Day Program Monitoring Tool (DDD) by gyv12087

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									                                        Day Program Monitoring Tool

                                               Feb-08
Agency:
Program Site(s):
Date(s) of Review:
DDD Monitor:
Level of Service:
Vacancies:
# Respites:
# of Staff:
Accreditation Agency (If Applicable):                                 Yes   No   NA
DVRS Vendorship:                                                      Yes   No   NA
Approved Program Description:                                         Yes   No   NA
Current & Approved Annex A:                                           Yes   No   NA
Approved Behavior Support Manual or MOU (If Applicable):              Yes   No   NA
Approved Restraint P&P (If Applicable):                               Yes   No   NA
Approved Life Threatening Emergencies Policy & Procedure:             Yes   No   NA


Weight        C= Critical
              S= Significant
              M= Moderate
              D= Data purposes only
                                                                                      Day Program Monitoring Tool
                                                                                       Individual Record Review
                                                                                                DRAFT

1    Individual Record Review : (Please list individuals initials: ________________________)                    Standard         Yes        No         N/A      Domain   Weight   Comments
2    Date of admission into program (found on notification of movement form):                                   Date:
3    Is the individual record:
4     Readily accessible (maintained at the day program)                                                         27.1:1         Yes        No         N/A       PA        s
5     Legibly marked with the individual’s name or unique identifier                                             27.1:2         Yes        No         N/A       PA        s
6     Maintained in compliance with relevant Division Circulars related to confidentiality and privacy            27.2          Yes        No         N/A       PA        s
7    General Admission
     The Program Information Sheet is signed and maintained in the individual file? (Applies to admissions       17A.3:3
 8   after 2001 only)                                                                                                            Yes        No         N/A       PA        m
     Did the service provider complete a Notification of Movement Form (Applies to transfers that occurred        17A.6
 9   after 2001)?                                                                                                                Yes        No         N/A       PA        m
10   Does the Program Information Sheet indicate that a pre-admission interview was held?                        17A.3:3         Yes        No         N/A       PA        m
11   General Information
12   Does each individual’s day service record include the following:
13    Documentation of referral to Division of Vocational Rehabilitation (DVRS) or non-referral to DVRS          27.9:3         Yes        No         N/A       PCP       m
14    Guardianship documentation                                                                                 27.9:4         Yes        No         N/A       PCP       m
15    Completed Emergency Card which is:                                                                         27.9:5         Yes        No         N/A       PCP       m
         sSigned by the individual or his/her home representative with current information (cross reference)    27.9:5a/b
16                                                                                                                               Yes        No         N/A       PCP       s
17 Emergency Consent for Treatment (Revised upon change of guardianship status)                                  27.9:6a        Yes        No         N/A       PCP       m
   Transportation Sign-Off Form (current w/in 5 years) *New Form effective 1/2008- when 5 year update            27.9:7
18 takes place)                                                                                                                  Yes        No         N/A       PCP       m
   Initial 30 day observation and assessment (for individuals who have been admitted with in last year)          27.9:11
19                                                                                                                               Yes        No         N/A       PCP       m
20 Current Adaptive Behavior Summary/ Uniform Assessment                                                         27.9:13        Yes        No         N/A       PCP       m
21 Service Plan
                                                                                                                 Residential                       Support
22 Please indicate the Service Plan Coordinator                                                                   Provider     DDD CM Day Program Coordinator
23 Is a current IHP/Service Plan maintained within the Individual Record?                                         27.9:12        Yes        No         N/A       PCP       s
   Is a current Self Care Assessment maintained within the Individual Record? (Annual certification)               23.1
   If no, is there evidence that the agency tried to obtain the SP? (Applies only when DP is not SP
   coordinator)                                                                                                                  Yes        No         N/A       PCP       d
26 Was the Service Plan Meeting completed within one year?                                                         23.2          Yes        No         N/A       PCP       s
   Did the service provider complete a vocational assessment/profile if the individual expressed and interest
27 in seeking employment?                                                                                          23.4          Yes        No         N/A       PCP       m
28 Were a minimum of three objectives related to day services established?                                         23.3          Yes        No         N/A       PCP       s
29 Daily Training Record
30 Are Division-approved Daily Training Record (DTR) Forms in use by the day service provider?                     24.1          Yes        No         N/A       PCP       m
31 Does the service provider maintain DTR's for the current year and two years prior?                             27.9:14        Yes        No         N/A       PCP       m


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                                                                                     Day Program Monitoring Tool
                                                                                      Individual Record Review
                                                                                               DRAFT
32   Does the DTR form contain at minimum:
33   Individual’s first and last name                                                                        24.2:2a       Yes   No   N/A   PCP   d
34   Current month and year                                                                                  24.2:2b       Yes   No   N/A   PCP   d
35   Name of day service                                                                                     24.2:2c       Yes   No   N/A   PCP   d
36   Day service objectives as stated in the current IHP                                                     24.2:2d       Yes   No   N/A   PCP   m
37   Daily entry for each objective which documents:                                                          24.2:2e       Yes   No   N/A   PCP   m
38   the level of assistance needed to meet the objective                                                   24.2:2e-i      Yes   No   N/A   PCP   m
39   staff initial indicating that the IHP objective was addressed on that day                              24.2:2e-ii     Yes   No   N/A   PCP   s
40   Service Plan Goal(s) Modifications
     When applicable was the Service Plan modified due to the achievemant or lack of achievement of goals or
41   objectives?                                                                                              23.1:4        Yes   No   N/A   PCP   s
42   Health/Medical Information
43   Did the individual file contain the following:
44   Medication Administration Records (MAR)                                                                 27.9:9        Yes   No   N/A   PCC   m
45    Prescriptions (should be cross referenced with the MAR)                                                27.9:16       Yes   No   N/A   PCC   m
46   Seizure Log, where indicated including documentation of seizure activity                                27.9:10       Yes   No   N/A   PCC   m
     Did each individual file reviewed contain a current annual copy of the mandatory physical examination,   27.9:8
47   documented on the Medical Form for Adults?                                                                             Yes   No   N/A   PCC   s
     Did the examining physician sign, date and document the results of the examination of the medical form?  19.2:1
48                                                                                                                          Yes   No   N/A   PCC   m
     Are medical restrictions or special instructions documented on the Medical Form for Adults by physician       19.3
49   maintained:                                                                                                                             PCC   s
50    In the client record?                                                                                      19.3:1    Yes   No   N/A   PCC   s
51    In the Service Plan?                                                                                       19.3:2    Yes   No   N/A   PCC   s
52    On the Emergency Card (if applicable)                                                                      19.3:3    Yes   No   N/A   PCC   s
53   Are they being implemented?                                                                                   19.16    Yes   No   N/A   PCC   s
54   Are feeding evaluations are maintained in the individual record (if applicable)                              19.16:2   Yes   No   N/A   PCC   s
     If applicable, observe to see if the individual's special dietary and/or texture requirements are being       19.17
55   implemented by staff during lunchtime.                                                                                 Yes   No   N/A   PCC   s
     Was the date and result of the mantoux test recorded on the Medical Form for Adults? If no, is a Physician   19.5:1
56   Statement or Chest X-Ray maintained in the individual record?                                                          Yes   No   N/A   PCC   m
     Did each individual file reviewed contain documentation that a tetanus booster was current within ten (10)    19.7
57   years?                                                                                                                 Yes   No   N/A   PCC   m
58   Individuals who Self-Medicate (If Applicable)
59   Was a self-medication assessment conducted?                                                                  20D.1     Yes   No   N/A   PCP   s
       Were the results of the Self-medication assessment discussed by the IDT and documented in the             20D.1:1
60    individual’s Service Plan?                                                                                            Yes   No   N/A   PCP   s
61   Is the following information maintained in the individual’s record:
62    The name of the medication(s)                                                                              20D.3:1   Yes   No   N/A   PCP   s
63    Type of medication(s)                                                                                      20D.3:2   Yes   No   N/A   PCP   s


