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CONFIDENTIAL FILE REVIEW                                    SITE                         REVIEWER                                     DATE     
   The Confidential File maintains current information for all individuals including emergency, medical, financial, and legal documentation.

  The Confidential File is a useful resource and reference guide. Staff Advocates should be encouraged to review these files to gain a better understanding of each individual and
their needs prior to working with them. Support Directors should make certain that information within the Confidential File is kept up-to-date to ensure that proper medical attention
                                is being provided, finances and budgets are well-maintained, and emergency information is accurate in a time of need.

The Confidential File Review Tool breaks down each file section and further explains the requirements for each. When looking through each section, it is helpful to take note of
   information that you know will be in proceeding sections. This allows for consistency within the file, and efficiency while reviewing its contents. For example, in Section 1 the
   Emergency Fact Sheet includes the current height and weight for an individual based on their most recent annual physical. The annual physical is documented in Section 6;
therefore, you can take note of the height and weight written in Section 1 by writing it down on the review tool and cross-referencing it with the Annual Physical Exam Form when
   you get to Section 6. This can also be done with the Social Security benefit amounts found in Section 2 if benefits are received, which can then be cross-referenced with the
  verification form in Section 7. This particular review generally does not require any assistance from the Support and Senior Directors; however, it is recommended that one be
                                                                    present to answer any questions that may arise.
  The Confidential File Review Tool is shown on the next page, with comments regarding when certain documentation is due and how much time should be reflected in specific
                sections before paperwork can be moved to an inactive file. All documentation should be completed annually unless otherwise specified.


                                                                                 INDIVIDUAL        

              SECTION 1                                      MATERIAL TO REVIEW                                      COMPLETED – MISSING – TIMELINE FOR COMPLETION

                                                                                                                DATE                     DATE                       DATE      


                                             Make sure age, height, and weight are accurate according
                                             to most recent annual physical. A copy of the current
                                             medication list should be attached to the back of this form.
       Emergency Fact Sheet                                                                                                                                                 

                                             All sections of the current medication list should be filled
                                             out- the name of the medication, dose, frequency,
                                             prescribing physician, address, phone # and whether or
                                             not vitals need to be taken
       Current Medication List                                                                                                                                              




                                                                                                                                                                      SPRING 2012
Must be signed each year. It can be recommended that
                                this be signed during the annual ISP.

Support Services Consent Form                                                                                                                 

         SECTION 2              MATERIAL TO REVIEW                                               COMPLETED – MISSING – TIMELINE FOR COMPLETION

                                                                                              DATE               DATE                 DATE      

                                The ID# on the first page should be the social security
                                number, and the eligibility date is the day the individual
                                turned 22 years old. The second sheet should include two
                                awake and two asleep fire drills for the current year, as
                                well as the “Basis for Determination” which should state:
                                “evacuated in <2.5 minutes”. “Additional Information”
                                section should include a rep-payee, burial plan/plot, trust
                                fund, and/or life insurance where appropriate.
           ID Sheet                                                                                                                           

         SECTION 3              MATERIAL TO REVIEW                                               COMPLETED – MISSING – TIMELINE FOR COMPLETION

                                                                                              DATE               DATE                 DATE     
                                Assessments should include summaries of the following
                                Quality of Life areas: Personal Well-Being;
                                Nutrition/Diet/Exercise; Cooking Skills; Housekeeping;
                                Financial Status; Travel/Mobility/Community; Personal
                                Care; Socialization/Communication; Least
       ISP Assessments          Restrictive/Appropriate Residential Placement; and
         (current year)         Safety.                                                                                                       


                                This should be given to the Support Director by the
                                individual’s DDS Service Coordinator, but it is frequently
                                missing.
    Individual Support Plan
         (current year)                                                                                                                       




                                                                                                                                        SPRING 2012
Generally found at the beginning or very end of the ISP
                                       and is frequently not stapled to the ISP.

       ISP Attendance Sheet                                                                                                                         



                                       This should be a copy of the original that was sent to
                                       DDS, not an original.
     Provider Response Sheet
           (current year)                                                                                                                           

                                       Service Coordinator receives this from the guardian and
                                       should give a copy to the Support Director. It is frequently
                                       missing from the file so it should be recommended that
                                       the Support Director contact the Service Coordinator for a
   Individual Response Sheet           copy during the next ISP.
           (current year)                                                                                                                           
BBSI Service Agreement Response
                                       ISP period should be for two years and the form should be
               Sheet
                                       signed after receiving the ISP for the respective year.
        (2 year document)                                                                                                                           


  ISP Assessments (prior year)                                                                                                                      


Individual Support Plan (prior year)                                                                                                                


ISP Attendance Sheet (prior year)                                                                                                                   
     Provider Response Sheet
          (previous year)                                                                                                                           
    Individual Response Sheet
          (previous year)                                                                                                                           

                                       Should be given by DDS with ISP. Not all individuals
                                       have/need a Plan of Care. Use Information Request
                                       letter if DDS does not supply plan at ISP.
           Plan of Care                                                                                                                             

           SECTION 4                   MATERIAL TO REVIEW                                              COMPLETED – MISSING – TIMELINE FOR COMPLETION




                                                                                                                                              SPRING 2012
DATE               DATE                 DATE      
                                      Should reflect ISP goals for the current year, with
                                      objectives explaining how those goals will be met and who
                                      is responsible for documenting and assisting with the
  Provider Support Strategies         goals.                                                                                                          
                                      Risk Trackers are only needed for those who fall into the
                                      “individual support” category, meaning that they receive
          Risk Trackers               less than 15 hours per week.                                                                                    
                                      Should reflect 12 months since the ISP and should be
    Monthly Progress Notes            completed every month.                                                                                          
                                      Behavior Plans are generally only found within the
Behavior Plan (with staff sign off)   behavioral modules, most individuals will not have one.                                                         

           SECTION 5                  MATERIAL TO REVIEW                                                 COMPLETED – MISSING – TIMELINE FOR COMPLETION

                                                                                                      DATE               DATE                 DATE     
                                      Not all files will have these as they may not be available.
  Social &Development History                                                                                                                         

   Psychological/Neurological              .    Ensure that a goal and objectives are specified
           Assessments                          and all sections are complete. At least one goal                                                      
  Emergency Skills Assessment                   should be chosen, even if it simply states that
(with attached goal/teaching plan)              the individual will maintain their current level of                                                   
      Financial Assessment                      ability.
                                                                                                                                                      
(with attached goal/teaching plan)
 Community Safety Assessment
                                           .    Individuals who fall under Individual Support
                                                hours do not need a Community Safety                                                                  
(with attached goal/teaching plan)
   Self-Medication Assessment                   Assessment, but do need an Emergency
                                                Evacuation and Safety Assessment.                                                                     
(with attached goal/teaching plan)

