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Pennsylvania Office of Developmental ProgramsQuality Assessment & Improvement (QA&I) Questions Tool for Supports Coordination Organizations

Overview of the Quality Assessment & Improvement Process

The mission of the Office of Developmental Programs (ODP) is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives.

ODP’s vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person-centered.

The Quality Assessment & Improvement Process is a way for ODP to evaluate our current system and identify ways to improve it for all individuals.

General Instructions

1. In preparation for completing the QA&I Tool, Administrative Entities (AEs), Supports Coordination Organizations (SCOs) and Providers should review all relevant materials regarding the QA&I process that are posted on the MyODP Training & Resource Center at https://www.myodp.org.

2. In case of questions, issues or concerns related to the questions asked in the tool or the QA&I Process, please contact the ODP Regional QA& Lead and copy the QA&I Process Mailbox at [email protected].

3. If an incident is discovered during the course of the QA&I process that has not been reported, the incident must be immediately reported in the Enterprise Incident Management (EIM) system and Incident Management procedures should be followed. The AE, SCO and Provider shall ensure the health and welfare of individuals at all times. If any entity determines there is an imminent threat to the health and welfare of the individual, immediate steps should be taken to ensure the health and welfare of the individuals and the appropriate regional ODP office should be contacted. Based on circumstances, the entity shall proceed according to the policy established in ODP Bulletin #6000-04-01, Incident Management and as determined appropriate by the regional ODP office.

*KEY – Desk Review (D); Onsite Review (O); Remediation (R) 1Last updated: 6/21/2018

mailto:[email protected]

https://www.myodp.org/

Tool Completion Instructions

The following guidelines are intended to help a user complete this tool successfully.

1. Use the SCO QA&I Review spreadsheet to answer all questions. The Yes/No/NA, the total applicable and the total compliant and any remediation responses are the final answers that should be entered into the web database.

2. When there are instances in which an entity has not met the standards of a QA&I question, ODP expects that remediation will occur within 30 days of discovery unless there are concerns for health and safety where remediation must occur immediately. This remediation must be recorded on the SCO QA&I Review Spreadsheet and entered into QuestionPro for the self-assessment.

3. All questions applicable to the entity have to be answered before the tool can be submitted.

4. The timeframe for each question is 12 months from the date of the review unless otherwise specified. When looking back 12 months, always go to the 1st day of the month i.e. the review begins on July 15, 2018, look back to July 1, 2017.

5. It is strongly recommended that the guidance associated with each question be reviewed before answering the question as the guidance will assist you in your responses.

6. When responding to questions, the entity MUST retain all related documentation, including policy & procedure documentation, training curriculum, records and other training documentation as well as documentation associated with service/supports delivery. This documentary evidence along with the SCO MCI Review spreadsheet and a copy of the confirmation email or print out from QuestionPro must be retained and made available to ODP upon request.

7. Questions that are labeled as exploratory are intended to inform the entity of new changes and requirements which began July 1, 2017.


# Question Type Guidance Source DocumentsDEMOGRAPHIC INFORMATION1. SCO Name

Non-Scored Enter organization’s name used in HCSIS during the enrollment process

2. Master Provider Index (MPI) NumberNon-Scored

Enter nine-digit Master Provider Index (MPI) number. This number is located in HCSIS and is the first nine digits of PROMISe ID.

3. Region in which SCO is located.Non-Scored

Select the appropriate region for the SCO from the drop-down list. If the SCO serves waiver participants in multiple regions, please designate the region

in which the SCO serves the most waiver participants

4. Contact information for person completing QA&I Tool Contact Name (First & Last Name) Contact Telephone Number Contact Email AddressNon-Scored

Enter the contact information for the person who is entering the self-assessment for the SCO.


DATA & POLICY

# Question Type Guidance Source DocumentsQUALITY MANAGEMENT – There are systemic efforts to continuously improve quality.The SCO demonstrates continuous quality improvement.5. The SCO has a Quality Management

Plan (QMP) that reflects ODP’s Mission, Vision and Values.

O The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives.ODP’s vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person-centered.

The values articulated as principles in the Everyday Lives document set the direction for the developmental disability service system. They provide context and guidance for policy development, service design and implementation, and decision-making. The reviewer determines if the SCO’s QMP reflects ODP’s Mission, Vision and Values

by reviewing the QMP. Some examples of what the QMP could include are:

- Assuring effective communication- Increasing employment- Increasing community participation- Ensuring ISPs are updated timely when there is a change in need- Ensuring individuals are free from abuse, neglect and exploitation- Ensuring people with complex needs have supports they need

Mark YES if the QMP reflects the Mission, Vision and Values. Mark NO if the QMP does not reflect them.

55 Pa. Code Chapter 51 Section 51.25 Informational Memo 038-15

Implementation Instructions for Providers, including SCOs on Quality Management Plans

Bulletin 00-17-01 Quality Management Strategy of the Office of Developmental Programs

5a. The SCO updated the plan to reflect ODP's Mission, Vision and Values.

R The SCO updated the QMP to reflect ODP's Mission, Vision and Values. Mark YES if the SCO updated their QMP. Mark NA if no remediation action is required or another remediation action was

selected.



5b. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the SCO to comply with the requirements. Reviewer records in comment field the REMEDIATION ACTION taken by the SCO to remediate. Mark YES if the SCO submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.




# Question Type Guidance Source Documents5c. If YES, when: R The reviewer calculates the number of days between the notification date to the

SCO and the remediation action date. The reviewer chooses the appropriate time frame from the drop down.

Mark NA, if no remediation action was necessary or if no remediation action was taken by the SCO.



5d. Remediation action outstanding - referred to appropriate staff for follow up.

R Mark YES if referred for appropriate follow-up as a result of no remediation action within 90 days of notification of the review findings. Utilize the comment field to record follow-up action.

Mark NA if the issue was remediated or if no remediation was required.



6. The SCO revises the QMP at least every three years.

O The reviewer determines if the QMP was revised every 3 years based on a review of the QMP. Mark YES if the QMP was revised every 3 years. Mark NO if the QMP was not revised every 3 years or there is no QMP.



6a. Documentation was located. R The SCO has located evidence that they have revised the QMP at least every three years. Mark YES if the SCO has located the documentation. Mark NA if no remediation action is required or another remediation action was

selected.



6b. SCO revises the QMP. R The SCO revises the QMP. Mark YES if the SCO has revised the QMP. Mark NA if no remediation action is required or another remediation action was

selected.



6c. SCO staff is retrained as appropriate on QMP requirements.

R The SCO provides/ensures retraining of the appropriate SCO staff regarding the QMP requirements.

The SCO provides notification to ODP that the SCO staff was retrained. Mark YES if SCO provides notification to ODP of retraining provided to the SCO

staff. Mark NA if no remediation action is required or another remediation action was

selected.



6d. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the 55 Pa. Code Chapter 51 Section 51.25*KEY – Desk Review (D); Onsite Review (O); Remediation (R) 5

Last updated: 6/21/2018

# Question Type Guidance Source DocumentsSCO to comply with the requirements.

The reviewer records in comment field the REMEDIATION ACTION taken by the SCO to remediate. Mark YES if the SCO submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.

Informational Memo 038-15 Implementation Instructions for Providers, including SCOs on Quality Management Plans

6e. If YES, when: R The reviewer calculates the number of days between the notification date to the SCO and the remediation action date.

The reviewer chooses the appropriate time frame from the drop down. Mark NA if no remediation action was necessary or if no remediation action was

taken by the SCO.



6f. Remediation action outstanding - referred to appropriate staff for follow up.





7. The SCO reviews and evaluates performance data in selecting priorities for the QMP.

O The reviewer determines if the SCO used performance data to develop their QMP based on a review of the QMP.

o Performance data can include but is not limited to:- Performance results from QA&I self-assessments and full reviews,

including individual interviews, targeting those areas where performance falls below 86%

- Employment Data - IM4Q Data- Data on individual with communication needs- Community Participation data- Data on self-direction, choice and control- Data on management of incidents of abuse, neglect, exploitation and

unexplained deaths- Data on use of restrictive interventions including restraints- SCO Performance Review Reports

Mark YES if the SCO used performance data in the development of the QMP. Mark NO if the SCO did not use performance data or there is no QMP.



7a. Documentation was located. R The SCO has located evidence that they have reviewed and evaluated performance data in selecting priorities for the QMP.



# Question Type Guidance Source Documents Mark YES if the SCO has located the documentation. Mark NA if no remediation action is required or another remediation action was

selected.


7b. SCO staff is retrained as appropriate on QMP requirements.

R The SCO provides/ensures retraining of the appropriate SCO staff regarding the QMP requirements.

The SCO provides notification to ODP that the SCO staff was retrained. Mark YES if SCO provides notification to ODP of retraining provided to the SCO

staff. Mark NA if no remediation action is required or another remediation action was

selected.



7c. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the SCO to comply with the requirements.

The reviewer records the REMEDIATION ACTION (RA) taken by the SCO to remediate in the comment field. Mark YES if the SCO submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.



7d. If YES, when: R The reviewer calculates the number of days between the notification date to the SCO and the remediation action date.

The reviewer chooses the appropriate time frame from the drop down. Mark NA if no remediation action was necessary, or if no remediation action was

taken by the SCO.



7e. Remediation action outstanding - referred to appropriate staff for follow up.





PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The system of support is straightforward.The SCO is responsive to the individuals’ needs and identified issues.


# Question Type Guidance Source Documents8. The SCO has an escalation process for

issues that need to be sent to the AE for assistance in resolution.

Non-Scored

O The reviewer determines if the SCO has a process in place for escalating issues to the AE, especially provider issues.

The reviewer discusses the SCO’s process for addressing issues that require assistance in resolution.

The reviewer documents any promising practices in the comment section. Mark YES if the SCO has a process for notifying AEs of issues Mark NO if the SCO does not have a process for notifying AEs of issues.

