Free 51682.pdf - Indiana

State Form 51682 (4-04) / BQIS 0006

GUIDELINES BQIS POST-TRANSITION QUALITY ASSURANCE CHECKLIST
1 Personal belongings in the home and available to resident? Expectations: The home reflects the taste and interests of the Individual. Personal belongings are available readily; i.e. the Individual is not dependent on staff to access personal possessions. · How do you like your home? · Did you help pick out the decorations? · Are the Individual's clothes readily available to him/her? · If access is restricted, is there evidence of a behavior plan? · Is there evidence a less restricted alternative has been tried? · Are there restrictions identified in the PCP? Expectations: All adaptations identified in the PCP/ISP are in place. The Individual can move about the location without restrictions, or as independently as feasible. · Are there supports/adaptations identified in the PCP/ISP? · Are they in place at the home? (N/A for a Nursing Facility) Expectations: An emergency telephone list is posted in an area visible from the phone (or as indicated in the PCP/ISP) that includes numbers for: · The local emergency number (e.g. 911) · The Individual's legal representative (or advocate, if applicable) · The local BDDS office · The Case Manager or QMRP · Adult Protective Services, or Child Protective Services ­ depending on age of Individual · The Developmental Disabilities Ombudsman ­ Only if Waiver, not for SGL · Any other Service Provider Identified Expectations: All medical equipment indicated as needed in the PCP/ISP is present and in good condition, being used by the Individual as prescribed. · Are there medical equipment needs identified in the PCP/ISP? · Is the equipment available and being used by the Individual as prescribed? Expectations: All adaptive equipment indicated as needed in the PCP/ISP is present and in good condition, being used by the Individual as prescribed. · Are there adaptive equipment needs identified in the PCP/ISP? · Is the equipment available and being used by the Individual as prescribed? Expectations: The home will look and smell clean. · Is the carpeting/flooring sanitary? · Are the walls clean? · Do any rooms have unusual odors? · Are the kitchen and all appliances clean (do not ask in Nursing Home setting) · Is the bathroom clean? Are bathroom fixtures clean? · Does the staff know procedures for universal precautions? (do not ask in Nursing Home setting) (N/A for a Nursing Facility) Expectations: Medications are stored safely. Chemicals, sharps and other potential hazardous items are stored in the home in a manner that does not pose a threat to the Individual. · Are medications stored safely, per the needs of the Individual? · Are cleaning supplies stored separately from food? · Are chemicals, sharp instruments and other hazardous items stored in a manner which ensures the safety of the Individual per the support plan? (N/A for a Nursing Facility) Expectations: Visual inspection of the interior and exterior of the home reveals no observed hazards. · Are there obvious hazards? · Are ramps, rails, etc. secured when tested? · Are there bare light bulbs, frayed cords, or overloaded sockets in the walls? 1

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Home adaptations in place?

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Is an emergency telephone list present?

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Medical equipment/adaptation s present (ex: G-tube, C-pap, and Oxygen)? Adaptive equipment present (cups, braces, etc.)? Home clean and hygienic?

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Safe storage of medications, cleaning supplies, knives and other potential hazards?

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House, lot, yard, garage, wall, driveway, etc., free of environmental hazards?

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Hot water no warmer than 110º Fahrenheit?

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Support plan updated?

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Transportation needs met?

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Are all issues identified as "High Risk" addressed appropriately?

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Day program needs met?

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Other programs/training (other than day program) relevant and functional? Opportunities for leisure that are relevant and promote independence?

