administration assessment completed? 5123:2-6-02; 5123:2-3-04 identified as self-administering may not have an assessment. 3.002 If the individual is unable to self-administer medications has the assessment been reviewed annually, and revised as-needed? 5123:2-6-05; 5123:2-3-04 A new assessment must be done at least every 3 years or if there has been a change 3.003 If the individual’s assessment indicates that they are unable to self-medicate, does the Individual service plan address their medication administration needs? 5123:2-1-11; 5123:2-3-04 An individual is presumed to be able to self –medicate. Assessment should be completed only if the team believes the individual is unable to safely 3.004 If the individual is unable to self-administer their medications, is the medication stored in a secure location based on the needs of the individual and their living environment? 5123:2-6-06; 5123:2-3-04 Secured doesn't have to mean locked. It means secured based on the individual's needs 3.005 If the individual is unable to self-administer medications, is the medication in a pharmacy labeled container? 5123:2-6-06; 5123:2-3-04 3.006 If delegated nursing is identified in the plan, is a statement of delegation, evidence of assessment, and annual staff skills checklist? 5123:2-6-01; 5123:2-6-03; 5123:2-3-04 REFERENCE DELEGATED NURSING GRID Day service locations serving 17 or more individuals must have delegated nursing. Residential facilities with 6 or more beds must have delegated nursing Delegation is required for G/J tube medication administration, insulin injection or pump and administration of nutrition by G/J tube. SECTION 4 – BEHAVIOR SUPPORT going
Yes/No (If not compliant) 7.001 Does service delivery documentation include the following elements below? Date of service; Individual's name; Individual's Medicaid #; Provider name; Provider # Signature or initials of person delivering the service 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; 5123:2-9-20 May be maintained on multiple Review service specific rule for documentation requirements 7.002 Does the waiver service delivery documentation for all waiver billing codes include the place of service? 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; 5123:2-9-20 Place of service in NMT is the vehicle license plate number For Transportation (HPC), this is origination/destination points 7.003 Does the waiver service delivery documentation for all waiver include the type of service? 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; 5123:2-9-20 Review service specific rule for documentation requirements NMT: requires type of NMT service – or per-mile 7.004 Does the waiver service delivery documentation for all waiver billing codes include the number of units (amount) provided? 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; 5123:2-9-20 Not required for services billed using a daily rate except adult day services Documentation may be maintained on multiple documents/forms Review service specific rule for documentation requirements For Transportation (HPC, NMT, and SELF), this is total number of miles as indicated by the odometer readings 7.005 Does the waiver service delivery documentation for all waiver billing codes include scope? 5123:2-9-06; 5123:2-9-40; 5123:2-9-39 Scope- the definition of each waiver service must describe in concrete terms the goods and services that will be provided to waiver participants, including any conditions that apply to the provision of the service trip
7.011 Is the service plan and/or plan of care being implemented as written? 5123:2-2-01; 5123:2-9-39 Info may come from service documentation and review of the frequency/duration of services delivered and/or observation. Documentation should match services in the plan. Includes access to adaptive equipment/modifications important to/for the individual 7.012 Is the provider/facility following all applicable local, state and federal rules and regulations? Must include rule cite 7.013 Does the individual’s plan of care (485) include: The current certification period Provider’s name including all RNs and LPNs providing service. All sections of Plan of Care are completed Medication list and MAR 5123:2-9-39 Required for agency nursing services Must be signed and dated by the treating physician every 60 days Verbal orders on the plan of care can be worked under for two weeks Referred to as the 485 7.014 Does the nursing documentation include clinical notes or progress notes and documentation of the face to face visits? 5123:2-9-39 7.015 For providers of employment services (including prevocational services), (vocational habilitation, group employment supports, career planning and individual employment supports) was a written progress report submitted to the individual’s team at least once every twelve months to show progress towards desired employment outcome? 5123:2-2-05 Prevocational services include vocational habilitation Ensure the employment outcome is outlined in progress report. The written progress report shall outline the following: Desired employment outcome Place to path on community employment Anticipated and progress towards reaching desired outcome If Employment outcome was not met, does it explain barriers identified and steps to address barriers or revise employment outcome?