Exploratory

PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – Individuals are afforded employment first.The SCO is responsive to the individuals’ employment goals.9. The SCO supports the SCs to offer

appropriate opportunities related to the individual’s skills and interests, and encourage the individual to seek competitive, integrated employment at the annual ISP meeting.

Non-Scored

O The reviewer determines if the SCO supports the SCs to offer appropriate opportunities via conversation.

The reviewer documents any promising practices in the comment section. Mark YES if the SCO supports the SCs to offer opportunities. Mark NO if the SCO does not support the SCs to offer opportunities.

Exploratory Pathways of Employment guidance

document Executive Order 2016-03

10. The SCO identifies how they collaborate with OVR and the school district for transition age youth and employment.

Non-Scored

O The reviewer determines if the SCO collaborates with both OVR and the local school districts.

The reviewer documents any promising practices in the comment section. Mark YES if the SCO collaborates with OVR and local school districts. Mark NO if the SCO does not collaborate with OVR and local school districts.



11. The SCO has an employment lead.

Non-Scored

O The reviewer determines if the SCO has an employment lead. The reviewer documents any promising practices in the comment section.

Mark YES if the SCO has an employment lead. Mark NO if there is the SCO does not have an employment lead.



PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual is supported to communicate.The SCO assesses and addresses communication needs for the individual.


# Question Type Guidance Source Documents12. The SCO currently has staff or available

contractors/language services who are trained to communicate with people who are deaf or hard of hearing (certified intermediate plus in ASL)

Non-Scored

O The reviewer determines if the SCO has staff or available contractors/language services to communicate with individuals who are deaf or hard of hearing. Mark YES if the SCO has staff or contractors/language services who are trained to

communicate with individuals who are deaf or hard of hearing (certified intermediate plus in ASL).

Mark NO if the SCO does not have staff or contractors/language services who are trained to communicate with individuals who are deaf or hard of hearing (certified intermediate plus in ASL).

Exploratory

PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual ‘s family receives the supports needed.The SCO provides information to address family support needs.13. The SCO promotes information sharing

with families.

Non-Scored

O The reviewer determines how the SCO supports the SC in offering/providing information to families.

The reviewer accepts evidence of information sharing such as SC trainings, family/consumers mailings, newsletters, etc. Mark YES if the SCO promotes information sharing with families. Mark NO if the SCO does not promote information sharing with families.

Exploratory Everyday Lives: Values in Action pg 17,

Support Families throughout the Lifespan

HEALTH & WELFARE – There are systemic efforts to ensure health and welfare.The SCO assesses and addresses the need for additional monitoring.14. The SCO has a process to identify

criteria triggers for higher frequency monitoring for individuals.

Non-Scored

O The reviewer determines if the SCO has a process in place to increase monitoring frequency when needed.

The reviewer discusses the SCO’s process for determining if individuals need extra support and monitoring.

The reviewer will have a conversation with the SCO representatives about their protocols in regards to increased monitoring for individuals.

o Triggers can include but are not limited to:- Crisis situations- Homelessness- Loss of monthly service- Critical incidents- Reports of abuse, neglect, exploitation

Mark YES if the SCO has a process for determining if individuals need increased monitoring.

Mark NO if the SCO does not have a process for determining if an individual needs increased monitoring.


Support People with Complex Needs Consolidated, Person/Family Directed

Support (P/FDS) and Community Living (CL) waivers

The SCO assesses need for Nursing Home Care.15. The SCO receives the Preadmission O The reviewer determines if the SCO receives any PASRR information about Exploratory


# Question Type Guidance Source DocumentsScreening and Resident Review (PASRR) information for individuals.

Non-Scored

individuals being placed in Nursing Facilities for long term care. This does not have to be the PASRR document. Mark YES if the SCO receive PASRR information. Mark NO if the SCO does not receive PASRR information.

Everyday Lives: Values in Action pg 17, Support Families Throughout the Life Span

The SCO has a certified investigator.16. The SCO maintains a certified

investigator.O The reviewer determines whether the SCO has a certified investigator on staff or has

a current agreement with another entity to investigate incidents directly related to SC services.

If the SCO has a CI on staff, the CI certification is good for 3 years from the date on the certificate. Mark YES if the SCO has a certified investigator or current agreement. Mark NO if the SCO does not have a certified investigator on staff or a current

agreement or the date on the CI certificate is over 3 years old.

Bulletin 00-10-06, Supports Coordination Services

Bulletin 6000-04-01, Incident Management

16a. Documentation was located. R The SCO has located the documentation. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



16b. The SCO acquires a certified investigator.

R The SCO acquires a certified investigator, either via contract with another entity or by having staff complete certified investigator training. Mark YES if the SCO acquired a certified investigator via contract or staff

certification. Mark NA if no remediation action is required or another remediation action was

selected.





selected.




The reviewer chooses the appropriate time frame from the drop down.


Bulletin 6000-04-01, Incident

*KEY – Desk Review (D); Onsite Review (O); Remediation (R)10


# Question Type Guidance Source Documents Mark NA if no remediation action was necessary, or if no remediation action was

taken by the SCO.Management


R Mark Yes if referred for appropriate follow-up as a result of no remediation action within 90 days of notification of the review findings. Utilize the comment field to record follow-up action.




QUALIFIED PROVIDERS – The individual’s providers meet necessary training requirements.The SCO ensures training requirements are met.17. All SCs completed the required

number of training hours in the training year.

O The reviewer determines if the SCs completed the required 24 hours of annual training in the Fiscal Year (7/1 to 6/30) based on SCO training records.

The reviewer will review 25% of SCs, but no less than 5 SCs. Exclude SCs with a discrete Base caseload Exclude staff that are no longer employed with SCO.

Mark YES if all SCs took the required number of hours. Mark NO if all of the SCs did not take the required number of hours.


Bulletin 00-10-13, Supports Coordination Training Waiver Requirements

17a. Documentation was located. R The SCO has located training records which indicate that all SCO staff have completed the required number of training hours in the training year. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



17b. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the SCO to comply with the requirements.


selected.



17c. If YES, when: R The reviewer calculates the number of days between the notification date to the SCO and the remediation action date.


taken by the SCO.



17d. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to SC no longer being employed at the SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was


Bulletin 00-10-13, Supports Coordination Training Waiver



# Question Type Guidance Source Documentsselected. Requirements






18. All SC Supervisors with a caseload (or who submitted billable service notes) completed the required number of training hours in the training year.

O The reviewer determines if all SC Supervisors completed the required 24 hours of annual training in the Fiscal Year (7/1 to 6/30) based on SCO records.

Exclude staff that are no longer employed with SCO. Mark YES if all SC Supervisors took the required number of hours. Mark NO if all of the SC Supervisors did not take the required number of hours.


Qualifications for Supports Coordination Organization.

18a. Documentation was located. R The SCO has located training records which indicate that all SCO staff have completed the required number of training hours in the training year. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.





selected.





taken by the SCO.



18d. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to SC no longer being employed at the SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

ODP Bulletin 00-10-06, Supports Coordination Services




# Question Type Guidance Source Documentsselected. Requirements






19. The SCO’s staff completed Annual training that includes core courses as required.

O The reviewer determines if all staff completed the annual training and all required core courses based on SCO records.

The reviewer will review 25% of SCs, but no less than 5 SCs. Exclude staff that are no longer employed with SCO.

o Core courses are:- Department policy on intellectual disability principles and values- Training to meet the needs of a participant as identified in the ISP- QM plan- Identification and prevention of abuse, neglect and exploitation of a

participant- Recognizing, reporting and investigating an incident- Participant grievance resolution- Department issued policies or procedures- Accurate billing and documentation of HCBS delivery.

Mark YES if all staff took the required annual training core courses. Mark NO if all staff did not take the required annual training core courses.

55 Pa. Code Chapter 51 Section 51.23


selected.


19b. SCO ensures the SCs and SC Supervisors take the annual training

R The SCO ensures that the staff take the required training. Mark YES if the staff took the training. Mark NA if no remediation action is required or another remediation action was

selected.



The reviewer records in comment field the REMEDIATION ACTION taken by the SCO to remediate.




# Question Type Guidance Source Documents Mark YES if the SCO submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.



taken by the SCO.


19e. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to SC no longer being employed at the SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.

55 Pa. Code Chapter 51





20. All new SCO staff have completed the required number of hours of orientation and required topics within the first year of employment.

O The reviewer uses the date of hire on the SC training spreadsheet and the SC Orientation packet to ensure the orientation was completed. Mark YES if all of the SC Orientation packets indicate completion. Mark NO if any of the SC Orientation packets do not indicate completion. Mark NA if there were no new hires.




selected.



20b. SCO ensures the SCs and SC Supervisor take required training.


selected.





# Question Type Guidance Source DocumentsRequirements



selected.





taken by the SCO.




selected.








21. All new SCs completed the required ODP SC Orientation prior to working independently with waiver participants.

DO

The reviewer looks at the SC Orientation packet and uses the date of the SC and SC Supervisor signature on the packet as the date orientation was completed.

Exclude discrete base caseloads as identified by the SCO. The reviewer searches service notes from the date of hire to the date of orientation

completed (per the SC Orientation certificate).





# Question Type Guidance Source Documents PATH: HCSIS > SC > Service Notes > Search > Advanced Search > Comment Author

Last Name and First Name. The reviewer searches for waiver billable face-to-face service notes and ensures

they have evidence that the SC did not attend these independently (i.e. documenting supervisor or co-workers attendance). Mark YES if all of the service notes indicate that the new SC did not work

independently prior to completion of SC Orientation. Mark NO if any services notes indicate that the SC worked independently with an

individual prior to completion of SC Orientation. Mark NA if there were no new hires.

21a. Documentation was located. R The SCO has located the documentation that the SC completed ODP SC Orientation prior to working independently with waiver participants. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



21b. The new SC completes the required training.


selected.





selected.





taken by the SCO.





