QUALITY ASSURANCE PROCESS
FOR ADULT AND GROUP HOME SERVICES
Developmental Disabilities Program
Department of Public Health and Human Services
State of Montana
July 11, 2003
07/11/2003
Table of Contents
Purpose:.........................................................................................................2
Introduction and History:.................................................................................2
Initial Quality Assurance Review of Qualified Providers: .....................................2
Annual Quality Assurance Review of Qualified Providers: ...................................2
Quality Assurance Observation Sheets (QAOS): ................................................3
Procedures for Quality Assurance Review: ........................................................3
Consumer Sample: ..........................................................................................4
QA Process: ....................................................................................................4
Staff Interview: ...............................................................................................6
Other Visits: ...................................................................................................7
Use of the QAOS as a tool for ongoing Quality Assurance: .................................7
Imminent Danger: ..........................................................................................8
Systemic or Pervasive Deficiencies: ..................................................................9
Levels of Corrective Action: ........................................................................... 10
Format for all Quality Assurance Reviews ....................................................... 11
Appendix A: Quality Assurance Observation Sheet .......................................... 14
Appendix B: IP Checklist ................................................................................ 16
Appendix C: Forms A & B .............................................................................. 17
Appendix D: Medication Error Reporting Form (Optional Form) ....................... 21
Appendix E: Staff Ratio Checklist ................................................................... 24
Appendix F: Consumer Sample ...................................................................... 26
Appendix G: Implementation Features............................................................ 27
Appendix H: Rule/Contract Authority .............................................................. 34
Appendix I: Staff Interview Questionnaire ...................................................... 38
Appendix J: Consumer Satisfaction Survey ...................................................... 54
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Purpose:
The purpose of the Annual Quality Assurance Review by the
Developmental Disabilities Program (DDP) is to serve as a comprehensive
review of contract monitoring, licensing, accreditation, and other
collateral / external sources.
Quality Assurance Specialists endeavor to maintain an ongoing presence
at provider organizations and to ensure the Waiver Assurances of Health
/ Safety, Design and Implementation of Individual Plans, Services
Provided by Qualified Providers, and Fiscal Accountability.
Through the course of ongoing service delivery, Quality Improvement
Specialists work with provider organizations and Individual Planning
Teams to ensure quality, adherence to administrative rules, federal
regulations, waiver assurances, and compliance with a provider
organization’s contract with the Department.
Introduction and History:
In July 2002, the Developmental Disabilities Program implemented a new
Quality Assurance Review process. The process was updated from
feedback received during the first year. This document reflects the
process for use beginning July 1, 2003.
This document reflects procedures for Quality Improvement Specialists to
use in the initial, annual, and ongoing quality assurance reviews of
Qualified Providers providing services to adults with developmental
disabilities, and to children living in community homes. These
procedures were developed from the CMS Waiver Review Protocol, the
State of Montana Administrative Rules, the Code of Federal Regulations
and the Department contract(s) with Qualified Providers.
Initial Quality Assurance Review of Qualified Providers:
Once standards for Qualified Provider status are met, service contracts/
service agreements can be initiated (see Standards and Procedures for
Qualified Providers). Within nine months of the initiation of providing
services, a full Quality Assurance review will be completed and an
annual review conducted thereafter.
Annual Quality Assurance Review of Qualified Providers:
Qualified Providers will have a full Quality Assurance review no less than
once per year. In order to allow for possible scheduling conflicts (i.e.,
another Quality Assurance Review, or extenuating circumstance of the
provider), the timeline for an annual visit may be extended 2 months
(past the one-year) in order to complete a Quality Assurance review. To
extend the timeline, the provider organization must make a request in
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writing to the Regional Office, justifying the need for an extension. If a
Quality Assurance Team cannot complete the necessary QA review within
the annual time frame, the Quality Improvement Specialist will notify the
provider organization, in writing, of the extension of dates.
These visits are conducted at the service site. The purpose of the visit is
to determine whether the provider organization is meeting state and
federal regulatory requirements, providing quality services, and providing
services as specified in Individual Plans. Aspects of the provider
organization and services are reviewed using specific protocols.
Regulatory compliance in all areas is required.
Quality Assurance Observation Sheets (QAOS):
Quality Assurance Observations Sheets are the primary documentation
to record exemplary practices and indicate deficiencies (See Appendix A).
Quality Assurance Observation Sheets are used during routine visits and
for documentation review during Quality Assurance Reviews.
Use of the QAOS for Annual Quality Assurance Reviews:
Quality Assurance Observation Sheets record what was observed, what
Administrative Rule, Policy, or Contract requirement is surpassed or
deficient, and the effect on the consumer/provider organization. For
exemplary practices, no response to DDP is required. For deficiencies, a
response date of no longer than 10 calendar days from the date of receipt
of the Quality Assurance Observation Sheet is required.
Procedures for Quality Assurance Review:
Quality Assurance Reviews utilize three techniques, which are
incorporated throughout the review process and throughout the year:
observation, interview and documentation review. All provider
organizations are visited and reviewed within their initial nine months of
service provision, and annually thereafter.
Quality Assurance Teams may be comprised of one or more members.
The lead member is the Quality Improvement Specialist assigned to work
with the provider organization. The other member(s) could include a
second Quality Improvement Specialist, a Regional Manager, the Quality
Assurance Specialist or Waiver Training Specialist from the central office,
a consumer/advocate, or other professional. The size and composition of
the team will be at the discretion of the Department.
For organizations that provide services across regions/large geographic areas, or
where multiple QIS’s are assigned to specific services/service areas, the Quality
Assurance Review will be coordinated among the QIS’s and be completed during
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the same time frame. For provider organizations operating services in different
regions, with local administrators, the Quality Assurance Reviews will be
completed as separate reviews.
Consumer Sample:
Except for Community Supports Services (where 100% of all consumer
surveys completed by the Case Managers are reviewed by the QIS), a
sample of 10% of service recipients (no less than 5) is selected for review
(Appendix F). The sample should include one person from each service
category and geographical area (group home, congregate residential,
supported living, community employment, facility-based employment,
facility-based day, senior day, recreation, etc.). The QIS will review the
Consumer Survey conducted by the Case Manager during the annual IP
process. Review of Individual Plans and the implementation of these
should be conducted throughout the year. If there have been issues
noted during the year, Quality Assurance Observation Sheets should
have been submitted with follow-up from the provider organization. At
the annual quality assurance visit, a small sample of Individual Plan
reviews should be completed and reviewed to ensure the issues noted
throughout the year are not systemic or pervasive.
For Community Supports Services at least five individuals will be
reviewed. If the agency serves less than five in this service, then all
individuals will be reviewed. Of the five, three individuals reviewed must
be Title XIX Waiver funded.
QA Process:
The QA process is defined as (see Appendices for forms):
I. Data collected throughout the year including but not limited to:
 Assessment of incident reporting trends, medication errors, Adult
Protective Services issues, Client Rights issues, IP issues, etc.;
 Completed Quality Assurance Observation Sheets (QAOS) from the
year regarding exemplary practices or follow up from previously
recorded problems;
 A consumer sample selected as described above (Appendix F); and
 Review of consumer surveys conducted by Case Managers during the
annual IP process.
II. Prior to Review:
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
Notification is made to the Executive Director, or designee, at the
provider organization two weeks prior to the annual Quality
Assurance (on-site) review.
III. During the Review:
 Verify trends and administrative standards (Form A);
 Verify service site standards (Form B); and
 Interview one staff from each service area using the staff
interview/questionnaire.
IV. Exit Interview/Conference:
 Review commendations and findings (Quality Assurance Observation
Sheets) with staff at the provider organization. Within one week copies
of Quality Assurance Observation Sheets are given to the provider
organization and timelines for those requiring a response to Quality
Improvement Specialist are jointly negotiated (not to exceed 10
calendar days).
 Within one month of the on-site review, the Quality Improvement
Specialist will complete the Annual Report Summary to include the
information as outlined in the Format, page 10. The Summary is sent
to the President of the Board of Directors, Executive Director,
Regional Manager, Community Services Bureau Chief, and the
Quality Assurance Specialist.
The QIS does not copy Forms A or B to the provider organization. Quality
Assurance Observation Sheets are numbered during the review for ease
in reference in the summary letter. In filling out Forms A and B, the QIS
places a “+” in the box for items which are met. Identifying numbers
should appear on Forms A & B in boxes for exemplary practice or
deficient items. These numbers should correspond to the identifying
numbers on the Quality Assurance Observation Sheets.
Trends in exemplary practices and deficiencies are easily identifiable
vertically across Forms A & B. For a trend, it is not necessary to write
separate Quality Assurance Observation Sheets. One QAOS can be used
to summarize the commendation/deficiency referenced; in this case be
sure to include specific site or initials of consumer reviewed.
For exemplary practices and deficiencies identified throughout the year,
the Quality Improvement Specialist will correspond immediately with the
agency using the Quality Assurance Observation Sheets. The on-site
review period should be used to increase the sample size to verify that
corrections throughout the year were generalized to the larger population
served.
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Response to Issues/Deficiencies noted during the Quality Assurance
Review:
The Quality Assurance Observation Sheets are issued to the

Executive Director, or designee, of the provider organization.
 The provider responds in writing by the negotiated Response Due
Date to the Quality Improvement Specialist at the regional or
satellite DDP office. The response documents the issue and what
action was taken to address prevention of recurrence of the
problem.
 The Quality Improvement Specialist accepts the action taken or
requests further review by the provider organization. If further
review is requested, the Quality Improvement Specialist documents
further concerns regarding the follow-up and returns the Quality
Assurance Observation Sheet to the provider organization with a
new timeline for response.
 Once the responses are accepted, the Quality Improvement
Specialist documents that it as accepted, copies the form (and any
supporting documentation) to the provider organization for their
files, and maintains a copy at the regional office with the contract
file. Completed Quality Assurance Observation Sheets
documenting Imminent Danger or Systemic/Pervasive Deficiencies
additional copies may be routed to: the Quality Assurance
Specialist, the Community Services Bureau Chief, and/or the DDP
Program Director. The Quality Improvement Specialist may visit a
site to ensure the response has been implemented/completed.