Does the provider have a procedure to take care of hazards, which may occur in the home? (N/A for a Nursing Facility) Expectations: The maximum temperature of the hot water in the home is no higher than 110º Fahrenheit making it safe for bathing, unless otherwise specified in the PCP/ISP. · Does the PCP/ISP confirm that hot water temperature control is not necessary? · Is the home in compliance with the PCP/ISP? · If water temperature is not addressed in the PCP/ISP, is the hot water no warmer than 110º Fahrenheit as tested at the bathtub (or shower if no tub) following full stream running for approximately 3 minutes (ensuring water is at maximum temperature)? (N/A for a Nursing Facility) Expectations: The support plan has been updated, and the new ISP implemented. · When was the support plan updated or when is the support plan scheduled to be updated? · Is there documentation to support the update of the support plan? · Is the written support plan in the home and has it been implemented? (N/A for a Nursing Facility) Expectations: Individuals are not restricted in the access to the community by lack of transportation. · How do you shop? · What sort of vehicle do you use? · Ask staff how the Individual gets to the store, doctor, or leisure outings. · Is the person satisfied with the amount of time they spend in the community? · Is there training in place to address problems/needs with transport? Expectations: The provider is knowledgeable of all high-risk issues identified in the PCP/ISP and has a plan addressing each issue. Provider staff is trained on all plans. · Does the provider staff demonstrate knowledge of all high-risk issues? · Is there a plan that addresses each issue? · Is provider staff knowledgeable of the possible negative consequences if plans are not carried out correctly? · Is there a designated person for staff to obtain information as needed? · Does staff know who the designated person is? (N/A for a Nursing Facility) Expectations: Day program needs identified in the PCP are met. · Is there a need for programming identified in the PCP/ISP? · Is the day program IN ADDITION to ADL and leisure experiences provided by the residential provider, allowing for relationships with people outside of the provider staff? · Is the Individual satisfied with day services? · A plan for day programming does not result in a "yes" score. Program has to be implemented. (N/A for a Nursing Facility) Expectations: The activities the Individual participates in on a daily basis (other than the day program) correspond to the type of activities identified in their PCP/ISP. · What does the Individual do during the day? · Are these activities relevant to the services/needs identified in the PCP/ISP? (N/A for a Nursing Facility) Expectations: Based on the ability of the Individual and the information provided in their PCP/ISP, the Individual will move about both the residence and the community participating in social and recreational activities. The activities are of the nature to encourage the Individual to be independent and to make connections with others. · What does the Individual like to do for leisure activities? · How does the staff interact with the Individual during the activity? Do they support the Individual or do they complete the activity for the Individual? · Are the activities linked to the outcomes identified in their PCP/ISP?

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Opportunities for community experiences?

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Activities of Daily Living documented?

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Data collection processes in place and consistently implemented?

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If medications have been changed, is there documented justification for the changes? Medication administered and charted appropriately?

(N/A for a Nursing Facility) Expectations: Based on the ability of the Individual and the information provided in their person centered plan, the Individual will frequent the community for personal, social and recreational purposes. · How often does the Individual go to places outside of their home? · Does the Individual complete their own shopping, banking, go to the pharmacy or does someone else complete these tasks for them? · Does the Individual participate in leisure and recreational activities in the community? (N/A for a Nursing Facility ­ N/A for SGL setting) Expectations: Documentation of daily activity is objective and descriptive to the point of "painting a picture" of the Individual's day for the reader, including evidence of participation in activities as directed by the PCP/ISP. · Does the documentation provide you with a picture of what the Individual has been doing and how they are progressing? · Is there absence of language that is subjective and open to varied interpretation ­ such as, "it was a good day?" · Is there evidence of participation in activities as directed by the PCP/ISP? (N/A for a Nursing Facility) Expectations: A data collection system is in place, with data collected per the PCP/ISP. · Is data collected as designated in the ISP · Is there documented evidence that the Individual is actively working on their goals? · Is there clear evidence the Individual is making progress on the goal? If lack of progress, have revisions been made? · For an SGL, data collection is not required for the first 30 days. This should be marked "No" until new objectives are in place and data is being collected. Expectations: There is documented justification from the physician/psychiatrist for all changes in medicine regime (increases; decreases; starting; stopping). · Has there been a change in medication regime? · Is there documentation from the physician/psychiatrist regarding the changes? Expectations: Medication is administered and charted according to physician orders. · Is medication administered according to physician's orders? · Is administration of the medication charted appropriately? Is the Individual able to self-medicate? (N/A for a Nursing Facility)) Is the Individual's ability to self-medicate addressed in the PCP/ISP? (N/A for a Nursing Facility) (N/A for a Nursing Facility) Expectations: Each PRN psychotropic usage has been reported per the BDDS incident reporting policy, & documentation describing each usage in detail is present. · Do the physician's orders and/or medication administration sheets include any evidence of psychotropic medication being administered on a PRN basis? · If PRN psychotropic medications have been used, is there documentation describing each usage in detail? Has an incident report been filed for each usage? (N/A for a Nursing Facility) Expectations: There is adequate staff to meet the needs of the Individual? · Is there enough staff to provide care and services that is identified in the ISP? · Is there enough staff to be able to respond to emergencies, e.g. fire, illness, etc? Expectations: Staff is able to provide services to meet the Individual's medical needs as identified in the PCP/ISP (or care plan if Nursing Facility). · Is there a medical plan for the Individual? · Is staff knowledgeable of the services needed by the Individual? 3