 Individual Satisfaction Survey
                                           .    Self-Medication Assessments are not needed                                                            
                                                for individuals who are not currently taking any
                                                medications.                                                                                          
 Sexuality Training Assessment
                                           .    Options Day/Employment only need
                                                Emergency, Community, and Individual
                                                Satisfaction Assessments if meds and money
                                                are not handled while the individual is at
  Community Interest Inventory                  Options.                                                                                              




                                                                                                                                                SPRING 2012
SECTION 6                   MATERIAL TO REVIEW                                                COMPLETED – MISSING – TIMELINE FOR COMPLETION

                                                                                                       DATE               DATE                 DATE      

                                        There are two different consent forms depending upon
                                        what is appropriate: one form to be signed by the
                                        guardian/Roger’s Monitor, another form to be signed by
                                        the physician if the individual is his/her own guardian and
Behavior Modifying Med Assessment       does not have a Roger’s Monitor.                                                                               

 Behavior Modifying Consent Form                                                                                                                       
                                        The full version of this form should be in the file, not the
                                        condensed form or summary. The full document is 6
           Health Record                pages.                                                                                                         
                                        Options Day/Employment does not need a copy of this
      Health Review Checklist           checklist                                                                                                      
                                        Supportive and protective devices include, but are not
                                        limited to: wheelchair, leg rest, pelvic support strap, gel
                                        seat, AFO’s, free stander, chest harness, Merri-walker,
                                        gait belt, parallel bars, walker, electric wheelchair, Hoyer
 Supportive and Protective Devices      lift, custom contour seat, helmet, bedrail, bed alarm/chair
                Form                    alarm.                                                                                                         
   List of Medical Appointments         All appointments should be dated and described. Should
 Refer to Healthcare Screening Self     reflect 1 year of appointments from ISP. This is not
Audit for requirements of all medical   needed at Options Day/Employment. Make sure to add
      appointments and tests.           follow-up appointments to this list.                                                                           
                                        This should be documented on the Annual Physical
                                        Evaluation Form and signed by the PCP. Print-out
  Current Annual Physical Exam          summaries of the physical from the physician’s office are
 Refer to Healthcare Screening Self     also acceptable. Every individual needs an annual
Audit for requirements of all medical   physical exam. If doctor complete an electronic summary,
      appointments and tests.           use this form as a cover to the doctor’s report.                                                               
        Current Dental Exam
                                        Each individual should have an exam every 6 months
 Refer to Healthcare Screening Self
                                        unless they have no teeth, in which case they should be
Audit for requirements of all medical
                                        seen yearly.
      appointments and tests.                                                                                                                          
      Current Audiology Exam            The annual physical form may reflect that ears/hearing                                                         
 Refer to Healthcare Screening Self     were “WNL”. This can take the place of a separate
Audit for requirements of all medical   audiology exam. This is not needed at Options




                                                                                                                                                 SPRING 2012
appointments and tests.           Day/Employment
                                        Each individual should have an initial exam with follow-
     Current Annual Eye Exam            ups as documented by their eye doctor. Any individual
 Refer to Healthcare Screening Self     with diabetes, high blood pressure, or a family history
Audit for requirements of all medical   of eye related medical concerns should be seen
      appointments and tests.           annually.                                                                         
        Current Mammogram
                                        Mammograms are recommended for women age 50 and
 Refer to Healthcare Screening Self
                                        older every year, but clinical breast exams should be
Audit for requirements of all medical
                                        conducted annually during the annual physical.
      appointments and tests.                                                                                             
                                        Pap smears should be conducted every 1-3 years per
                                        HCP recommendations. It is not uncommon to see that an
                                        individual has signed a refusal form for pap smears. It is
                                        also not uncommon that pap smears not be conducted
                                        annually, especially for women who are not sexually
                                        active. If a current pap smear is not documented, there
         Current Pap Smear              should be some form of documentation explaining why.
 Refer to Healthcare Screening Self     There is frequently no separate documentation, however,
Audit for requirements of all medical   for a pap smear so make sure to look for this within the
      appointments and tests.           annual physical documentation                                                     
        Current Colonoscopy             Colonoscopies are only needed for individuals age 50 and
 Refer to Healthcare Screening Self     older every 5 years unless they are recommended to have
Audit for requirements of all medical   them more frequently by their PCP due symptoms or
      appointments and tests.           family history.                                                                   
 Current Testicular/Prostate Exam
                                        Testicular exam should be conducted as ordered by a
 Refer to Healthcare Screening Self
                                        HCP. Prostate exams should be conducted annually
Audit for requirements of all medical
                                        beginning at age 40 if recommended by a HCP.
      appointments and tests.                                                                                             
                                        There should be an encounter form for each medical
                                        appointment consisting of two pages reflecting 1 year.
                                        There should be the date and time of appointment, what
                                        the appointment was for, the results of the appointment,
                                        any follow-up needed, the physician’s signature, and a
                                        staff signature on the completed second page. These
                                        forms are not needed for Options Day/Employment
      Misc. Encounter Forms             services.                                                                         
                                        This form is only needed if the individual actually self-
  Doctor’s Letter to Self-Medicate      medicates                                                                         




                                                                                                                     SPRING 2012
Not all files will include this as it may not have been
          Medical History              accessible                                                                                                    
                                       These forms should have a copy of the side effects of the
                                       medication attached. They must be signed by the
                                       physician and dated within the current year. The name
                                       and purpose of the medication must be present, as well as
                                       what to do if the medication is accidently omitted. The
                                       dose, strength, route, and frequency should be accurate.
                                       Make sure the individual’s name, address, and pharmacy
                                       information is accurate, as well as the physician’s name,
                                       address, and phone number. Side effects sheets should
                                       be from the pharmacies filling the prescriptions. If this
                                       isn’t available use the website www.drugs.com. Side
     Medication Treatment and          effects sheets should be updated annually or when there
      Communication Form               is a change to a prescription.                                                                                
                                       These charts only need to be present if the individual does
                                       not self-medicate. There should be one year’s worth. The
                                       current month will be found in the medication folder.
                                       Check these documents for post and verify; reason for
Completed Medication Sign Off Charts   medication; page numbers; allergies; staff signatures, etc.                                                   

            SECTION 7                  MATERIAL TO REVIEW                                               COMPLETED – MISSING – TIMELINE FOR COMPLETION

                                                                                                     DATE               DATE                 DATE      
                                       Make sure there is a copy of the current medications
                                       attached, and that the information on this sheet matches
            Copy of EFS                the EFS in Section 1.                                                                                         
                                       This is a copy of the document in Section 1.
       Current Medication List                                                                                                                       