Staff Interview:
Staff interviews are conducted during the on-site review. A 10% sample (no less
than 5) of direct service staff should be interviewed using the staff survey
(Appendix I). Staff who are selected for interview are selected based on those
consumers selected for review to ensure that staff interviewed correlate to the
consumers’ particular services. Attempts should be made to interview direct
service staff from a variety of shifts and with differing tenure at the site/agency.
The staff survey questions cover the following areas: Abuse/Neglect Reporting,
Client Rights, Behavior Support Plans and Protocols, Orientation Training, Abuse
Prevention, Supervising Medications, Behavior Interactions, Individual Plans,
DDCPT/CBT (for intensive services), and Incident Reporting.
There are multiple questions under each heading. If a staff is unable to answer
up to two probe questions, that area will be considered unmet for that staff
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member. Trends will be identified if multiple staff miss questions for the same
topic area, or multiple staff miss various topic areas.
During the review of administrative records, the Quality Improvement
Specialist should work with the Executive Director or Human Resources
Manager to select the random sample of staff for staff interviews and
review of training attendance documentation. Verification of Criminal
Background checks will be completed for a sample, no less than 5, of
individuals hired since the last Quality Assurance Review.
Expansion of the Review Process
If, during the course of a visit, the QA Team finds a situation where imminent
danger or systemic / pervasive deficiencies are identified, a Quality Assurance
Observation Sheet is issued to the provider organization immediately. The QA
Team must review the data and trends from the consumer surveys and IP
reviews from the year to determine whether the sample size will be expanded to
encompass additional consumers from the provider organization.
Other Visits:
At the discretion of DDP, announced or unannounced visits to any
provider organization may occur as specified in the “Access to Premises”
section of the Department’s contract. These visits may occur for a
variety of reasons including: the provision of training and technical
assistance to provider organization staff; to inspect, monitor or otherwise
evaluate; and/or in response to complaints received from consumers,
family, staff, or the general public. Prior approval for visits to individuals’
community work sites or homes may be necessary. All visits should be
conducted with sensitivity and attempts to keep disruption of daily
routines or work schedules to a minimum.
Use of the QAOS as a tool for ongoing Quality Assurance:
Quality Assurance Observation Sheets record what was observed, what
Administrative Rule, Policy, or Contract requirement is surpassed or
deficient, and the effect on the consumer/provider organization. For
exemplary practices, no response to DDP is required. For deficiencies, a
response date no longer than 10 calendar days from the date of receipt of
the Quality Assurance Observation Sheet is required.
Response to Issues/Deficiencies:
A Quality Assurance Observation Sheet is issued to the Executive

Director, or designee, of the provider organization.
 The provider responds in writing by the Response Due Date to the
Quality Improvement Specialist at the regional or satellite DDP office.
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

The response documents the issue and what action was taken to
address prevention of recurrence of the problem.
The Quality Improvement Specialist accepts the action taken or
requests further review by the provider organization. If further review
is requested, the Quality Improvement Specialist documents further
concerns regarding the follow-up and returns the Quality Assurance
Observation Sheet to the provider organization with a new timeline for
response.
Once the response to a Quality Assurance Observation Sheet is
accepted, the Quality Improvement Specialist documents it has been
accepted, copies the form (and any supporting documentation) to the
provider organization for their files, and maintains a copy at the
regional office with the contract file. The Quality Improvement
Specialist may visit a site to ensure the response has been
implemented/completed. Completed Quality Assurance Observation
Sheets documenting Imminent Danger or Systemic/Pervasive
Deficiencies additional copies may be routed to: the Quality
Assurance Specialist, the Community Services Bureau Chief, and/or
the DDP Program Director. The Quality Improvement Specialist may
visit a site to ensure the response has been implemented/completed.
Imminent Danger:
Imminent danger, or a serious and imminent threat, is defined as any
situation in which it is determined that conditions or practices exist
which, if allowed to continue, have a high probability of causing serious
harm. Imminent danger need not result in actual harm to a person if the
threat of probable harm is perceived as being serious or significant.
Below are guidelines clarifying when a situation is to be considered one
of imminent danger:
 The threat could result in severe temporary or permanent injury,
disability, or death and it is likely to occur in the very near future.
 Mental abuse can be as damaging as physical abuse and may
constitute imminent danger.
 Only one individual needs to be jeopardized; the entire or large
percentage of the population does not have to be threatened or
injured.
 The situation is severe enough that it outweighs potential concerns of
a move to another facility.
 Elimination of the danger is the only response to the problem.
The identification of a serious and immediate threat always results in the
issuance of a Quality Assurance Observation Sheet (QAOS). The danger
must be immediately eliminated and the provider organization’s response
must ensure that the situation will be addressed systemically in order to
prevent recurrence. The provider organization’s response must include
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time lines for completion and the name of the staff member(s) responsible
for completion.
Systemic or Pervasive Deficiencies:
Systemic and/or pervasive deficiencies are those deficiencies that are
found to occur throughout a provider organization or service area, which
affect a provider organization or service overall. Deficiencies may be
identified in the provision of services, the promotion of consumer-valued
outcomes, and the provision of required safeguarding. They are
determined to be systemic/ pervasive and have significant negative
consequences for an individual and/or individuals receiving services.
Examples of systemic/pervasive deficiencies include:
 Individuals do not attend or rarely attend meetings to develop their
program plans nor are other provisions made for them to participate
in program development.
 Staff interviews and reviews of records confirm that habilitation plans
are only sporadically implemented for the majority of people in the
sample.
 A review of incident reports shows that the follow-up of incidents is
almost always inadequate. Either reports are not timely or thorough
or the incident reporting process does not comply with state and/or
provider organization requirements.
 Timely follow-up of referrals for medical appointments is found to be
lacking for many individuals in the sample.
 Individuals’ opportunities to participate in the life of the community,
including use of stores, banks, libraries, parks, restaurants, movies,
etc., are rare, non-existent or unnecessarily restricted. The service
supports fail to teach individuals needed skills to participate in
community life.
 Individuals have almost no opportunity to make choices about any
aspect of their lives/treatment. They do not have the opportunity to
participate productively in the life of the home and/or practice skills
learned.
 Failure of a provider organization to follow or implement internal
policies and state administrative rules and codes regarding reporting
abuse, neglect or exploitation.
 A facility is observed to be insect or rodent infested.
 A staff member documented as having physically abused service
recipients continues to work with them, with no corrective measures
taken.
 A consumer exhibits a pattern of behaviors (assaults, SIB) dangerous
to himself and/or others. There is no plan in place to address the
behaviors and staff is unclear as to how to work with the person.
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Generally, if a review reveals a systemic/pervasive deficiency, it is
necessary to investigate further to confirm the finding. This will usually
mean expanding the sample size to determine whether the identified
issues apply beyond the original sample. It is not necessary that there be
many issues identified at a provider organization for a Corrective Action
Plan to be requested. It is not necessary that a Quality Assurance Review
be in progress for a Quality Improvement Specialist to submit a Quality
Assurance Observation Sheet that requires a Corrective Action Plan.
Levels of Corrective Action:
Level One: Request for Corrective Action Plan
This is the first level of action for providers of DD services that have been
found to have serious/systemic deficiencies. The Quality Assurance
Observation Sheets (QAOS) summarize the issues of deficiency including
reference to administrative rule or contract and formally request that a
Corrective Action Plan (CAP) be completed. The Quality Assurance
Observation Sheets requesting corrective action are sent via mail to the
Executive Director and the President of the Board of Directors. Corrective
Action Plans (CAP’s) are developed by the provider organization and
negotiated with the regional office. A working draft of a Corrective Action
Plan must be initially negotiated within 10 calendar days of the original
request.
Minimally, Corrective Action Plans must include a description of how the
immediacy of the issue was addressed, how the provider organization
plans to address the issue systemically, time lines for completion, and
the name of the staff member(s) at the provider organization who are
responsible for completion. The Corrective Action Plan is verified and
followed up by the assigned Quality Improvement Specialist, other
members of the original survey team and/or the Regional Manager.
When a Corrective Action Plan is requested, the Quality Improvement
Specialist may request that a Caregiving Assessment be completed as a
part of the action plan.
Upon successful completion of the Corrective Action Plan, the Quality
Improvement Specialist notifies the provider organization, in writing, of
the completion of the plan. Failure to comply or cooperate with
development or completion of a Corrective Action Plan may lead to more
significant adverse actions. Those actions may include, but are not
limited to: a Notification of Deficiency letter, a moratorium on any new
placements, or fiscal consequences. It is possible for a provider
organization to have their community home licensed or to achieve
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successful accreditation status while working under a Corrective Action
Plan.
Level Two: Notification of Deficiency
This is a more serious action. Based on the survey, the provider
organization has such serious deficiencies that a Corrective Action Plan
must be developed and implemented immediately. Serious and systemic
deficiencies are identified on Quality Assurance Observation Sheets and
summarized in a Notification of Deficiency letter. The letter will require
that a Corrective Action Plan be developed and returned within 10
calendar days of the receipt of the Notification of Deficiency letter.
The Notification of Deficiency letter is sent via certified mail to the
Executive Director and all members of the Board of Directors. The
Corrective Action Plan must indicate a completion date within 45
calendar days of the receipt of the Notification of Deficiency. Re-visits will
occur every 15 days to ensure implementation and success of the
Corrective Action Plan.
A Notification of Deficiency letter may be written in response to the
failure to submit or successfully implement a Corrective Action Plan.
Under this circumstance, a more serious adverse action could follow.
That action may be fiscal consequences, or notification of termination of
the contract within the 30-day time frame specified by the contract.
Format for all Quality Assurance Reviews
Scope of Review
General Areas
A.