7.016 Did the provider submit employment outcome data for individuals who receive employment services (vocational habilitation, employment supports, career planning, and individual employment supports) through the web-based data collection system maintained by the Department? 5123:2-2-05; 5123:2-9-13; 5123:2-9-14; 5123:2-9-15; 5123:2-9-16 Was employment outcome data submitted at least once per year or more frequently as status changes occur? Provider should have the data they submitted disseminated in a confidential manner based on services provided, how individuals obtained employment, hours worked, wages earned, and occupations. This is information you could request to see. Does not apply to Adult Day Support service 7.017 Were records maintained in a confidential manner and available upon request? 5123:2-2-01; 5123:2-9-06 and 5123:2-3-13; 5123:2-9-39 7.018 Does the waiver provider ensure that records related to the provision of services are maintained by the provider for a minimum of six years? 5123:2-9-06 These records can be stored electronically. 7.019 Does the waiver service documentation for applicable waiver services include the the delivered service started and stopped? 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; 5123:2-9-20 Check the rule for the service under review; this may not apply for services billed at a daily rate. 7.020 Are waiver services being provided in this setting being delivered in a manner which supports individual choice, preferences, and needs in a manner to supports each individual’s full participation in his/her access to the greater community? 5123:2-9-02 42 CFR 441.301 (c) (4-6); 441.701 (a) (1-2) Are opportunities to access the community offered Engagement in meaningful activities (work and non-work activities) Age appropriate activities Are the activities similar to those without disabilities?
7.021 Is staff available based on the assessed needs of the individual? 5123:2-3-01 Are supervision levels being met? 7.022 DAY SERVICES For providers of Adult Day Support and Vocational Habilitation only: If the provider is billing the community integration rate modification, are the following conditions met? Staff providing the service have successfully completed a department approved program of instruction in community integration. The service is provided in integrated settings in groups of four or fewer individuals. 5123:2-9-14; 5123:2-9-17 Community Integration rate modification only applies when the ADS/Voc Hab service is billed in 15 minute units. Community integration training is found within the DSP 8 hour training on DODD MyLearning. It can be watched individually or as the entire 8 hour DSP training. 7.023 DAY SERVICES Providers of Career Planning only: When the provider is billing the Career Planning service for any of the components listed below, does the documentation include a description and details sufficient to demonstrate achievement of the desired outcomes? Assistive technology assessment Benefits education and analysis Career discovery Employment/self-employment plan Situational observation and assessment 5123:2-9-13 This question only applies to the Career Planning components listed in the question. This does NOT apply to: Career exploration Job development Self-employment launch Worksite accessibility Please review the Career Planning rule for information on each of the service components.
