EASTPOINTE
SERVICE ASSESSMENT TOOL
Provider Agency: _______________ Type of Review: ____________ Service Reviewed:_____________________ Date:___________________
Time Period of Review: __________________ Name of Reviewers:_____________________________________________________
SECTION I – QUALITY MANAGEMENT
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
1. Provider agency follows its P/P dealing with Quality Assurance and Quality
Improvement and has a written plan with evidence of implementation.
Evidence: QM plan, interview with provider management and staff, evidence of
improvements due to QI feedback, ect.
2. Provider agency submits critical incident reports, client rights tracking
form, and grievances as indicated in service contract.
Evidence: Review of data base, reports, and interview with QI Department
COMMENTS FOR SECTION I
SECTION II – PERSONNEL AND STAFF COMPETENCIES
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
3. Providers demonstrate knowledge, skills, and abilities required by
population served by qualified professionals and paraprofessionals.
Evidence: Review of staffing and training records
4. Provider agency follows its P/P regarding Healthcare registry, driver’s
license, and criminal background checks.
Evidence: Review of Personnel Files including dates for license, criminal
background checks, and copies of healthcare registry.
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
5. For Medicaid services, staff meets standards for services provided and are
appropriately privileged/qualified.
Evidence: Review of personnel/staff records and Area Authority database.
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6. Staff receives supervision as required per applicable guidelines.
Evidence: Review of personnel records, supervision plans, and supervision
notes/logs.
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
7. Staff training follows agency’s P/P in the areas of Prevention, Restraint,
Seclusion, and Isolation Timeout.
Evidence: Review of personnel records. Staff is trained within required time
frame for services provided as defined in P/P.
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COMMENTS FOR SECTION II
REVISED 3/25/04
SECTION III - ASSESSMENT AND SERVICE PLAN
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
8. Provider agency participates in person centered planning for the
development of the service plan.
Evidence: Service Plan, Provider and Staff Interview. N/A
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9. Was the service plan current with the date of service rendered?
Evidence: Review of service records
N/A
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Outcome for Section:
REVISED 3/25/04
COMMENTS FOR SECTION III
SECTION IV – SERVICES AND SUPPORTS
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
10. Provider follows CAP-MR/DD requirements for back-up staff when
necessary.
N/A
Evidence: Family Interview
11. Provider agency adheres to ethical practice standards as addressed in their
P & P.
Evidence: Interview with family, consumer, and Area Authority staff.
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
12. Provider agency will not employ individuals who are legally responsible for
the care and support of the recipient of services as referenced in CFR
440.167 and CAP-MR/DD requirements. N/A
Evidence: Family Interview, Personnel Records, and Medical Records.
13. Is there communication between the Area Authority and Service Provider of
changes in the recipient’s situation (i.e. needs, service delivery) and needed
changes in the service plan? N/A
Evidence: Interview with Area Authority Staff and Provider Staff
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
14. Is there cooperation between the Area Authority and Service Provider when
additional information is needed?
N/A
Evidence: Interview with Area Authority Staff and Provider Staff
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15. Provider agency bills only for services contracted and authorized/ordered.
Evidence: Review of paid claims with CAP-MR/DD service orders and service N/A
authorization for non-CAP services.
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
16. Is the documentation written and signed by the person who delivered the
services?
N/A
Evidence: Review of service records
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17. Does the service note/log reflect the staff intervention?
Evidence: Review of service records N/A
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
18. Does the service note relate to client goals listed in the service plan?
Evidence: Review of service records N/A
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19. Do the units billed match the duration of service?
Evidence: Review of service records N/A
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
20. Does the documentation substantiate the duration of service?
Evidence: Review of service records, Service Documentation Review Sheet, Peer N/A
Review
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21. Provider maintains a current license for population served and each facility
subject to licensure.
N/A
Evidence: Review of Licensure
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REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
COMMENTS FOR SECTION IV
SECTION V - MEDICATIONS
22. A physician or other practitioner licensed to prescribe dispenses
medications only on written order.
Evidence: Review of medication orders, medication dispensing log
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
23. Self-administered medications only when authorized in writing by the
individuals physician,
Evidence: Review of medication logs and medication dispensing log
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24. Medications administered only by licensed persons or by properly trained
unlicensed persons.
Evidence: Review of staff qualifications, training, and MAR
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
25. Current MAR including consumer’s name, name, strength and quantity of
drug, instructions for administering drug, date and time drug is to be
administered, and name and initials of person administering drug.
Evidence: Review of MAR
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COMMENTS FOR SECTION V
REVISED 3/25/04
SECTION VI – CLIENT RIGHTS
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
26. Provider agency reports the need for protective services of a child or
disabled adult as indicated in Contract for Services.
Evidence: Review of critical incident reports and interview with Area Authority
staff and provider staff.
27. Each individual & legally responsible person is informed of rights upon
admission or entry to service in a manner consistent with the person’s level
of comprehension and given a written summary of rights.
Evidence: Review of consent, authorization, & other rights forms with signature,
interview with consumer & family
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
28. Provider agency follows P/P for client rights meetings.
Evidence: Interview with Client rights Coordinator and minutes of provider’s
meetings
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29. Provider adheres to the P/P that addresses disbursement and use of client’s
personal funds.
Evidence: Interview of Consumers/family/guardian/provider staff and review of
financial records.
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
30. Atmosphere conducive to sleep and consumer has areas for personal
privacy.
Evidence: Observation, interviews with consumers & family, review of
complaints
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31. Individual has rights to decorate their own personal space.
Evidence: Observation, interview with consumer & family
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REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
32. Individuals right to dignity, privacy and humane care for personal health,
hygiene, and grooming, including bathtubs and showers that ensure privacy
and handicap facilities if needed.
Evidence: Observation, interviews with consumers & family, review of
complaints
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33. Protection of individuals’ personal clothing and possessions from theft,
damage, destruction, loss & misplacement.
Evidence: Inventory forms, observation of personal space, interview with
consumer & family
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Outcome for Section:
REVISED 3/25/04
Criteria P/P Met Not N/A Comments
Met **See also back of Sheet
34. Individuals provided with nutritious meals.
Evidence: Menus, adherence to menus &options, consumer interview to include
satisfaction with quantity & quality, food stock, review of complaints
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35. Provider agency has meetings with individuals and staff to determine quality
of care as required in 10A NCAC 27D.0302.
Evidence: Consumer Interview and review of minutes
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Outcome for Section:
REVISED 3/25/04
COMMENTS FOR SECTION VI
Date of Next QI Review:_____________________
Other Comments: _______________________________________________
FOR QI USE ONLY:
Date Plan Submitted to Provider: ________________
Date Plan of Correction due to Area Authority: _________
REVISED 3/25/04
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