                                                                                                      3
                                                                                      Day Program Monitoring Tool
                                                                                       Individual Record Review
                                                                                                DRAFT
64  Dosage                                                                                                      20D.3:3    Yes   No   N/A   PCP   s
65  Frequency                                                                                                   20D.3:4    Yes   No   N/A   PCP   s
66  Date prescribed; and                                                                                        20D.3:5    Yes   No   N/A   PCP   s
67  Location of the medication                                                                                  20D.3:6    Yes   No   N/A   PCP   s
68 Is medication maintained safely?                                                                               20D.4     Yes   No   N/A   PCP   c
69 Emergency Administration of Prescription Medication (If Applicable)
   Written orders/protocols are current for individuals who have a history of life-threatening conditions that   20D.10
70 require the emergency administration of prescription medication.                                                         Yes   No   N/A   PCP   c
71 Behavior Management (If applicable)

72 Is a current & approved Behavior Support Plan w/goals incorporated into the Individuals Service Plan?          22.1      Yes   No   N/A   PCP   s
   Is there evidence that all staff responsible for implementation of the Behavior Support Plan have received
73 training in the plans implentation?                                                                            22.1      Yes   No   N/A   PS    c
74 Is the data collection being completed according to the Behavior Support Plan?                                 22.1      Yes   No   N/A   PS    m
75 Does the plan include provisions for teaching positively reinforcing adaptive behavior?                        22.1      Yes   No   N/A   PS    c
   Are necessary approvals documented in the client record? (Level 1 & 2= IDT approval; Level- 3 = BMC,
76 HRC & RA/CEO approvals)                                                                                        22.1      Yes   No   N/A   PS    c


77 Is there evidence of ongoing reviews by the IDT, or for Level 3 plans, the Behavior Support Committee?         22.1      Yes   No   N/A   PS    s
78 Human Rights
   Have individuals receiving services been informed of their rights upon entering the program? (Admissions       14.2:1
79 after 1/2008)                                                                                                            Yes   No   N/A   PR    s
   Is there signed and dated documentation (by individual and provider represenative) that the individual         14.2:3
80 was provided an an explanation and copy of the Division’s Rights document?                                               Yes   No   N/A   PR    m
   Is a copy of written acknowledgement that the above has been reviewed annually signed and dated by the         14.3:1
81 individual and the provider representative and maintained in the individual file?                                        Yes   No   N/A   PR    m
82 Volunteer Opportunities (If Applicable)
    Documentation of an individual’s participation in volunteer opportunities, if unsupervised, which
83 includes:
84     sName, address, and phone number of volunteer site;                                                       27.9:23a   Yes   No   N/A   PCP   m
85 sContact person at the volunteer site;                                                                        27.9:23b   Yes   No   N/A   PCP   m
86     sVolunteer job description;                                                                               27.9:23c   Yes   No   N/A   PCP   m
87     sStart date and end dat e if applicable                                                                   27.9:23d   Yes   No   N/A   PCP   m
88     sScheduled hours                                                                                          27.9:23e   Yes   No   N/A   PCP   m




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                                                                                    Day Program Monitoring Tool
                                                                                        Medication Review
                                                                                              DRAFT

 1   Medication Records Review ( Minimum 10% review)                                                   Standard   Yes   No   N/A   Domain   Weight   Comments
 2   Prescription Medication
 3   Is a copy of the prescription on record stating:                                                    20A.1
 4    The individual’s full name                                                                       20A.1:1   Yes   No   N/A    PS        c
 5    Date of prescription                                                                             20A.1:2   Yes   No   N/A    PS        c
 6    Name of the medication                                                                           20A.1:3   Yes   No   N/A    PS        c
 7    Dosage,                                                                                          20A.1:4   Yes   No   N/A    PS        c
 8    Frequency                                                                                        20A.1:5   Yes   No   N/A    PS        c
 9    The word “copy” written or stamped on it                                                         20A.1:6   Yes   No   N/A    PS        m
     Is a Medication Administration Record (MAR) maintained for each individual receiving prescription   20A.3
10   medication?                                                                                                  Yes   No   N/A    PS        c
     Did service provider transcribe all information from the pharmacy label onto the Medication        20A.3:1
11   Administration Record (MAR)?                                                                                 Yes   No   N/A    PS        c
     Does the information on the pharmacy label match the information on the prescription and the         20.1
12   MAR?                                                                                                         yes   No   N/A    PS        c
13   Is there an adequate supply of medication to ensure no interuption in medication schedule?          20A.4    Yes   No   N/A    PS        s
14   Are medication changes by the physician documented?                                                 20A.7    Yes   No   N/A    PS        s
15   Is there written confirmation of verbal orders from a physician?                                   20A.7:1   Yes   No   N/A    PS        s
16   PRN (as needed) Prescription Medication
     Are PRN prescription medications authorized by a physician? Does the authorization clearly state:   20B.1
17                                                                                                                Yes   No   N/A    PS        c
18 The individual’s full name                                                                          20B.1:1   Yes   No   N/A    PS        c
19 Date                                                                                                20B.1:2   Yes   No   N/A    PS        c
20 Name of medication                                                                                  20B.1:3   Yes   No   N/A    PS        c
21 Dosage                                                                                              20B.1:4   Yes   No   N/A    PS        c
22 Interval between dosages                                                                            20B.1:5   Yes   No   N/A    PS        c
23 Maximum amount to be given during a 24-hour period                                                  20B.1:6   Yes   No   N/A    PS        c
24 Stop date (if applicable)                                                                           20B.1:7   Yes   No   N/A    PS        s
25 Under what conditions the PRN medication shall be administered                                      20B.1:8   Yes   No   N/A    PS        c
26 Are all PRN prescription medications which are administered in adult day services:
27 Documented on the individual's current MAR including the time of administration                     20B.2:2   Yes   No   N/A    PS        c
28 Does the service provider communicate the following with the caregiver:                              20B.3                       PS        c
29 To determine the time the previous PRN medication was given                                         20B.3:1   Yes   No   N/A    PS        c
30 To convey the time the PRN is/was given by the day service provider                                 20B.3:2   Yes   No   N/A    PS        c
33 PRN Over the Counter (OTC) Medication
   Are OTC Medications adminstered at the day program?                                                            Yes   No   N/A    PS        s
35 Are OTC Medications current (Look at expiration date)?                                               20E.2     Yes   No   N/A    PS        s
36 Do all OTC forms signed by the physician specify:                                                    20C.1
37 The type of medication administered                                                                 20C.1:1   Yes   No   N/A    PS        s