       List of Record Access                                                                                                                         
                                       If the individual has a guardian, there must be a
                                       Permanent Decree of guardianship, not a petition. There
                                       should also be documentation for a Roger’s Monitor if
        Adjudication Papers            applicable. Roger’s Monitor must be updated annually.                                                         
                                       DDS should provide this assessment with the ISP, but
                                       STEP forms are available if this does not occur. Options
                                       Day/Employment does not need a copy of this
         Legal Assessment              assessment                                                                                                    




                                                                                                                                               SPRING 2012
Should be signed by individual, regardless of guardianship
  Human Rights Sign Off        status. Please show 2 years.                                                         

    DDS “Your Rights”                                                                                               
                               Given by the main office annually. There should also be a
                               breakdown of the Charges for Care. Options
        Rent Letter            Day/Employment does not need a copy of this letter                                   
                               This document only needs to be signed one time, not
                               annually. If an individual does not live in a Beaverbrook
                               home, a lease agreement or amendment should be in the
                               file from the landlord or management company. Options
                               Day/Employment does not need a copy of this
                               documentation. HUD properties (Individual Support and
    Lease Agreement            Phillips Street) DO NOT have this document in the file.                              
                               This form can be retrieved from the main office if
                               Beaverbrook is the rep-payee. Options Day/Employment
SSI Verification of Benefits   does not need a copy of this documentation                                           
                               The consent form and budget only need to be signed and
                               present if staff assist the individual with his/her finances.
                               The budget should reflect all income as well as bills and
                               regular expenses. MMP should be used when there is a
 Financial Consent Form        financial goal in the ISP.                                                           

    Budget Breakdown                                                                                                

 Money Management Plan                                                                                              
                               This sign-off should clearly mark which expense the
                               individual pays and the current amount if applicable, and it
 Shared Expense Sign Off       is not needed at Options Day/Employment                                              
                               This sign-off is only needed for individuals who are given
  Personal Care Sign Off       direct care; therefore it may not be seen in all files.                              
                               Copies of these forms are given by the main office if an
                               incident has been filed; they may not be found if an
  Incident Report Forms        incident has not occurred within the past two years                                  
                               This section may include forms from insurance
                               companies, MassHealth, birth certificates, life insurance
Miscellaneous Legal Papers     policies, etc.                                                                       




                                                                                                               SPRING 2012
FINANCIAL FILE REVIEW                                         SITE                 REVIEWER                                          DATE      

Financial Files guarantee proper management of individuals’ money, as well as appropriate budgeting and documentation. In order to aide individuals in making purchases,
paying bills, and saving for special occasions, all financial information should be kept in an organized fashion. All transactions must be accounted for to ensure proper support and
documentation. Currently, all financial transactions are recorded in Quicken accounts, which should be reviewed, printed, and placed into the financial file on a quarterly basis.
Financial Files guarantee proper management of individuals’ money, as well as appropriate budgeting and documentation.
The Financial Review Tool assesses records of financial transactions, verification of benefits, storage systems, individuals’ accounts and budgets, and signed consent forms.
Financial records are only necessary when staff assist individuals with their finances. When reviewing these systems, it is important to make sure that all transactions are
balanced, meaning that all cash that goes out has an associated credit when change is given back. It is also important that money taken from one account and placed into another
is documented in both Quicken accounts in order to accurately reflect monetary amounts.
For this review, it is helpful to have both the Support Director and Senior Director available. One director should look at receipts, the other should look at the Savings Passbook if
applicable, and the auditor should look at the Quicken print-outs. This allows cross-referencing to ensure that each matches the other in terms of accurate documentation. Any
time money is withdrawn from savings, it must be reflected in the cash on hand account through Quicken unless a money order was obtained and the receipt is
present. This is an issue that occasionally presents itself when money has been withdrawn for bills but there is no documentation once the money is withdrawn from the savings
account.
Another issue that frequently arises is in regards to paychecks. If in individual receives a paycheck, the full amount should be logged into their cash on hand account before any
purchases are made. This should be done so that if during Survey and Certification the surveyor sees that an individual receives a certain amount of money each week/month
from their employer, how that individual spends their money is documented and there is no question as to where the money goes once the paycheck is cashed.
The Financial File Review Tool is shown in the proceeding pages with explanations where necessary.

INDIVIDUAL      

   FINANCIAL TRANSACTION RECORD                                      MATERIAL TO REVIEW                                  COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                   DATE                      DATE                      DATE      
Individual’s name is present?                          The name should be at the top of each printed page                                                                        
                                                       This should happen automatically within Quicken,
                                                       however, make sure that the month and year at the top
                                                       of the page in terms of when the page was printed is
Every transaction is dated?                            accurate. If someone has had to go back and print                                                                         
                                                       several months of transactions, the dates at the top of
                                                       the page should not be the same- they should reflect
                                                       the months or the quarterly review dates
Every transaction is documented?                       There should be a transaction recorded for each time                                                                      
                                                       an individual is given money and change has been
                                                       returned. If the individual kept the change, this should




                                                                                                                                                                       SPRING 2012
be stated in Quicken and on the receipt. The receipt
                                                   should also be initialed by the individual or staff person
                                                   who handled the money.
                                                   It is important to check each transaction carefully
                                                   where change is received, as a frequent mistake is
Amount received or spent is noted?                                                                                                                               
                                                   placing the change into the “spent” column instead of
                                                   the “received” column
Each transaction has been balanced and the         If the transaction is more than $20, a receipt must be
final amount matches the money located in the      present and change must be either entered back into
                                                                                                                                                                 
locked area?                                       the account, or the documentation should reflect that
                                                   the individual kept the change where appropriate
                                                   Because only the Support Director and Senior Director
                                                   should have access to individuals’ money, it should
Staff initials are present for each transaction?   only be their initials for each transaction. If the money                                                     
                                                   was given to another staff person or the individual, this
                                                   should be reflected in the memo line
                                                   The Quicken print out should have “Balanced” typed in
Senior Director has reviewed record, balanced
                                                   the memo line, and the Senior Director should sign and                                                        
and signed off on a quarterly basis?
                                                   date below on a quarterly basis
Staff have logged cash out when money is           Many directors have individuals sign a form stating that
removed from the account, and have also            they are given a certain amount of money each
logged the receipt and the change from the         day/week/month when the total is over $20 rather than
                                                                                                                                                                 
transaction back into the account? Exceptions      have them sign a petty cash receipt or return receipts
may include, but not be limited to, daily and      each time this amount is given. This should be signed
weekend spending.                                  each year as it continues.
                                                   Receipts should be initialed by staff and/or individuals,
                                                   depending on who the money was physically given to
There are receipts for all transactions over
                                                                                                                                                                 
$20.00?