ADMINISTRATIVE
Significant Events from the agency
Policies & administrative (DDP) directives
Licensing
Accreditation
Agency internal communication systems
Fiscal (results of A133 audit, referrals to Medicaid Fraud or QAD review, client
funds & record keeping).
Appendix I
Specific Services Reviewed
A.
Residential
Accomplishments
Programmatic Deficiencies
Corrections to Deficiencies
i. HEALTH AND SAFETY
Vehicles
Consumers
Medication Safety (psychotropics, training, programs, prns,
certification,errors)
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Sites (appearance, evacuation drills, SL apartments, emergency backup, etc.)
ii. SERVICE PLANNING AND DELIVERY
Individual Planning (Assessment, implementation, monitoring)
Leisure / Recreation
Client Rights (restrictions/promotion of rights, grievance procedure)
Medical / health care
Emotionally Responsible Care Giving
Consumer Surveys
Agency’s consumer satisfaction surveys (do you? what info? what do
you do to address?) (accreditation requirement)
iii. STAFFING
Screening/Hiring
Orientation/training
Ratios
Staff Surveys
iv. INCIDENT MANAGEMENT
APS
Incident Reporting
B.
C.
Work/Day/Community Employment
Accomplishments
Programmatic Deficiencies
Corrections to Deficiencies
i. HEALTH AND SAFETY
Vehicles
Consumers
Medication Safety (psychotropics, training, programs, prns, certification,
errors)
Sites (appearance, evacuation drills, SL apartments, emergency backup, etc.)
ii. SERVICE PLANNING AND DELIVERY
Individual Planning (Assessment, implementation, monitoring)
Leisure / Recreation
Client Rights (restrictions/promotion of rights, grievance procedure)
Medical / health care
Emotionally Responsible Care Giving
Consumer Surveys
Agency’s consumer satisfaction surveys (do you? what info? what do
you do to address?) (accreditation requirement)
iii. STAFFING
Screening/Hiring
Orientation/training
Ratios
Staff Surveys
iv. INCIDENT MANAGEMENT
APS
Incident Reporting
Community Supports
Accomplishments
Programmatic Deficiencies
Corrections to Deficiencies
i. HEALTH AND SAFETY
Vehicles
Consumers
Medication Safety (psychotropics, training, programs, prns, certification,
errors)
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Sites (appearance, evacuation drills, SL apartments, emergency backup, etc.)
ii. SERVICE PLANNING AND DELIVERY
Individual Planning (Assessment, implementation, monitoring)
Leisure / Recreation
Client Rights (restrictions/promotion of rights, grievance procedure)
Medical / health care
Emotionally Responsible Care Giving
Consumer Surveys
Agency’s consumer satisfaction surveys (do you? what info? what do
you do to address?) (accreditation requirement)
ii. STAFFING
Screening/Hiring
Orientation/training
Ratios
Staff Surveys
iv. INCIDENT MANAGEMENT
APS
Incident Reporting
D.
Transportation
Accomplishments
Programmatic Deficiencies
Corrections to Deficiencies
Conclusion
Findings Closed
Findings Open / Plan of Correction
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Appendix A: Quality Assurance Observation Sheet
STATE OF MONTANA
Department of Public Health and Human Services
Developmental Disabilities Program
No.
QUALITY ASSURANCE OBSERVATION SHEET
Provider: _____________________
DDP QIS: _____________________
Recipient: ____________________
 Routine

Concern: ______________________
Quality Assurance Review
Date: ________________________
DDP
OBSERVATION (What):
_____________________________
 Plan of Correction needed
CRITERION (Reference ARM, Contract, DD Policy, Appendix I, etc.):
EFFECT (What is the result):
QIS Signature: _________________________ Date Response Due: ________________
Provider
CAUSE (Why did it occur):
ACTION (What action will be taken to address):
Signature: _____________________________ Response: ________________
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DDP
Disposition: ACCEPTED  REQUESTING FURTHER REVIEW  Response Date: ______
Comments: ______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Copy to (check all that apply):  Regional Manager  Executive Director  DDP Bureau Chief
 Contract File  Quality Assurance Specialist  President, Board of Directors  Other _____________
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Appendix B: IP Checklist
IP Checklist
Name: _________________
Date of IP: ______________________
Casemanager: __________________
Date document distributed: ________
Service provider: _______________________________________________________
_____
Individual Preference/Needs Identified Through
Comprehensive Assessments/Surveys
_____
Individual Preferences/Needs Addressed in Plan of
Care
_____
Evidence of Individual Attendance at
meeting/Reason for No Attendance
_____
Objectives Measurable
_____
Objectives Matched to Long-Range Goals
_____
Rights Restrictions (Training and QIS Approval)
_____
Medications Self-Administered
_____
Consumer Survey / Concerns Addressed
_____
All Areas Covered
QIS: ____________________
Date: _______________
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Appendix C: Forms A & B
QUALITY ASSURANCE CHECKLIST (FORM A)
Agency:
Period of Review: ___________________
Consumer reviews list initials and date of verification: ____________________________
________________________________________________________________________
Indiv.
IP’s
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
IP’s (at
case
management)
Rights Restrictions
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*
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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
Q1
Q2
Q3
Q4
Medication Errors
Quarterly reviews from the past year
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 35 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
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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
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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
Site
specifics/
SelfDetermination
/Active
Treatment/
Staff
training/
Daily
routines
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
20
07/11/2003
Appendix D: Medication Error Reporting Form (Optional Form)
DDP MEDICATION ERROR REPORTING FORM (05/06/02)
OPTIONAL FORM
Individual s Name:
Location:

ACTUAL ERROR

POTENTIAL ERROR
Please describe the error. Include the sequence of events, antecedents, personnel involved, and the work environment (e.g.
change of shift, relief staff, short of staff, no 24-hour pharmacy). If more space is needed please attach a separate page.
Was the medication administered to or used by the individual?
event:____________________________

NO
 YES
Date and time of
What type of staff or medical practitioner made the initial error?
____________________________________________________________
If an Actual Error, was there an observable outcome (e.g. death, injury, adverse reaction)? Describe
:_________________________________
If the medication was not administered what action(s) did you take?:
___________________________________________________________
Who discovered the error?
____________________________________________________________________________________________
When and how was the error discovered?
_______________________________________________________________________________
Where did the error occur (e.g. home, group home, work site, pharmacy)?
____________________________________________________
Name of the staff person who made the error (if other than the staff reporting the error):
__________________________________________
21
07/11/2003
Was another staff person involved in the error?  NO
____________________________________________
 YES
If yes, identify staff?
_________________________________________________________________________________________________________
_______
Was an explanation provided to the individual?
taken?__________________________
 NO  YES
If yes, before or after the med was
Were any of the following notified or consulted for instructions?
 Physician  Pharmacist  Nurse
Instructions/Comments:
_________________________________________________________________________________________________________
_______
_________________________________________________________________________________________________________
_______
_________________________________________________________________________________________________________
_______
_________________________________________________________________________________________________________
_______
Please check:
 the type of administration error and  the level of severity of the error:
Type of error:
Level of severity:
 Medication given to wrong individual
 Level 1: Error detected and corrected before medication was given or before
affecting the individual.
 Wrong medication given
 Level 2: Error occurred, caused no change in individual
s condition, did not require
monitoring or any additional treatment.
 Wrong dosage of the medication
 Level 3: Error occurred, caused temporary change in individual
given
required additional monitoring and treatment.
 Medication given by wrong route
 Level 4: Error occurred, caused a temporary disability or required transfer to a
s condition or
higher level of care.
 Medication given at the wrong time
 Level 5: Error occurred, caused permanent harm or contributed to death of the
individual.
 Scheduled dose of the medication
not given
 PRN medication given without
meeting criterion
22
07/11/2003
List any actions you have taken to respond to this error, to prevent recurrence of this error or describe any procedures you have
instituted to prevent similar errors in the future:
Your name and title:
Telephone number:
Your agency name address and ZIP:
Signature
Reviewers Comments
Reviewer Signature
Date
Date
Date
23
07/11/2003
Appendix E: Staff Ratio Checklist
INSTRUCTIONS FOR THE STAFF/CLIENT RATIOS: MONTHLY
MONITORING REPORT FORM
1. Each sheet will cover one month of staff ratio checks per QIS.
2. Fill in the name of the provider and list each group home name and work/day
site.
3. Staff ratio checks should be made across different days of the week and
across different shifts. While on-site drop in visits are preferable, three other
options to conduct checks may be used to accomplish this: telephone calls,
contractor self-reports and QIS review of time sheets. When checks are made by
telephone or contractor self-report, record the name of the person providing the
information.
4. Enter both the date of the check and the day of the week (abbreviated) in
order to track both variables.
5. For the contract ratio, enter the minimum staffing ratio from Appendix I for
the site. This will vary depending on the time checked.
6. Enter the number of staff and the number of consumers actually present.
7. Enter Ayes@ or Ano@ for whether the number of staff to consumers meets the
contract ratio for the time period checked.
8. If Ano,@ was a Quality Assurance Observation Sheet filled out and submitted
to the corporation for their response? If a QAOS sheet was submitted, attach a
copy to the monitoring report.
9. When the corporation satisfactorily responds to the QAOS sheet finding, enter
the date that you close the finding for the corporation.
Note: This sheet can be filled out by hand or it can be filled in and sent
electronically. When you receive the form, it=s a WordPerfect table and you
move through the rows using your tab or your arrow keys. In either case, once
you receive the form you can make a Amaster copy@ by filling in the form with
your group home and work/day sites. Print a new form for each month or open
the master and rename it for each new month. Send the completed form to John
Zeeck.
24
STAFF/ CLIENT RATIOS: MONTHLY MONITORING REPORT
QIS:__________________________ MONTH/YEAR:___________________
Group Home and
Facility-based Work /
Day Sites
Method
of
Check
Code
Date/ Day
Time
METHOD OF CHECK CODES:
1. PHONE CALL TO GROUP HOME.
2. CONTRACTOR SELF REPORT OF STAFFING DATA.
3. QIS DROP IN VISIT.
4. QIS REVIEW OF TIME SHEETS.
5. OTHER.
Contra
ct
Ratio
Staff Present
/ Clients
Present
Ratio
Met?