                                                                                                    5
                                                                                     Day Program Monitoring Tool
                                                                                         Medication Review
                                                                                               DRAFT
38    Dosage                                                                                               20C.1:2    Yes   No   N/A   PS   c
39    Frequency                                                                                            20C.1:3    Yes   No   N/A   PS   c
40    The maximum amount to be given in a 24 hour period                                                   20C.1:4    Yes   No   N/A   PS   c
41   Is the OTC form updated annually by the physician?                                                      20C.2     Yes   No   N/A   PS   s
     Is the administration of OTC medications documented on an MAR separate from the one utilized            20C.3
42   for prescription medication?                                                                                      Yes   No   N/A   PS   m
43   Does the service provider document the following communication to the caregiver:                        20C.4
44    To determine the time the previous PRN medication was given                                          20C.4:1    Yes   No   N/A   PS   c
45    To convey the time the PRN is/was given by the day service provider                                  20C.4:2    Yes   No   N/A   PS   c
48   Medication Storage
     Are all prescription medications stored in the original container issued by the pharmacy and are        20E.1
49   properly labeled?                                                                                                 Yes   No   N/A   PS   c
50   Are Over the Counter medications stored in the original containers (label kept in tact)?                20E.2     Yes   No   N/A   PS   c
51   Are Over the Counter medications stored separately from prescription medications in a locked            20E.8     Yes   No   N/A   PS   c
     Are prescription medications and non-prescription medications kept and locked in a storage area         20E.3
52   of adequate size?                                                                                                 Yes   No   N/A   PS   s
     Is the medication storage area accessible to only those individuals designated by the service           20E.4
53   provider?                                                                                                         Yes   No   N/A   PS   s
54   Does designated staff have a key to permit access to all medications at all times?                     20E.4:1    Yes   No   N/A   PS   c
55   Are prescribed medications separated and compartmentalized by individual within the medication          20E.5     Yes   No   N/A   PS   c
56   Are refrigerated medications stored in a locked box in the refrigerator, or in a separate locked        20E.6     Yes   No   N/A   PS   c
57   Are oral medications separated from other medications?                                                  20E.7     Yes   No   N/A   PS   s
58   Medication storage off-site
59   Are all medications stored in a locked box/container?                                                  20E.9:1    Yes   No   N/A   PS   s
     Is each person’s prescribed medication separated and compartmentalized within a locked                 20E.9:2
60   box/container?                                                                                                    Yes   No   N/A   PS   s
61   Are special storage arrangements made for medication requiring temperature control?                    20E.9:3    Yes   No   N/A   PS   c
     Does the service provider ensure that all medication to be administered off-site is placed in a        20E.10
62   sealed container labeled with the following:
63    Individual’s name                                                                                    20E.10:1   Yes   No   N/A   PS   c
64    Name of medication                                                                                   20E.10:2   Yes   No   N/A   PS   c
65    Dosage                                                                                               20E.10:3   Yes   No   N/A   PS   c
66    Frequency                                                                                            20E.10:4   Yes   No   N/A   PS   c
67    Time of administration, and                                                                          20E.10:5   Yes   No   N/A   PS   c
68    Method of administration                                                                             20E.10:6   Yes   No   N/A   PS   c




                                                                                                        6
                                                                                      Day Program Monitoring Tool
                                                                                      Day Program Facility Review
                                                                                                DRAFT
 1   Day Program Facility Review                                                                                 Standard    Yes   No   N/A   Domain   Weight   Comments
 2   Transportation review
 3   Agency Vehicles (10% of agency vehicles)
 4   Does the agency have a preventative maintenance system?                                                      12A.13     Yes   No   N/A    PS        s
 5   Are monthly vehicle safety reviews conducted ?                                                               12A.14     Yes   No   N/A    PS        s
 6   Are vehicles used to transport service recipients equipped with the following:
 7    10:BC dry chemical fire extinguisher                                                                      12A.15:1    Yes   No   N/A    PS        s
 8    First Aid kit to include: (To be collapsed into one data set)                                             12A.15:2    Yes   No   N/A    PS        s
 9       sAntiseptic                                                                                             12A.15:2a   Yes   No   N/A    PS        m
10       sRolled gauze bandages                                                                                  12A.15:2b   Yes   No   N/A    PS        m
11       sSterile gauze bandages                                                                                 12A.15:2c   Yes   No   N/A    PS        m
12       sAdhesive paper or ribbon tape                                                                          12A.15:2d   Yes   No   N/A    PS        m
13       sScissors                                                                                               12A.15:2e   Yes   No   N/A    PS        m
14       sAdhesive bandages (i.e. Band-Aids)                                                                     12A.15:2f   Yes   No   N/A    PS        m
15    At least three portable red reflector warning devices                                                     12A.15:3    Yes   No   N/A    PS        s
16    Spare tire and jack                                                                                       12A.15:4    Yes   No   N/A    PS        s
     Are copies of the emergency/accident procedures and any accompanying forms be kept in each                   12A.3
17   vehicle?                                                                                                                Yes   No   N/A    PS        c
18   Are current/valid copies of liability insurance maintained in each vehicle?                                  12A.5      Yes   No   N/A    PS        c
19   Is a valid registration maintained in each vehicle?                                                          12A.6      Yes   No   N/A    PS        c
20   Are vehicles transporting service recipients in wheelchairs:                                                 12A.11     Yes   No   N/A    PS        c
21    Wheelchair accessible by design                                                                           12A.11:1    Yes   No   N/A    PS        c
22    Equipped with lifts and wheelchair securing devices                                                       12A.11:2    Yes   No   N/A    PS        c
23   Physical Plant Review
     Is there a minimum of two exits unlocked from the inside during program hours with doors that open out        11.3
24   with ease?                                                                                                              Yes   No   N/A    PS        c
25   If program has an occupancy of more than 50 people, is panic hardware installed?                             11.3:1     Yes   No   N/A    PS        D
26   Are Exit signs posted over all exits?                                                                        11.3:2     Yes   No   N/A    PS        c
     Does the site have sufficient ventilation in all areas and, if applicable, be in compliance with Appendix     11.5
27   #2?                                                                                                                     Yes   No   N/A    PS        D
28   Does the site have adequate lighting?                                                                         11.6      Yes   No   N/A    PS        m
29   Does the site have a lunch area that is separate from the work area?                                          11.7      Yes   No   N/A    PS        m
     Is a copy of the Certificate of Continued Occupancy (CCO) or Certificate of Occupancy (CO) or other           11.8
30   documentation issued by local authority available?                                                                      Yes   No   N/A    PCC       s
31   Is the facility maintained in a clean, safe condition, including the internal and external structure?         11.1      Yes   No   N/A    PS        s
32   Are aisles, hallways, stairways, and main routes of egress clear of obstruction and stored material?         11.10:1    Yes   No   N/A    PS        c
33   Are floors and stairs free and clear of obstruction and slip resistant?                                      11.10:2    Yes   No   N/A    PS        c
34   Are adequate sanitary supplies available including soap, paper towels, toilet tissue?                        11.10:4    Yes   No   N/A    PS        c
35   Are appropriate local or county Department of Health certificates maintained where appropriate?              11.11:1    Yes   No   N/A    PCC       s