                  STORAGE                                        MATERIAL TO REVIEW                                 COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                DATE               DATE                 DATE      
                                                   The locked area should not be a safe that could easily
All monies and banking materials are kept          be removed from the area. Smaller safes should be
locked with access limited to Support Director     bolted to the floor or a larger piece of furniture such as                                                    
and Senior Director?                               a desk. It should be recommended that safes be fire
                                                   and water resistant.




                                                                                                                                                         SPRING 2012
SAVINGS/CHECKING ACCOUNTS                               MATERIAL TO REVIEW                              COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                         DATE               DATE                 DATE      
Individual has an interest bearing account in   Not all individuals will have savings accounts, and
                                                some may have an account that a family member                                                             
his/her own name?
                                                helps them with. If they do receive assistance by the
Individual has bank statements or passbook      program with their savings account, either a bankbook                                                     
for the account?                                or bank statements must be present
                                                 This should be done in concurrence with the quarterly
Account is reconciled on a monthly basis?       reviews, and transactions from one account to another                                                     
                                                    must be documented in both Quicken accounts.
Budget accounts for all expenditures, i.e.,
monthly spending, cable, phone, toiletries,                                                                                                               
meds, activities, transportation, etc.?
Is signed and dated by the individual or
                                                                                                                                                          
guardian and Support Director?
All shared expenses are checked off
                                                                                                                                                          
appropriately?




                                                                                                                                                  SPRING 2012
ANCILLARY FILE REVIEW                          SITE                                           REVIEWER                                        DATE      

Ancillary Files verify that safety and evacuation plans are up to date, fire drills are regularly conducted, and that staff are in compliance with all trainings. Ancillary files include
those related to safety and trainings. These files reflect that staff trainings are up-to-date, meetings are held in order to maintain open communication, and that necessary
information is made readily available for individuals and staff at each program. Staff and individuals should understand the rules and regulations of each specific program, as well
as the agency, and every effort should be made to ensure the safety of all in the event of an emergency or required evacuation.
The Ancillary Review Tool assists the surveyor in assessing the safety of a program and communication systems in place that allow for the rules and regulations of the program
and agency to be available to all. Smoking, Administrator on Call, and Human Rights policies, to name a few, should be in clear view for all individuals and staff. Sign-off forms
should accompany trainings such as fire safety, HIPPA, human rights, universal precautions, etc. as well as Personnel and Support Services Policy books. Inspection tags should
also been present on fire extinguishers, hot water heaters, etc., and all smoke and carbon monoxide detectors should be working.
The Ancillary Review Tool is shown in the proceeding pages with explanations where necessary.


INDIVIDUAL      

                           FIRE DRILL LOG                                           MATERIAL TO REVIEW                          COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                               DATE                 DATE                  DATE      
Log is easily accessible                                                                                                                                                           
                                                                               
Provider Assurance Form is current
                                                                                                                                                                                   
(22 months)                                                                    
2 years of drills are present
                                                                                                                                                                                   
(alternating asleep and awake)                                                 
Secondary means of egress/blocked primary exit used at least once
                                                                                                                                                                                   
yearly (recommendation from DDS)                                               
Safety plan is present, accurate, and current
                                                                                                                                                                                   
(with floor plans)                                                             
Staff have been trained in the Safety Plan and have signed off                                                                                                                     
                                                                               
Staff have read the Search and Disaster Plan and have sign off                                                                                                                     
                                                                               
             STAFF/HOUSE MEETING MINUTES                                            MATERIAL TO REVIEW                          COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                               DATE                 DATE                  DATE      
                                                                           It is adequate to say that informal meetings are
One year of Staff Meeting Minutes                                         held on a regular basis, with formal meetings                                                            
                                                                          held when necessary




                                                                                                                                                                          SPRING 2012
Many house managers have sign-offs within
One year of House Meeting Minutes                                      the Confidential Files for each individual stating                                            
                                                                       that they choose not to hold house meetings.
              STAFF/HOUSE MEETING MINUTES                                         MATERIAL TO REVIEW                        COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                            DATE            DATE            DATE      
                                                                       Trainings include Mandatory Trainings book,
                                                                       DPPC, Human Rights, Mission and Philosophy,
All training materials are easily accessible                                                                                                                         
                                                                       Fire Safety, HIPAA, WISP and Universal
                                                                       Precautions
                                                                       Relief workers should also sign these forms if
There are current staff signoffs (within one year) for all trainings                                                                                                 
                                                                       they complete regular hours at the program
                      FIRST AID/OSHA KITS                                         MATERIAL TO REVIEW                        COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                            DATE            DATE            DATE      
Present and easily accessible                                                                                                                                        
                                                                            
                                                                        If the kits are missing materials, a list should
Contain necessary items                                                                                                                                              
                                                                       be submitted to Jessica
Bleach is located near, but not in, OSHA kit                                                                                                                         

    PERSONNEL/SUPPORT SERVICE POLICY BOOKS                                        MATERIAL TO REVIEW                        COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                            DATE            DATE            DATE      
Present and easily accessible                                                                                                                                        
                                                                            
All staff have signed off on both within the last year                                                                                                               
                                                                            
                        DPH CERTIFICATE                                           MATERIAL TO REVIEW                        COMPLETED – MISSING – TIMELINE FOR COMPLETION


                                                                                                                            DATE            DATE            DATE      
Present, current (within one year) and displayed near location of
                                                                                                                                                                     
medications                                                                 
                        TAGS AND SIGNS                                            MATERIAL TO REVIEW                        COMPLETED – MISSING – TIMELINE FOR COMPLETION

                                     
                                                                                                                            DATE            DATE            DATE      




                                                                                                                                                            SPRING 2012
Fire Extinguisher on every floor                                                                                                  
                                                         These tags are placed by maintenance after
Fire Extinguisher tag is current
                                                        they have inspected the home, all of the dates                            
(within one year)
                                                        will be the same on all fire extinguishers
                                                         Even if the lights on the monitor indicate that
Working CO Monitor on every floor                       the battery does not need to be changed, the                              
                                                        monitor should still be tested during the review
                                                         Smoke detectors should also be tested during
Working Smoke Detectors where necessary                                                                                           
                                                        the review to make sure that they are working
                                                        The date on this tag will most likely be the
Current Inspection Tag on Hot Water Heater and Burner   same as on the extinguishers if maintenance                               
                                                        has done an inspection.
                                                         All water mains should be painted red/orange,
Water main easily identified                                                                                                      
                                                        or have a brightly colored, easily read tag
DPPC info posted                                                                                                                  

AOC policy posted                                                                                                                 
                                                        These posting are generally found in the
Nurse-on-Call info posted                               kitchen or other common area, but may also be                             
                                                        located in the program’s office
Smoking Policy posted                                                                                                             

Human Rights info posted                                                                                                          




                                                                                                                           SPRING 2012
PHYSICAL SITE REVIEW
Physical site evaluations should be conducted in concurrence with all file and system reviews. It is essential that each individual has a home that is safe and well-maintained. Site
evaluations should be thorough and complete. In addition to overall cleanliness, the home should be well-stocked with general need items such as paper towels, toilet paper, and
hand soap. The home should look and feel appropriate for the individuals who reside there, and should be appropriate for an adult household. The home should feel like a home
so that individuals are comfortable and have a sense of belonging.
The Physical Site Evaluation confirms that the home is safe, clean, and well-maintained. The following checklist assists the surveyor in making sure all areas are assessed that
will be evaluated during Survey and Certification. Recommendations and information given during the site evaluation will provide the house manager, senior team, and
Maintenance of any issues that can be easily taken care of, or that may require outside services. It is recommended that this evaluation coincide with the ancillary review, allowing
for efficiency and accuracy.