Y/N
QAOS Sheet
Filled Out? Y
/ N (attach)
QAOS Finding
Closed Date
07/11/2003
Appendix F: Consumer Sample
Consumer Sample
Except for Community Supports Services, the Quality Improvement Specialist
will select a 10% sample (no less than 5) to represent all service categories in
all geographical areas where services are provided. (For provider organizations
serving five or less people, all service recipients are reviewed.) The sampling
procedures should, to the extent possible, ensure that various consumers are
selected from year to year. The provider organization may request that a certain
individual be incorporated into the sample. Procedures for selection of the
sample may include selecting a number from 1 - 5 and picking every X# person
from each invoiced category until the 10% sample is selected.
For Community Supports services, at least five individuals will be reviewed. If
the agency serves less than five in this service, then all individuals will be
reviewed. Of the five, three individuals must be Title XIX Waiver funded.
NAME
Social security #
Service
Category
How selected
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Service Categories: SE = Supported employment; D=Day (facility); I day = Intensive
Day; SenDay = Senior Day; SL = Supported Living (residential); Cong SL =
Congregate Supported Living; GH = Group Home; CGH = Children’s Group Home;
IGH = Intensive Group Home; R = Respite (only); CS = Community Supports
(indicate funding source – XIX/GF); T = Transportation; Rec = Recreation/Leisure
How selected: 1 = Random; 2 = Complaints received; 3 = Concerns (external agency
involvement eg., DDP, APS, Licensing, etc.); 4 = Provider request
26
07/11/2003
Appendix G: Implementation Features
THROUGHOUT THE YEAR CONSUMER SURVEYS AND IP’s:
AREA OF REVIEW
Consumer / Family
Interviews *completed
by Case Managers*
Individual Plans
IP documents
ARM 37.34.1101, et
seq.
Individual Plans
IPP’s and objectives
ARM 37.34.1101, et seq.
Individual Plans
IPP
and objective data
collection ARM
37.34.1101, et seq.,
ARM 37.34.102
Individual Plans
IPP
and objective data
monitoring ARM
37.34.1101, et seq.
Individual Plans
Self Medication
objectives
ARM 37.34.114
Individual Plans
Rights Restrictions
ARM 37.34.1418
ARM 37.34.102
(GH)- ARM 37.100.330
FEATURES
Are there particular commendations? If issues, verify via
case management contact notes. Follow up with provider, IP
Team, etc. as necessary depending on input.
Are staff aware of Individual Plans? Are IP documents readily
available to staff? *Is IP implementation a concern due to
lack of staff knowledge?
Are objectives from the IP implemented on time? Are IPP’s
available where necessary? Are IPP’s implemented by the
date prescribed in the IP document? * Are there concerns
about IP follow through due to lack of IPP’s, data sheets or
lack of implementation?
Are data keeping systems in place to document
implementation of objectives and IPP’s? Do IPP’s and the
data keeping systems meet the intent of the objective(s)? *Do
concerns exist regarding IP implementation?
Are data keeping systems in place to monitor implementation
of objectives and IPP’s? Is documentation from IPP’s and
objective(s) monitored to ensure success? *Do concerns exist
regarding internal IP monitoring systems?
For individuals that do not self administer medication, are
self-medication objectives written? Or, does the annual IP
document that self-medication administration training is not
needed? Does training take place to enhance individual
independence in medication administration?
Are any Rights Restrictions in place? Are any Rights
Restriction implemented only for health/safety reasons? Are
Rights Restrictions accompanied by training
programs/supports (to decrease the need for this
restriction)? Are Rights Restrictions the least intrusive
approach? Are Rights Restrictions reviewed at least
annually?
IN CASEMANAGEMENT FILE (SAME SAMPLE AS CONSUMER SURVEYS):
AREA OF REVIEW
IP Checklist
ARM 37.34.1101, et
seq.
Individual Plans
Addresses specific
needs of the individual
ARM 37.34.1101, et
FEATURES
Are trends noted in IP Checklists completed for individuals in
the sample? Verify in Casemanagement records.
Are individual specific needs addressed by the IP Team?
Does the IP Team address specific medical, behavioral,
communication, training needs of the person? Is any use of
wholistic/vitamin/ homeopathic treatments referred through
27
07/11/2003
seq.
Individual Plans
Assessments
ARM 37.34.1101, et
seq.
the primary physician for approval?
Is the IP developed based on Assessments, wishes, desires,
and needs of the individual? Are assessments listed in the IP
available for review? *Do the IP’s address individual’s needs?
Do concerns exist due to lack of assessments?
AREA OF REVIEW
Individual Plans:
Quarterly Status
Reports
ARM 37.34.1108
Individual Plans
Incident Reports
ARM 37.343.1501, et
seq.
FEATURES
Are quarterlies routinely submitted? Do quarterlies present
an accurate account of IPP data? Are there issues at this
provider regarding quarterly reports?
Individual Plans
Behavior Supports
ARM 37.34.1401, et
seq.
ARM 37.34.2101, et
seq.
ARM 37.34.102
Aversive Procedures
ARM 37.34.1401 et seq.
ARM 37.34.102
(GH) – ARM 37.100.330
Are there outstanding issues/concerns regarding individual
planning due to trends of incident reports? Have behavioral
supports been employed to address trends in behavioral
reports? Have functional analyses been completed for
behavioral issues? Do health/safety and treatment issues
exist due to lack of follow up on Reporting trends?
Are behaviors which pose risk of harm/injury addressed in
IP’s? Are behaviors which limit an individual’s acceptance in
the community addressed in IP’s? Are behavioral supports
designed to be proactive and positive in nature? Are
functional analyses completed to determine the function of
the behavior? Are more appropriate alternative behaviors
being taught to the person? Does a quality of life concern
exist due to lack of or inappropriate behavioral supports?
Is the person free from aversive procedures? Are staff trained
in positive behavioral supports? Are emergency procedures
used according to the Aversive Rule? Is use of emergency
physical restraints inappropriate or excessive? Do quality of
life concerns exist due to unapproved use of aversive
procedures? Do health/safety concerns exist due to
unapproved aversive procedures?
DESK REVIEW:
AREA OF REVIEW
Accreditation
ARM: 37.34.1801
Fiscal:
A-133 Audit
Contract
FEATURES
As determined by Qualified Provider definition, is the agency
currently accredited? If yes, is it a 3-Year, 2-Year, 1-Year?
With distinction? *Could be a commendation. If no, is an
accreditation review scheduled? Review recommendations
from Accreditation for commendations or implementation of
recommendations.
As determined by Contract, is there a current external audit
on file with the Regional DDP office? If yes, could be a
commendation. If no, is there an external audit scheduled?
Are there extenuating circumstances involving an external
audit? Are all contract documents and year-end reports
received on time?
28
07/11/2003
Fiscal:
Cost Plans
ARM 37.34.917
Fiscal:
Invoices
ARM 37.34.913
AREA OF REVIEW
QAOS from the year
Medication Errors
ARM 37.34.114
Rights Restrictions
/Violations
ARM 37.34.1418
ARM 37.34.1501
Incident
Reports/Trends:
ARM 37.34 1501, et seq.
As determined by ARM and contract, are Cost Plans available
for individuals? If no, not met.
Are submitted cost plans in agreement with individual’s
plans of care? Are cost plans submitted on time?
*Review IP’s, staffing schedules and ratios.
Are invoices for contracted services submitted to the
Regional DDP office on time? Are invoices generally correct?
Are there ongoing issues with invoices that are being/have
been addressed? *Review contract file for QA Sheets
involving invoices and outcomes.
FEATURES
Were trends documented on QAOS this year? Re-check
documentation that specific areas addressed have not
recurred.
Are there outstanding issues regarding medication errors?
*Review contract file for QA Sheets involving medication
errors and outcomes.
*Review Quarterly Medication Errors.
Does a health/safety concern exist due to medication errors?
Were there issues with Rights Restrictions/Rights violations
this year? For Rights Restrictions in place, are they
addressed through IP’s with corresponding training and
support strategies?
Are there outstanding issues/concerns regarding Abuse/
Neglect Reporting?
 Are incidents reported as required by MCA & ARM?
 Does the agency policy for incident reporting match the
APS/DDP Reporting Protocol?
Are there health/safety concerns due to Abuse/Neglect? Are
incidents reported according to timelines specified in rule?
Are incident reports complete according to required
documentation? Are incidents regarding potential abuse,
neglect, or exploitation reported to Adult Protective Services?
Does a health/safety concern exist due to lack of reporting
incidents?
AT THE MAIN OFFICE OF THE AGENCY:
AREA OF REVIEW
Licensing
ARM: 37.100.301-340
ARM: 37.34.702
ARM: 37.34.706
ARM: 37.34.912
Community homes (GH,
IGH, CGH)
Criminal background
Checks
FEATURES
As determined by ARM, are the Community Home(s)
currently licensed?
If yes, could be a commendation.
If no, or the license(s) are provisional are there extenuating
circumstances involving licensing?
Review the licensing report for verification of outcomes,
status of completion/implementation of recommendations.
Does a health/safety concern exist due to the absence of a
current license?
As determined by ARM, review a sample of staff Department
of Justice checks (sample of 10% or no less than 5, sample
29
07/11/2003
ARM: 37.34.2102
*Verify
information from
personnel files
with the Human
Resources
Manager, DDP staff
should not review
personnel files.
AREA OF REVIEW
Fire Drills
ARM 37.34.713
ARM 37.34.706
GH – approval to remain
at home unattended
ARM 37.34.706
(Adult services)
ARM 37.100.340
Orientation training
(within 30 days of hire)
ARM 37.34.2102 &
2107
ARM 37.100.322
ORIENTATION
TRAINING FOR ALL
STAFF *includes relief,
substitute staffing lists
*Verify attendance
and
agenda/curricula
with the Training
Manager,
personnel files
should not be
reviewed by DDP
staff.
to include new hires employed in last 12 months; relief staff,
and staff employed for longer than 1 year). Have requests for
criminal background checks been returned from the
Montana Department of Justice prior to starting on shift?
