Free 51681.FH11 - Indiana

POST-TRANSITION QUALITY ASSURANCE CHECKLIST
State Form 51681 (R / 3-06) / BQIS 0005

INSTRUCTIONS:

1. Prior to conducting the survey, check to see if any incidents have been reported; attach a copy of those incidents and follow up to this survey form. Note in question 45 if any incident reports do not have appropriate follow up submitted. 2. For the 7-day post-move visit, the existing ISP should still be in place regardless of type of placement setting. For the 30-day post-move visit, at a minimum, a meeting should be scheduled to review the existing ISP for individuals moving into supported living setting, and an IPP should be in place for individuals moving into group homes. 3. All questions below are to be scored using the current support plan (supported living) or individual program plan (group home) for the resident: Yes = compliance with plan, No = not in compliance with plan, N/A = not a need in plan. Note: All No responses must include a narrative explaining the deficit.

Name of individual Address of home (number and street, city, state, and ZIP code) Setting

(

Telephone number

)

Date resident moved into home (month, day, year) Date of individual support plan used for this checklist (month, day, year)

SL
New residential provider

SGL

Other (please describe)
Previous residential provider / SOF Signature of BQIS / BDDS representative completing this form Date of visit for transition QA checklist (month, day, year)

Printed name(s) of BQIS / BDDS staff performing this checklist Type of visit

7-day

30-day

60-day

90-day

Other

Name of case manager (SL) / QMRP (SGL) Name of residential provider contact person

( (
QUESTIONS

Telephone number

) )

Telephone number

YES 1. 2. 3. 4. 5. 6. 7. 8. Personal belongings in the home and available to individual? Home adaptations in place? (list adaptations per PCP / ISP) Is an emergency telephone list present? (N/A for nursing home placement) Medical equipment present (ex: G-tube, C-pap, Oxygen)? (list equipment per PCP / ISP) Adaptive equipment present (mealtime equipment, communicative devices, braces etc.)? (list equipment per PCP / ISP) Home clean and hygienic? Safe storage of medications, cleaning supplies, knives and other potential hazards? (N/A for nursing home placement) House, lot, yard, garage, walks, driveway, etc. free of environmental hazards? (N/A for nursing home placement) Page 1

NO

N/A

State Form 51681 (R / 3-06) / BQIS 0005

Name of individual who is transitioning

Date of checklist visit (month, day, year)

QUESTIONS (continued) YES 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Hot water no warmer than 110º Fahrenheit (or documentation of safeguards in place to ensure that the individual is not at risk for scalding)? (N/A for nursing home placement) Support plan updated? (Enter date / time ISP meeting held. If planned & not yet held, enter date planned.) (N/A for nursing home placement) Transportation needs met? (Describe how transportation needs are being met.) (N/A for nursing home placement) Are all issues identified as High Risk addressed appropriately, including staff training on each? (List individual risk issues.) Day program needs met? (N/A for nursing home placement) Other programs/training (other than day programs) relevant and functional? (N/A for nursing home placement) Opportunities for leisure relevant and promote independence? (N/A for nursing home placement) Opportunities for community experiences? (N/A for nursing home placement) Activities of Daily Living documented? (N/A for nursing home placement & SGL setting) Data collection processes in place and consistently completed? (N/A for nursing home placement) If medications have been changed, is there documented justification for the changes? (List changes including dosages pre and post change.) (Include date of change.) Medication administered and charted appropriately? (for nursing home placement, see guidelines) PRN Psychotropic medications reported and documented? (N/A for nursing home placement) Adequate staff assigned and present? (describe staffing ratios) (N/A for nursing home placement) Staff trained on individuals medical needs including side effects of medications? Staff trained on individuals dietary / nutritional needs? Staff trained on individuals personal hygiene needs? Staff trained on individuals mobility needs? Staff trained on programs for individuals behavioral considerations and/or psychiatric needs / symptoms? Staff trained on individuals communication needs? NO N/A

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State Form 51681 (R / 3-06) / BQIS 0005