# Question Type Guidance Source Documents


selected.








RECORD REVIEW – DESK REVIEW

# Question Type Guidance Source DocumentsADMINISTRATIVE AUTHORITY – The individual has a determination of urgency of need.



# Question Type Guidance Source DocumentsThe SC assures a current PUNS for the individual.22. There is an active Prioritization of

Urgency of Need for Services (PUNS) for the individual.

Non-Scored

D The reviewer determines if the individual has an active PUNS. An active PUNS is required when

o Individuals are currently waiting for new or enhanced services.o Individuals who have a projected need for service within the next five years.o Individuals who request or who are recommended for a change in residential

services/supports (request or recommendation could come from the individual, family, friends, professionals currently supporting the individual).

(PATH: HCSIS > Individual > PUNS > PUNS Change). Mark YES if there is an active PUNS. Mark NO if there is a service need and no active PUNS Mark NA if there is no PUNS needed or the PUNS is inactive or fully served.

Consolidated, P/FDS and CL waivers Appendix B: Section B-3


PUNS Manual

23. The SC completes a PUNS for the individual that reflects the individual’s needs.

D The reviewer determines if the PUNS reflects the needs of the individual based on a review of service notes, Individual Monitoring Tools and the ISP to identify individual’s current needs.

Active PUNS must be updated at least annually. (PATH: HCSIS > Individual > PUNS > PUNS Change).

Mark YES if the PUNS is reflective of current needs. Mark NO if the PUNS does not reflect current needs or there is no PUNS and the

record indicates there should be a PUNS or the PUNS is older than 365 days. Mark NA if there is no PUNS or the PUNS is inactive or fully served.

NOTE - Identify the current needs that were not included in the PUNS.



PUNS Manual

23a. Documentation was located R The SCO has located the documentation from the previous 12 months that indicates the PUNS was updated that reflected the current needs. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



PUNS Manual23b. The SC updates the PUNS and the

information is entered into HCSIS.R The SC updated the PUNS and the information is entered into HCSIS.

Mark YES if the PUNS was updated. Mark NA if no remediation action is required or another remediation action was

selected.



PUNS Manual23c. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the

SCO to comply with the requirements. The reviewer records in comment field the REMEDIATION ACTION taken by the SCO

to remediate.






selected.

PUNS Manual



taken by the SCO.



PUNS Manual23e. Remediation by exception R Remediation CAN BE completed by exception, meaning there is no way to remediate

the non-compliance due to death, moving out of state, inactive record status or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.



PUNS Manual23f. Remediation action outstanding -

referred to appropriate staff for follow up.





PUNS Manual

The SC works with the individual to address all identified needs.24. The individual had an identified

change in need.

Non-Scored

D The reviewer determines if any change of any service funded by ODP results in services being reduced, suspended, terminated or denied was identified based on a review of service notes, Individual Monitoring Tools and ISPs completed during the review period.

The reviewer notes the date the change in need was identified, the service changed and what type of change it was (reduced, suspended, terminated or denied). Mark YES if a change in need was documented. Mark NA if a change in need was not documented.

55 Pa. Code Chapter 51 Section 51.28 Bulletin 00-10-06, Supports

Coordination Services ISP Manual Section 8

25. The individual’s ISP is updated timely when a change in need is identified.

D The reviewer determines if the ISP was updated timely when a change in need was identified based on a review of service notes, Individual Monitoring Tools and the ISP.

PATH: HCSIS > Plan > History > Critical Revision. The SC has seven (7) calendar days from identification of a change in need to update

the ISP and submit for review.





# Question Type Guidance Source Documents The reviewer uses the ISP history screen to assure a draft Critical Revision ISP has a

“Pending Revision” date within seven (7) days of the change being identified. Mark YES if the ISP was updated timely. Mark NO if the ISP was not updated within seven (7) days and identify the

current needs that were not included in the ISP. Mark NA if there was no change in need.

25a. Documentation was located. R The SCO has located the documentation. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



25b. The SCO completes an update to the ISP.

R The SCO must update the ISP to reflect the change in need. Mark YES if the SCO updated the ISP to reflect the change in need. Mark NA if no remediation action is required or another remediation action was

selected.





selected.





taken by the SCO.



25e. Remediation by exception R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.



QUALITY MANAGEMENT – There are systemic efforts to continuously improve quality.The SC works with the individual to address IM4Q considerations.26. There is an Independent Monitoring D The reviewer determines if the individual has an IM4Q consideration. Bulletin 00-10-06, Supports



# Question Type Guidance Source Documentsfor Quality (IM4Q) consideration for the individual.

Non-Scored

(PATH: HCSIS > M4Q > IM4Q > Considerations). Mark YES if there is an IM4Q consideration. Mark NA if there is not an IM4Q consideration.

Coordination Services IM4Q Considerations Manual Section 3

27. SC follows the process to inform the individual, family members and the provider of all IM4Q considerations.

D The reviewer determines if the SC informed the individual, family members and the provider of all IM4Q considerations based on the review of service notes and the IM4Q section in HCSIS.

(PATH: HCSIS > M4Q > IM4Q > Considerations) Mark YES if the SC documented sharing IM4Q consideration. Mark NO if the SC did not document sharing of the IM4Q consideration. Mark NA if there is not an IM4Q consideration.


IM4Q Considerations Manual Section 3

27a. Documentation was located R The SCO has located the documentation that the SC informed the individual, family members and the provider of an IM4Q consideration. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



27b. The SCO develops a process for sharing IM4Q information with all stakeholders.

R The SCO develops a process with timeframes to ensure IM4Q considerations are shared with all stakeholders. Mark YES if the process was developed. Mark NA if no remediation action is required or another remediation action was

selected.



27c. The SC shares the IM4Q considerations with all stakeholders.

R The SC shares the IM4Q consideration information will all stakeholders. Mark YES if the IM4Q information was shared. Mark NA if no remediation action is required or another remediation action was

selected.



27d. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the SCO to comply with the requirements.


selected.



27e. If YES, when: R The reviewer calculates the number of days between the notification date to the Bulletin 00-10-06, Supports



# Question Type Guidance Source DocumentsSCO and the remediation action date.


taken by the SCO.

Coordination Services IM4Q Considerations Manual Section 3






28. The SC documents follow-up of an IM4Q consideration.

D The reviewer determines if the SC documented the IM4Q consideration follow-up based on the review of service notes, individual monitoring tools and the IM4Q section in HCSIS.

(PATH: HCSIS > M4Q > IM4Q > Considerations) Mark YES if the SC documented follow-up to all IM4Q considerations. Mark NO if the SC did not document follow-up on all the IM4Q considerations. Mark NA if there is not any IM4Q considerations.

NOTE – Identify the considerations that did not have documented follow-up.


IM4Q Considerations Manual Section 2 & 3

28a. Documentation was located. R The SCO has located the consideration documentation and entered it into HCSIS. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



28b. The SCO develops a process to ensure the loop is closed.

R The SCO develops a process to ensure the loop is closed for all IM4Q considerations. Mark YES if the process was developed. Mark NA if no remediation action is required or another remediation action was

selected.



28c. The SC completes follow-up of the IM4Q consideration and the information is entered into HCSIS.

The SC completes the follow-up of the IM4Q consideration and enters the information in to HCSIS. Mark YES if the IM4Q consideration follow-up was completed and documented. Mark NA if no remediation action is required or another remediation action was

selected.




The reviewer records in comment field the REMEDIATION ACTION taken by the SCO





# Question Type Guidance Source Documentsto remediate. Mark YES if the SCO submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.

& 3



taken by the SCO.








PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The system of support is straightforward.The SC accurately documents information in the individuals’ records. 29. The Service Notes (SNs) meet quality

standards.D The reviewer determines if the service notes meet quality standards.

The reviewer reviews the SNs for the review period. (PATH: HCSIS > SC > Service Notes > Search).

o Quality Standards (as per the trainings):- Person centered- Clear and concise- Objective- Include Who, What, When and Where- Detailed- Describe actions taken and actions needed

Mark YES if the services notes meet quality standards. Mark NO if the services notes do not meet quality standards.


Coordination Services ODP Trainings “Service Notes Basics

2013 – Part 1” & “Service Notes – Part 2 (2014)”.

29a. The SCO ensures the SCs are trained on the requirements.

R The SCO ensures that the staff are trained on the quality standards. Mark YES if the staff took the training. Mark NA if no remediation action is required or another remediation action was

selected.




29b. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the 55 Pa. Code Chapter 51 Section 51.28



# Question Type Guidance Source DocumentsSCO to comply with the requirements.


selected.


ODP Trainings “Service Notes Basics 2013 – Part 1” & “Service Notes – Part 2 (2014)”.



taken by the SCO.




29d. Remediation action outstanding - referred to appropriate staff for follow up.






The SC is responsive to the individuals’ needs and identified issues.30. There were identified issues

documented.

Non-Scored

D The reviewer determines if there are any issues identified based on service notes and Individual Monitoring Tools.

o Issues are defined as:- Any situation that warrants corrective action and timely response by an

individual providing supports- Circumstances that negatively impact an individual’s providing supports- An individual is not receiving the appropriate quality, type, duration and




# Question Type Guidance Source Documentsfrequency of services as identified in the ISP

- An individual is dissatisfied with the manner in which the services or supports are delivered

Mark YES if identified issues were documented. Mark NA if there were no issues.

31. The SC documents follow-up on issues identified.

D The reviewer determines if the SC followed-up on issues based on a review of service notes, Individual Monitoring Tools and the ISP.

Documentation within service notes, monitorings or the ISP should indicate follow-up action which includes notification of the Provider of the issue. Mark YES if there is documentation of the follow-up actions, including

notification of the Provider. Mark NO if there is not documentation of the follow-up actions or the follow-up

actions do not include notification of the Provider. Mark NA if there were no issues.


31a. Documentation was located R The SCO has located the documentation of the follow-up. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


31b. The SCO follows up on the issue and documents in HCSIS.

