Free 51684.pdf - Indiana

State Form 51684 (4-04) / BQIS 0008

BQIS GUIDELINES PRE-TRANSITION QUALITY ASSURANCE CHECKLIST
1 Home and Community Preferences met? (type and location) Expectations: The type and location of the home meet the specifications as outlined in the support plan. · Home and Community meet wants of individual, as described in PCP/ISP? · Has the guardian/health care rep. visited the home and/or have they approved a move to this home? Expectations: All adaptations identified in the PCP/ISP are in place at the home. The individual can move about the location without restrictions as independently as feasible. · Are home adaptations identified in the PCP/ISP? · Are they in place at the home? Expectations: The home will look and smell clean. · Is the carpeting/flooring sanitary? · Are the walls clean? · Do any rooms have unusual odors? · Are the kitchen and all appliances clean? · Is the bathroom clean? Are bathroom fixtures clean? Expectations: Medications can be stored safely. Chemicals, sharps and other potential hazardous items will be stored in the home in a manner that does not pose a threat to the individual. · Is there a plan for safe storage of medications, per the needs of the individual? · Will cleaning supplies be stored separately from food? · Is there a plan for storage of chemicals, sharp instruments and other hazardous items, which ensures the safety of the individual per the support plan? · Is all safety/storage equipment identified in any of the above plans present? Expectations: Visual inspection of the interior and exterior of the home reveals no observed hazards. · Are there obvious hazards? · Are ramps, rails, etc. secured when tested? · Are there bare light bulbs, frayed cords, or overloaded sockets in the walls? · Does the provider have a procedure to take care of hazards, which may occur in the home? Expectations: Individuals will not be restricted in their access to the community due to inadequate transportation. · Is there a plan that addresses transportation needs as identified in the PCP/ISP? · How will the individual leave the home for shopping and appointments? · What sort of vehicle will be used? · Is there any transportation issue that will cause a barrier to travel into the community? Expectations: The individual has a personal physician identified and an appointment scheduled. · Is the name and contact information present for the personal physician? · Is there an appointment scheduled? · If individual is moving from one residence to another and is keeping the same physician, is there evidence of continued physician services (follow-up or routine return appointment scheduled)? Expectations: The individual has a personal dentist identified and an appointment scheduled. · Is the name and contact information present for the dentist? · Has an appointment been scheduled? · If individual is moving from one residence to another and is keeping the same Dentist, is there evidence of continued dental services (follow-up or routine return appointment scheduled)? page 1

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Home adaptations in place?

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Home clean and hygienic?

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Safe storage of medications, cleaning supplies, knives and other potential hazards?

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House, lot, yard, garage, driveway, etc., free of environmental hazards?

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Transportation available to meet all community access needs?

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Personal Physician identified, and appointment scheduled?

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Personal Dentist identified, and an appointment scheduled?

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Behavior Support provider identified.

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Psychiatrist identified?

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Adequate staff assigned? Staff received information addressing individual's medical needs? Staff received information addressing the individual's dietary/nutritional needs? Staff received information addressing the individual's personal hygiene needs? Staff received information addressing individual's mobility needs?

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Staff received information addressing the individual's behavioral considerations? High-risk issues identified and plans developed to address them?

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Phone installed in the home? Is an emergency telephone list present?

Expectations: If there is a diagnosis of any behavioral or emotional challenges which require professional care, a Behavioral Support provider will be a part of the support team. · Does the PCP/ISP identify a need for a Behavior Support provider? · Has the provider identified this specialist? Expectations: If the individual is taking psychotropic medications, a psychiatrist will be part of the medical support team. · Is the individual taking psychotropic medications? · Has a psychiatrist been identified? Expectations: There will be adequate staff available to meet the needs of the individual. · Does the provider state that adequate staff have been hired and are ready to provide care and services as identified in the PCP/ISP? Expectations: Staff are able to perform services to meet the individual's medical needs as identified in the PCP/ISP. · Is there a medical plan for the individual? · Is documentation of information shared addressing medical needs present? · Is there a designated person for staff to obtain information as needed? Expectations: Staff are able to perform procedures to meet the individual's dietary/nutritional needs. · Is there a dietary/nutritional plan in the PCP/ISP? · Is documentation of information shared addressing dietary/nutrition present? · Is there a designated person for staff to obtain information as needed? Expectations: Staff are able to perform procedures/interventions to meet the individual's personal hygiene needs. · Is documentation of information shared addressing the individual's personal hygiene needs present? · Is there a designated person for staff to obtain information as needed? Expectations: Staff are able to perform procedure/interventions to meet the individual's mobility needs. · Does the individual's PCP/ISP address mobility needs? · Is documentation of information shared addressing the individual's mobility needs (ex. transfers) present? · Is there a designated person for staff to obtain information as needed? Expectations: Staff are able to perform procedures/interventions to meet the individual's behavioral considerations. · Does the individual PCP/ISP address behavioral support needs? · Is documentation of information shared addressing the individual's behavioral considerations present? · Is there a designated person for staff to obtain information as needed? Expectations: The provider is knowledgeable of all high risk issues identified in the PCP/ISP and has a plan addressing each issue. · Does the provider demonstrate knowledge of all high-risk issues? · Is there a plan that addresses each issue? · Is the provider knowledgeable of the possible negative consequences if plans are not carried out correctly? Expectations: There is a phone installed in the home and the phone number is known to the residential provider, the Targeted Case Manager, the Guardian/Healthcare Representative, and the BDDS Transitions Coordinator. Expectations: An emergency telephone list is posted in an area visible from the phone (or as indicated in the PCP/ISP) that includes numbers for: The local emergency number (e.g. 911) The Individual's legal representative (or advocate, if applicable) The local BDDS office The Targeted Case Manager Adult Protective Services, or Child Protective Services ­ depending on age of Individual page 2