Name of individual who is transitioning

Date of checklist visit (month, day, year)

QUESTIONS (continued) YES 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. Personal physician identified and appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) Personal Dentist identified, and if appropriate, appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) Psychiatrist identified, and if appropriate, appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) Neurologist identified, and if appropriate, appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) Other Medical Specialist identified and if appropriate, appointment scheduled and kept? (Enter specialty, name, phone number & appointment date / time.) (N/A for nursing home placement) Behavior Support provider identified and appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) OT/PT provider identified and if appropriate, appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) Speech Language Pathologist provider identified, and if appropriate, appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) Dietician identified and if appropriate, appointment scheduled and kept? (Enter name, phone number & appointment date / time.) (N/A for nursing home placement) Is the Individual adjusting to the home (i.e. - Is there a lack of any observed or reported problems such as poor eating, sleeping disturbance, depression, etc)? If there have been any recent illnesses, injuries or hospitalizations, were they adequately and appropriately documented in the Individual's personal file? (List illnesses with dates.) (N/A for nursing home placement) If there have been any recent illnesses, injuries or hospitalizations, did the Individual receive appropriate medical care including follow-up? (N/A for nursing home placement) If there has been a change in home, provider or case manager, has the change resulted in positive outcomes for the individual? (N/A for nursing home placement) Does interview and/or documentation indicate adequate involvement from the case manager, if on waiver? (N/A for nursing home or SGL placement) Does a review of the documentation indicate that the BDDS Incident Reporting Policy is being followed? (If no document dates and types of incident on this form and assure that the incident is filed per the BDDS Incident and file an incident regarding the non-reporting of the initial incident.) (N/A for nursing home placement) Are all reported incidents resolved appropriately? (N/A for nursing home placement) Are all needs (with emphasis on High-Risk needs) addressed at out-of-home habilitation service locations, including documentation of communication between the residential provider and providers at the out-of-home locations? NO N/A

44. 45.

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State Form 51681 (R / 3-06) / BQIS 0005

Name of individual who is transitioning

Date of checklist visit (month, day, year)

SPECIALTY RECOMMENDATIONS During post transition monitoring and as physician and other specialty appointments are scheduled and kept, enter recommendations resulting from these specialists in cells below, including time frames for actions if pertinent. Enter N/A where appropriate. Include other specialists as needed. Confirm implementation (yes or no) in column on right. SPECIALIST Primary Care MD Dentist Psychiatrist Neurologist Behavior Support OT PT SLP Dietician RECOMMENDATION RECOMMENDATION IMPLEMENTED?

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State Form 51681 (R / 3-06) / BQIS 0005

Name of individual who is transitioning

Date of checklist visit (month, day, year)

NOTES

PARTICIPANTS (including titles)

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State Form 51681 (R / 3-06) / BQIS 0005

Name of individual who is transitioning

Date of checklist visit (month, day, year)

CORRECTIVE ACTION RESPONSES FOR DEFICIENCIES NOTED ITEM NUMBER DETAILED EXPLANATION OF DEFICIT
(includes specific actions planned, names of people contacted & dates/times of contact, targeted date for completion)

CORRECTIVE ACTION PLAN

TARGET DATE FOR ACTION (month, day, year)

ENTITY RESPONSIBLE FOR ACTION

DATE RESOLVED (month, day, year)

RESOLUTION VERIFIED BY

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State Form 51681 (R / 3-06) / BQIS 0005

Name of individual who is transitioning

Date of checklist visit (month, day, year)

CORRECTIVE ACTION RESPONSES FOR DEFICIENCIES NOTED (continued) ITEM NUMBER DETAILED EXPLANATION OF DEFICIT
(includes specific actions planned, names of people contacted & dates/times of contact, targeted date for completion)

CORRECTIVE ACTION PLAN

TARGET DATE FOR ACTION (month, day, year)

ENTITY RESPONSIBLE FOR ACTION

DATE RESOLVED (month, day, year)

RESOLUTION VERIFIED BY

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