Each participant receives services only in accordance with an individualized written service plan. Y N N/A Each participant’s service plan is developed by program staff in conjunction and/or consultation with the participant and, if applicable, with the participant’s authorized representative and/or informal caregivers. Y N N/A Participant service plans are developed no later than 30 days after participant admission to the program. Y N N/A Participant service plans are reviewed as necessary, or at least once annually. Y N N/A Participant service plans are based on the assessment conducted and consistent with the needs of the participant. Y N N/A To the maximum extent possible, the participant service plan is designed to attain and maintain the physical, mental and psychosocial wellbeing of the participant including the optimal capacity for independence and selfcare. Y N N/A Criteria Met Criteria Documentation Comments To the maximum extent possible, the participant service plan is designed to encourage the participant to use existing capacities, develop new capacities and interests and compensate Y N N/A
SUPERVISION and MONITORING Criteria Met Criteria Documentation Comments Staff is observant and aware of the participants' whereabouts, activities and current needs during attendance at the program. Y N N/A Staff protects the safety and welfare of participants and provides ongoing encouragement and assistance as necessary. Y N N/A Personal Care Services: The personal care worksheet must be completed before completing this section. Criteria Met Criteria Documentation Comments 3.1 Required Personal Care Services: The Program provides some assistance for the participant with toileting, mobility, transfer and eating (NYSOFA interprets this as some hands on assistance). Y N N/A Criteria Met Criteria Documentation Comments 3.2 Optional Personal Care Services as allowed in the regulation: The Program provides total assistance to the participants with toileting, mobility, transfer and eating is provided. Y N N/A The Program provides some or total assistance to the participants with dressing, bathing, grooming, the Y N N/A
Identify sources of assistance and facilitate access to that assistance for the informal caregiver including support groups, respite and other related assistance. Y N N/A CASE COORDINATION AND ASSISTANCE Criteria Met Criteria Documentation Comments If offered, the following service components are required: The program shall establish and maintain effective linkages. Y N N/A The Program shall coordinate services, and make and accept referrals to and from other service providers. ☐Y ☐N ☐N/A Optional Service Component: The Program may choose to advise and assist participants and their caregivers in relation to benefits, entitlements, and other information. Y N N/A Required Program Standard: ADMINISTRATIVE POLICIES AND PROCEDURES Criteria Met Criteria Documentation Comments Written policies and procedures are established, followed and on file for review covering, but not limited to, the following areas: Participant Eligibility Y N
N/A Admission and Discharge Y N N/A Criteria Met Criteria Documentation Comments Service/Care Plan Y N N/A Staffing Plan, including paid and unpaid staff Y N N/A Participant’s Rights Y N N/A Service Delivery including forms or written documentation of service delivery Y N N/A Program self-evaluation Y N N/A Records, including confidentiality Y N N/A Emergency Preparedness: emergencies regarding participants, building, weather, and closure procedures Y N N/A