                                                                                                                                                                      SPRING 2012
Kitchen
          Kitchen cabinets over the stove are empty
          Pot holders should be clean and in good condition
          The refrigerator and cabinets should be well-stocked, and all dates must be checked regularly to ensure that no food has expired
          The oven and stove-top should be clean with all burners working
          The exhaust fan and filter over the stove should be clean
          The microwave should be clean and the toaster/toaster oven free of crumbs
          All lights and light bulbs should be working and operating safely, and no sockets should be missing a bulb
          The kitchen table, countertops, and floors should be clean and free of food and crumbs
Common Areas
             Lamps must be working properly and lamp shades should be clean and in good condition
             All lights and light bulbs should be working and operating safely, and no sockets should be missing a bulb
             There should be working lights by the front and back door
             Stairwells and all areas of the home should be free of combustible materials, i.e. paint cans, spray cans, newspapers
             Each egress route should be free from obstacles and dangers with lighting, railings, and stair treads in good repair
             Furniture should be clean and in good condition
             Water temperature should be between 110 and 130 degrees in all water sources
             The oil furnace has been cleaned in the last year or the gas burner has been inspected within the past year
             The house is free from broken furniture and appliances, inside and out
             Cellars and storage areas should be organized and secure
             All trash barrels should have adequate covering
             There should be no exposed wires or junction boxes
             All air conditioners should be plugged directly into a wall socket
             All fuses and circuit breakers must be properly labeled
             Flashlights are readily available and have working batteries
             All windows are working properly with no broken glass or locks
             Home should be free from interior locks that are not on individuals’ rooms or bathrooms, i.e. locked closets or cupboards unless appropriate documentation is
             completed and approved
             All exits have working locks- no hook and eye, draw bolts, or chain latches
             2nd means of egress routes do not have locks
             Screens and storm windows are in place and in good condition
             Names of current occupants are on the mailbox
             The home should be free of extension cords, but power strips are acceptable
Laundry
             There is an adequate amount of laundry detergent
             Laundry area is clean
             Dryer vents should be free of lint and cleaned with mild soap and water to remove excess buildup from dryer sheets, as this build up can become a fire hazard
Bedrooms
             Lamps must be working properly and lamp shades should be clean and in good condition
             All lights and light bulbs should be working and operating safely, and no sockets should be missing a bulb
             All windows are working properly with no broken glass or locks
             Screens are in place and in good condition
             Curtains and shades are in all windows where privacy may be an issue                                                                                 SPRING 2012
SPRING 2012

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Confidential File Review Guide