The Developmental Disabilities Ombudsman Any other Service Provider Identified 20 Hot water no warmer than 110º Fahrenheit? Expectations: The maximum temperature of the hot water in the home is no higher than 110º Fahrenheit making it safe for bathing, unless otherwise specified in the PCP/ISP. · Does the PCP/ISP confirm that hot water temperature control is not necessary? · Is the home in compliance with the PCP/ISP? · If water temperature is not addressed in the PCP/ISP, is the hot water no warmer than 110º Fahrenheit as tested at the bathtub (or shower if no tub) following full stream running for approximately 3 minutes (ensuring water is at maximum temperature)? Expectations: The Plan of Care identifies and addresses all necessary services and supports as outlined in the Individual Support Plan · Has the Service Coordinator confirmed that all services and supports identified in the ISP are identified and addressed in the Plan of Care? Expectations: If epilepsy, seizure disorder, head injury, hydrocephaly, or other neural disorders exist, a neurologist will be part of the medical support team. · Does the individual's PCP/ISP present neural disorders as indicated above? · Has a neurologist been identified? · Is the provider committed to having the Primary Care Physician make a referral to the Neurologist? Expectations: If additional medical conditions exist which require medical specialist care (such as vision impairments), the specialist/s will be part of the medical support team. · Does the PCP/ISP present additional medical specialist needs? · Have all additional specialists been identified? · Is the provider committed to having the Primary Care Physician make referrals to all specialists as indicated? Expectations: If there are needs relating to mobility difficulties, fine motor coordination, sensory sensitivity, eye hand coordination, transfer difficulties, etc., which would require professional care, OT and/or Pt will be part of the support team. · Does the PCP/ISP present needs for OT/PT services as indicated above? · Has an OT and/or a PT been identified? · Is the provider committed to having the Primary Care Physician make referrals as indicated? Expectations: If there are communication deficits or swallowing difficulties that require professional care, a Speech/Language Pathologist will be part of the medical support team. · Does the individual present a need for SLP services as indicated in the PCP/ISP? · Has a SLP been identified? · Is the provider committed to having the Primary Care Physician make a referral to the SLP? Expectations: If there are concerns regarding the individual's food intake due to diabetes, g-tube, food allergies, caloric limits, etc., a dietician will be part of the medical support team. · Does the individual have a special diet or special dietary needs as described in the PCP/ISP? · Has a dietician been identified? · Is the provider committed to having the Primary Care Physician make a referral to the dietician as indicated? Expectations: The individual will have the medical equipment prescribed for them in the PCP/ISP available at the time of their move into the home (c-pap; nebulizer; glucometer; oxygen; etc.). · Does the PCP/ISP identify medical equipment needs? · Does the provider have a plan to ensure all equipment is in the home at the page 3

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Services/supports identified and addressed in the POC? Neurologist identified?

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Other Medical Specialist identified?

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OT/PT provider identified?

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Speech Language Pathologist identified?

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Dietician identified and a plan in place for meeting nutritional needs?

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Medical equipment present or arrangements made to obtain the equipment?

time of the individual's arrival?

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Adaptive equipment present or arrangements made to obtain them?

Expectations: The individual will have the adaptive equipment prescribed in the PCP/ISP available at the time of their move into the home (wheelchair; walker; gait belt; braces; shower chair; dining equipment; positioning equipment; etc). · Does the PCP/ISP identify adaptive equipment needs? · Does the provider have a plan to ensure all adaptive equipment is in the home at the time of the individual's arrival? Expectations: Food will be available in the home to accommodate the individual's wants and needs upon arrival. · Does the provider have a plan to have staples and main course food items in the home to accommodate the individual's wants and needs upon their arrival?

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Home stocked with food to accommodate the new occupant?

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