Agency Name: ANNUAL RECERTIFICATION MCH Nurse Consultant: Region: Visit Date: # Active Charts Randomly Selected for review: Woman: Infant: Child: Total = OUTCOME INDICATOR: # Records Reviewed # Expected # Completed % in Compliance IDHS Report Period Data from IDHS Reports Performance Standard or State Average Assessments (701, 706 AR infants, 711 or 712 or 713,708 A-R infants, Nutrition) AS01s AS01s AS01s 90% Records Records Records Individual Care Plan 90% All Referrals on RF01, CM02, CM03, CM04 including follow-up 100% Initiation of prenatal care with medical provider in 1st trimester ( PA07) 75% Reproductive Life Plan (SV01:941& 942) 95% Preconception /Interconception Ed (SV01: PEWW) EI Referral (0-3) # Indicated # Expected 100% NAR Pregnant or Infant: 2 F2F +1 other contact 80% AR Pregnant: 3 F2F (1 per trimester) 80% AR Infant:3 F2F + 1 HV 80% AR Infant: Home Visit: 1 HV 75% Primary Care Provider 95% Immunizations 3-2-2 90% EPSDT Visits FCM Infants Age 1: > 3 80% Developmental Screenings (1 Standardized screen by12 months) 80% Prenatal depression screening 95% Postpartum depression screening 95% AR & NAR Over rides HSPR0749 <10%
Perform standardized development screening by age 1 year (or referral to CFC is made and followed). If receiving EI services, Dev screening not required but document EI assessment date on SV01. Ages & Stages Questionnaire or any approved screening tool by IHFS Handbook for Providers of Healthy Kids. Contract Performance Standard 80% SV01 824 Case Notes RF01/RF03 Referrals Referrals of participants to appropriate providers within the community for services identified in the individual care plan and documented on the RF01. WIC Family Planning Perinatal depressions screening if not provided by FCM agency Linkages/Referral Agencies Other: Intimate Partner Violence, Substance Abuse, Housing, etc. Contract Performance Standard 100% Cornerstone screens: Case Notes – CM04 &/9r Service Provider Selection (RF01, RF03) CM02, CM03 RF01/RF03 Or by agency approved policy Document referral follow-up on RF01: WIC FP Perinatal depression screening Linkages/Referral Agencies Other: Intimate Partner Violence, Substance Abuse, Housing, etc 3. EI Referrals are completed on all Infants and children 0-3 indicated by dev screening, including follow-up. Performance Standard 100% CM02:814, CM03, CM04 or approved policy All referrals are to be recorded on the RF01 Screen. Use the comment line of the RF01 Screen to document follow up. Or documented by agency approved policy.
EVALUATION ITEM Code part Quarterly Reports EVALUATION MECHAMISM MET NOT MET N/A CO: Commendation COMMENTS KEY: R: Recommendation RQ: Required (typed bold) IV. EPSDT/Well Child Exams Are written policies/protocols in place at the agency outlining what steps to follow for abnormal findings on EPSDT exams and developmental screenings performed by nurses? Code Contract Code Contract Code Contract Healthy Kids Manual Healthy Kids Manual Code Contract Healthy Kids Manual Policy/ Procedure/ Protocol Standing orders present? Certificate of completion for IDHS Pediatric Assessment Course on file for RN(s) Policy/ Procedure/ Protocol Does the agency have written standing orders signed by the medical director, allowing the nurses to do EPSDT exams under his/her authority? YES, Agency is billing Medicaid for EPSDT? 1a. Physical Assessments are completed by a Registered Nurse who has completed the IDHS Pediatric Assessment Course or a similar course approved by IDHS at each visit. NO, Agency is NOT billing Medicaid. 1b. Physical assessments are completed by a Registered Nurse who has knowledge in pediatric assessment skills at each visit.