                                                                                                        7
                                                                                           Day Program Monitoring Tool
                                                                                           Day Program Facility Review
                                                                                                         DRAFT
     If the adult day service is located in a facility housing other aspects of service provision of the agency
36   during operational hours is there a;
37    Separate designated space                                                                                11.12:1   Yes   No   N/A   PCC   m
38    Separate designated personnel                                                                            11.12:2   Yes   No   N/A   PCC   m
39   Emergency Plan
     Is an evacuation diagram specific to the facility/program posted conspicuously throughout the facility?     13A.2
40                                                                                                                        Yes   No   N/A   PS    s
41   Does the evacuation diagram include the following:
42   Evacuation route and/or nearest exit                                                                    13A.2:1     Yes   No   N/A   PS    m
43   Location of all exits                                                                                   13A.2:2     Yes   No   N/A   PS    m
44   Location of alarm boxes (pull station)                                                                  13A.2:3     Yes   No   N/A   PS    m
45   Location of fire extinguishers                                                                          13A.2:4     Yes   No   N/A   PS    m
46   Are emergency numbers posted by each telephone?                                                           13A.3      Yes   No   N/A   PS    c
47   Are emergency cards available in a central location so that they are portable in emergencies?             13A.4      Yes   No   N/A   PS    c
48   Fire Safety Review
49   Are fire drills:
50   Conducted monthly with individuals served present                                                       13B.1:1     Yes   No   N/A   PS    s
51   Varied as to accessible exits                                                                           13B.1:2     Yes   No   N/A   PS    s
52   Does the documentation of Fire Drills include the following:
53   Date                                                                                                   13B.1:3a     Yes   No   N/A   PS    m
54   Time of drill                                                                                          13B.1:3b     Yes   No   N/A   PS    m
55   Length of time to evacuate                                                                             13B.1:3c     Yes   No   N/A   PS    m
56   Number of individuals served participating                                                             13B.1:3d     Yes   No   N/A   PS    m
57   Name(s) of participating staff                                                                         13B.1:3e     Yes   No   N/A   PS    m
58   Problems noted                                                                                         13B.1:3f     Yes   No   N/A   PS    m
59   Signature of person in charge                                                                          13B.1:3g     Yes   No   N/A   PS    m
60   Are fire extinguishers serviced annually?                                                                 13B.2      Yes   No   N/A   PS    c
61   Are fire extinguishers examined quarterly with documentation that they are adequately charged?            13B.3      Yes   No   N/A   PS    s
     Are non-wired (battery-operated) smoke detectors examined quarterly with documentation that they are      13B.4
62   operable?                                                                                                            Yes   No   N/A   PS    s
63   Does the site have a fire alarm system appropriate to the population served?                              11.4       Yes   No   N/A   PS    D
64   Are any of the following safety inspections conducted and records maintained on file:                     13B.5      Yes   No   N/A   PS    m
65      Insurance (Please indicate date)                                                                      13B.5      Yes   No   N/A   PCC   d
66      Fire (Please indicate date)                                                                           13B.5      Yes   No   N/A   PCC   d
67      DCA (Please indicate date)                                                                            13B.5      Yes   No   N/A   PCC   d
68   Rules Review
69   Does the program have program rules? If so, please answer the following:                                  15.1       Yes   No   N/A
70   Are the rules commensurate with the individuals’ abilities and rights?                                    15.2       Yes   No   N/A   PR    s
71   Are the individuals affected by such rules able to suggest the implementation of new rules ?              15.4       Yes   No   N/A   PR    m
72   Are the individuals affected by such rules consulted whenever a revision is considered?                   15.5       Yes   No   N/A   PR    m

                                                                                                    8
                                                                                            Day Program Monitoring Tool
                                                                                             Day Program Facility Review
                                                                                                           DRAFT
      Do the rules include provisions to ensure that an individual exercising his/her rights does so in such a           15.6
 73   way as to not infringe upon the rights of, or endanger, others?                                                             Yes   No   N/A   PR    s
 74   Activity Schedule Review
      Are activities planned at least one week in advance and documented on an activity schedule which                   16.5
 75   contains information including, but not limited to: (including standardized schedules)                                      Yes   No   N/A   PCP   m
 76    Date and time of activity or period of time in which the schedule is in effect .                                16.5:1    Yes   No   N/A   PCP   m
 77    Activity (location is specified if activity is community based and cost is specified if applicable)            16.5:2/3   Yes   No   N/A   PCP   m
 78    Individuals who are scheduled to participate                                                                    16.5:4    Yes   No   N/A   PCP   m
 79    Alternate activity, in the event the scheduled community based activity is canceled                             16.5:5    Yes   No   N/A   PCP   m
 80    The staff person responsible if activity is community based                                                     16.5:6    Yes   No   N/A   PCP   m
      Does the activity schedule reflect activities related to at least one of the following: Vocational, Life Skills, 16.4:1
      Personal Development, Community Participation                                                                               yes   No   N/A   PCP   m
      Was the Activity schedule being implemented at the time of the review?                                             16.4     Yes   No   N/A   PCP   m
 83   Required Staff/Client Ratios Review
      Is the day service program in compliance with the following staff/client ratios (Conduct observation)?           16.10:1,
                                                                                                                       16.10:2,
      (ie. (1) Adult Day Services- the total program ratio is no more than six individuals served to one direct
                                                                                                                       16.10:3
      service staff (2) Adult Day Services, Special Needs- the total program ratio is no more than three
      individuals served to one direct service staff (3) Adult Day Services, Crew Labor- the total program ratio
 84   is no more than five individuals served to one direct service staff                                                         Yes   No   N/A   PS    c
      Is a supervisor available on site or an on site “in charge” person designated during hours of operation?          16.11
85                                                                                                                                Yes   No   N/A   PS    c
86    Health/Medical Review
87    Are liquids available and accessible for individuals throughout the day to prevent dehydration?              19.19          Yes   No   N/A   PS    c
88    Does the day program site have a first aid kit which includes the following: (To be collapsed into one       19.21
89    domain)
      Antiseptic                                                                                                 19.21:1         Yes   No   N/A   PS    m
90    Rolled gauze bandages                                                                                      19.21:2         Yes   No   N/A   PS    m
91    Sterile gauze bandages                                                                                     19.21:3         Yes   No   N/A   PS    m
92    Adhesive paper or ribbon tape                                                                              19.21:4         Yes   No   N/A   PS    m
93    Scissors                                                                                                   19.21:5         Yes   No   N/A   PS    m
94    Adhesive bandage (Band-Aids)                                                                               19.21:6         Yes   No   N/A   PS    m
95    Standard type or digital thermometer                                                                       19.21:7         Yes   No   N/A   PS    m
96    Compensation Review
      Does the service provider have a current State or Federal Certificate to Pay Wages Below the               25.2:3a/b
 97   Minimum?                                                                                                                    Yes   No   N/A   PCC   m
 98   Financial Review
      Where the service provider holds an individual's funds, does the service provider maintain a record of all    26.1
 99   purchases made with the personal funds of service recipients that have been entrusted to them? (does                        Yes   No   N/A   PS    s
      Does the service provider maintain financial records for the current year and two years prior? (Effective   26.1:1
100   1/2008)                                                                                                                     Yes   No   N/A   PS    m
101   Does the service provider maintain receipts for all purchases over $5.00?                                     26.2          Yes   No   N/A   PS    m