R The SCO follows up on the issue and documents the action in HCSIS. Mark YES if the SCO followed up and documented in HCSIS. Mark NA if no remediation action is required or another remediation action was

selected.




selected.


31d. If YES, when: R The reviewer calculates the number of days between the notification date to the Bulletin 00-10-16, Supports





taken by the SCO.

Coordination Services



32. There are unresolved issues where the SCO/SC notified the Provider but no action was taken by the Provider.

Non-Scored

D The reviewer determines if there are any issues that were unresolved by the provider during the review period based on a review of service notes and Individual Monitoring Tools. Mark YES if there are unresolved issues and note the issues. Mark NA if there are no unresolved issues.


33. If there were issues that were unresolved by the Provider, there is documentation that the SCO/SC notified the AE of the unresolved issue.

DO

The reviewer determines if the record contains notification to the AE of identified issues that were unresolved by the Provider.

The reviewer also accepts emails and letters as verification at the onsite visit. Mark YES if there were unresolved issues and there is documentation of AE

notification. Mark NO if there were unresolved issues and there is no documentation of AE

notification. Mark NA if there are no unresolved issues.


33a. Documentation was located R The SCO has located the documentation of the notification of the AE. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


33b. SCO notifies the AE of the unresolved issue.

R The SCO notifies the AE of the issues unresolved by the Provider. Mark YES if the AE is notified. Mark NA if no remediation action is required or another remediation action was

selected.



The reviewer records in comment field the REMEDIATION ACTION taken by the SCO to remediate.





selected.33d. If YES, when: R The reviewer calculates the number of days between the notification date to the


Mark NA if no remediation action was necessary or if no remediation action was taken by the SCO.




The SC identifies and addresses risk for the individual.34. The SC documents a risk assessment. D The reviewer determines if the SC documented a risk assessment based on a review

of service notes, incident reports, Individual Monitoring Tools. Risk assessment information should be incorporated into the ISP. ISP PATH: HCSIS > Plan > Health & Safety > Focus Area > General Health Safety Risks,

Fire Safety, Traffic, Cooking/Appliance Use, Outdoor Appliances, Water Safety, Safety Precautions, Knowledge of Self-Identifying Info, Stranger Awareness, Sensory Concerns, Meals/Eating. Mark YES if the ISP includes evidence of a risk assessment. Mark NO if the ISP does not include evidence of a risk assessment

NOTE - Identify the risks that have not been documented.

ISP Manual Section 2.4

34a. The SCO documents a risk assessment in HCSIS.

R The SCO documents a risk assessment in HCSIS. Mark YES if the SCO documents in HCSIS. Mark NA if no remediation action is required or another remediation action was

selected.




selected.


34c. If YES, when: R The reviewer calculates the number of days between the notification date to the ISP Manual Section 2.4





taken by the SCO.34d. Remediation by exception R Remediation CAN BE completed by exception, meaning there is no way to remediate

the non-compliance due to death, moving out of state, inactive record status or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.


PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual’s assessed needs are addressed in the ISP through waiver-funded services or other funding sources or natural supports.The SC identifies and addresses risk for the individual.35. The SC incorporates risk mitigation

strategies into the ISP.D The reviewer determines if the SC incorporated risk mitigation strategies based on a

review of the entire ISP. Risks can be found in the service notes, Individual Monitoring Tools, ISP and SIS

assessment. Mark YES if the ISP includes risk mitigation strategies. Mark NO if the there are risks identified but the ISP does not include risk

mitigation strategies. Mark NA if there were no risks that required mitigation.

NOTE -Identify the risks that did not have risk mitigation documented.


35a. The SCO documents risk mitigation strategies in the ISP.

R The SCO documents risk mitigation strategies in the ISP. Mark YES if the SCO documents in the ISP. Mark NA if no remediation action is required or another remediation action was

selected.




selected.




# Question Type Guidance Source Documents35c. If YES, when: R The reviewer calculates the number of days between the notification date to the




35d. Remediation by exception R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.


The SC assures a person-centered ISP is completed. 36. The SC submits the annual review ISP

for approval and authorization at least 30 days prior to the Annual Review Update Date (ARUD).

D The reviewer determines if the SC submitted the current annual review ISP at least 30 days prior to the Annual Review Update Date based on a review of the ISP.

PATH: HCSIS > Plan > History. The reviewer looks at the date of the “Pending Approval” ARU to determine the 30

days. If there is more than one ARU in the FY, the reviewer uses the ARU closer to the

ARUD. Mark YES if the annual ISP was submitted timely. Mark NO if the annual ISP was not submitted timely.

NOTE – If not submitted timely, record how late.


PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual is supported to achieve personal goals.The SC develops an ISP that is person-centered and addresses all assessed needs.37. The SC develops a person-centered ISP

to address all assessed needs.D The reviewer determines if the SC developed a person-centered ISP that

incorporates all assessed needs based on a review of service notes, PUNS the SIS assessment and the ISP.

The reviewer determines if the SC incorporated all services and support through waiver funded services or other funding sources or natural supports to mitigate identified risks into the ISP.

ISP Manual Section 1 & 2



# Question Type Guidance Source Documents Mark YES if the ISP is person-centered and includes evidence that all assessed

needs have been reviewed and/or addressed. Mark NO if the ISP is not person-centered or the identified assessed needs are

not included.

NOTE -Identify the assessed needs that have not been documented.

37a. Documentation was located R The SCO has located the documentation of the assessed needs in HCSIS. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


37b. The SC develops a person-centered ISP.

R The SCO ensure the SC develops a person-centered ISP. Mark YES if the SCO ensures a person-centered ISP is developed. Mark NA if no remediation action is required or another remediation action was

selected.


37c. The SC documents all assessed needs in the ISP.

R The SCO ensures the SC documents all assessed needs in the ISP. Mark YES if all assessed needs are documented in the ISP. Mark NA if no remediation action is required or another remediation action was

selected.




selected.




taken by the SCO.


37f. Remediation by exception R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status or transferring to another SCO.




# Question Type Guidance Source Documents Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.

38. The SC documents service frequency for all services in the ISP.

D The reviewer determines if the SC documented service frequency based on a review of the ISP.

The service frequency should be recorded in the Frequency and Duration section of the ISP.

The service frequency must include how often a service will be provided and can be flexible to meet the needs of the individual (i.e. 2 days/week, 4 hours/day, etc).

The service frequency can state “up to” or “not to exceed” as needed. “Approximate” amounts are not acceptable.

PATH: HCSIS > Plan > Serv & Supp > Outcome Act > Frequency and Duration section. Mark YES if the ISP includes all service frequencies. Mark NO if any service in the ISP does not include service frequencies.

NOTE - Identify the services that have no frequency documented.

ISP Manual Section 3.5 ODP Training “The Outcome Section of

the ISP Part 2: Outcome Actions”

38a. Documentation was located R The SCO has located the documentation of the service frequency in HCSIS. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



38b. The SCO documents service frequency in the ISP as appropriate.

R The SCO documents service frequency in the ISP. Mark YES if the SCO documents in the ISP. Mark NA if no remediation action is required or another remediation action was

selected.





selected.







# Question Type Guidance Source Documents The reviewer chooses the appropriate time frame from the drop down.






39. An ISP is developed that supports the outcomes throughout the entire plan.

D The reviewer determines if the SC developed an ISP that supports the outcomes throughout the ISP based on a review of the ISP.

Outcomes should reflect the personal goals of the individual. Mark YES if the outcomes are supported by the information in the ISP. Mark NO if the outcomes are not supported by the information in the ISP and

identify the outcomes that are not supported.NOTE – Identify the outcomes that are not supported and what is missing


39a. Documentation was located R The SCO has located the documentation in HCSIS. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


39b. The SCO updates the ISP to support the outcomes.

R The SCO must ensure that an ISP is updated to support the outcomes. Mark YES if the SCO updates the ISP. Mark NA if no remediation action is required or another remediation action was

selected.




selected.


39d. If YES, when: R The reviewer calculates the number of days between the notification date to the ISP Manual Section 3.4





taken by the SCO.



40. The SC develops an ISP that reflects the person’s interests and goals related to employment.

D The reviewer determines if the SCs developed an ISP that reflects interest and goals related to employment.

The reviewer answers based on review of service notes and the entire ISP. Mark YES if the ISP reflects that the SC developed an ISP that reflects interest and

goals related to employment, including information if the individual is already employed or not interested in employment.

Mark NO if the ISP does not reflect that the SC developed an ISP that reflects interest and goals related to employment.



PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual receives all approved services in the ISP.The SC monitors service delivery.41. The SC conducts all monitoring at the

required frequency.D The reviewer determines if the SC conducted monitorings at the required frequency

based on a review of the Individual Monitoring Tools. PATH: HCSIS > SC > Indiv Monitoring. If the individual has approved non-statutory frequency, identify them in the

comments section by MCI#. Mark YES if the SC conducted all monitorings at the required frequency. Mark NO if the SC did not conduct all monitorings at the required frequency. Mark NA if the individual is newly enrolled and no monitoring was due at time of

Consolidated, P/FDS and CL waivers Appendix D-2


ODP Announcement 126-17 CMS Approves the Targeted Support Management State Plan Amendment



# Question Type Guidance Source Documentsthe review.

Consolidated face-to-face every 60 days P/FDS face-to-face every 3 months (regardless of living situation) Community Living face-to-face every 60 days TSM face-to-face at least 1 time a year other than the ISP meeting

*3 months is calculated as calendar months, and not interpreted as per quarter. The 3 months are a rolling 3 months [i.e. Feb, Mar, April; Mar, Apr, May; etc.]

41a. Documentation was located. R The SCO has located the documentation and entered the information in HCSIS. Mark YES if documentation was located and entered into HCSIS. Mark NA if no remediation action is required or another remediation action was

selected.