  • 1. CONFIDENTIAL FILE REVIEW SITE      REVIEWER       DATE      The Confidential File maintains current information for all individuals including emergency, medical, financial, and legal documentation. The Confidential File is a useful resource and reference guide. Staff Advocates should be encouraged to review these files to gain a better understanding of each individual and their needs prior to working with them. Support Directors should make certain that information within the Confidential File is kept up-to-date to ensure that proper medical attention is being provided, finances and budgets are well-maintained, and emergency information is accurate in a time of need. The Confidential File Review Tool breaks down each file section and further explains the requirements for each. When looking through each section, it is helpful to take note of information that you know will be in proceeding sections. This allows for consistency within the file, and efficiency while reviewing its contents. For example, in Section 1 the Emergency Fact Sheet includes the current height and weight for an individual based on their most recent annual physical. The annual physical is documented in Section 6; therefore, you can take note of the height and weight written in Section 1 by writing it down on the review tool and cross-referencing it with the Annual Physical Exam Form when you get to Section 6. This can also be done with the Social Security benefit amounts found in Section 2 if benefits are received, which can then be cross-referenced with the verification form in Section 7. This particular review generally does not require any assistance from the Support and Senior Directors; however, it is recommended that one be present to answer any questions that may arise. The Confidential File Review Tool is shown on the next page, with comments regarding when certain documentation is due and how much time should be reflected in specific sections before paperwork can be moved to an inactive file. All documentation should be completed annually unless otherwise specified. INDIVIDUAL       SECTION 1 MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       Make sure age, height, and weight are accurate according to most recent annual physical. A copy of the current medication list should be attached to the back of this form. Emergency Fact Sheet                   All sections of the current medication list should be filled out- the name of the medication, dose, frequency, prescribing physician, address, phone # and whether or not vitals need to be taken Current Medication List                   SPRING 2012
  • 2. Must be signed each year. It can be recommended that this be signed during the annual ISP. Support Services Consent Form                   SECTION 2 MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE      DATE       DATE       The ID# on the first page should be the social security number, and the eligibility date is the day the individual turned 22 years old. The second sheet should include two awake and two asleep fire drills for the current year, as well as the “Basis for Determination” which should state: “evacuated in <2.5 minutes”. “Additional Information” section should include a rep-payee, burial plan/plot, trust fund, and/or life insurance where appropriate. ID Sheet                   SECTION 3 MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE      DATE      DATE      Assessments should include summaries of the following Quality of Life areas: Personal Well-Being; Nutrition/Diet/Exercise; Cooking Skills; Housekeeping; Financial Status; Travel/Mobility/Community; Personal Care; Socialization/Communication; Least ISP Assessments Restrictive/Appropriate Residential Placement; and (current year) Safety.                   This should be given to the Support Director by the individual’s DDS Service Coordinator, but it is frequently missing. Individual Support Plan (current year)                   SPRING 2012
  • 3. Generally found at the beginning or very end of the ISP and is frequently not stapled to the ISP. ISP Attendance Sheet                   This should be a copy of the original that was sent to DDS, not an original. Provider Response Sheet (current year)                   Service Coordinator receives this from the guardian and should give a copy to the Support Director. It is frequently missing from the file so it should be recommended that the Support Director contact the Service Coordinator for a Individual Response Sheet copy during the next ISP. (current year)                   BBSI Service Agreement Response ISP period should be for two years and the form should be Sheet signed after receiving the ISP for the respective year. (2 year document)                   ISP Assessments (prior year)                   Individual Support Plan (prior year)                   ISP Attendance Sheet (prior year)                   Provider Response Sheet (previous year)                   Individual Response Sheet (previous year)                   Should be given by DDS with ISP. Not all individuals have/need a Plan of Care. Use Information Request letter if DDS does not supply plan at ISP. Plan of Care                   SECTION 4 MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION SPRING 2012
  • 4. DATE       DATE       DATE       Should reflect ISP goals for the current year, with objectives explaining how those goals will be met and who is responsible for documenting and assisting with the Provider Support Strategies goals.                   Risk Trackers are only needed for those who fall into the “individual support” category, meaning that they receive Risk Trackers less than 15 hours per week.                   Should reflect 12 months since the ISP and should be Monthly Progress Notes completed every month.                   Behavior Plans are generally only found within the Behavior Plan (with staff sign off) behavioral modules, most individuals will not have one.                   SECTION 5 MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE      Not all files will have these as they may not be available. Social &Development History                   Psychological/Neurological . Ensure that a goal and objectives are specified Assessments and all sections are complete. At least one goal                   Emergency Skills Assessment should be chosen, even if it simply states that (with attached goal/teaching plan) the individual will maintain their current level of                   Financial Assessment ability.                   (with attached goal/teaching plan) Community Safety Assessment . Individuals who fall under Individual Support hours do not need a Community Safety                   (with attached goal/teaching plan) Self-Medication Assessment Assessment, but do need an Emergency Evacuation and Safety Assessment.                   (with attached goal/teaching plan) Individual Satisfaction Survey . Self-Medication Assessments are not needed                   for individuals who are not currently taking any medications.                   Sexuality Training Assessment . Options Day/Employment only need Emergency, Community, and Individual Satisfaction Assessments if meds and money are not handled while the individual is at Community Interest Inventory Options.                   SPRING 2012
  • 5. SECTION 6 MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       There are two different consent forms depending upon what is appropriate: one form to be signed by the guardian/Roger’s Monitor, another form to be signed by the physician if the individual is his/her own guardian and Behavior Modifying Med Assessment does not have a Roger’s Monitor.                   Behavior Modifying Consent Form                   The full version of this form should be in the file, not the condensed form or summary. The full document is 6 Health Record pages.                   Options Day/Employment does not need a copy of this Health Review Checklist checklist                   Supportive and protective devices include, but are not limited to: wheelchair, leg rest, pelvic support strap, gel seat, AFO’s, free stander, chest harness, Merri-walker, gait belt, parallel bars, walker, electric wheelchair, Hoyer Supportive and Protective Devices lift, custom contour seat, helmet, bedrail, bed alarm/chair Form alarm.                   List of Medical Appointments All appointments should be dated and described. Should Refer to Healthcare Screening Self reflect 1 year of appointments from ISP. This is not Audit for requirements of all medical needed at Options Day/Employment. Make sure to add appointments and tests. follow-up appointments to this list.                   This should be documented on the Annual Physical Evaluation Form and signed by the PCP. Print-out Current Annual Physical Exam summaries of the physical from the physician’s office are Refer to Healthcare Screening Self also acceptable. Every individual needs an annual Audit for requirements of all medical physical exam. If doctor complete an electronic summary, appointments and tests. use this form as a cover to the doctor’s report.                   Current Dental Exam Each individual should have an exam every 6 months Refer to Healthcare Screening Self unless they have no teeth, in which case they should be Audit for requirements of all medical seen yearly. appointments and tests.                   Current Audiology Exam The annual physical form may reflect that ears/hearing                   Refer to Healthcare Screening Self were “WNL”. This can take the place of a separate Audit for requirements of all medical audiology exam. This is not needed at Options SPRING 2012
  • 6. appointments and tests. Day/Employment Each individual should have an initial exam with follow- Current Annual Eye Exam ups as documented by their eye doctor. Any individual Refer to Healthcare Screening Self with diabetes, high blood pressure, or a family history Audit for requirements of all medical of eye related medical concerns should be seen appointments and tests. annually.                   Current Mammogram Mammograms are recommended for women age 50 and Refer to Healthcare Screening Self older every year, but clinical breast exams should be Audit for requirements of all medical conducted annually during the annual physical. appointments and tests.                   Pap smears should be conducted every 1-3 years per HCP recommendations. It is not uncommon to see that an individual has signed a refusal form for pap smears. It is also not uncommon that pap smears not be conducted annually, especially for women who are not sexually active. If a current pap smear is not documented, there Current Pap Smear should be some form of documentation explaining why. Refer to Healthcare Screening Self There is frequently no separate documentation, however, Audit for requirements of all medical for a pap smear so make sure to look for this within the appointments and tests. annual physical documentation                   Current Colonoscopy Colonoscopies are only needed for individuals age 50 and Refer to Healthcare Screening Self older every 5 years unless they are recommended to have Audit for requirements of all medical them more frequently by their PCP due symptoms or appointments and tests. family history.                   Current Testicular/Prostate Exam Testicular exam should be conducted as ordered by a Refer to Healthcare Screening Self HCP. Prostate exams should be conducted annually Audit for requirements of all medical beginning at age 40 if recommended by a HCP. appointments and tests.                   There should be an encounter form for each medical appointment consisting of two pages reflecting 1 year. There should be the date and time of appointment, what the appointment was for, the results of the appointment, any follow-up needed, the physician’s signature, and a staff signature on the completed second page. These forms are not needed for Options Day/Employment Misc. Encounter Forms services.                   This form is only needed if the individual actually self- Doctor’s Letter to Self-Medicate medicates                   SPRING 2012