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PRN Psychotropic medications:

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Adequate staff assigned and present?

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Staff trained on Individual's medical needs including side effects of

medications?

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Is there documentation that confirms all staff working with the Individual has been trained? Is there a designated person for staff to obtain information as needed? Does the staff know who the designated person is?

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Staff trained on Individual's dietary/nutritional needs?

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Staff trained on Individual's personal hygiene needs?

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Staff trained on Individual's mobility needs?

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Staff trained on Individual's behavioral considerations and psychiatric needs/symptoms ?

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Staff trained on Individual's communication needs?

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Personal Physician identified and appointment scheduled and kept?

Expectations: Staff is able to provide services to meet the Individual's dietary/nutritional needs. · Is there a dietary/nutritional plan? · Does staff demonstrate knowledge of the dietary/nutritional plan? · Is there documentation that confirms all staff working with the Individual has been trained? · Is there a designated person for staff to obtain information as needed? · Does the staff know who the designated person is? Expectations: Staff is able to provide services/interventions to meet the Individual's personal hygiene needs. · Does staff demonstrate knowledge of universal precautions? · Does staff demonstrate knowledge of the Individual's personal hygiene needs? · Is there documentation that confirms all staff working with the Individual has been trained? · Is there a designated person for staff to obtain information as needed? · Does the staff know who the designated person is? Expectations: Staff is able to provide services/interventions to meet the Individual's mobility needs. · Does staff demonstrate knowledge of the Individual's mobility needs? · Is there documentation that confirms all staff working with the Individual has been trained? · Is there a designated person for staff to obtain information as needed? · Does staff know who the designated person is? Expectations: Staff is able to provide services/interventions to meet the Individual's behavioral and psychiatric considerations. · Does staff demonstrate knowledge of behavior interventions? · Is there documentation that confirms all staff working with the Individual has been trained in the individual's behavioral considerations and psychiatric needs/symptoms? · Is there a designated person for staff to obtain information as needed? · Does staff know who the designated person is? Expectations: Staff is able to provide services/training to meet the Individual's communication needs. · Does staff demonstrate knowledge of the communication need? · Is there documentation that confirms all staff working with the Individual has been trained? · Is there a designated person for staff to obtain information as needed? · Does staff know who the designated person is? (N/A for a Nursing Facility) Expectations: The Individual has a personal physician identified and is being seen routinely and as needed. · Is the name and contact information present for the primary physician? · Has the Individual had an appointment, or is an appointment scheduled? · Is documentation of the appointment present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. · EXCEPTION: If individual is moving from one residence to another and the Personal Physician remains the same with uninterrupted services, note so on checklist and mark "NA".

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Personal Dentist identified, and, if appropriate, appointment scheduled and kept?