41b. The SC completes a monitoring. The SCO ensures the SC completes a monitoring and documents the activity in HCSIS. Mark YES if a monitoring was completed and the information was entered into

HCSIS. Mark NA if no remediation action is required or another remediation action was

selected.




41c. The SCO ensures the SCs are trained on the requirements.

R The SCO ensures that the staff are trained on the monitoring requirements. Mark YES if the staff took the training. Mark NA if no remediation action is required or another remediation action was

selected.





The reviewer records in comment field the REMEDIATION ACTION taken by the SCO to remediate. Mark YES if the SCO submitted remediation documentation.



ODP Announcement 126-17 CMS *KEY – Desk Review (D); Onsite Review (O); Remediation (R)

34Last updated: 6/21/2018

# Question Type Guidance Source Documents Mark NA if no remediation action is required or another remediation action was

selected.Approves the Targeted Support Management State Plan Amendment



taken by the SCO.




41f. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to SC no longer being employed at the SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.




41g. Remediation action outstanding - referred to appropriate staff for follow up.






42. The SC conducts all monitoring at the required location.

D The reviewer determines if the SC conducted monitorings at the required location based on a review of the Individual Monitoring Tools.

(PATH: HCSIS > SC > Indiv Monitoring). If the individual has approved non-statutory frequency, identify them in the

comments section by MCI#. Mark YES if the SC conducted all monitorings at the required location. Mark NO if the SC did not conduct all monitorings at the required location. Mark NA if the individual is newly enrolled and no monitoring was due at time of

the review.

Consolidated Waiver – during a 6-month timeframe – 1 face-to-face in home, 1 face-to-face at day service and 1 time any location agreeable to the individual






# Question Type Guidance Source Documents P/FDS Waiver – 1 face-to-face in home every 6 months, 1 face-to-face at day service

and 1 time any location agreeable to the individual Community Living Waiver – during a 6-month timeframe – 1 face-to-face in home, 1

face-to-face at day service and 1 time any location agreeable to the individual TSM and Base have no location requirements

*3 months is calculated as calendar months, and not interpreted as per quarter. The 3 months are a rolling 3 months [i.e. Feb, Mar, April; Mar, Apr, May; etc.]


selected.




42b. The SCO ensures the SCs are trained on the requirements.

R The SCO ensures that the staff are trained on the monitoring requirements. Mark YES if the staff took the training. Mark NA if no remediation action is required or another remediation action was

selected.




42c. The SC completes a monitoring at the required location.

The SCO ensures the SC completes a monitoring and documents the activity in HCSIS. Mark YES if a monitoring was completed at the correct location and the

information was entered into HCSIS. Mark NA if no remediation action is required or another remediation action was

selected.






selected.






# Question Type Guidance Source Documents42e. If YES, when: R The reviewer calculates the number of days between the notification date to the


Mark NA if no remediation action was necessary, or if no remediation action was taken by the SCO.




42f. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to SC no longer being employed at the SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.










43. The SC monitoring documentation meets quality standards.

D The reviewer determines if the SC entered monitoring tools during the review period that meet quality standards based on a review of the Individual Monitoring Tools.

o Quality Standards (as per the trainings):- Person centered- Checks whether services are meeting needs as per the ISP- If the person has access to services- If services are being delivered according to the ISP- Describe actions needed

Mark YES if all the monitoring tools meet quality standards. Mark NO if any of the monitoring tools don’t meet quality standards. Mark NA if the individual is newly enrolled and no monitoring was due at time of

the review.


Coordination Services ODP Trainings “Introduction to

Individual Support Plan (ISP) Monitoring” & “ISP Monitoring 2014”.

44. The individual received services in type, scope, amount, duration and

D The reviewer determines if the individual’s approved services and supports are received in the type, scope, amount, duration and frequency as defined in the ISP




# Question Type Guidance Source Documentsfrequency as defined in the ISP. based on a review of the service notes and Individual Monitoring Tools.

ISP should be used to determine what services need to be monitored. Mark YES if the individual received all approved services and supports as per the

ISP. Mark NO if the individual did not receive all approved services and supports as

per the ISP.

NOTE – Identify which services and supports are missing


44a. Documentation was located R The SCO has located the documentation in HCSIS. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.





selected.





taken by the SCO.



44d. Remediation by exception R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.



45. If service is not being provided as authorized, the SC documents justification of service not being provided.

D The reviewer determines if the SC documented evidence of justification when services are not being received based on a review of the service notes, Individual Monitoring Tools and the ISP. Mark YES if services are not being provided and there is documented





# Question Type Guidance Source Documentsjustification.

Mark NO if services are not being provided and there is no documented justification.

Mark NA if all services are being provided as authorized. 45a. Documentation was located R The SCO has located the documentation in HCSIS.

Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



45b. The SCO documents justification of services not being provided as authorized.

R The SCO ensures that the justification of services not being provided as authorized is documented. Mark YES if the SCO ensures justification of services not being provided as

authorized is documented. Mark NA if no remediation action is required or another remediation action was

selected.





selected.





taken by the SCO.






HEALTH & WELFARE – The individual’s health, safety and rights are protected.The SC monitors health, safety and welfare.46. The individual’s identified health care

needs are addressed. D The reviewer determines if the individual’s health care needs are being addressed

based on a review of the ISP, service notes, and Individual Monitoring Tools. The reviewer will put the information (ISP, SNs, IMTs) into context by first


Everyday Lives: Values in Action pg 17,



# Question Type Guidance Source Documentsconsidering this question: does the documentation identify and address acute and chronic health conditions and wellness health promotion?

1. This includes:o ongoing routine health care needs (recommended health screenings,

checkups and annual physicals), o acute (unexpected situations that require follow-up such as infection

treatment, injuries), o chronic health (diabetes, high blood pressure, seizure disorder,

medication management, etc.);o wellness and health promotion (nutritional consults, weight

management, exercise, access to activities); ando other needs such as mobility or assistive technology. o To put information into context, apply a holistic approach to health and

wellness that includes: Behavioral Dental/Vision Emotional/Mental Physical Psychological That occurs over time

2. Before determining a final response, review and incorporate the information from these two additional IMT questions:

Have there been changes observed in the individual's overall health functioning and health status since the last monitoring? (A YES response needs follow-up of some type)

Necessary appointments were scheduled and kept. Multiple SNs may need to be reviewed to determine this.

Mark YES if:a. ALL of the above have been addressed as identifiedb. PLUS, the responses to the two additional IMT questions are:

i. YES to 1st question indicates there was a change, but review indicates follow-up occurred;

ii. No to 1st question but review indicates everything identified had a follow-up as needed;

c. THEN the individual’s health care needs are being addressed or the SC documents follow-up on health care needs is occurring (scheduled, etc.).

Promote Health, Wellness and Safety



# Question Type Guidance Source Documents Mark YES if the person does not take any medications and no health needs have

been identified; i.e., “Health is stable” (interpret to mean health needs are being addressed).

Mark NO if:a. Any health item identified is not addressed; b1. OR the SC does not document follow-up on identified health care needs; b2. OR it appears follow-up occurred but there is no documentation to verify follow-up.


selected.


Everyday Lives: Values in Action pg 17, Promote Health, Wellness and Safety

46b. The SCO ensures the individual’s health care needs are addressed and follow up is documented in HCSIS.

The SCO ensures the individual’s health care needs are addressed and follow up is documented in HCSIS. Mark YES if the health care needs are addressed and follow up is documented in

HCSIS. Mark NA if no remediation action is required or another remediation action was

selected.





selected.





taken by the SCO.





# Question Type Guidance Source Documents46e. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate

the non-compliance due to death, moving out of state, inactive record status, or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.








PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual receives all approved services in the ISP.The SC monitors the individual’s health and welfare.47. The SCO maintains records that they

notified the AE/Regional Program Manager (RPM) if there was imminent risk to the health & welfare of the individual.

DO

The reviewer determines if the SCO notified the AE and RPM of the imminent risk based on a review of service notes and Individual Monitoring Tools.

The On Site Team accepts any proof of notification during the onsite visit if it is not in the record. Mark YES if there was imminent risk and there is documentation of AE and RPM

notification. Mark NO if there was imminent risk and there is no documentation of AE and

RPM notification. Mark NA if there is no documented imminent risk.



47a. Documentation was located R The SCO has located the documentation. Mark YES if the documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.



47b. The SCO notifies the AE and RPM as R The SCO ensures that the AE and RPM are notified. Bulletin 00-10-06, Supports



# Question Type Guidance Source Documentsrequired. Mark YES if the SCO ensures the AE and RPM are notified.

Mark NA if no remediation action is required or another remediation action was selected.

Coordination Services Bulletin 6000-04-01, Incident

Management47c. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the


to remediate. Mark YES if the SCO submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.





taken by the SCO.






PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual has an active life in the community.The SC offers and monitors an active life in the community for the individual.48. The SC includes evidence in the record

that they facilitated conversations with the individual about receiving on-going opportunities and support necessary to participate in community activities of the person’s choice.

Non-Scored

D The reviewer determines if the SC is facilitating conversations to ensure the individual is getting support for community activities based on a review of service notes, Individual Monitoring Tools and the ISP. Mark YES if the SC is documenting the facilitation of discussions. Mark NO if the SC does not document the facilitation of discussions.

Exploratory

49. The SC reflects in the ISP that the individual is afforded the same degree

D The reviewer determines if the SC included information about the individual being afforded the same degree of community access and choice based on a review of the

Exploratory



# Question Type Guidance Source Documentsof community access and choice as an individual who is similarly situated in the community who does not have a disability and who does not receive an HCBS.Non-Scored

ISP. Mark YES if the SC included information on community access and choice in the

ISP. Mark NO if the SC did not include information on community access and choice

in the ISP.

50. The SC uses the individual monitoring tool to record if the individual, who is receiving community participation supports, is engaged in community activities aligned with their preferences at the rate identified in their ISP and in accordance with the waiver.

