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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:METNOT 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.
+ -Q: Describe your agencys 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.
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.
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.
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+ -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 theyve 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.
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:MET NOT MET
(ARM 37.34.114)
+ -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 persons medications?
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:METNOT 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.
+ -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:METYESN0
(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 youre 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.
INDIVIDUAL PLANS (IPS)METNOT 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 persons 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:METNOT MET
(ARM 37.34.1501, et seq.)
+ -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.
+ -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.
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+ -Q: If two consumers are involved in an incident, how do you document?
A: 2 IRs (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.