(N/A for a Nursing Facility) Expectations: The Individual has a personal dentist identified and is being seen routinely and as needed. · Is the name and contact information present for the dentist? · Has the Individual had an appointment, or is an appointment scheduled? · Is documentation of the appointment present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. · EXCEPTION: If individual is moving from one residence to another and the dentist remains the same with uninterrupted services, note so on checklist and mark "NA". (N/A for a Nursing Facility) Expectations: The Individual, if taking psychotropic medications, has a personal psychiatrist identified and is being seen routinely and as needed. · Is the Individual taking psychotropic medications? · Is the name and contact information present for the psychiatrist? · Has the Individual had an appointment, or is an appointment scheduled? · Is documentation of the appointment present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. · EXCEPTION: If individual is moving from one residence to another and the psychiatrist remains the same with uninterrupted services, note so on checklist and mark "NA". (N/A for a Nursing Facility) Expectations: If there exists a diagnosis of epilepsy, seizure disorder, head injury, hydrocephalus, or other neural disorders, there will be considerations made for including a neurologist as part of the medical support team. There will be a record of contacts made as well as appointment dates/times. · Does the Individual's PCP/ISP present neural disorders as indicated above? · Is the name and contact information present for the neurologist? · Has the Individual had an appointment, or is an appointment scheduled? · Is documentation of the appointment present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. · EXCEPTION: If individual is moving from one residence to another and the Neurologist remains the same with uninterrupted services, note so on checklist and mark "NA". (N/A for a Nursing Facility) Expectations: If there exists a diagnosis of any medical condition which would require professional specialist care (such as vision impairments) the PCP/ISP will include the particular specialists as a part of the support team. There will be a record of contacts made and appointment dates/times. · Does the Individual's PCP/ISP identify needs of other medical specialists? · Is the name and contact information present for each specialist needed? · Has the Individual had an appointment, or is an appointment scheduled for each specialist needed? · Is documentation of each of the appointments present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that all needed specialists' appointments were kept. · EXCEPTION: If individual is moving from one residence to another and the Other Medical Specialists remain the same with uninterrupted services, note so on checklist and mark "NA".

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Psychiatrist identified, and, if appropriate, appointment scheduled and kept?

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Neurologist identified, and, if appropriate, appointment scheduled and kept?

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Other Medical Specialist identified and, if appropriate, appointment scheduled and kept?

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Behavior Support provider identified and appointment scheduled and kept?

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OT/PT provider identified and, if appropriate, appointment scheduled and kept?

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Speech Language Pathologist provider identified, and, if appropriate, appointment scheduled and kept?

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Dietician identified and if appropriate, appointment scheduled and kept?

(N/A for a Nursing Facility) Expectations: If there exists a diagnosis of any behavioral or emotional challenges which would require professional care, a behavior support provider will be a member of the support team. There will be a record of contacts made as well as appointment date/time. · Does the PCP/ISP indicate the need for a behavior support provider? · Is the name and contact information present? · Has the Individual had an appointment, or is an appointment scheduled? · Is documentation of the appointment present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. · EXCEPTION: If individual is moving from one residence to another and the Behavioral Support provider remains the same with uninterrupted services, note so on checklist and mark "NA". · For an SGL, the QMRP often authors the behavior plan. In rare cases, there may actually be a behavior support provider. (N/A for a Nursing Facility) Expectations: If there exists conditions relating to mobility difficulties, fine motor coordination, sensory sensitivity, eye hand coordination, transfer difficulties, etc., which would require professional care, there will be consideration made for including therapist(s) as a part of the support team. There will be a record of contacts made as well as appointment date/time. · Does the PCP/ISP include the need for OT and/or PT services? · Is the name and contact information present? · Has the Individual had appointments, or are appointments scheduled? · Is documentation of the appointments present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. · EXCEPTION: If individual is moving from one residence to another and the OT/PT provider/s remains the same with uninterrupted services, note so on checklist and mark "NA". (N/A for a Nursing Facility) Expectations: If there exists a communication deficit, swallowing or pronunciationenunciation difficulty, which would require professional care, there will be considerations made for including a specialist as a part of the medical support team. There will be record of contacts made as well as appointment date/time. · Does the PCP/ISP include the need for SLP services? · Is the name and contact information present? · Has the Individual had appointments, or are appointments scheduled? · Is documentation of the appointments present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. · EXCEPTION: If individual is moving from one residence to another and the Speech Language Pathologist remains the same with uninterrupted services, note so on checklist and mark "NA". (N/A for a Nursing Facility) Expectations: If there exists a condition that results in a need for a modified or special diet or individualized dining plan, &/or if the Individual uses specially adapted equipment for dining, there will be consideration made for including a registered dietician as a part of the support team. · Does the PCP/ISP include the need for a dietician? · Is the name and contact information present? · Is documentation of the appointment present? · NOTE: If an appointment is scheduled but has not occurred, score remains "NO" pending confirmation that the appointment was kept. 6

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EXCEPTION: If individual is moving from one residence to another and the Dietician remains the same with uninterrupted services, note so on checklist and mark "NA".