Non-Scored

D The reviewer determines if the SC used the individual monitoring tool to record information about engaging in community activities that align with the individual’s preference based on a review of service notes, Individual Monitoring Tools and the ISP. Mark YES if the SC used the monitoring tool to record information about

Community Participation Supports. Mark NO if the SC did not use the monitoring tool to record information about

Community Participation Supports Mark NA if the individual does not receive Community Participation Supports.

Exploratory

PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual is supported to communicate.The SC assesses and addresses communication needs for the individual.51. There is a communication need for this

individual.

Non-Scored

D The reviewer determines if the individual has a communication need based on services notes, Individual Monitoring Tool and the ISP. Mark YES if there is a communication need. Mark NA if there is not a communication need.

NOTE – Identify the communication need.

Bulletin 00-08-18, Communication Supports and Services

Everyday Lives: Values in Action pg 16, Assure Effective Communication

52. The ISP includes information about communication supports and services the individual needs based on their communication assessment/reassessment.

D The reviewer determines if the ISP includes information about communication supports and services, including services and technologies authorized and funded by ODP or outside ODP.

The SIS and PA Supplement communication and assistive technology sections are used to inform the communication assessment/reassessment. Mark YES if the ISP includes information about the primary mode of

communication and communication specifics. Mark NO if the ISP does not includes information about the primary mode of

communication and communication specifics. Mark NA if communication assistance is not needed.





# Question Type Guidance Source Documents53. The SC explores with the individual

options for communication assistance and supports the individual to choose.

D The reviewer determines if the SC explores with the individual options for communication assistance when appropriate and supports the individual to choose based on a review of service notes, Individual Monitoring Tools and the ISP. Mark YES if the SC explores with the individual options for communication

assistance when appropriate and supports the individual to choose. Mark NO if the SC did not explore with the individual options for communication

assistance when appropriate and support the individual to choose. Mark NA if communication assistance is not needed.

Bulletin 00-08-18, Communication Supports and Services,


54. The SCO offers communication assistance when providing direct supports coordination services.

D The reviewer determines if the SCO offered communication assistance to individuals when providing direct supports coordination services based on a review of service notes, Individual Monitoring Tools and the ISP.

Communication assistance is for all individuals who need it, including individuals who are deaf or hard of hearing. Mark YES if the SCO provided communication assistance while providing direct

supports coordination services. Mark NO if the SCO did not provide communication assistance while providing

direct supports coordination services. Mark NA if communication assistance is not needed.



54a. SCO staff is retrained on requirements. R The SCO provides/ensures retraining of the appropriate SCO staff regarding requirements.

The SCO provides notification to ODP that the staff were retrained. Mark YES if SCO provides notification to ODP of retraining provided to the staff. Mark NA if no remediation action is required or another remediation action was

selected.





selected.



54c. If YES, when: R The reviewer calculates the number of days between the notification date to the Bulletin 00-08-18, Communication





taken by the SCO.

Supports and Services Everyday Lives: Values in Action pg 16,

Assure Effective Communication

54d. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.








55. The individual is identified as deaf or hard of hearing.

Non-Scored

D The reviewer determines if the individual is identified as deaf or hard of hearing based on a review of services notes and the ISP.

An individual is identified as “deaf” when there is a hearing impairment and: Is unable to understand/communicate verbal expressions commensurate with

the intellectual disability level even with the use of hearing aids, OR Whose primary language is one of the following:

o American Sign Language (ASL) o Sign language from other countries (such as Spanish) o Signed Exact English o A mixture of ASL and Signed Exact English, or o Visual-Gestural Communication

Mark YES if the individual is identified as deaf or hard of hearing. Mark NA if the individual is not identified as deaf or hard of hearing.

Bulletin 00-14-04, Accessibility of Intellectual Disability Services for Individuals Who Are Deaf

56. The SC appropriately identifies the individual as a Harry M class member.

D • The reviewer determines if Demographics > Demo Harry M indicator is marked.• Harry M class members consist of:

- Individuals who are deaf or hard of hearing- Are enrolled in the Consolidated waiver

Mark YES if the Harry M indicator is correctly checked.

Harry M vs. PA DPW settlement agreement / Enhanced Communication Services Job Aid 12.4.2014



# Question Type Guidance Source Documents Mark NO if the Harry M indicator is not checked and should be. Mark NA if the individual is not identified as deaf or hard of hearing or is enrolled

in P/FDS, CL or Base.57. The SC is trained in all required

training within 30 days of an individual who is deaf or hard of hearing being added to their caseload.

D The reviewer determines if the SC of the individual who is deaf or hard of hearing completed the required training within 30 days of the individual being added to the SC’s caseload.

If the individual is deaf or hard of hearing, the reviewer look at the SC’s training records.

o Required trainings are:- Department’s training on deaf culture - the unique needs of deaf waiver participants- relevant service descriptions- the role of the Deaf Services Coordinator- the SC’s responsibilities in serving the deaf

Mark YES if the SC received all trainings within 30 days. Mark NO if the SC did not receive all trainings within 30 days. Mark NA if the individual is not identified as deaf or hard of hearing.

Harry M. Settlement Agreement, Paragraph 2-e-ii, pages 6-7

57a. The SC completes the required training.

R The SCO ensures that the SC completes the required training. Mark YES if the SCO ensures the required training was completed. Mark NA if no remediation actions were required or another remediation action

was selected.




selected.




taken by the SCO.


57d. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another SCO.




# Question Type Guidance Source Documents Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.57e. Remediation action outstanding -





PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual‘s family receives the supports needed.The SC provides information to address family support needs.58. There is evidence that the SC offers

information about services and resources to the family.

D The reviewer determines if the SC offered the family information about services and resources (i.e. trainings, community resources, support groups, etc.) based on a review of service notes, Individual Monitoring Tools and the ISP. Mark YES if there is evidence that the SC provided information to the family in

the record. Mark NO if there is no evidence that the SC provided information to the family in

the record. Mark NA if there is no family involvement.

Consolidated, P/FDS and CL waivers Appendix E

Everyday Lives: Values in Action pg 17, Support Families throughout the Lifespan


selected.



58b. The SCO ensures information is offered to the family.

The SCO ensures that SCs offer information to the family and document it in HCSIS. Mark YES if information was shared and documented in HCSIS. Mark NA if no remediation action is required or another remediation action was

selected.





selected.



58d. If YES, when: R The reviewer calculates the number of days between the notification date to the Consolidated, P/FDS and CL waivers





taken by the SCO.

Appendix E Everyday Lives: Values in Action pg 17,

Support Families throughout the Lifespan

58e. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.








HEALTH & WELFARE – The individual’s health, safety and rights are protected.The SC ensures that the individual is aware of how to identify and report Abuse, Neglect and Exploitation.59. The individual receives information on

how to identify and report abuse, neglect and exploitation.

D The reviewer determines if the SC provided the individual with information about Abuse, Neglect, and Exploitation (ANE) based on the Individual Monitoring Tool.

The ANE information must be provided at any meeting other than the annual ISP meeting. Mark YES if there is a service note that details the SC providing the ANE

information at a meeting other than the annual ISP meeting. Mark NO if there is not a service note that details the SC providing the ANE

information or the information was shared during the annual ISP meeting.

ODP Informational Packet 033-17 Rights to be Free from Abuse Notification Handout


selected.


59b. The SCO ensures the ANE information is shared with the individual.

The SCO ensures the ANE information is shared and a service note is created in HCSIS. Mark YES if the ANE information was shared and a service note entered in HCSIS.




# Question Type Guidance Source Documents Mark NA if no remediation action is required or another remediation action was

selected.



selected.




taken by the SCO.



selected.








# Question Type Guidance Source Documents

60. The SC identifies any current medical personnel such as doctors, dentists, psychiatrists, therapists/counselors, allied health professionals, specialists, etc. seen in the review period.

D The reviewer determines if required health care practitioners are identified based on a review of service notes, the Individual Monitoring Tool and the ISP. Mark YES if the SC identified all health care practitioners seen in the last 12

months in HCSIS. Mark NO if the SC did not identify all health care practitioners seen in the last 12

months in HCSIS.

ISP Manual Section 2.2 & 2.3 Everyday Lives: Values in Action pg 17,


The SC ensures reportable incidents are reviewed and corrective action is completed.61. All reportable incidents are

documented in Enterprise Incident Management (EIM) as required.

D The reviewer determines if there was a reportable incidents, including critical incidents, based on a review of the services notes and Individual Monitoring Tools.

The reviewer determines that if there is an incident in the record that there is an incident recorded in EIM.

PATH: HCSIS > M4Q > EIM > Search > Individualo Critical incidents are defined as incidents in the IM Bulletin as those requiring

an investigation at any level.- Abuse- Neglect- Misuse of funds- Rights Violation- Death

Mark YES if the SC documented a reportable incident and there is an incident report in EIM.

Mark NO if the SC documented a reportable indent but no there is incident report in EIM.

Mark NA if the SC did not document a reportable incident in the service notes or Individual Monitoring Tool.

55 Pa. Code Chapter 51 Section 51.17 55 Pa Code Chapter 6000 subchapter Q

– Incident Management ODP Informational Packet 072-13

Incident Management Clarification of Responsibilities for the Supports Coordination Organizations



# Question Type Guidance Source DocumentsNOTE - If a critical incident is found that doesn’t have an incident report in EIM – the unreported critical incident protocol should be followed.

62. The SCO/SC notified the Provider of the need to report the incident as per ODP guidelines.

D The reviewer determines if there is a reportable incident based on a review of the record, based on a review of the services notes and Individual Monitoring Tools.

If there is a reportable incident, the reviewer will check EIM and ensure there is a report in EIM.

If the report in EIM is dated after the date of SCO/SC discovery, the reviewer determines if the SCO/SC notified the Provider of the need to enter a reportable incident based on a review of service notes and Individual Monitoring Tools.