Does a health/safety concern exist due to lack of criminal
background checks?
FEATURES
Review fire drill reports.
Ensure that any individual trends in lack of/delay in
response to drill are addressed through IP Team and/or
Safety Committee at agency. Are drills conducted at nonlicensed facilities? Are drills conducted to demonstrate safety
for those receiving Supported Living services?
Best practices: Quarterly drills, with all shifts represented.
At community homes are monthly fire drills run?
Does the Orientation Training include:
 Familiarity with the individuals and their particular
needs
 Philosophy of DD services and of the organization
 First aid and emergency procedures
 Normalization principles
 Meeting the needs of individuals through care,
supervision and training
 Client Rights
 Incident Reporting (and Mandatory Reporter status)
 Application of treatment and training techniques
 Behavior Management Techniques
Does Annual re-training /re-inservicing occur?
Do staff receive training information to equip them to
complete the duties of their job(s)?
Does a health/safety concern exist due to lack of staff
training?
Are staff enrolled in DDCPT/equivalent within 45 days?
(ARM 37.34.2107)
For Intensive Service
30
07/11/2003
Supervision of staff /
staff satisfaction
surveys
ARM 37.34.702 & .2111
ARM 37.34.985 (SL)
Individuals / families
have choice in
Supported Living staff
ARM 37.34.712
(“new” SL)
Review policies and procedures to ensure staff are supervised
in completion of their job duties. Does supervision involve
ongoing observation and feedback? Do staff duties conflict
with values of increasing independence and involvement in
daily life? Review compilation of staff satisfaction surveys.
*Do health/safety or quality of life concerns exist due to lack
of/limited supervision of staff?
Do individual’s (families) have choice supported living staff?
(Hiring decisions are the responsibility and relationship
between the agency and the staff.) Review agency policy and
procedures for individuals or their families to have some
choice in Supported Living staff (for SL starting in 1994).
ON SITE REVIEWS:
AREA OF REVIEW
Health/Safety
Bathing Policy
DD Policy – Jeff Sturm
2002
Health/Safety
Clean / Sanitary
Environment
ARM37.34.702&706
ARM37.34.2107&
.2111
Health/Safety
Egress
ARM 37.100.321GH
ARM 37.34.713 SL ARM
37.34.702 & .706 (Adult
Svcs.)
Health/Safety
Water temperature in
bathing areas
ARM 37.100.320
Health/Safety
Emergency back-up
ARM 37.34.702
ARM 37.34.2111
Health/Safety
Fire extinguishers/
Smoke Detectors
ARM 37.34.713
(SL)
IMPLEMENTATION FEATURES
Is safety during bathing addressed for people with seizure
disorders in the IP? Are written procedures in place? Are the
procedures easily available to staff? Have staff been trained
in the procedure? Does a health/safety concern exist due to
bathing procedures?
Per sites reviewed, is the site clean? Is furniture in good
repair? Are there visible safety concerns? Is there a presence
of insects/rodents? Does the laundry system and area
provide for sanitary conditions? Do health/safety concerns
exist due to cleanliness/unsanitary conditions?
Are there two means of egress in Supported Living settings?
Are means of egress at facilities/group homes clearly
marked? Unblocked? Does a health/safety concern exist due
to limited/blocked means of egress? Are health/safety
concerns addressed in Individual Plan and Documentation of
Choice?
Hot water temperature in bathing areas should not exceed
120 degrees Fahrenheit. Check the temperature, check
agency logs for hot water temperature checks. If too hot, take
immediate measures to contact maintenance/agency
supervisor to have thermostat on hot water heater turned
down. Does a health/safety concern exist due to temperature
of water in bathing areas?
At site(s), are policies and procedures in place for
Emergency assistance/back-up? Staffing schedules? Phone
lists? Emergency on-call/beeper number posted?
Check batteries functional in smoke detectors? Are smoke
detectors located outside of bedrooms and in kitchen area?
Check monthly log of agency check of detectors being
operational. Are fire extinguishers present in kitchen of
supported living apartment? Are fire extinguishers serviced
31
07/11/2003
Health/Safety
PRN medications
ARM 37.34.114
Health/Safety
Medication Procedures
ARM 37.34.114
ARM 37.34.702
Health/Safety
Medication storage
ARM 37.34.114
ARM 37.100.320
AREA OF REVIEW
Health/Safety
Medication
Administration Logs
ARM 37.34.114
Health/Safety
Staff ratios ARM
37.34.702 & .2111
Health/Safety
Awake overnight staff
ARM 37.34.2111
Health/Safety
Adequate supplies
ARM 37.34.702 &.706
ARM 37.34.2107&2111
Health/Safety
Storage of supplies
ARM 37.34.702 &.706
ARM 37.34.2107&2111
Individual Plans
Integrated Community
Activities
ARM: 37.34.706 GH
ARM:37.34.711 Day
ARM: 37.34.712 SL
Individual Plans
House/Site Rules
DD Policy 411.5
ARM 37.34.701
within 1 year of this visit?
Are PRN medications for prescribed? Are protocols in place
for staff to know when they can be used? Are protocols
reviewed and approved by the IP Team?
Talk with individuals and staff about procedures to assist
with medications. Are individuals involved in maximum
independence in self-administration of medications? Are
procedures in place to minimize possibility for medication
errors (medication stored and supervision of medication in
quiet area, clear indication which staff responsible to
supervise meds, only med certified staff supervise
medications? * Does a health/safety concern exist due to
ongoing problems with medication errors?
Are medications stored in a locked cabinet in licensed
facilities? In non-licensed settings, is medication stored
safely? Are out-of-date medications disposed of? *Does a
health/safety concern exist due to storage of medications or
presence of out-of-date medications?
IMPLEMENTATION FEATURES
Are Medication Administration logs clearly written? Do only
med certified staff sign for medications? Are systems in place
to clearly indicate medication changes? Are medication
administration logs files with information regarding side
effects of medications? *Does a health/safety concern exist
due to medication administration records?
Does staff schedule and ratio meet contracted ratio in
Appendix I or individual’s cost plan?
*Is health/safety a concern due to staff ratios?
Does site require awake-overnight staff? Are overnight staff
supervised to ensure they are not sleeping? Talk to
individuals and staff. Is health/safety a concern due to lack
of supervision of awake-overnight staff?
Are personal care and cleaning supplies available? Are
personal care supplies stored hygienically? *Does a
health/safety concern exist due to inadequacy of or storage
of supplies?
Are cleaning supplies stored safely? Are potentially
hazardous or toxic chemicals and supplies kept locked or
secured in licensed facilities? In unlicensed facilities, does
storage of supplies pose a health/safety concern? *Does a
health/safety concern exist due to storage of supplies?
Do individuals have opportunities to participate in integrated
community activities? Review community activity data, does
it reflect integration or are activities in groups with disabled
peers? Do community activities reflect involvement or only
passive attendance? *Does a quality of life concern exist due
to limited integration in the community?
For facilities/apartments, do site rules exist which conflict
with the values of integration, independence, choice and selfdetermination? Do residents have a bedtime? Is access to all
areas of the living space restricted without valid concern? Is
food accessible by residents? Are residents allowed in the
32
07/11/2003
ARM 37.34.1418
ARM 37.100.330
Daily Living
Choice-making
ARM 37.34.701
Daily Living
Meal Preparation/
Mealtime
ARM 37.34.102
ARM 37.34.701 (Adult
Svcs.)
AREA OF REVIEW
Involvement and
Engagement in daily life
ARM: 37.34.102
ARM 37.34.701
ARM 37.34.941 & .942
Daily Living
Participation in Daily
Life
ARM 37.34.102
ARM 37.34.701
Daily Living
Leisure activities
ARM 37.34.706, .711, &
.712
Staff Training
Individual Specifics
ARM 37.100.322
ARM 37.34.712 (SL)
ARM 37.34.2102
&.2107
Staff Training
Staff Surveys
kitchen area? Do residents assist with meal
preparation/clean up? *Does a quality of life concern exist
due to inflexible house/site rules? Are site rules developed
for convenience of staff, site, and agency?
Are individuals encouraged to make choices and exert selfdetermination in areas of their daily life? If concern exists
regarding informed choices, are protections and training in
place to assist individuals in making healthy choices? *Do
quality of life concerns exist due to inability to make choices?
Are individuals encouraged to participate in meal
preparation to the best of their abilities? Are meals served
family style? In congregate facilities, are staff present to
supervise and encourage mealtime behaviors? Are
specialized diets and individual preferences addressed? Are
specialized diets addressed through the Individual Plan?
*Does a quality of life concern exist due to meal preparation,
mealtime procedures, implementation of diets without
physician’s approval?
IMPLEMENTATION FEATURES
What are people doing within their environment? Are they
involved? Or, are indications of custodial care present? What
activities are available? What activities are people
encouraged to participate in? Are individual plans being
implemented? Are people engaged in their own lives?
Are individuals encouraged to maintain participation in
activities of daily life? Are previously developed daily living
skills maintained? Are individuals involved in daily routines?
Do individuals have opportunities to assist with general
household maintenance? Do individuals access and utilize
community resources (banking, libraries, movie theatres,
shopping). Does the person have an adequate amount of
education/work/retirement activities available? Are efforts
made to find community based employment for those who
wish to seek employment? *Does a quality of life concern
exist due to lack of / limited opportunities to participate in
daily life?
Do daily opportunities exist for participation in a variety of
leisure activities for GH residents? Are
Staff encouraging variety or only recording what activity the
person participated in. *Does a quality of life concern exist
due to limited/lack of assistance leisure time?
