c Staff recognizes and honor people’s rights.
•1e Decision-making supports are provided to people as needed
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Quality Assessment, Assurance and Improvement /

1. DIDD Provider Manual

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1. Providers must have a process for conducting self-assessments.

1. Self-assessment is the process by which the provider identifies issues affecting the quality of services provided, as well as areas of operation resulting in non-compliance.

1. Providers must react to self-assessment findings by determining the causative factors and taking action to improve quality or compliance

Comments:
Reviewer(s): Date:
Policy / Policy Reference / Critical Elements / Complete
Yes No
Records Management /

1. DIDD Provider Manual
2. Health Insurance Portability and Accountability Act (HIPAA)
3. Health Information Technology for Economic and Clinical Health Act (HITECH)
4. Provider agreement
5. T.C.A. § 33-3-103

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1. Providers shall create an individual record for each person supported that contains documentation of services provided