  • 7. Not all files will include this as it may not have been Medical History accessible                   These forms should have a copy of the side effects of the medication attached. They must be signed by the physician and dated within the current year. The name and purpose of the medication must be present, as well as what to do if the medication is accidently omitted. The dose, strength, route, and frequency should be accurate. Make sure the individual’s name, address, and pharmacy information is accurate, as well as the physician’s name, address, and phone number. Side effects sheets should be from the pharmacies filling the prescriptions. If this isn’t available use the website www.drugs.com. Side Medication Treatment and effects sheets should be updated annually or when there Communication Form is a change to a prescription.                   These charts only need to be present if the individual does not self-medicate. There should be one year’s worth. The current month will be found in the medication folder. Check these documents for post and verify; reason for Completed Medication Sign Off Charts medication; page numbers; allergies; staff signatures, etc.                   SECTION 7 MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       Make sure there is a copy of the current medications attached, and that the information on this sheet matches Copy of EFS the EFS in Section 1.                   This is a copy of the document in Section 1. Current Medication List                   List of Record Access                   If the individual has a guardian, there must be a Permanent Decree of guardianship, not a petition. There should also be documentation for a Roger’s Monitor if Adjudication Papers applicable. Roger’s Monitor must be updated annually.                   DDS should provide this assessment with the ISP, but STEP forms are available if this does not occur. Options Day/Employment does not need a copy of this Legal Assessment assessment                   SPRING 2012
  • 8. Should be signed by individual, regardless of guardianship Human Rights Sign Off status. Please show 2 years.                   DDS “Your Rights”                   Given by the main office annually. There should also be a breakdown of the Charges for Care. Options Rent Letter Day/Employment does not need a copy of this letter                   This document only needs to be signed one time, not annually. If an individual does not live in a Beaverbrook home, a lease agreement or amendment should be in the file from the landlord or management company. Options Day/Employment does not need a copy of this documentation. HUD properties (Individual Support and Lease Agreement Phillips Street) DO NOT have this document in the file.                   This form can be retrieved from the main office if Beaverbrook is the rep-payee. Options Day/Employment SSI Verification of Benefits does not need a copy of this documentation                   The consent form and budget only need to be signed and present if staff assist the individual with his/her finances. The budget should reflect all income as well as bills and regular expenses. MMP should be used when there is a Financial Consent Form financial goal in the ISP.                   Budget Breakdown                   Money Management Plan                   This sign-off should clearly mark which expense the individual pays and the current amount if applicable, and it Shared Expense Sign Off is not needed at Options Day/Employment                   This sign-off is only needed for individuals who are given Personal Care Sign Off direct care; therefore it may not be seen in all files.                   Copies of these forms are given by the main office if an incident has been filed; they may not be found if an Incident Report Forms incident has not occurred within the past two years                   This section may include forms from insurance companies, MassHealth, birth certificates, life insurance Miscellaneous Legal Papers policies, etc.                   SPRING 2012
  • 9. FINANCIAL FILE REVIEW SITE       REVIEWER       DATE       Financial Files guarantee proper management of individuals’ money, as well as appropriate budgeting and documentation. In order to aide individuals in making purchases, paying bills, and saving for special occasions, all financial information should be kept in an organized fashion. All transactions must be accounted for to ensure proper support and documentation. Currently, all financial transactions are recorded in Quicken accounts, which should be reviewed, printed, and placed into the financial file on a quarterly basis. Financial Files guarantee proper management of individuals’ money, as well as appropriate budgeting and documentation. The Financial Review Tool assesses records of financial transactions, verification of benefits, storage systems, individuals’ accounts and budgets, and signed consent forms. Financial records are only necessary when staff assist individuals with their finances. When reviewing these systems, it is important to make sure that all transactions are balanced, meaning that all cash that goes out has an associated credit when change is given back. It is also important that money taken from one account and placed into another is documented in both Quicken accounts in order to accurately reflect monetary amounts. For this review, it is helpful to have both the Support Director and Senior Director available. One director should look at receipts, the other should look at the Savings Passbook if applicable, and the auditor should look at the Quicken print-outs. This allows cross-referencing to ensure that each matches the other in terms of accurate documentation. Any time money is withdrawn from savings, it must be reflected in the cash on hand account through Quicken unless a money order was obtained and the receipt is present. This is an issue that occasionally presents itself when money has been withdrawn for bills but there is no documentation once the money is withdrawn from the savings account. Another issue that frequently arises is in regards to paychecks. If in individual receives a paycheck, the full amount should be logged into their cash on hand account before any purchases are made. This should be done so that if during Survey and Certification the surveyor sees that an individual receives a certain amount of money each week/month from their employer, how that individual spends their money is documented and there is no question as to where the money goes once the paycheck is cashed. The Financial File Review Tool is shown in the proceeding pages with explanations where necessary. INDIVIDUAL       FINANCIAL TRANSACTION RECORD MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       Individual’s name is present? The name should be at the top of each printed page                   This should happen automatically within Quicken, however, make sure that the month and year at the top of the page in terms of when the page was printed is Every transaction is dated? accurate. If someone has had to go back and print                   several months of transactions, the dates at the top of the page should not be the same- they should reflect the months or the quarterly review dates Every transaction is documented? There should be a transaction recorded for each time                   an individual is given money and change has been returned. If the individual kept the change, this should SPRING 2012
  • 10. be stated in Quicken and on the receipt. The receipt should also be initialed by the individual or staff person who handled the money. It is important to check each transaction carefully where change is received, as a frequent mistake is Amount received or spent is noted?                   placing the change into the “spent” column instead of the “received” column Each transaction has been balanced and the If the transaction is more than $20, a receipt must be final amount matches the money located in the present and change must be either entered back into                   locked area? the account, or the documentation should reflect that the individual kept the change where appropriate Because only the Support Director and Senior Director should have access to individuals’ money, it should Staff initials are present for each transaction? only be their initials for each transaction. If the money                   was given to another staff person or the individual, this should be reflected in the memo line The Quicken print out should have “Balanced” typed in Senior Director has reviewed record, balanced the memo line, and the Senior Director should sign and                   and signed off on a quarterly basis? date below on a quarterly basis Staff have logged cash out when money is Many directors have individuals sign a form stating that removed from the account, and have also they are given a certain amount of money each logged the receipt and the change from the day/week/month when the total is over $20 rather than                   transaction back into the account? Exceptions have them sign a petty cash receipt or return receipts may include, but not be limited to, daily and each time this amount is given. This should be signed weekend spending. each year as it continues. Receipts should be initialed by staff and/or individuals, depending on who the money was physically given to There are receipts for all transactions over                   $20.00? STORAGE MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       The locked area should not be a safe that could easily All monies and banking materials are kept be removed from the area. Smaller safes should be locked with access limited to Support Director bolted to the floor or a larger piece of furniture such as                   and Senior Director? a desk. It should be recommended that safes be fire and water resistant. SPRING 2012
