07/11/2003
APPENDIX G
IMPLEMENTATION FEATURES
THROUGHOUT THE YEAR CONSUMER SURVEYS AND IP’s:
AREA OF REVIEW / FEATURESConsumer / Family Interviews *completed by Case Managers* / Are there particular commendations? If issues, verify via case management contact notes. Follow up with provider, IP Team, etc. as necessary depending on input.
Individual Plans
IP documents
ARM 37.34.1101, et seq. / Are staff aware of Individual Plans? Are IP documents readily available to staff? *Is IP implementation a concern due to lack of staff knowledge?
Individual Plans
IPP’s and objectives
ARM 37.34.1101, et seq. / 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?
Individual Plans IPP and objective data collection ARM 37.34.1101, et seq., ARM 37.34.102 / 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?
Individual Plans IPP and objective data monitoring ARM 37.34.1101, et seq. / 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?
Individual Plans
Self Medication objectives
ARM 37.34.114 / 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?
Individual Plans
Rights Restrictions
ARM 37.34.1418
ARM 37.34.102
(GH)- ARM 37.100.330 / 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 / FEATURESIP Checklist
ARM 37.34.1101, et seq. / Are trends noted in IP Checklists completed for individuals in the sample? Verify in Casemanagement records.
Individual Plans
Addresses specific needs of the individual ARM 37.34.1101, et seq. / 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 the primary physician for approval?
Individual Plans Assessments
ARM 37.34.1101, et seq. / 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 / FEATURES
Individual Plans: Quarterly Status Reports
ARM 37.34.1108 / Are quarterlies routinely submitted? Do quarterlies present an accurate account of IPP data? Are there issues at this provider regarding quarterly reports?
Individual Plans Incident Reports
ARM 37.343.1501, et seq. / 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?
Individual Plans Behavior Supports
ARM 37.34.1401, et seq.
ARM 37.34.2101, et seq.
ARM 37.34.102 / 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?
Aversive Procedures
ARM 37.34.1401 et seq.
ARM 37.34.102
(GH) – ARM 37.100.330 / 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 / FEATURESAccreditation
ARM: 37.34.1801 / 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.
Fiscal:
A-133 Audit
Contract
Fiscal:
Cost Plans
ARM 37.34.917
Fiscal:
Invoices
ARM 37.34.913 / 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?
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.
AREA OF REVIEW / FEATURES
QAOS from the year / Were trends documented on QAOS this year? Re-check documentation that specific areas addressed have not recurred.
Medication Errors
ARM 37.34.114 / 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?
Rights Restrictions /Violations
ARM 37.34.1418
ARM 37.34.1501 / 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?
Incident Reports/Trends:
ARM 37.34 1501, et seq. / 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?
AT THE MAIN OFFICE OF THE AGENCY:
AREA OF REVIEW / FEATURESLicensing
ARM: 37.100.301-340
ARM: 37.34.702
ARM: 37.34.706
ARM: 37.34.912
Community homes (GH, IGH, CGH) / 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?
Criminal background Checks
ARM: 37.34.2102
*Verify information from personnel files with the Human Resources Manager, DDP staff should not review personnel files. / As determined by ARM, review a sample of staff Department of Justice checks (sample of 10% or no less than 5, sample 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?
AREA OF REVIEW / FEATURES
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 / 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 non-licensed 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?
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.
(ARM 37.34.2107)
For Intensive Service / 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
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?
Supervision of staff / staff satisfaction surveys
ARM 37.34.702 & .2111
ARM 37.34.985 (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?
Individuals / families have choice in Supported Living staff
ARM 37.34.712
(“new” SL) / 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 / IMPLEMENTATION FEATURESHealth/Safety
Bathing Policy
DD Policy – Jeff Sturm
2002 / 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?
Health/Safety
Clean / Sanitary Environment
ARM37.34.702&706
ARM37.34.2107&
.2111 / 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?
Health/Safety
Egress
ARM 37.100.321GH
ARM 37.34.713 SL ARM 37.34.702 & .706 (Adult Svcs.) / 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?
Health/Safety
Water temperature in bathing areas
ARM 37.100.320 / 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?
Health/Safety
Emergency back-up
ARM 37.34.702
ARM 37.34.2111 / At site(s), are policies and procedures in place for
Emergency assistance/back-up? Staffing schedules? Phone lists? Emergency on-call/beeper number posted?
Health/Safety
Fire extinguishers/ Smoke Detectors
ARM 37.34.713
(SL) / 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 within 1 year of this visit?
Health/Safety
PRN medications
ARM 37.34.114 / 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?
Health/Safety
Medication Procedures
ARM 37.34.114
ARM 37.34.702 / 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?
Health/Safety Medication storage
ARM 37.34.114
ARM 37.100.320 / 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?
AREA OF REVIEW / IMPLEMENTATION FEATURES
Health/Safety
Medication Administration Logs
ARM 37.34.114 / 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?
Health/Safety
Staff ratios ARM 37.34.702 & .2111 / 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?
Health/Safety
Awake overnight staff
ARM 37.34.2111 / 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?
Health/Safety
Adequate supplies
ARM 37.34.702 &.706 ARM 37.34.2107&2111 / 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?
Health/Safety
Storage of supplies
ARM 37.34.702 &.706 ARM 37.34.2107&2111 / 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?
Individual Plans
Integrated Community Activities
ARM: 37.34.706 GH
ARM:37.34.711 Day
ARM: 37.34.712 SL / 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?
Individual Plans House/Site Rules
DD Policy 411.5
ARM 37.34.701
ARM 37.34.1418
ARM 37.100.330 / For facilities/apartments, do site rules exist which conflict with the values of integration, independence, choice and self-determination? 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 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?
Daily Living
Choice-making
ARM 37.34.701 / Are individuals encouraged to make choices and exert self-determination 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?
Daily Living
Meal Preparation/ Mealtime
ARM 37.34.102
ARM 37.34.701 (Adult Svcs.) / 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?
AREA OF REVIEW / IMPLEMENTATION FEATURES
Involvement and Engagement in daily life
ARM: 37.34.102
ARM 37.34.701
ARM 37.34.941 & .942 / 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?
Daily Living
Participation in Daily Life
ARM 37.34.102
ARM 37.34.701 / 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?
Daily Living
Leisure activities
ARM 37.34.706, .711, & .712 / 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?
Staff Training
Individual Specifics
ARM 37.100.322
ARM 37.34.712 (SL)
ARM 37.34.2102 &.2107 / 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?
Staff Training
Staff Surveys / Do trends exist in staff responses to the survey questions?
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