                                                                                                           9
                                                                                    Day Program Monitoring Tool
                                                                                    Day Program Facility Review
                                                                                              DRAFT
102   Other Required Records Review
103   Is attendance recorded daily?                                                                        28.1:1   Yes   No   N/A   PCC   s
104   Does the Service provider maintain completed Adult Services Monthly Reports on site?                 28.1:2   Yes   No   N/A   PCC   m
105   Is the Policy & Procedure Manual available on site for the Day Program staff to review?               7.5     Yes   No   N/A   PCC   m
106   Unusual Incidents Review
      Are Unusual Incident Reports and Follow Up reports maintained separate from the individual record?   21.2:1
107                                                                                                                 Yes   No   N/A   PCC   m




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Day Program Facility Review
          DRAFT




            11
                                                                                     Day Program Monitoring Tool
                                                                                    Employee Personnel File Review
                                                                                               DRAFT
 1   Employee Personnel File Review (Review 10% Sample)                                                           Standard         Yes   No   N/A   Domain   Weight   Comments
 2   Employee Initials:                                                                                           Date of Hire :
 3   Does the employee personnel file include the following:
 4   A signed application                                                                                          10.1.1         Yes   No   N/A    PCC       m
 5   Documentation of the employee’s qualifications                                                                10.1.2         Yes   No   N/A    PCC       m
 6   Documentation of licenses for professionally credentialed staff and consultants                               10.1.3         Yes   No   N/A    PCC       s
 7   Receipt for fingerprinting upon hire (Employee's hired after 2002)                                            10.1.4         Yes   No   N/A    PCC       c
 8   Documentation that reference checks were completed                                                            10.1.5         Yes   No   N/A    PCC       m
 9   A signed and dated job description                                                                            10.1.6         Yes   No   N/A    PCC       m
     Written physician statement of medical clearance completed at time of hire (Employees hired before            10.1.7
10   1/2008=N/A)                                                                                                                   Yes   No   N/A    PCC       s
     Results of initial and annual Mantoux Skin Tests, chest x-ray and/or physician’s certification (Employees     10.1.8
11   hired before 1/2008=N/A)                                                                                                      Yes   No   N/A    PCC       s
12   NJ Pre Service Training Certificates (Core Training)
13      Current First Aid certification (3 year renewal)                                                           10.1.10        Yes   No   N/A    PCC       c
14      Current CPR certification (1 year renewal)                                                                 10.1.11        Yes   No   N/A    PCC       c
15      Overview                                                                                                    9.2:1         Yes   No   N/A    PCC       s
16      Abuse and neglect                                                                                           9.2:3         Yes   No   N/A    PCC       c
        Medication Training                                                                                         9.2:2         Yes   No   N/A    PCC       c
     Non Core Trainings
19   Documentation that the employee received an Orientation to aquaint them with the following topics:             10.1:12       Yes   No   N/A    PCC       m
20      The organization’s mission, philosophy, goals, services and practices                                      8.11:1         Yes   No   N/A    PCC       m
21      The prevention of abuse, neglect and exploitation                                                          8.11:2         Yes   No   N/A    PCC       m
22      Unusual Incident reporting and investigation procedures                                                    8.11:3         Yes   No   N/A    PCC       m
23      Emergency procedures as identified in the agency procedure manual to include at a minimum:                 8.11:4         Yes   No   N/A    PCC       m
24          Fire Evacuation                                                                                        8.11:4a        Yes   No   N/A    PCC       m
25          Use of Fire Extinguishers                                                                              8.11:4b        Yes   No   N/A    PCC       m
             “Responding to Life Threatening Emergencies” (Signed certification of training must be present)       8.11:4c
26                                                                                                                                 Yes   No   N/A    PCC       m
       An overview of Developmental Disabilities and any special needs of the individuals being served, for        8.11:5
27     example medical or behavioral problems requiring specific tailored training                                                 Yes   No   N/A    PCC       m
28     Personnel Policies of the Provider Agency                                                                   8.11:6         Yes   No   N/A    PCC       m
       Prevention of blood borne pathogens including the use of Universal Precautions as per DC #45                8.11:7
29     “HIV/AIDS”                                                                                                                  Yes   No   N/A    PCC       m
30     Rights of Individuals Served (Effective 1/2008)                                                             8.11:8         Yes   No   N/A    PCC       m
     Dated records of completion of specialized trainings including signatures of the trainer and trainee.           9.12
     (Compare to individual records for appropriateness of trainings, ie; specialized diets, wheelchair
31   accomodations etc.))                                                                                                          Yes   No   N/A    PCC       m
32   Annual review of Rights & Repsonsibilities (Effective 1/2008)                                                 9.13:1         Yes   No   N/A    PCC       m
33   Annual review of Emergency Procedures                                                                         9.13:2         Yes   No   N/A    PCC       m


                                                                                                      12
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                                                                                   Employee Personnel File Review
                                                                                              DRAFT
34 Annual review of Medication Policies & Procedures                                                              9.13:3    Yes   No   N/A   PCC   m
   Additional Documentation
36 Copies of current driver’s licenses for all employees who drive vehicles which transport service recipients.   10.1:16   Yes   No   N/A   PCC   c
    Documentation of employees driving record                                                                       8.5     Yes   No   N/A   PCC   c
38 Employee performance evaluation                                                                                 10.2     Yes   No   N/A   PCC   m
39 Volunteers (if applicable)
   Is there a written description of the duties of direct services volunteers?                                      10.4     Yes   No   N/A   PCC   m
   Is there documentation that direct service volunteers have received an orientation that include the following    10.5
41 policies and procedures:                                                                                                  Yes   No   N/A   PCC   m
42 Emergencies                                                                                                    10.6:1    Yes   No   N/A   PCC   m
43 Abuse, neglect, and exploitation                                                                               10.6:2    Yes   No   N/A   PCC   m




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                    DRAFT

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                      19
                                                                              Supported Employment Monitoring Tool
                                                                                            DRAFT