  • 11. SAVINGS/CHECKING ACCOUNTS MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       Individual has an interest bearing account in Not all individuals will have savings accounts, and some may have an account that a family member                   his/her own name? helps them with. If they do receive assistance by the Individual has bank statements or passbook program with their savings account, either a bankbook                   for the account? or bank statements must be present This should be done in concurrence with the quarterly Account is reconciled on a monthly basis? reviews, and transactions from one account to another                   must be documented in both Quicken accounts. Budget accounts for all expenditures, i.e., monthly spending, cable, phone, toiletries,                   meds, activities, transportation, etc.? Is signed and dated by the individual or                   guardian and Support Director? All shared expenses are checked off                   appropriately? SPRING 2012
  • 12. ANCILLARY FILE REVIEW SITE       REVIEWER       DATE       Ancillary Files verify that safety and evacuation plans are up to date, fire drills are regularly conducted, and that staff are in compliance with all trainings. Ancillary files include those related to safety and trainings. These files reflect that staff trainings are up-to-date, meetings are held in order to maintain open communication, and that necessary information is made readily available for individuals and staff at each program. Staff and individuals should understand the rules and regulations of each specific program, as well as the agency, and every effort should be made to ensure the safety of all in the event of an emergency or required evacuation. The Ancillary Review Tool assists the surveyor in assessing the safety of a program and communication systems in place that allow for the rules and regulations of the program and agency to be available to all. Smoking, Administrator on Call, and Human Rights policies, to name a few, should be in clear view for all individuals and staff. Sign-off forms should accompany trainings such as fire safety, HIPPA, human rights, universal precautions, etc. as well as Personnel and Support Services Policy books. Inspection tags should also been present on fire extinguishers, hot water heaters, etc., and all smoke and carbon monoxide detectors should be working. The Ancillary Review Tool is shown in the proceeding pages with explanations where necessary. INDIVIDUAL       FIRE DRILL LOG MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE      DATE       DATE       Log is easily accessible                         Provider Assurance Form is current                   (22 months)       2 years of drills are present                   (alternating asleep and awake)       Secondary means of egress/blocked primary exit used at least once                   yearly (recommendation from DDS)       Safety plan is present, accurate, and current                   (with floor plans)       Staff have been trained in the Safety Plan and have signed off                         Staff have read the Search and Disaster Plan and have sign off                         STAFF/HOUSE MEETING MINUTES MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       It is adequate to say that informal meetings are One year of Staff Meeting Minutes held on a regular basis, with formal meetings                   held when necessary SPRING 2012
  • 13. Many house managers have sign-offs within One year of House Meeting Minutes the Confidential Files for each individual stating                   that they choose not to hold house meetings. STAFF/HOUSE MEETING MINUTES MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION DATE       DATE       DATE       Trainings include Mandatory Trainings book, DPPC, Human Rights, Mission and Philosophy, All training materials are easily accessible                   Fire Safety, HIPAA, WISP and Universal Precautions Relief workers should also sign these forms if There are current staff signoffs (within one year) for all trainings                   they complete regular hours at the program FIRST AID/OSHA KITS MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION       DATE       DATE       DATE       Present and easily accessible                         If the kits are missing materials, a list should Contain necessary items                   be submitted to Jessica Bleach is located near, but not in, OSHA kit                   PERSONNEL/SUPPORT SERVICE POLICY BOOKS MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION       DATE       DATE       DATE       Present and easily accessible                         All staff have signed off on both within the last year                         DPH CERTIFICATE MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION       DATE      DATE       DATE       Present, current (within one year) and displayed near location of             medications       TAGS AND SIGNS MATERIAL TO REVIEW COMPLETED – MISSING – TIMELINE FOR COMPLETION             DATE       DATE       DATE       SPRING 2012
  • 14. Fire Extinguisher on every floor                   These tags are placed by maintenance after Fire Extinguisher tag is current they have inspected the home, all of the dates                   (within one year) will be the same on all fire extinguishers Even if the lights on the monitor indicate that Working CO Monitor on every floor the battery does not need to be changed, the                   monitor should still be tested during the review Smoke detectors should also be tested during Working Smoke Detectors where necessary                   the review to make sure that they are working The date on this tag will most likely be the Current Inspection Tag on Hot Water Heater and Burner same as on the extinguishers if maintenance                   has done an inspection. All water mains should be painted red/orange, Water main easily identified                   or have a brightly colored, easily read tag DPPC info posted                   AOC policy posted                   These posting are generally found in the Nurse-on-Call info posted kitchen or other common area, but may also be                   located in the program’s office Smoking Policy posted                   Human Rights info posted                   SPRING 2012
  • 15. PHYSICAL SITE REVIEW Physical site evaluations should be conducted in concurrence with all file and system reviews. It is essential that each individual has a home that is safe and well-maintained. Site evaluations should be thorough and complete. In addition to overall cleanliness, the home should be well-stocked with general need items such as paper towels, toilet paper, and hand soap. The home should look and feel appropriate for the individuals who reside there, and should be appropriate for an adult household. The home should feel like a home so that individuals are comfortable and have a sense of belonging. The Physical Site Evaluation confirms that the home is safe, clean, and well-maintained. The following checklist assists the surveyor in making sure all areas are assessed that will be evaluated during Survey and Certification. Recommendations and information given during the site evaluation will provide the house manager, senior team, and Maintenance of any issues that can be easily taken care of, or that may require outside services. It is recommended that this evaluation coincide with the ancillary review, allowing for efficiency and accuracy. SPRING 2012
  • 16. Kitchen       Kitchen cabinets over the stove are empty       Pot holders should be clean and in good condition       The refrigerator and cabinets should be well-stocked, and all dates must be checked regularly to ensure that no food has expired       The oven and stove-top should be clean with all burners working       The exhaust fan and filter over the stove should be clean       The microwave should be clean and the toaster/toaster oven free of crumbs       All lights and light bulbs should be working and operating safely, and no sockets should be missing a bulb       The kitchen table, countertops, and floors should be clean and free of food and crumbs Common Areas       Lamps must be working properly and lamp shades should be clean and in good condition       All lights and light bulbs should be working and operating safely, and no sockets should be missing a bulb       There should be working lights by the front and back door       Stairwells and all areas of the home should be free of combustible materials, i.e. paint cans, spray cans, newspapers       Each egress route should be free from obstacles and dangers with lighting, railings, and stair treads in good repair       Furniture should be clean and in good condition       Water temperature should be between 110 and 130 degrees in all water sources       The oil furnace has been cleaned in the last year or the gas burner has been inspected within the past year       The house is free from broken furniture and appliances, inside and out       Cellars and storage areas should be organized and secure       All trash barrels should have adequate covering       There should be no exposed wires or junction boxes       All air conditioners should be plugged directly into a wall socket       All fuses and circuit breakers must be properly labeled       Flashlights are readily available and have working batteries       All windows are working properly with no broken glass or locks       Home should be free from interior locks that are not on individuals’ rooms or bathrooms, i.e. locked closets or cupboards unless appropriate documentation is completed and approved       All exits have working locks- no hook and eye, draw bolts, or chain latches       2nd means of egress routes do not have locks       Screens and storm windows are in place and in good condition       Names of current occupants are on the mailbox       The home should be free of extension cords, but power strips are acceptable Laundry       There is an adequate amount of laundry detergent       Laundry area is clean       Dryer vents should be free of lint and cleaned with mild soap and water to remove excess buildup from dryer sheets, as this build up can become a fire hazard Bedrooms       Lamps must be working properly and lamp shades should be clean and in good condition       All lights and light bulbs should be working and operating safely, and no sockets should be missing a bulb       All windows are working properly with no broken glass or locks       Screens are in place and in good condition       Curtains and shades are in all windows where privacy may be an issue SPRING 2012