Free 51678.FH11 - Indiana

PROVIDER STANDARDS AGENCY SURVEY
State Form 51678 (R / 3-06) / BQIS 0002 BUREAU OF QUALITY IMPROVEMENT SERVICES

Name of provider agency Name(s) of contact(s)

Address (number and street, city, state, and ZIP code) Telephone number(s) E-mail address(es)

(

)

REVIEW OF APPROVAL FOR SERVICES 1. Services approved by provider Adult day services Adult foster care services Behavioral support services - Basic Behavioral support services - Level I Case management services Crisis assistance services Day Services (providers approved prior to November 1, 2005 for: Supported employment follow-along; Pre-vocational services; Community habilitation & support) Enhanced dental services Environmental modification supports Family and caregiver training services Music therapy services Nutritional counseling services Occupational therapy services Personal emergency response system supports Physical therapy services Psychological therapy services Recreational therapy services Rent and food for unrelated live-in caregiver supports Residential habilitation and support services Residential living allowance and management Respite care services Specialized medical equipment and supplies supports Speech language therapy services Transportation - Adult Day Service
Number of complaints entered in CIRS (if none, indicate none) Notes

PROVIDER MEETS QUALIFICATIONS FOR SERVICES CHECKED? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No No 6-5-2 6-5-3 6-5-4 6-5-4 6-5-5 6-5-4 6-5-6*; 6-5-12*; 6-5-29* 6-5-10 6-5-11 6-5-13 6-5-15 6-5-16 6-5-17 6-5-18 6-5-19 6-5-21 6-5-22 6-5-23 6-5-24 6-5-25 6-5-26 6-5-27 6-5-28 6-5-30 *

NOTES

Qualifications under these tags are required ONLY for providers providing community based employment services.

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State Form 51678 (R / 3-06) / BQIS 0002

REVIEW OF POLICIES AND PROCEDURES FOR EACH OF THE FOLLOWING POLICIES AND / OR PROCEDURES: 2. 3. Provider complaint procedure 460 IAC 6-8-3 (5)(B) Written procedure for provider or employee/agent to inform APS/CPS, the individuals legal representative, any person designated by the individual, and the provider of Case Management services of a situation involving abuse, neglect, exploitation, mistreatment of an individual or the violation of the individuals rights. 460 IAC 6-9-4(n) 4. Written procedure for reporting reportable incidents to BDDS 460 IAC 6-9-4(o), 6-9-5 Does the agency deliver services through employees or agents and/or serve individuals? If NO, skip to the Behavioral Supports part of this section. 5. Prohibiting violations of individual rights 460 IAC 6-9-3(b), 6-9-2(c) 6. Written procedure for employees/agents to report violations of policies and procedures. 460 IAC 6-9-4(m) 7. Written personnel policy that is distributed to each employee/agent. A job description for each position with minimum qualifications, major duties/responsibilities of the employee and the name and title of the supervisor to whom the employee in the position must report. 460 IAC 6-16-2(b)(1) 8. Written procedure for conducting reference, employment, and criminal background checks. 460 IAC 6-16-2(b)(2) 9. Written prohibition against employing or contracting with a person convicted of offenses listed in 460 IAC 6-10-5, 6-16-2(b)(2) 10. A process for evaluating the job performance of each employee/agent at the end of the training period and annually thereafter, including a process for feedback from individuals receiving services from the employee/agent. 460 IAC 6-16-2(b)(4) 11. Disciplinary procedures 460 IAC 6-16-2(b)(5) 12. A description of grounds for disciplinary action against or dismissal of an employee or agent 460 IAC 6-16-2(b)(6) 13. This item is not currently used. 14. Written training procedure that is distributed to providers employees or agents 460 IAC 6-16-3 Does the agency provide Behavioral Support services? If NO go to the Review of Individual Records section. 15. Written policies and procedures that limit the use of highly restrictive procedures, including physical restraint or medication to assist in the management of behaviors and that focus on behavioral supports that begin with less restrictive or intrusive methods before more intrusive or restrictive methods are used. 460 IAC 6-18-3
DOES IT MEET THE REQUIREMENTS IN THE STANDARDS? HAS APPROPRIATE STAFF BEEN PROVIDED WITH A COPY? HAVE INDIVIDUALS BEEN PROVIDED WITH A COPY?