Supported Employment Review                                                                    Standard      Yes        No   N/A   Domain   Weight          Comments
Administrative Review
Is there an approved Program Description?                                                       IV.2.A       Yes        No   N/A    PCC       D      Collect prior to review
Is there an current and approved Annex A ?                                                      IV.3.A       Yes        No   N/A    PCC       D      Collect prior to review
Does the agency have current CARF or equivalent accreditation ?                                 IV.1.5       Yes        No   N/A    PCC       s      Collect prior to review
If yes, please indicate the length of accreditation (Provisional 1 year or 3 years )            DATA      Provisional   1     3     PCC       D      Collect prior to review
Is the agency a DVRS/ CBVI contracted SE or Time Limited Job Coach vendor ?                      III.2       Yes        No   N/A    PCC       D      Collect prior to review
Does the program have a Continuous Quality Improvement Plan maintained on file?                 IV.4.A       Yes        No   N/A    PCC       s
Does the program have an Outcome Management Report maintained on file?                          IV.4.B       Yes        No   N/A    PCC       s
Policy and Procedure Manual
Is the Policy and Procedure manual available for review by the Division?                        IV.1-A       Yes        No   N/A    PCC       s
Is there a Reporting Unusual Incidents Policy & Procedure?                                     IV.1.F-1      Yes        No   N/A    PCC       s
Does this policy and procedure include, at a minimum:
    Title                                                                                     IV:1.B-1      Yes        No   N/A    PCC       m
    Purpose                                                                                   IV:1.B-2      Yes        No   N/A    PCC       m
    The steps required to complete a task or action                                           IV:1.B-3      Yes        No   N/A    PCC       m
    Reporting and recording requirements                                                      IV:1.B-4      Yes        No   N/A    PCC       m
    Assignment of staff responsibilities                                                      IV:1.B-5      Yes        No   N/A    PCC       m
Is this policy & procedure in compliance with DC #14 "Reporting Unusual Incidents"?            IV.1.F-1      Yes        No   N/A    PCC       s
Is there a Complaint Investigations in Community Programs Policy & Procedure?                  IV.1.F-2      Yes        No   N/A    PCC       s
Does this policy and procedure include, at a minimum:
    Title                                                                                     IV:1.B-1      Yes        No   N/A    PCC       m
    Purpose                                                                                   IV:1.B-2      Yes        No   N/A    PCC       m
    The steps required to complete a task or action                                           IV:1.B-3      Yes        No   N/A    PCC       m
    Reporting and recording requirements                                                      IV:1.B-4      Yes        No   N/A    PCC       m
    Assignment of staff responsibilities                                                      IV:1.B-5      Yes        No   N/A    PCC       m
Is this policy & procedure in compliance with DC #15 " Complaint Investigations in Community
Programs"?                                                                                     IV.1.F-2      Yes        No   N/A    PCC       s
Is there an abuse, neglect and exploitation Policy & Procedure?                                IV.1.F-3      Yes        No   N/A    PCC       s
Does this policy and procedure include, at a minimum:
    Title                                                                                     IV:1.B-1      Yes        No   N/A    PCC       m
    Purpose                                                                                   IV:1.B-2      Yes        No   N/A    PCC       m
    The steps required to complete a task or action                                           IV:1.B-3      Yes        No   N/A    PCC       m
    Reporting and recording requirements                                                      IV:1.B-4      Yes        No   N/A    PCC       m
    Assignment of staff responsibilities                                                      IV:1.B-5      Yes        No   N/A    PCC       m
Is there a Complaint/Grievance Policy & Procedure                                              IV.1.F-4      Yes        No   N/A    PCC       s
Does this policy and procedure include, at a minimum:
    Title                                                                                     IV:1.B-1      Yes        No   N/A    PCC       m
    Purpose                                                                                   IV:1.B-2      Yes        No   N/A    PCC       m


                                                                                               20
                                                                        Supported Employment Monitoring Tool
                                                                                      DRAFT

    The steps required to complete a task or action                                     IV:1.B-3   Yes        No   N/A   PCC   m
    Reporting and recording requirements                                                IV:1.B-4   Yes        No   N/A   PCC   m
    Assignment of staff responsibilities                                                IV:1.B-5   Yes        No   N/A   PCC   m
Is there an approved Life Threatening Emergencies Policy & Procedure?                    IV.1.F-5   Yes        No   N/A   PCC   s   Collect prior to review
Is there a Personnel Policy & Procedure?                                                 IV.1.F-6   Yes        No   N/A   PCC   s




                                                                                        21
                                                                                 Supported Employment Monitoring Tool
                                                                                               DRAFT

Employee Personnel File Review (Review 10% Sample)                                                    Standard       Yes   No     N/A       Domain   Weight
Employee Initials:                                                                                 Date of Hire :
Does the employee personnel file include the following:
 A signed application                                                                                IV.2.5.A-1     Yes   No     N/A        PCC       m
 Documentation of the employee’s qualifications                                                      IV.2.5.A-3     Yes   No     N/A        PCC       m
 Documentation of licenses for professionally credentialed staff and consultants                     IV.2.5.A-3     Yes   No     N/A       PCC        m
 Receipt for fingerprinting on hire (Employee's hired after 2002?)                                   IV.2.5.A.4     Yes   No     N/A       PCC        c
 Copies of current driver’s licenses for all employees who drive vehicles which transport service   IV.2.5.A.16     Yes   No     N/A       PCC        c
 Documentation that reference checks were completed?                                                 IV.2.5.A-5     Yes   No     N/A       PCC        m
 A signed and dated job description                                                                  IV.2.5.A-6     Yes   No     N/A       PCC        m
 Written physician statement of medical clearance completed at time of hire (Employees hired         IV.2.5.A-7
 before 1/2008=N/A)                                                                                                  Yes   No     N/A        PCC       s
 Employee Performance Evaluation                                                                      IV.2.5.B      Yes   No     N/A        PCC       s
Staff Training
Did the employee complete the following trainings, w/in 120 days of hire, prior to
independently performing job duties: (If the employee is newly hired, please indicate if they
have been scheduled to attend the trainings)
 Overview of Developmental Disabilities                                                              IV.2.3.A-1                                              completed w/in 120 time
                                                                                                                     Yes   No   Scheduled   PCC        s      frame? Yes or No
Preventing Abuse and Neglect (certificate)                                                            IV.2.3.A-2                                             completed w/in 120 time
                                                                                                                     Yes   No   Scheduled   PCC        c      frame? Yes or No
First Aid Training (current certificate w/in 3 years)                                                 IV.2.3.A-3                                             completed w/in 120 time
                                                                                                                     Yes   No   Scheduled   PCC        c      frame? Yes or No
CPR training (current certificate w/in 1 year)                                                        IV.2.3.A-4                                             completed w/in 120 time
                                                                                                                     Yes   No   Scheduled   PCC        c      frame? Yes or No
Employment Specialist- Introduction (Elizabeth M. Boggs Center) OR                                                                                           completed w/in 120 time
Regional Rehabilitation Continuing Education Program (RRCEP) Orientation                               IV.2.3.A-5    Yes   No   Scheduled   PCC        s      frame? Yes or No
Employment Specialist- Advanced (Elizabeth M. Boggs Center) OR                                                                                                completed w/in 120 time
Regional Rehabilitation Continuing Education Program (RRCEP)- Job Coach 1                              IV.2.3.A-5    Yes   No   Scheduled   PCC        s      frame? Yes or No
                                                                                                                                                              completed w/in 120 time
Regional Rehabilitation Continuing Education Program (RRCEP)- Job Coach 2                              IV.2.3.A-5    Yes   No   Scheduled   PCC        s      frame? Yes or No
Life Threatening Emergencies                                                                           IV.2.3.B     Yes   No   Scheduled   PCC        m
Universal Precautions & Blood borne Pathogens Training                                                 IV.2.3.E     Yes   No   Scheduled   PCC        m
Unusual Incident Reporting and & Investigation Procedures                                              IV.2.3.F     Yes   No   Scheduled   PCC        m
Overview of Agency Mission, Policies & Procedures                                                      IV.2.3.G     Yes   No   Scheduled   PCC        m
Overview of the Service Plan                                                                           IV.2.3.H     Yes   No   Scheduled   PCC        m
Orientation to Supported Employment (Provided by Agency)                                                IV.2.3.I    Yes   No               PCC        m
Training Reviews
Annual Review of Rights & Responsibilities (Effective 1/2008)                                          IV.2.3.I-1   Yes   No     N/A       PCC        m
Annual Review of Emergency Procedures                                                                  IV.2.3.I-2   Yes   No     N/A       PCC        m