Are staff trained in individual specific needs, diagnoses,
specialized treatment concerns, specialized medical
concerns, specialized behavioral concerns? Talk to
individuals and staff. *Do health/safety or quality of life
concerns exist due to lack of/limited staff training?
Do trends exist in staff responses to the survey questions?
33
07/11/2003
Appendix H: Rule/Contract Authority
ARM References for the QAOS:
Abuse/Neglect Reporting: ARM 37.34.1501; ARM 37.34.1506; MCA 41-3-201 and 523-811
Abuse Prevention:
ARM 27.34.2107; ARM 37.34.1501, et seq.
Accreditation:
ARM 37.34.1801
Active treatment:
ARM 37.34.102; ARM 37.34.701; ARM 37.34.941 and .942
Audit:
Contract
Awake- night Staff:
ARM 37.34.2111
Background Checks:
ARM 37.34.2102
Bathing Procedures:
2002 DD Policy, Jeff Sturm
Behavior Support:
ARM 37.34.2107; ARM 37.34.1427; ARM 37.34.1502
(MANDT or equivalent); ARM 37.34.102
Behavior Support/
Emergency Procedures:
ARM 37.34.1502; ARM 37.34.1420; ARM.37.34.702
Behavior Support Plans: ARM 37.34.1401 through 37.34.1428;
ARM 37.34.2101 through 37.34.2112
Choice-making /
Self-determination:
ARM 37.34.701
Client Rights/
Freedom from Abuse:
ARM 37.34.1501; ARM 37.34.1506;
ARM 37.34.1418; ARM 37.100.330
Client Rights:
DD Policy 411.5; ARM 37.34.701; ARM 37.34.1418
Cost plans:
ARM 37.34.917
Criminal Background
Checks:
ARM 37.34.2102
Data collection
& Documentation:
ARM 37.34.102
DDCPT/Equivalent:
ARM 37.34.2107 (Intensive Services)
Egress:
ARM 37.100.321 (Group Home);
ARM 37.34.713 (Supported Living);
ARM 37.34.702 & .706 (Adult Services)
Emergency Assistance/
Back-up Staff:
ARM 37.34.702; ARM 37.34.2111
Engaged in Meaningful
Activities:
ARM 37.34.706; ARM 37.34.711 & .712
Fire Drills:
ARM 37.34.713; ARM 37.100.340 (monthly at GH)
Fire Extinguisher:
ARM 37.34.713 (Supported Living)
GH residents at
home unattended:
ARM 37.34.706
Habilitation:
ARM 37.34.941 and .942
Incident Reporting:
ARM 37.34.1501, et seq.
Individual Plans:
ARM 37.34.701 & .702, ARM 37.34.1101, et seq.;
34
07/11/2003
ARM 37.34.2107
Integrated Community
Activities:
Invoices:
Leisure/Recreation:
Licensing:
Mealtime
& Meal Preparation:
ARM 37.34.706, .711, & .712 (Adult Services)
ARM
ARM
ARM
ARM
37.34.913
37.34.706; ARM 37.34.711 & .712
37.100.301-340; ARM 37.34.702; ARM 37.34.706;
37.34.912
ARM 37.34.102; ARM 37.34.701 [Adult Services];
ARM 37.100.301 (Group Home)
Medication Errors:
HCFA/CMS Review
Protocol - Health/Safety: ARM 37.34.102; ARM 37.34.114; ARM 37.34.701; ARM
37.34.1201; ARM 37.34. 1501 et seq.; ARM 37.34.2107
Medication Procedures:
ARM 37.34.114; Managing Medications Dr. Docktor
Medication Administration
Logs:
ARM 37.34.114
Medication Storage:
ARM 37.34.114
Medication Supervision: ARM 37.34.114
Medication Training:
ARM 37.34.114
Orientation Training:
ARM 37.100.322; ARM 37.34.2102; ARM 37.34.2107
Positive programming:
ARM 37.34.102
PRN Medications:
ARM 37.34.114; Policy Clarification 1992
Rights Restrictions/
Violations of Rights:
ARM 37.34.1414; ARM 37.34.1501; ARM 37.100.330
Safe environment:
ARM 37.34.702; ARM 37.34.706; ARM 37.34.2107;
ARM 37.34.2111
Site Rules:
ARM 37.34.701, ARM 37.34.1408, DD Policy 411.5
Smoke Detectors:
ARM 37.34.713 (Supported Living)
Supported Living Hiring: ARM 37.34.712
Staff Ratios:
Contract - Appendix I, ARM 37.100.322;
ARM 37.34.701 & .702; ARM 37.34.1101, et seq.;
ARM 37.34.2111
Staff Supervision:
ARM 37.34.2111; ARM 37.34.702; ARM 37.34.985 (SL)
Staff Training/
Individual Specifics:
ARM 37.100.322; ARM 37.34.2102 & .2107;
ARM 37.34.702
Storage & Adequacy of
Person and Cleaning
Supplies:
ARM 37.34.702; ARM 37.34.706; ARM 37.34.2107;
ARM 37.34.2111
Water Temperature:
ARM 37.100.320, CMS Review Protocol - Health/Safety
35
07/11/2003
HEALTH/SAFETY
Federal Authority:
42 CFR 441.302 & .33
SMM (State Medicaid Manual)
4442.4; 4442.9
DESIGN &
IMPLEMENTATION
OF IP’s
Federal Authority:
42 CFR 441.301, .302 & .303
SMM 4442.6; 4442.7
DDP Review
Medication Errors
Incident Reporting
Medication Errors
Water Temperature
Health Sanitation:
 Safe environment
 Egress
 Storage of
supplies/cleaning
materials
 Bathing Policy
 Staff Ratios
 Awake Overnight
staff
 Supervision of Staff
 Emergency
Assistance/Back-up
Medication
Administration
 Staff certification
 Procedures
Fire Drill Documentation
SERVICES
PROVIDED BY
QUALIFIED
PROVIDERS
Federal Authority:
DDP Review:
Individual Plans
 Implementation
 Self administration of
medications
 Address person’s
needs
Staff training/in service
training regarding
individual specifics
Leisure/Recreations
 Daily opportunities
for variety in leisure
 Integrated activities
Staff ratios support
services outlined in
individual plans
Supervision of staff to
ensure guidance in
implementation of plans
42 CFR 441.302
SMM 4442.4
DDP Review:
Licensing
Background Checks
Accreditation
Orientation Training
 Abuse / Neglect
Reporting & training
 Client Rights Training
 Behavior Support
Training
 Medication
Certification
 DDCPT/CBT
 Behavior
Management
 Emergency
Procedures & Backup Plans
Fiscal Accountability:
Federal Authority:
42 CFR 441.302, .303 & .308
45 CFR 74
SMM 2500; 4442.8 & .10
36
DDP Review:
External Audit
Cost Plans
Invoices
37
07/11/2003
38
Appendix I: Staff Interview Questionnaire
IS QFORM D
STAFF SURVEY
Agency/Site:________________________________________________Date:________
______
Name of Staff:____________________________________How long
employed?____________
Ask one staff from each service area any two questions under each heading. Staff will
need to answer both questions correctly in order to get the section “MET.” If a staff
member misses one or both questions, the staff survey area will be considered NOT
MET ; the QIS will fill out a QAOS. When doing the survey, the QIS will circle “+” if the
staff answered correctly or circle
“-“ if the staff answered incorrectly.
ABUSE/NEGLECT REPORTING:
MET
NOT MET
(ARM 37.34.1501 & .1506, MCA 41-3-201 and 52-3-811)
*review June 11, 2002 letter from Jeff Sturm regarding Incident Report
Procedures and agency policy.
+
- Q: When ABUSE/NEGLECT/EXPLOITATION is witnessed or suspected, direct
service staff are MANDATORY REPORTERS. Allegations are reported to........
A: Adult Protective Services (or Tribal Social Services if on a reservation and not
in a group home).
+
- Q: If you witness or suspect ABUSE/NEGLECT/EXPLOITATION and want to report
it to APS, do you have to first notify your supervisor?
A: NO
+
- Q: If there is imminent risk to a consumer, is a report to APS adequate:
A: NO--it needs to also be reported internally to management so that steps can
be taken to protect the consumer.
+
- Q: If you discovered a consumer being physically abused by a staff person, what
should be your first course of action?
A: Take steps to protect the consumer.
38
07/11/2003
+
39
- Q: Describe your agency s internal reporting procedure for allegations of
ABUSE/NEGLECT/EXPLOITATION.
A: Answer should include the name/title of the person in the agency to whom
staff persons are expected to report.
39
07/11/2003
40
CLIENT RIGHTS:
MET
NOT MET
(DD Policy 411.5, ARM 37.34.701, ARM 37.34.1418, 37.34.1501 & .1506,
GH ARM 37.100.330)
+
- Q: You have a consumer with a history of stealing. You suspect he has
taken another consumer’s gloves. What would you do?
A: Talk to him. Ask him if he has seen the individual’s gloves. Do not
accuse him of stealing.
+
- Q: A doctor appointment has been requested by the individual’s IP team. The
symptoms which prompted the request have not been seen in 3 weeks. You
think the appointment is no longer necessary? What do you do?
A: Talk to my supervisor and/or contact the IP team. Do not cancel the
appointment unless the IP team agrees.
+
- Q: You and a new staff are working together with an individual. The individuals
bumps his/her elbow and lets out a curse word. You ask the individual if he/she
are okay and remind him/her of other words he/she can use. The new staff asks
you why you don’t punish the person (i.e. go to his/her room, leave work, not let
him/her go on an outing). What is your response?
A: Explain that the individual is an adult and deserves to be treated as an adult.
The role of staff is not to parent the individual but rather to assist them in living
the life of their choice. That any type of punishment would need team approval.
+
- Q: An individual wants to walk to the store. She has no jacket and it is –25
degree outside. What can you do?
A: Offer her a ride, offer her someone else to drive. Do not let her walk due to her
health and safety (Explain that to her also). Complete an incident report.
+
- Q: Do any of the consumers have rights restrictions here? Who? What is the
restriction?