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Is the Individual adjusting to the home?

Expectations: Any problem that the Individual may have had in adjusting to their new home should be identified, documented and addressed with the team for resolution. · Is the Individual having problems eating, sleeping, being depressed etc.? · Is there documentation of a team meeting to address any problem? · Is the resolution of the issue/s documented? Expectations: Documentation is complete on all illness, injuries and hospitalizations. · Were there any illness, injuries, or hospitalizations? · Are the incidents documented in the Individual's file? · Was the documentation performed in a timely manner? · Was the documentation detailed enough to create a clear picture? · Does documentation confirm ongoing management, or if resolved, resolution of the illness, injuries, or hospitalization? (N/A for a Nursing Facility) Expectations: All illnesses, injuries or hospitalizations receive prompt medical attention. Any follow-up appointments are kept as scheduled. · Were there any illness, injuries, or hospitalizations? · Who provided medical attention? · Was the incident documented? · If direct care staff provided basic first aid, was the health care professional notified? · If a follow-up appointment was made was it kept or is it scheduled? · NOTE: Answer must be NO until follow up visit is actually completed (N/A for a Nursing Facility) Expectations: If there have been changes in the home, provider or Independent Case Manager/QMRP, the results have been positive for the Individual. · Were the changes the Individual's choice? · What were the reasons for the change? · Have the new providers addressed the reasons for change resulting in positive outcomes for the Individual? (N/A for a Nursing Facility & SGL setting)) Expectations: There has been adequate involvement from the Case Manager. · Has the Independent Case Manager been to the home at least once every 90 days? · Are there issues of ongoing (or long-standing) inadequate or incomplete services from any provider that are not addressed by the Case Manager in the documentation? (N/A for a Nursing Facility) Expectations: All reportable incidents are reported per the Incident Reporting Policy. · Is there evidence of reportable incidents that have not been reported per policy? · If there have been unreported incidents, document dates and types of incidents on the post transition check list, and ensure that the incident is filed per BDDS policy. · File an additional incident report addressing the provider not reporting the initial incident. (N/A for a Nursing Facility) Expectations: Providers resolve all reported incidents successfully, and set systems in place to prevent reoccurrence. 7

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If there have been any recent illnesses, injuries, or hospitalizations, were they adequately and appropriately documented in the Individual's file? If there have been any recent illnesses, injuries, or hospitalizations, did the Individual receive appropriate medical care including followup?

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If there has been a change in home, provider or Case Manager/QMRP, has the change resulted in positive outcomes for the Individual? Does interview or documentation indicate adequate involvement from the case manager, if on the waiver? Does a review of the documentation indicate that the BDDS incident policy is being followed?

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Are all reported incidents resolved appropriately?

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Review the BDDS Incident Reports including documented follow-up. Verify that follow-up occurred and satisfactorily addressed the identified risk. Verify that systems are in place to prevent reoccurrence of reported incidents.

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Are all needs (with emphasis on HighRisk needs) addressed at out-ofhome habilitation service locations, including documentation of communication between the residential provider and providers at the out-of-home locations?

Expectations: Support needs (with emphasis on High-Risk needs) as identified in the PSP/ISP are provided and monitored by all providers of services, at all service locations. (Example: dining needs ­ if the Individual has a dining plan implemented for meals at home, is that same or comparable plan implemented for lunch at the workshop or when eating with the job coach, community habilitation aide, etc.?) Will require site visits to workshops, day program areas, etc. · Does the Individual receive habilitation services from providers other than the residential provider? · Is there an alternate site for habilitation services outside of the Individual's residence? · Is there a system of documentation that confirms ongoing communication between the residential provider and other habilitation services providers regarding the Individual's needed supports as stated in the PCP/ISP (with emphasis on High-Risk needs)? · Are staff that do not routinely work with the Individual in the home knowledgeable of the support needs of the Individual and are they implementing services to provide these supports as included in the PCP/ISP?

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