                                                                                                       22
                                                                           Supported Employment Monitoring Tool
                                                                                         DRAFT

Annual Review of Responding to Life Threatening Emergencies                                IV.2.3.A-5   Yes      No   N/A   PCC   c
CPR Recertification (Annual Renewal)                                                       IV.2.3.D     Yes      No   N/A   PCC   c
First Aid Recertification (3 Year Renewal)                                                 IV.2.3.D     Yes      No   N/A   PCC   c
Professional Development Trainings
Documentation of the completion of 1 Annual Professional Development Trainings (Does not
apply to new employees)                                                                       IV.2.4     Yes      No   N/A   PCC   D
Documentation of the completion of 2 Annual Professional Development Trainings (Does not
apply to new employees)                                                                       IV.2.4     Yes      No   N/A   PCC   D




                                                                                            23
                                                                                 Supported Employment Monitoring Tool
                                                                                               DRAFT

Individual Record Review (review only waiver eligible individuals, 10% sample)                           Initials:
Is the individual record:
 Readily accessible                                                                                     IV.4.1-C         Yes        No         N/A      PCP   m
 Legibly marked with the individual’s name or unique identifier                                        IV.4.1.G-1        Yes        No         N/A      PCP   m
 Maintained in compliance with relevant Division Circulars related to confidentiality and privacy       IV.4.1-B
                                                                                                                          Yes        No         N/A      PCP   s
Service Plan
                                                                                                       Residential                          Support
Please indicate the Service Plan Coordinator                                                            Provider        DDD CM Day Program Coordinator         D
Is a current copy of the individual's Service Plan maintained in the client record?                    IV.4.1.H.3.i       Yes        No         N/A      PCP   s
Is the Service Plan for the prior two years available for review?                                      IV.4.1.H.3.i       Yes        No         N/A      PCP   s
Is there evidence that the job coach or designated SE representative attended the annual service
plan meeting?                                                                                            IV.3.3-C         Yes        No         N/A      PCP   m
Does the service plan:
  Identify and address employment barriers?                                                            IV.3.3-A.2        Yes        No         N/A      PCP   m
 Document the supports which are to be provided by the supported employment agency                     IV.3.3-A-5        Yes        No         N/A      PCP   m
Intervention Plan & Service Log
Are copies of the individual’s current Intervention Plan and Service Log maintained in the              IV.4.2-A.4
individual’s file?                                                                                                        Yes        No         N/A      PCP   s
Does the Intervention Plan & Service Log match the Service Plan?                                         IV.3.3-D         Yes        No         N/A      PCP   s
Is each specific service provided to the individual or on behalf of the individual documented on the     IV.4.2-A
Intervention Plan and Service Log?                                                                                        Yes        No         N/A      PCP   s
 Is the log legible                                                                                    IV.4.2-A.2        Yes        No         N/A      PCP   m
 Is the log dated                                                                                      IV.4.2-A.3        Yes        No         N/A      PCP   m
Does the Intervention Plan & Service Log document include, at minimum, one face to face contact          IV.4.2-B
per month between job coach and the served individual, unless otherwise defined and agreed
upon and documented in the Service Plan by the IDT?                                                                       Yes        No         N/A      PCP   s
When applicable was the Intervention Plan and Service Log modified when a major change
occurred in relation to the :                                                                           IV.3.3-A-6        Yes        No         N/A      PCP   s
    sAchievement or lack of achievement of goals, objectives                                           IV.3.3-A-6.i       Yes        No         N/A      PCP   s
    sAvailability of services, programs or supports                                                    IV.3.3-A-6.ii      Yes        No         N/A      PCP   s
    sChanges in the individuals physical condition, cognitive functioning, needs or preferences        IV.3.3-A-6.iii     Yes        No         N/A      PCP   s
Direct Time & Billable Hours                                                                                                                                   s
Are Billable hours documented on the Intervention Plan and Service Log form?                              IV.3.6          Yes        No         N/A      PCC   s
Are Billable hours documented on the Supported Employment Monthly Data Report?                            IV.3.6          Yes        No         N/A      PCC   s
Do the hours on the Intervention Plan & Service Log match the hours stated on the Supported
Employment Monthly Report?                                                                              IV.5.3.B.1        Yes        No         N/A      PCC   s
Supported Employment Monthly Data Report
 Are SE Monthly Data Reports maintained on site for three years?                                       IV.4.3-B.4        Yes        No         N/A      PCC   m
Online Attendance

                                                                                                        24
                                                                             Supported Employment Monitoring Tool
                                                                                           DRAFT

Are copies of the monthly attendance sheet maintained on file?                                IV.4.4-A     Yes      No   N/A   PCC   m
Do the hours on the Intervention Plan & Service Log match the hours stated on the Supported
Employment Monthly Report and the Monthly Attendance Report?                                  IV.5.3.B.1   Yes      No   N/A   PCC   m