What is being done to allow that consumer to get his/her rights reinstated?
A: Staff should be able to name who has rights restrictions, what the restrictions
are for, and what plan is in place to allow the consumer to get the restriction
lifted.
40
07/11/2003
41
BEHAVIOR SUPPORT PLANS & PROTOCOLS:
MET
NOT MET
(Only applies if a person at that site has a behavior support plan/protocol)
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM 2101, et
seq.)
Review the plan first. Make sure you are using the same terms as written in
the plan.
+
- Q: Ask staff to label and define at least one of the target behaviors.
A: Staff should be able to define at least one of the target behaviors in the plan.
+
- Q: Ask staff to describe the Reactive Strategies.
A: Staff should be able to describe what they do when the target behaviors
occur.
+
- Q: Ask staff to list 2 or 3 of the Proactive or Environmental Strategies.
A: Staff should be able to describe what procedures are in place to try to reduce
the likelihood that the target behaviors occur in the first place.
+
- Q: What can happen if the Behavior Plan is not implemented with consistency?
A: Answer should include giving the consumer mixed signals and possible
intermittent reinforcement of target behaviors, leading to strengthening the behaviors.
+
- Q: Describe the training you received in the implementation of the plan? How
often? Who does the training?
A: Staff should state that they have had training and that they feel comfortable
with the
amount of training they ve received.
ORIENTATION TRAINING:
MET
NOT MET
(GH - ARM 37.100.322, SL - ARM 37.34.712, ARM 37.34.2102 & .2107)
+
- Q: You run into Mike (who you used to work with at the day program) at the
local grocery store. He says he heard that Joe’s (a consumer) health is not good
and he would like to visit Joe. He asks how to reach Joe. What do you tell him?
A: Tell him that you will relay that information to Joe. Ask Mike how Joe can get
in touch with him. Explain that you can’t give any information due to
confidentiality.
+
- Q: Explain what confidential information is? Who has access to the consumer’s
information.
41
07/11/2003
42
A: Pretty much everything, except what cannot be identified directly to the
person. Guardian, individual, supervisors, IP team members, case manager,
DDP, etc.
+
- Q: What type of orientation training did you receive when you started working
here?
When did you receive it? (ask this question if hired within the past
1 year).
A: Staff should indicate what type of training they received and that they
received some training prior to working alone with consumers. Answer may
include Incident Reporting, Abuse Reporting, Confidentiality, Health/Safety,
Behavior Strategies, Infection Control, Emergency Evacuation, and other training
specific to the individuals they are working with.
+
- Q: How were you trained to meet the health and safety needs of the individuals?
(this question can be for staff who have been employed longer than
one year).
A: 1st Aid/CPR or other health/safety information, information specific to the
individual’s needs, evacuation procedures, reporting requirements, etc.
+
- Q: Describe the emergency evacuation procedure? How do you
document an emergency evacuation? What happens if problems are
identified?
A: Refer to agencies policy and form. Concerns are referred to the supervisor
and/or IP team and documented.
SUPERVISING MEDICATIONS:
(ARM 37.34.114)
MET
NOT MET
+
- Q: Role-play or describe the procedure for supervising medications.
A: Minimally to include: check med sheet to bubble-pack/bottle; double check
meds to med sheet after filling med cup; and documenting
+
- Q: What would you do if a medication was unavailable (bottle/bubble-pack
empty), missing, etc.
A: Minimally, the answer should include to call a physician and/or pharmacist
immediately and complete an incident report or medication error report.
+
- Q: What would you do if you erroneously gave someone a different person s
medications?
42
07/11/2003
43
A: Minimally, the answer should include: contacting a medical professional
immediately (nurses if agency has a nursing department, call to physician and/or
pharmacy, visit to ER), complete an incident report or medication error report.
+
- Q: If someone were capable of taking his/her own medications and they move to
a new living situation or started taking a new medication, what do you need to
do?
A: Document 30-day showing the person has maintained independence taking
medications.
+
- Q: What is required for staff to assist consumers in taking their medications?
A. Someone who has a valid Medication Administration certificate. (Optional: a
licensed nurse).
+
- Q: Does anyone here receive PRN or OTC medications? How is it decided when
to administer a PRN or OTC medication?
A: Staff should be able to state who, if anyone, receives PRN or OTC
medications; there should be a written protocol for administering those
medications.
+
- Q: What constitutes a medication error? How do you document a medication
error?
A: Answer should such things as an omission, giving the wrong med or the
wrong dose, giving a medication by the wrong route, to the wrong person, or at
the wrong time, and also charting errors. An IR or Medication Error Report Form
must be filled out.
BEHAVIOR INTERACTIONS WITH CONSUMERS:
MET
NOT MET
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM 2101, et
seq.)
+
- Q: If a consumer were destroying things, what would you do?
A: Answer should include trying to redirect, calm the person down, etc.
+
- Q: If a consumer were to pinch a staff and you observe the staff pinching back,
what do you do?
A: Intervene and separate the staff and the individual, report to APS, document
the incident and report to your supervisor if they were not involved.
43
07/11/2003
44
+
- Q: If a consumer was hurting himself or others and you have tried a number of
non-aversive techniques such things as talking to him, redirection, stimulus
change, yet the individual is still causing or about to cause significant injury to
another person (tipping an individual’s wheelchair over) what emergency
procedures can be used?
A: Physical restraint (Mandt restraint technique) and/or time-out (have person go
to their room or go outside into the fenced yard) (Optional: seclusionary time
out with an approved time-out room) and complete an Incident Report.
+
- Q: If a consumer frequently becomes out of control and endangers themselves
or others and they surpassed the 3 times in a 6 month time period for the use of
emergency procedures, what do you do?
A: Team discussion about how to best intervene, some type of behavior protocol.
+
- Q: What sorts of things would lead you to believe that someone needed a
behavior support plan? What would you do?
A: Answer should include consumer engaging in a behavior that injures
themselves or others, causes property damage on a regular basis, or prevents
the individuals from participating in the community and discussing the problem
with a supervisor or management staff.
EMOTIONALLY RESPONSIBLE CAREGIVING:
MET
YES N0
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM 2101, et
seq.)
+
- Q: An indicator of abuse in a caregiving environment is a power struggle. If
during your shift, a consumer refused to get onto the van what steps would you
take to avoid a power struggle?
A: Answer should include some things that lead to conflict and what steps staff
take to
avoid getting into a power struggle.
+
- Q: Another indicator of abuse in a caregiving environment is the response to
an upset person. If you observed an individual becoming agitated because
he/she couldn’t find his/her lunchbox, how can you assist the individual?
A: Staff should talk about remaining calm themselves, talking quietly to the
individual, offering to assist the individual, reassuring the person. Other
techniques and responses that will help the person to de-escalate.
+
- Q: What can you do if you feel you re beginning to lose control?
A: Answer should include reporting to a supervisor, getting another staff to step
in, or taking a breather --stop, step back, & think.
44
07/11/2003
45
INDIVIDUAL PLANS (IP S)
MET
NOT MET
(ARM 37.34.701 & .702, ARM 37.34.1101, et seq., ARM 37.34.2107)
+
- Q: What are Individual Plans based on?
A: Minimally, staff should state wishes/desires of the person and assessments.
+
- Q: If you have an idea for a training objective or suggestions for changing a
current objective, who do you talk to?
A: They should know that they should talk to a supervisor/management at any
point in the year if something in the plan is not working or if they have
suggestions for additions to the plan.
+
- Q: What is an assessment? What is the purpose of doing assessments?
A: A formal or informal evaluation of a person s functional abilities. To
determine what
needs to happen for the person to achieve a desired goal.
+
- Q: How do you find out what a person would like to have happen or would like
to do?
A: Answer can include use of dream cards or self-survey (for verbal consumers)
or historical knowledge of what the person likes or dislikes (for non-verbal
consumers), ask the individual, observation form.
INCIDENT REPORTING:
(ARM 37.34.1501, et seq.)
+
MET
NOT MET
- Q: When would you fill out an incident report?
A: Anything unusual, anything that has the potential for harm or injury, alleged
unlawful activities, changes in the person’s residential or vocational placement
without IP team approval, emergency medical, suicide attempt, medication errors,
missing person, right’s violation, suspected abuse/neglect/exploitation, use of an
emergency procedure, unaccounted for absences. Reference to the agency form.
Name at least 5 or staff should be able to show where the information about
incident reporting is located.
45
07/11/2003
46
+
- Q: What is the notification procedure if an individual goes to the emergency
room?
A: Management staff (immediately) and complete an IR. Based on the agency
procedure should also include parents/guardians, advocates, Case Manager and
DDP representative.
+
- Q: If two consumers are involved in an incident, how do you document?
A: 2 IR s (one for each person) must be generated; confidentiality must be
maintained by using initials or another coding system.
+
- Q: Who writes the incident report?
A: The person who observed or had direct knowledge of the incident.
+
- Q: Do you fill out an incident report for alleged abuse/neglect/exploitation?
What do you do with that IR.
A: Yes, name the supervisor it is given to (or to DDP if the staff is concerned
about a supervisor’s involvement) and directly to APS (if requested by APS).
Maintain confidentiality of the report.
QIS FORM D
STAFF SURVEY
Agency/Site:________________________________________________Date:________
______
Name of Staff:____________________________________How long
employed?____________
Ask one staff from each service area any two questions under each heading. Staff will
need to answer both questions correctly in order to get the section “MET.” If a staff
member misses one or both questions, the staff survey area will be considered NOT
MET ; the QIS will fill out a QAOS. When doing the survey, the QIS will circle “+” if the
staff answered correctly or circle
“-“ if the staff answered incorrectly.
ABUSE/NEGLECT REPORTING:
MET
NOT MET
(ARM 37.34.1501 & .1506, MCA 41-3-201 and 52-3-811)
*review June 11, 2002 letter from Jeff Sturm regarding Incident Report
Procedures and agency policy.