If there is no report in EIM, the reviewer will follow notify the appropriate staff to get the incident entered into EIM. Mark YES if the SCO/SC notified the Provider of the need to enter the incident. Mark NO if the SCO/SC did not notify the Provider of the need to enter the

incident. Mark NA if there is no reportable incident nor filed in EIM.





selected.




62b. The SCO ensures that the Provider is notified of the need to enter reportable incidents into EIM.

R The SCO ensures Provider is notified of the need to enter reportable incidents into EIM. Mark YES if the provider is notified. Mark NA if no remediation action is required or another remediation action was

selected.




62c. SCO staff is retrained on requirements. R The SCO provides/ensures retraining of the appropriate SCO staff regarding requirements.




Incident Management Clarification of



# Question Type Guidance Source Documentsselected. Responsibilities for the Supports

Coordination Organizations62d. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the



selected.






taken by the SCO.




62f. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.










63. If there is a reported incident in EIM, the SC documents review of the initial incident report (including medication error and restraints incidents) for evidence that the individual’s health, safety and rights were safeguarded

D The reviewer determines if the SC documented review of the initial incident including that the individual’s health, safety and rights were safeguarded based on a review of service notes and Individual Monitoring Tools. Mark YES if the SC reviewed the initial incident and documented review. Mark NO if the SC did not document a review of the initial incident. Mark NA if there is no reportable incident.






# Question Type Guidance Source Documents64. If there is a critical incident in EIM, the

SC reviews the incident and documents in HCSIS.

D The reviewer determines if the SC documented review of the incident in a service note or Individual Monitoring Tool.

PATH: HCSIS > M4Q > EIM > Search > Individualo Critical incidents are defined as incidents in the IM Bulletin as those requiring

an investigation at any level.- Abuse- Neglect- Misuse of funds- Rights Violation- Death

Mark YES if the SC reviewed the incident and documented review. Mark NO if the SC did not document a review of the incident. Mark NA if there is no reportable incident.

55 Pa. Code Chapter 51 Section 51.17 & 51.18

55 Pa Code Chapter 6000 subchapter Q – Incident Management

ODP Informational Packet 072-13 Incident Management Clarification of Responsibilities for the Supports Coordination Organizations

65. The SC monitors the implementation of corrective action.

D The reviewer determines if the SC monitored the corrective action listed in the incident based on a review of the services notes and Individual Monitoring Tools.

EIM > Incident > Preventative Corrective Action (only required if the incident is confirmed – critical categories only)

EIM > Incident > Additional Corrective Action Mark YES if the SC monitored the incident corrective action. Mark NO if the SC did not monitor the incident corrective action. Mark NA if there are no reported incidents or there is no corrective action listed.





selected.




65b. The SC monitors the corrective action implementation.

R The SCO ensures that the corrective action is monitored for implementation and the monitoring is documented.




# Question Type Guidance Source Documents Mark YES if the SCO ensures monitoring of corrective action. Mark NA if no remediation action is required or another remediation action was

selected.





selected.






taken by the SCO.





selected.









ODP Informational Packet 072-13 Incident Management Clarification of



# Question Type Guidance Source DocumentsResponsibilities for the Supports Coordination Organizations

66. The SC follows up on corrective action as necessary.

D The reviewer determines if the SCO/SC followed-up with the Provider and AE when the corrective action was not completed based on a review of the service notes and Individual Monitoring Tools. Mark YES if the SC notified the Provider and AE if corrective action was not

completed. Mark NO if the SC did not notify the Provider and AE if corrective action was not

completed. Mark NA if there are no reported incidents.





selected.




66b. The SCO ensures that the Provider and the AE are notified of the need to complete the corrective action.

R The SCO ensures that the Provider and the AE are notified of the need to complete the corrective action. Mark YES if the Provider and the AE are notified. Mark NA if no remediation action is required or another remediation action was

selected.






selected.




66d. If YES, when: R The reviewer calculates the number of days between the notification date to the 55 Pa. Code Chapter 51 Section 51.18*KEY – Desk Review (D); Onsite Review (O); Remediation (R)




taken by the SCO.




selected.










HEALTH & WELFARE –The individual’s restrictive intervention followed proper procedure.The SC ensures that restrictive procedures are followed-up.67. For incidents reported by the SCO in

which unauthorized restrictive interventions or restraints were used, the Human Rights Committee was notified.

Non-Scored

DO

The reviewer determines if the SCO reported an unauthorized restrictive intervention or restraint.

The reviewer reviews the record to ensure the HRC was notified. The reviewer also accepts emails and letters as verification of notification at the

onsite visit. Mark YES if there was an unauthorized restrictive intervention and the HRC was

notified. Mark NO if there was an unauthorized restrictive intervention and there is no

documentation of the HRC notification. Mark NA if there were no unauthorized restrictive interventions or restraints.

Exploratory

67a. Documentation is located. R Documentation is provided showing the SCO notified the HRC. Mark YES if documentation has been provided. Mark NA if no remediation action is required or another remediation action was

selected.

Exploratory

67b. SCO staff is retrained on requirements. R The SCO provides/ensures retraining of the appropriate SCO staff regarding Exploratory*KEY – Desk Review (D); Onsite Review (O); Remediation (R)


# Question Type Guidance Source Documentsrequirements.


selected.67c. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the



selected.

Exploratory



taken by the SCO.

Exploratory




Exploratory

HEALTH & WELFARE – Individuals with complex physical and behavioral needs receive appropriate supports.The SC provides Due Process Rights information to the individual.68. For individuals who have experienced

a crisis period, the SC completed additional monitoring during that crisis period in order to resolve the crisis.

Non-Scored

DO

The reviewer determines if there are any crisis periods and if the SC increased monitoring during the crisis based on a review of service notes and Individual Monitoring Tools.

NOTE – Service note documentation of increased monitoring is sufficient, increased monitoring tools are not required.

Mark YES if there are crisis periods and the SC increased their monitoring. Mark NO if there are crisis periods and the SC did not increase their monitoring. Mark NA if there are no crisis periods.


Support People with Complex Needs

69. The individual has complex needs.

Non-Scored

D The reviewer determines if the individual has complex needs based on a review of service notes, Individual Monitoring Tools and ISP.

Complex needs are multiple (2 or more) needs across personal, physical, mental, social and financial well-being that require significant attention or resources. This





# Question Type Guidance Source Documentscan include 2 or more need in one area and should be individualized.

o Examples:- Medical complexity - Socioeconomic factors - Mental illness - Behaviors and traits

Mark YES if the individual has complex needs. Mark NA if the individual does not have complex needs.

NOTE – Identify the complex needs.

70. If the individual has complex needs, the SC ensures there is a plan in place to address those needs.

D The reviewer determines if a plan is in place to address identified complex needs based on a review of service notes, Individual Monitoring Tools and ISP. Mark YES if a plan is in place to address complex needs. Mark NO if a plan is not in place to address complex needs. Mark NA if the individual does not have complex needs.




selected.



70b. The SCO ensures that a plan is in place to address complex needs.

R The SCO ensures that a plan is in place to address complex needs. Mark YES if that a plan is in place. Mark NA if no remediation action is required or another remediation action was

selected.





selected.







# Question Type Guidance Source Documents The reviewer chooses the appropriate time frame from the drop down.

Mark NA if no remediation action was necessary, or if no remediation action was taken by the SCO.



selected.



71. If there is a complex need identified for the individual, the SC addresses issues identified via monitoring related to support for the person.

D The reviewer determines if there are any complex needs and identified issues based on a review of service notes, Individual Monitoring Tools and ISP.

The reviewer determines if the complex need/issues have been addressed based on a review of service notes, Individual Monitoring Tools and ISP. Mark YES if there are complex needs and related issues that the SC has

addressed. Mark NO if there are complex needs and related issues that the SC has not

addressed. Mark NA if the individual does not have complex needs.



HEALTH & WELFARE – The individual has wellness opportunities.The SC ensures wellness resources are available.72. Where wellness needs have been

identified for the person, the SC worked with the team to ensure resources are available for the individual.

Non-Scored

D The reviewer determines if there are any wellness needs and if the SC worked with the team based on a review of service notes, Individual Monitoring Tools and ISP.

Health and wellness includes good nutrition, healthy diets, physical activity, strategies to reduce and manage and stress and protecting from all types of abuse and exploitation. Mark YES if there are wellness needs that have been discussed with the team. Mark NO if there are wellness needs and there have not been team discussions. Mark NA if there are no wellness needs.



73. Where wellness needs have been D The reviewer determines if the SC worked with the team to create a plan based on a Exploratory



# Question Type Guidance Source Documentsidentified for the person, the SC worked with the team to create a plan to use the identified resources to support wellness goals.

Non-Scored

review of service notes, Individual Monitoring Tools and ISP. Mark YES if the SC worked with the team to create a plan using resources to

support wellness needs. Mark NO if the SC did not work with the team to create a plan using resources to

support wellness needs. Mark NA if there are no wellness needs.


RECORD REVIEW – ONSITE REVIEW

# Question Type Guidance Source DocumentsADMINISTRATIVE AUTHORITY - The individual receives information about fair hearing and appeal rights.The SC provides Due Process Rights information to the individual.74. The SC provides due process rights

information at the annual ISP meeting.O The reviewer determines if the SC provided the due process rights at the annual ISP

meeting based on the ISP Signature Page. PATH: ISP Signature Page, page 2, Questions 14 and 15.

Mark YES if the ISP Signature Page is checked “Yes”. Mark NO if the ISP Signature Page is not checked or “No” is checked.

Consolidated, P/FDS and CL waivers Appendix F-1


Bulletin 00-08-05, Due Process and Fair Hearing Procedures for Individuals with Mental Retardation

74a. Written notice of Due Process rights was located.

R The SCO locates written notice of Due Process rights. Mark YES if the written notice of due process rights was located Mark NA if no remediation actions were required or another remediation action

was selected.




74b. Written notice of Due Process rights was completed.