Yes Yes Yes Yes Yes Yes

No No No No No No

Yes

No

Yes

No

Yes

No

Yes

No

Yes Yes Yes Yes

No No No No

Yes Yes Yes Yes Yes

No No No No No

Yes Yes

No No

Yes

No

Yes

No

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State Form 51678 (R / 3-06) / BQIS 0002

REVIEW OF INDIVIDUAL RECORDS - HEALTH CARE COORDINATION Is provider designated as responsible for Health Care Coordination in an individuals ISP? Yes No (If NO, go to the next section) If YES, does the provider have a personal file for each individual receiving Health Care NUMBER OF FILES REVIEWED Coordination services that includes: 16. The date of health and medical services provided to individual. 17. A description of health care or medical services. 460 IAC 6-25-3(b)(1)

NUMBER OF FILES NOT IN COMPLIANCE WITH STANDARDS

460 IAC 6-25-3(b)(2) 460 IAC 6-25-3(b)(3) N/A

18. The signature of the person providing the health care or medical services. 19. Documentation of an organized system of medication administration. 460 IAC 6-25-3 (b) (4)(A), 6-25-4 20. Documentation of the individuals refusal to take medication. 460 IAC 6-25-3(b)(4)(B), 6-25-4(d)(8), 6-25-5 21. Monitoring of medication side effects. 22. Seizure tracking. 460 IAC 6-25-3(b)(4)(C), 6-25-6

N/A

N/A N/A N/A

N/A

N/A N/A N/A N/A

460 IAC6-25-3(b)(4)(D), 6-25-7 460 IAC 6-25-3(b)(4)(E), 6-25-8 460 IAC 6-25-3(b)(4)(F), 6-25-9

23. Documentation of changes in an individuals status.

N/A N/A

24. An organized system of health related incident management.

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State Form 51678 (R / 3-06) / BQIS 0002

REVIEW OF INDIVIDUAL RECORDS - BEHAVIORAL SUPPORT Is agency providing Behavioral Support services for individuals? If NO, go to the Individual Records Case Management section. If YES, does the provider have the following in the individuals files: 25. A copy of the individuals behavioral support assessment. 26. A copy of the individuals behavioral support plan. 460 IAC 6-18-4(b)(1) N/A N/A Yes No NUMBER OF FILES NOT IN COMPLIANCE WITH STANDARDS

NUMBER OF FILES REVIEWED

460 IAC 6-18-4(b)(2)

27. Monthly report of behavioral progress. September 15, 2005 letter from P. Bisbecos 460 IAC 6-18-4(b)(3),(4,)&(5) 28. This item is not currently used. 29. This item is not currently used. 30. Documentation that the least intrusive method was attempted and exhausted first. 460 IAC 6-18-4(a)(1) 31. Documentation system in the behavioral support plan for direct care staff working with the individual to record episodes of targeted behavior(s), including date(s)and time(s) of behavior(s), duration of behavior(s), a description of what precipitated behavior(s), a description of activities that helped alleviate behavior(s), and the signature of staff observing and recording behavior(s). 460 IAC 6-18-2(h) 32. If the use of medication is included in the behavioral support plan, the behavioral support plan includes a plan for assessing the use of medication and the appropriateness of a medication reduction plan or documentation that a medication reduction plan was implemented in the past 5 years and proved not to be effective. 460 IAC 6-18-2(i) 33. If a highly restrictive procedure is deemed necessary and included in the behavioral support plan, the behavioral support plan also contains a functional analysis of the targeted behavior(s) for which the highly restrictive procedure is designed, documentation that the risks of the targeted behavior have been weighed against the risks of the highly restrictive procedure, and documentation that systemic efforts to replace the targeted behavior with an adaptive skill were used and found to be not effective. 460 IAC 6-18-2(j)(1)(2)(3) 34. Documentation that the individual, the individuals support team and the applicable human rights committee agree that the use of the highly restrictive method is required to prevent significant harm to the individual or others. 460 IAC 6-18-2(j)(4) 35. If support plan includes restrictive interventions, informed consent from the individual or the individuals legal representative. 460 IAC 6-18-2(j)(5) 36. Documentation that the behavioral support plan containing a highly restrictive procedure is reviewed regularly by the individuals support team. 460 IAC 6-18-2(j)(6) 37. This item is not currently used.

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

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State Form 51678 (R / 3-06) / BQIS 0002

REVIEW OF INDIVIDUAL RECORDS - CASE MANAGEMENT Is agency providing Case Management services to individuals? Yes No (If NO, go to the Employee Files section.) If YES, does the provider have documentation of contacts [6-19-7(a)] and the results of monitoring NUMBER OF FILES REVIEWED the quality, timeliness and appropriateness of care services and products delivered to the individuals [6-19-6(a)] 38. Documentation of each contact with the individual and the individuals service providers. 460 IAC 6-19-7(a) 39. Appropriateness of goals in the individuals ISP. 460 IAC 6-19-6(b)(1) 460 IAC 6-19-6(b)(2) N/A N/A 460 IAC 6-19-6(c)(3) N/A N/A N/A N/A N/A

NUMBER OF FILES NOT IN COMPLIANCE WITH STANDARDS

40. An individuals progress toward the goals in the individuals ISP. 41. Any medication administration system for the individual. 42. An individuals behavioral support plan.

460 IAC 6-19-6 (c)(1), 6-25-4

N/A N/A N/A N/A N/A N/A N/A

460 IAC 6-19-6(c)(2)

43. Any health related incident management system for the individual. 44. Any side effect monitoring system for the individual. 45. Any seizure management system for the individual.