46
07/11/2003
47
+
- Q: When ABUSE/NEGLECT/EXPLOITATION is witnessed or suspected, direct
service staff are MANDATORY REPORTERS. Allegations are reported to........
A:
+
- Q: If you witness or suspect ABUSE/NEGLECT/EXPLOITATION and want to report
it to APS, do you have to first notify your supervisor?
A:
+
- Q: If there is imminent risk to a consumer, is a report to APS adequate:
A:
+
- Q: If you discovered a consumer being physically abused by a staff person, what
should be your first course of action?
A:
+
- Q: Describe your agency s internal reporting procedure for allegations of
ABUSE/NEGLECT/EXPLOITATION.
A:
CLIENT RIGHTS:
MET
NOT MET
(DD Policy 411.5, ARM 37.34.701, ARM 37.34.1418, 37.34.1501 & .1506,
GH ARM 37.100.330)
+
- Q: You have a consumer with a history of stealing. You suspect he has
taken another consumer’s gloves. What would you do?
A:
+
- Q: A doctor appointment has been requested by the individual’s IP team. The
symptoms which prompted the request have not been seen in 3 weeks. You
think the appointment is no longer necessary? What do you do?
A:
47
07/11/2003
+
+
+
48
- Q: You and a new staff are working together with an individual. The individuals
bumps his/her elbow and lets out a curse word. You ask the individual if he/she
are okay and remind him/her of other words he/she can use. The new staff asks
you why you don’t punish the person (i.e. go to his/her room, leave work, not let
him/her go on an outing). What is your response?
A:
- Q: An individual wants to walk to the store. She has no jacket and it is –25
degree outside. What can you do?
A:
- Q: Do any of the consumers have rights restrictions here? Who? What is the
restriction?
What is being done to allow that consumer to get his/her rights reinstated?
A:
BEHAVIOR SUPPORT PLANS & PROTOCOLS:
MET
NOT MET
(Only applies if a person at that site has a behavior support plan/protocol)
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM 2101, et
seq.)
Review the plan first. Make sure you are using the same terms as written in
the plan.
+
- Q: Ask staff to label and define at least one of the target behaviors.
A:
+
- Q: Ask staff to describe the Reactive Strategies.
A:
+
- Q: Ask staff to list 2 or 3 of the Proactive or Environmental Strategies.
A:
48
07/11/2003
+
49
- Q: What can happen if the Behavior Plan is not implemented with consistency?
A:
49
+
- Q: Describe the training you received in the implementation of the plan?
How often? Who does the training?
A:
ORIENTATION TRAINING:
MET
NOT MET
(GH - ARM 37.100.322, SL - ARM 37.34.712, ARM 37.34.2102 & .2107)
+
- Q: You run into Mike (who you used to work with at the day program) at
the local grocery store. He says he heard that Joe’s (a consumer) health
is not good and he would like to visit Joe. He asks how to reach Joe.
What do you tell him?
A:
+
- Q: Explain what confidential information is? Who has access to the
consumer’s information.
A:
+
- Q: What type of orientation training did you receive when you started
working here?
When did you receive it? (ask this question if hired
within the past 1 year).
A:
+
- Q: How were you trained to meet the health and safety needs of the
individuals? (this question can be for staff who have been
employed longer than one year).
A:
+
- Q: Describe the emergency evacuation procedure? How do you
document an emergency evacuation? What happens if problems
are identified?
A:
SUPERVISING MEDICATIONS:
(ARM 37.34.114)
MET
NOT MET
07/11/2003
51
+
- Q: Role-play or describe the procedure for supervising medications.
A:
+
- Q: What would you do if a medication was unavailable (bottle/bubblepack empty), missing, etc.
A:
+
- Q: What would you do if you erroneously gave someone a different
person s medications?
A:
+
- Q: If someone were capable of taking his/her own medications and they
move to a new living situation or started taking a new medication, what
do you need to do?
A:
+
- Q: What is required for staff to assist consumers in taking their
medications?
A.
+
- Q: Does anyone here receive PRN or OTC medications? How is it decided
when to administer a PRN or OTC medication?
A:
+
- Q: What constitutes a medication error? How do you document a
medication error?
A:
BEHAVIOR INTERACTIONS WITH CONSUMERS:
MET
NOT
MET
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM
2101, et seq.)
07/11/2003
51
07/11/2003
52
+
- Q: If a consumer were destroying things, what would you do?
A:
+
- Q: If a consumer were to pinch a staff and you observe the staff pinching
back, what do you do?
A:
+
- Q: If a consumer was hurting himself or others and you have tried a
number of non-aversive techniques such things as talking to him,
redirection, stimulus change, yet the individual is still causing or about to
cause significant injury to another person (tipping an individual’s
wheelchair over) what emergency procedures can be used?
A:
+
- Q: If a consumer frequently becomes out of control and endangers
themselves or others and they surpassed the 3 times in a 6 month time
period for the use of emergency procedures, what do you do?
A:
+
- Q: What sorts of things would lead you to believe that someone needed a
behavior support plan? What would you do?
A:
EMOTIONALLY RESPONSIBLE CAREGIVING:
MET
YES
N0
(ARM 37.34.102, ARM 37.34.702, ARM 1401, et seq., ARM 37.34.1502, ARM
2101, et seq.)
+
- Q: An indicator of abuse in a caregiving environment is a power struggle.
If during your shift, a consumer refused to get onto the van what steps
would you take to avoid a power struggle?
A:
+
- Q: Another indicator of abuse in a caregiving environment is the
response to
an upset person. If you observed an individual becoming agitated
because he/she couldn’t find his/her lunchbox, how can you assist the
individual?
07/11/2003
52
07/11/2003
53
A:
+
- Q: What can you do if you feel you re beginning to lose control?
A:
INDIVIDUAL PLANS (IP S)
MET
NOT MET
(ARM 37.34.701 & .702, ARM 37.34.1101, et seq., ARM 37.34.2107)
+
- Q: What are Individual Plans based on?
A:
+
- Q: If you have an idea for a training objective or suggestions for changing
a current objective, who do you talk to?
A:
+
- Q: What is an assessment? What is the purpose of doing assessments?
A:
+
- Q: How do you find out what a person would like to have happen or
would like to do?
A:
INCIDENT REPORTING:
(ARM 37.34.1501, et seq.)
MET
NOT MET
+
- Q: When would you fill out an incident report?
A:
+
- Q: What is the notification procedure if an individual goes to the
emergency room?
A:
-
Q: If two consumers are involved in an incident, how do you document?
A:
+
- Q: Who writes the incident report?
A:
+
- Q: Do you fill out an incident report for alleged
abuse/neglect/exploitation? What do you do with that IR.
A:
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Appendix J: Consumer Satisfaction Survey
FORM J
Consumer Survey
Name:
Relationship to Consumer:
Address:
Service Provider:
Service:
Date(s):
The following questions are designed to assist is the assessment of the
agency providing services. There are several sections to the survey. Ask
those sections that apply to the person and/or their support system. Use
5 – 6 questions for each person interviewed.
Consumer Questions (if the individual is able to communicate with
you, these questions are rather open-ended).
1. Who helps you where you live? Work?
2. Who are some of your favorite people? What do you like about them?
3. Are there things that happen that you don’t like? What are they?
4. Does anyone ever yell at you? Who?
5. What are some of the nice things people do for you?
6. Do you like living/working here? Why?
7. Are you ever afraid of anyone (who)? Of anything (what)?
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8. Who do you talk to if you need help at home? At work? In the
community?
9. Who do you talk to if you don’t like someone or are have problems
with someone?
10. Who visits you?
11. What are some of the things you do for fun?
12. Does anyone take your stuff without it being okay with you?
13. Can you get your own food/drink where you live?
14. Do you ever give staff money, your stuff, cigarettes, food, etc? If so,
what for and to whom?
15. Do people come into you home/bedroom without knocking? Who?
16. If the staff don’t show up, who do you call?
17. What would you really like to be able to do? What do you wish for?
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FORM J
Name:
Relationship to Consumer:
Address:
Service Provider:
Service:
Date(s):
The following questions are designed to assist is the assessment of the
agency providing services. There are several sections to the survey. Ask
those sections that apply to the person and/or their support system. Use
5 – 6 questions for each person interviewed.
Consumer Questions: (these questions require a simple yes/no
answer and could be used with individuals who consistently respond
to yes/no).
1. Do you have nice staff to help you at home? At work?
2. Is anyone mean to you at home? At work? (if yes, go through names
of the peers/staff in the daily environment).
3. Do you like where you live? Work?
4. Are you ever afraid of anyone? (If yes, go through names of
peers/staff in the daily environment)
5. Can you get help when you need it? From staff? From case
manager?
6. Can you get your own food/drink?
7. Do people come into your house/bedroom with knocking/permission?
(if yes, go through names of peers/staff in daily environment).
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8. Do staff ever take things from you (i.e., cigarettes, money, food, pop)?
(if yes, go through names of peers/staff in daily environment).
FORM J
Name:
Relationship to Consumer:
Address:
Service Provider:
Service:
Date(s):
The following questions are designed to assist is the assessment of the
agency providing services. There are several sections to the survey. Ask
those sections that apply to the person and/or their support system. Use
5 – 6 questions for each person interviewed.
Support System Questions (these could be for family, guardians,
advocates, staff, case managers, friends, etc).
1. Who are some of the people in the person’s life who help the person?
What do they help with?
2. Are there some people (peers/staff) they like better than others?
Why?
3. If there are some people (peers/staff) they don’t like, why is that?
4. Are there any needs currently not being met? Are they health and
safety related? Who do you talk to about these concerns?
5. Does the individual have input into their life? to who/how?
6. Do you have the opportunity to provide input? to who/how?
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7. If you have concerns, who do you talk to? Are there concerns
resolved? Can you share an example with me?
8. What are this person’s wishes and dreams? Is there a plan in place
moving in that direction?
9. What would make things better for the person?
10. Does the individual ever seem afraid? Are you ever afraid for them?
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