                                                                                              25
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                                                                                       Day Program Monitoring Tool
                                                                                          Administrative Review
                                                                                                 DRAFT
 1   ADMINISTRATIVE REVIEW (to be completed at Administration Office)                                    Standard    Yes   No   N/A   Domain   Weight   Comments
 2   Continuous Quality Improvement
 3   Does the program have a Continuous Quality Improvement Plan (CQI Plan) on file?                       6.1       Yes   No   N/A    SP        s
 4   Does the program have a Outcome Management Report on file?                                            6.2       Yes   No   N/A    SP        s
 5   Is there a Reporting Unusual Incidents Policy & Procedure?                                           7.6:1      Yes   No   N/A    PCC       s
 6   Does this policy and procedure include, at a minimum:
 7       Title                                                                                           7.6:1      Yes   No   N/A    PCC       m
 8       Purpose                                                                                         7.6:1      Yes   No   N/A    PCC       m
 9       The steps required to complete a task or action                                                 7.6:1      Yes   No   N/A    PCC       m
10       Reporting and recording requirements                                                            7.6:1      Yes   No   N/A    PCC       m
11       Assignment of staff responsibilities                                                            7.6:1      Yes   No   N/A    PCC       m
12   Is this policy & procedure in compliance with DC #14 "Reporting Unusual Incidents"?                  7.6:1      Yes   No   N/A    PCC       s
13   Is there a Complaint Investigations in Community Programs Policy & Procedure?                        7.6:2      Yes   No   N/A    PCC       s
14   Does this policy and procedure include, at a minimum:
15       Title                                                                                           7.6:2      Yes   No   N/A    PCC       m
16       Purpose                                                                                         7.6:2      Yes   No   N/A    PCC       m
17       The steps required to complete a task or action                                                 7.6:2      Yes   No   N/A    PCC       m
18       Reporting and recording requirements                                                            7.6:2      Yes   No   N/A    PCC       m
19       Assignment of staff responsibilities                                                            7.6:2      Yes   No   N/A    PCC       m
     Is this policy & procedure in compliance with DC #15 " Complaint Investigations in Community
20   Programs"?                                                                                           7.6:2      Yes   No   N/A    PCC       s
21   Is there an abuse, neglect and exploitation Policy & Procedure?                                      7.6:3      Yes   No   N/A    PCC       s
22   Does this policy and procedure include, at a minimum:
23       Title                                                                                           7.6:3      Yes   No   N/A    PCC       m
24       Purpose                                                                                         7.6:3      Yes   No   N/A    PCC       m
25       The steps required to complete a task or action                                                 7.6:3      Yes   No   N/A    PCC       m
26       Reporting and recording requirements                                                           7.6:3b      Yes   No   N/A    PCC       m
27       Assignment of staff responsibilities                                                            7.6:3      Yes   No   N/A    PCC       m
28   Is there a Complaint/Grievance Policy & Procedure                                                    7.6:4      Yes   No   N/A    PCC       s
29   Does this policy and procedure include, at a minimum:
30       Title                                                                                           7.6:4      Yes   No   N/A    PCC       m
31       Purpose                                                                                         7.6:4      Yes   No   N/A    PCC       m
32       The steps required to complete a task or action                                                 7.6:4      Yes   No   N/A    PCC       m
33       Reporting and recording requirements                                                            7.6:4      Yes   No   N/A    PCC       m
34       Assignment of staff responsibilities                                                            7.6:4      Yes   No   N/A    PCC       m
35   Is there an Emergency Plan Policy & Procedure?                                                       7.6:5      Yes   No   N/A    PCC       s
36   Does this policy and procedure include, at a minimum:
37       Title                                                                                           7.6:5      Yes   No   N/A    PCC       m
38       Purpose                                                                                         7.6:5      Yes   No   N/A    PCC       m


                                                                                                    32
                                                                                      Day Program Monitoring Tool
                                                                                         Administrative Review
                                                                                                DRAFT
39       The steps required to complete a task or action                                                7.6:5      Yes   No   N/A   PCC   m
40       Reporting and recording requirements                                                           7.6:5      Yes   No   N/A   PCC   m
41       Assignment of staff responsibilities                                                           7.6:5      Yes   No   N/A   PCC   m
     Is this policy and procedure in compliance with DC #14 "Reporting Unusual Incidents"?               7.6:5      Yes   No   N/A   PCC   m
43   Is this policy and procedure in compliance with DC #20-A "Life Threatening Emergencies"?            7.6:5      Yes   No   N/A   PCC   s
44   Is there an approved Life Threatening Emergencies Policy & Procedure?                               7.6:6      Yes   No   N/A   PCC   s
45   Does this policy and procedure include, at a minimum:
46       Title                                                                                          7.6:6      Yes   No   N/A   PCC   m
47       Purpose                                                                                        7.6:6      Yes   No   N/A   PCC   m
48       The steps required to complete a task or action                                                7.6:6      Yes   No   N/A   PCC   m
49       Reporting and recording requirements                                                           7.6:6      Yes   No   N/A   PCC   m
50       Assignment of staff responsibilities                                                           7.6:6      Yes   No   N/A   PCC   m
51   Is there a Health/Medical Policy & Procedure?                                                       7.6:7      Yes   No   N/A   PCC   s
52   Does this policy and procedure include, at a minimum:
53       Title                                                                                          7.6:7      Yes   No   N/A   PCC   m
54       Purpose                                                                                        7.6:7      Yes   No   N/A   PCC   m
55       The steps required to complete a task or action                                                7.6:7      Yes   No   N/A   PCC   m
56       Reporting and recording requirements                                                           7.6:7      Yes   No   N/A   PCC   m
57       Assignment of staff responsibilities                                                           7.6:7      Yes   No   N/A   PCC   m
      Guidelines for seizure care including staff’s response to life-threatening situations            19.20:1     Yes   No   N/A   PCC   m
     Is this policy and procedure in compliance with DC #9 “Viral Hepatitis” ?                           19.8       Yes   No   N/A   PCC   m
     Is this policy and procedure in compliance with DC #45 “HIV/AIDS” ?                                 19.8       Yes   No   N/A   PCC   m
     Is this policy and procedure in compliance with DC #20 “Mechanical Restraint & Safeguarding         19.9
61   Equipment” ?                                                                                                   Yes   No   N/A   PCC   m
62   Is there a Medication Administration Policy & Procedure?                                            7.6:8      Yes   No   N/A   PCC   s
63   Does this policy and procedure include, at a minimum:
64       Title                                                                                          7.6:8      Yes   No   N/A   PCC   m
65       Purpose                                                                                        7.6:8      Yes   No   N/A   PCC   m
66       The steps required to complete a task or action                                                7.6:8      Yes   No   N/A   PCC   m
67       Reporting and recording requirements                                                           7.6:8      Yes   No   N/A   PCC   m
68       Assignment of staff responsibilities                                                           7.6:8      Yes   No   N/A   PCC   m
     Does this policy and procedure address the following:
      Prescription Medication                                                                           20A        Yes   No   N/A   PCC   m
      PRN (as needed) Prescription Medication                                                           20B        Yes   No   N/A   PCC   m
      PRN Over the Counter (OTC) Medication                                                             20C        Yes   No   N/A   PCC   m
      Medication Administration                                                                         20D        Yes   No   N/A   PCC   m
      Emergency Administration of Prescription Medication                                              20D.10      Yes   No   N/A   PCC   m
      Medication Storage                                                                                20E        Yes   No   N/A   PCC   m
76   Is there a Transportation Policy and Procedure ?                                                    7.6:9      Yes   No   N/A   PCC   s


                                                                                                   33
                                                                                      Day Program Monitoring Tool
                                                                                         Administrative Review
                                                                                                DRAFT
77 Does this policy and procedure include, at a minimum:
78     Title                                                                                          7.6:9        Yes   No   N/A   PCC   m
79     Purpose                                                                                        7.6:9        Yes   No   N/A   PCC   m
80 The steps required to complete a task or action                                                    7.6:9        Yes   No   N/A   PCC   m
81 Reporting and recording requirements                                                               7.6:9        Yes   No   N/A   PCC   m
82     Assignment of staff responsibilities                                                           7.6:9        Yes   No   N/A   PCC   m
83  A system for verifying licenses and driving records, including obtaining driver abstracts         8.5          Yes   No   N/A   PCC   m
84 Is this policy and procedure in compliance with Chapter 12 of the DP Manual?                         8           Yes   No   N/A   PCC   m
85 Is there a Personnel Policy & Procedure?                                                           7.6:10        Yes   No   N/A   PCC   s




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