460 IAC 6-19-6(c)(4) 460 IAC 6-19-6(c)(5) 460 IAC 6-19-8(a)(1)

46. Documentation of the providers follow-up on problems. 47. The resolution of problems. 460 IAC 6-19-8(a)(2)

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State Form 51678 (R / 3-06) / BQIS 0002

REVIEW OF PROVIDER AGENCY EMPLOYEE FILES Applicable to all providers (regardless if single person provider entity or provider with employees NUMBER OF RECORDS REVIEWED or agents) - Do the employee records have the following: 48. Limited criminal background check. 49. State nurse aide registry. 50. Negative TB test. 460IAC 6-10-5(a)(b)(c)

NUMBER OF RECORDS NOT IN COMPLIANCE WITH STANDARDS

460 IAC 6-10-5(d)

460 IAC 6-15-2(b)(1) 460 IAC 6-15-2(b)(2)

51. CPR certification, updated annually.

52. Automobile insurance information, updated when due to expire (if employee transports individuals in his/her personal vehicle). 460 IAC 6-15-2(b)(3) 53. This item not currently used. 54. Professional licensure, certification or registration, including renewals. 460 IAC 6-15-2(b)(5)

N/A

N/A

N/A

N/A

55. Copy of drivers license (if employee transports individuals in his/her personal vehicle). 460 IAC 6-15-2(b)(6) 56. This item not currently used. 57. Copies of the agenda for each training session including the subject matter, date and time of training, name of person(s) conducting the training, and documentation of the employee/agents attendance at each training session, signed by the employee/agent and the trainer. 406 IAC 6-15-2(b)(8) Does the agency deliver services through employees or agents? If NO, go to the Quality Assurance/Quality Improvement section. Documentation of Employee Training on the following topics that is completed before employee begins working with an individual: 58. Individual rights, including respecting the dignity of an individual, protecting an individual from abuse, neglect and exploitation, implementing person centered planning and an individuals ISP, and communicating successfully with an individual. 460 IAC 6-14-4(a) 59. This item not currently used. 60. (For direct-care staff) Providing a healthy and safe environments for an individual, including how to administer CPR, how to practice infection control, universal precautions, how to manage individual specific treatments and interventions, including management of the individuals seizures, behaviors, medication side effects, diet and nutrition, swallowing difficulties, emotional and physical crises, and significant health concerns. 460 IAC 6-14-4(c) Page 6 Yes No NUMBER OF RECORDS NOT IN COMPLIANCE WITH STANDARDS

NUMBER OF RECORDS REVIEWED

N/A

N/A

State Form 51678 (R / 3-06) / BQIS 0002

REVIEW OF PROVIDER INTERNAL QUALITY ASSURANCE / QUALITY IMPROVEMENT SYSTEM Applicable to all providers, except where specific provider type is named. 61. Annual survey of individual satisfaction for all providers. 460 IAC 6-10-10(b)(1) 460 IAC 6-10-10(b)(3) 460 IAC 6-10-10(b)(4) IS PROVIDER IN COMPLIANCE WITH STANDARDS? Yes Yes Yes Yes Yes Yes No No No No No No

62. Documentation of efforts to improve service delivery in response to the survey.

63. An assessment of the appropriateness and effectiveness of each service provided to an individual. 64. A process for analyzing data concerning reportable incidents. 460 IAC 6-10-10(b)(5)(A) 460 IAC 6-10-10(b)(5)(B)

65. Developing recommendations to reduce the risk of future incidents. 66. Reviewing recommendations to assess their effectiveness.

460 IAC 6-10-10(b)(5)(C)

For providers responsible for Medication Administration 67. A process of analyzing medication errors. 460 IAC 6-10-10(b)(6)(A) 460 IAC 6-10-10(b)(6)(B) Yes Yes Yes No No No N/A N/A N/A

68. A process for developing recommendations to reduce the risk of future medication errors. 69. A process for reviewing the recommendations to assess their effectiveness.

460 IAC 6-10-10(b)(6)(C)

For providers of Behavioral Support services 70. A process of analyzing the appropriateness and effectiveness of behavioral support techniques used for an individual. 460 IAC 6-10-10(b)(7)(A) 71. A process for developing recommendations concerning the behavioral support techniques used with an individual. 460 IAC 6-10-10(b)(7)(B) 72. A process for reviewing recommendations to assess their effectiveness. 460 IAC 6-10-10(b) (7)(C) Yes Yes Yes No No No N/A N/A N/A

For CHP or RHS providers 73. A process for analyzing the appropriateness and effectiveness of instructional techniques used for an individual. 460 IAC 6-10-10(b)(8)(A) 74. A process for developing recommendations concerning the instructional techniques used for an individual. 75. A process for reviewing recommendations to assess their effectiveness. 460 IAC 6-10-10(b)(8)(C) 460 IAC 6-10-10(b)(8)(B) Yes Yes Yes No No No N/A N/A N/A

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State Form 51678 (R / 3-06) / BQIS 0002

NOTES

Total amount of time spent executing this survey at agency site (total hours):

I attest that this survey is an accurate account of findings based on my observations on the date and time indicated.
Signature of lead surveyor Title Date of signature (month, day, year)

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