R The SCO provides Due Process Rights to the individual/surrogate. Mark YES if the notification of Due Process has been distributed. Mark NA if no remediation actions were required or another remediation was


Bulletin 00-10-06, Supports



# Question Type Guidance Source Documentsselected. Coordination Services



The reviewer records in comment field the REMEDIATION ACTION taken by the SCO to remediate. Mark YES if the SCO submitted remediation documentation. Mark NA if no remediation actions were required or another remediation was

selected.






taken by the SCO.




74e. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.










75. Choice of providers was offered to the individual/family.

O The reviewer determines if the SC offered individual choice based on the ISP Signature Page.

PATH: ISP Signature Page, page 2, Question 4.

ISP Manual Section 4



# Question Type Guidance Source Documents Mark YES if the ISP Signature Page is checked “Yes”. Mark NO if the ISP Signature Page is not checked or “No” is checked.


selected.


75b. The SCO offers the individual choice of providers and documents on the ISP Signature Page.

R The SCO ensures choice of providers is provided and documented on an ISP Signature page. Mark YES if completed. Mark NA if no remediation action is required or another remediation action was

selected.




selected.




taken by the SCO.



selected.






76. Choice of services was offered to the individual/family.

O The reviewer determines if the SC offered individual choice at the annual ISP meeting based on the ISP Signature Page.




# Question Type Guidance Source Documents PATH: ISP Signature Page, page 2, Question 5.



selected.


76b. The SCO offers the individual choice of services and documents on the ISP Signature Page.

R The SCO ensures choice of services is provided and documented on an ISP Signature page. Mark YES if completed. Mark NA if no remediation action is required or another remediation action was

selected.




selected.




taken by the SCO.



selected.






77. SC provides the individual information on participant directed service (PDS)

O The reviewer determines if the SC provided information about PDS at the annual ISP meeting based on the ISP Signature Page.

ISP Manual Section 3.6 & Section 4



# Question Type Guidance Source Documentsoptions annually. PATH: ISP Signature Page, page 2, Question 11.



selected.


77b. The SCO provides information about PDS to the individual and documents on the ISP Signature Page.

R The SCO ensures PDS information has been shared and documented on an ISP Signature page. Mark YES if completed. Mark NA if no remediation action is required or another remediation action was

selected.




selected.




taken by the SCO.



selected.






78. At the annual ISP meeting, the SC provides education and information to

O The reviewer determines if the SC offered individual information about employment services based on the ISP Signature Page.




# Question Type Guidance Source Documentsthe individual about employment services (i.e. competitive, integrated employment, OVR services, benefits counseling or the “Guidance for Conversations about Employment”).Non-Scored

PATH: ISP Signature Page, page 2, Question 10. Mark YES if the ISP Signature Page is checked “Yes”. Mark NO if the ISP Signature Page is not checked or “No” is checked.


PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual is supported in developing the ISP, including involvement of people chosen by the individual.The SC works with the individual in the planning and development of supports and services.79. The individual attends the Annual

Review Update ISP meeting.O The reviewer determines if the individual attended the ISP meeting based on the ISP

Signature Page. If the individual is under 18 or has a surrogate/legal representative, they are not

required to attend. PATH: ISP Signature Page, page 1, top of page

Mark Yes if the individual attended. Mark No if the individual did not attend.



80. If the individual did not attend the ARU ISP meeting, the SC reviews the results of the meeting with the individual and provides documentation of the review.

O The reviewer determines if the SC reviewed the results of the ISP meeting with any individuals who did not attend based on the ISP Signature Page.

If the individual is under 18 or the surrogate/legal representative attended, the ISP does not need to be reviewed.

PATH: ISP Signature Page, page 1, bottom of page (signature and date) & page 2, Question 1. Mark YES if the ISP Signature Page is signed by the individual. Mark NO if the ISP Signature Page is not signed by the individual. Mark NA if the individual was present at the ISP meeting or they are under 18 or

the surrogate/legal representative attended.




selected.



80b. The SCO ensures the ISP is reviewed The SCO ensures the ISP has been reviewed and documented on an ISP Signature Consolidated, P/FDS and CL waivers



# Question Type Guidance Source Documentswith the individual and documented. page.

Mark YES if the ISP has been reviewed and documented on an ISP Signature Page.

Mark NA if no remediation action is required or another remediation action was selected.

Appendix F-1 ISP Manual Section 4



selected.





taken by the SCO.




selected.








81. The SC includes required team members in the Annual Review Update ISP meeting.

DO

The reviewer determines if the SC included the required team members in the ISP meeting based on the ISP, ISP Signature Page and the ISP invitation letter.

The reviewer uses the ISP Service Details for the ARU ISP (PATH: Plan > History > Summary> Annual Update Review > Approved > Service Details > Print Selected Sections) and records all required team members. This information is shared for the onsite confirmation (copy of service details or list should be taken onsite).


ISP Manual Section 2 & 2.1



# Question Type Guidance Source Documents Providers who are required to implement the ISP are required to attend. PATH: ISP Signature Page, page 1. Team members who attended the ISP meeting sign the signature page. If a waiver provider chose not to be present, the reason for their absence is

documented on the ISP Signature Page Mark YES if the ISP Signature Page is signed by all waiver providers. Mark NO if the ISP Signature Page is not signed by all waiver providers and the SC

did not document the reason for the absence. Mark NA if there are no required team members.

82. The SC includes people chosen by the individual in ISP development and the ISP meeting.

DO

The reviewer determines if the SC included people chosen by the individual in the ISP meeting based on service notes and the ISP Signature Page.

The reviewer shares information gathered from the service notes and ISP Signature Page is reviewed onsite.

PATH: ISP Signature Page, page 1, signature and date. Mark YES if the SC included people chosen by the individual. Mark NO if the SC did not include people chosen by the individual or did not

document a discussion. Mark NA if the individual did not want to invite anyone.

NOTE - Identify people chosen by the individual outside of their family and providers.

Exploratory

PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – Individuals are afforded employment first.The SC offers employment first.83. The individual is under 25 years of age.

Non-Scored

D The reviewer reviews demographics to the determine individual’s age. PATH: HCSIS > Individual > Demographics > Demo. The reviewer indicates age in the comment filed.

Mark YES if individual is under 25 years old. Mark NA if the individual is 25 years or older.

Bulletin 00-16-02, OVR Referral Process for Employment-Related Services

84. The individual is authorized for Community Participation Supports in a prevocational setting.

Non-Scored

D The reviewer determines if the participant is under 25 years old and has been authorized for Community Participation Supports in a prevocational setting.

The reviewer is responsible to determine when the INITIAL authorization occurred. The reviewer indicates in the comment field the date of the initial authorization and

if it occurred prior to August 28, 2015 Mark YES if there is an authorization for Community Participation Supports in a

prevocational setting.




# Question Type Guidance Source Documents Mark NA if the individual is 25 years or older or if there is no authorization for

prevocational services.85. The SC ensures that a new Community

Participation Supports in a prevocational setting service for an individual who is under 25 years of age is permitted only after a referral is made to OVR and a determination from OVR that the individual is ineligible or closes the case.

O The reviewer determines if the file contains one of the following documents: o a determination from OVR that the individual is ineligible or o indication that OVR closed the case

Mark YES if there is evidence of OVR determination in file. Mark NO if there is no OVR determination in the file. Mark NA if the individual is 25 years or older or doesn’t get CPS in a

prevocational setting.



selected.


85b. The SCO ensures a referral to OVR is completed.

The SCO ensures that the individual is referred to OVR. Mark YES if the individual was referred to OVR. Mark NA if no remediation action is required or another remediation action was

selected.




selected.




taken by the SCO.


85e. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate Bulletin 00-16-02, OVR Referral



# Question Type Guidance Source Documentsthe non-compliance due to death, moving out of state, inactive record status, or transferring to another SCO. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.

Process for Employment-Related Services





SELF-ASSESSMENT

# Question Type Guidance Source DocumentsSELF-ASSESSMENT – The SCO completes an annual QA&I self-assessment.86. The SCO completed the annual self-

assessment using the ODP specified tool by August 31st.

D The reviewer determines if the SCO completed their self-assessment using the ODP specified tool by August 31st. Mark YES if there is evidence that the SCO has completed a self-assessment by

August 31st. Mark NO if there is no evidence indicating the self-assessment has been

completed by August 31st.

Consolidated, P/FDS and CL waivers QA&I Process Self Assessment Section

86a. The SCO completes their annual self-assessment.

R The reviewer should check the ODP specified tool for evidence that the SCO has completed their current annual self-assessment. Mark YES if the SCO has completed their annual self-assessment for the current

fiscal year. Mark NA if no remediation actions were required or another remediation action

was selected.


86b. The SCO participates in an onsite visit. R The SCO participates in an onsite visit during a year the SCO is not already scheduled. Mark YES if the SCO participates in an onsite visit on a non-QA& review year. Mark NA if no remediation actions were required or another remediation action

was selected.


86c. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the Consolidated, P/FDS and CL waivers



# Question Type Guidance Source DocumentsSCO to comply with the requirements of the Operating Agreement.


selected.

QA&I Process Self Assessment Section



taken by the SCO.






87. The SCO self-assessment is completed every year of the QA&I cycle.

D The reviewer determines if the SCO completed their self-assessment on the ODP specified tool every year of the QA&I cycle. Mark YES if there is evidence that the SCO has completed a self-assessment

annually. Mark NO if there is no evidence indicating the self-assessment has been

completed annually.


87a. The SCO implemented the DCAP. R The SCO implemented the DCAP activities. Mark YES if the SCO implemented the DCAP. Mark NA if no remediation actions were required or another remediation action

was selected.


87b. Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the SCO to comply with the requirements of the Operating Agreement.


selected.



The reviewer chooses the appropriate time frame from the drop down.




# Question Type Guidance Source Documents Mark NA if no remediation action was necessary, or if no remediation action was

taken by the SCO.87d. Remediation action outstanding -