8.004 Is there evidence that notifications were made on the same day of the incident to the following as applicable: Guardian or other person whom the individual has identified Residential provider (licensed or certified) SSA Staff or family living at the individual’s residence who have responsibility for individual’s care Support broker 5123:2-17-02 Applies to notifications for MUIs only, not UIs Notification to the Residential Provider only applies when the incident happens at a location operated by an agency provider that is not the residential provider Notifications or efforts to notify those listed above were documented Notifications were made to the individuals’ guardians and other person whom the individuals have identified in a peer to peer act unless such notifications could jeopardize the health and welfare of an involved individual. 8.005 If applicable, were appropriate notifications made to other agencies? Children’s Services for allegations of abuse and neglect) Law Enforcement (for allegations of a 5123:2-17-02 Any allegation of abuse or neglect under 2151.03 and 2151.031 for children under 21 years Any allegation of exploitation, failure to report, misappropriation, neglect, peer to peer acts, physical abuse, sexual abuse, verbal abuse which may constitute a crime must be immediately reported to LE Notifications or efforts to notify listed above were documented 8.006 Is there evidence the provider cooperated with the investigation of MUIs? Timely submission of requested information? 5123:2-17-02 For County Boards: Timely submission also Includes replies past due (Replies past due will only be reviewed by DODD MUI 8.007 Is evidence that the individual’s team including the provider, collaborated on the development of a prevention plan to address the causes and contributing factors identified in the investigation? 5123:2-17-02
5123:2-2-02; 5160-45-07; 9.010 Did the provider staff, while under final consideration for employment, sign a statement attesting that the staff person has never plead guilty to or been convicted of a disqualifying offense? 5123:2-2-02; 5160-45-07; 9.011 Did the provider have annual notification explaining conduct for which a DD employee may be included on the Abuser Registry? 5123:2-2-01 A staff signature is not required. Agency must have a process to implement. 9.012 Did the agency provider verify that the staff person has a high school diploma, GED or a rule waiver from the department? 5123:2-2-01; 5123:2-3-01 Review with provider their system to verify a high school diploma or GED. Staff enrolled in college are considered to meet this requirement. 9.013 If the provider/staff person is responsible for the following, do they have the appropriate certification for: Oral or topical medications (Category 1) Health related activities (Category 1) G-tube/J-tube (Category 2) Insulin injections (Category 3)Family delegation is not permitted for agency providers. 5123:2-6-03; 5123:2-3-01 Family delegation is not permitted for agency providers. Family delegation is permitted for agency staff when they are the paid provider and they live with the individual. Category 1 certification Authorizes Oxygen administration without delegation (in settings that do not require delegation of Cat 1 activities) Authorizes use of OTC topical products for musculoskeletal comfort without a prescription Authorizes 5 new health related activities: 1. Pulse Oximetry (for O2 saturation reading) 2. Bi/CPAP 3. Application of Prescription Compression Hose 4. Application of a Percussion Vest
(iii) Universal precautions (iv) Initial rights training (v) Initial MUI training including the health and welfare alerts issued by the department. 5123:2-2-01; 5123:2-3-01; 9.018 Did the staff person receive training prior to providing services that included person specific training? (i) on what is important to and important for the individual (ii) as it applies to behavioral supports (iii) as it applies to management (iv) as it applies to medication administration/delegated nursing 5123:2-2-01; 5123:2-3-01 The requirement for person specific training begins with the new certification rule on 10/1/2015. Look for this requirement to be met when there is a new staff person and for staff persons that are serving different individuals. Refers to the ISP training prior to implementation 9.019 Did the supervisory staff for direct services positions complete the following training within 90 days of becoming a supervisor? Service documentation; billing for services, management of individuals' funds 5123:2-2-01; 5123:2-3-01 New supervisory staff hired after 10/1/16 9.020 Did all direct service staff have initial training on actions to take in the event of a fire or other emergencies? 5123:2-3-01 LICENSED FACILITY ONLY Must be completed within 30 days 9.021 Did the provider staff have annual training on the MUI/UI requirements and health and welfare alerts from the previous year? 5123:2-17-02; 5123:2-3-01; Once during each calendar year Not required to be within 365 days Required for CEO and/or Administrators annually
5123:2-2-02 9.033 Did staff providing transportation obtain a new driver's abstract every 3 years? 5123:2-9-18; 5123:2-9-24; 9.034 Are all vehicles used to transport individuals covered by a current insurance policy that meets the requirements of the service provided? 5123:2-9-18; 5123:2-9-24; 9.035 If the provider is responsible for providing Per Trip Non-Medical Transportation, does the staff person have a signed form establishing the driver's physical qualification to provide non-medical transportation? 5123:2-9-18 This form must be completed and signed by a person who is licensed, certified, and/or registered in accordance with Ohio law to perform physical examinations. 9.036 If the provider is responsible for providing Non-Medical Transportation, did the staff person receive testing for controlled substances and was the staff person found to be drug free prior to providing transportation services? 5123:2-9-18 Per trip and per mile Non-Medical Transportation Drug testing must be from a lab, cannot be self-administered. Reviewer must see the results of the testing, not just receipts 9.037 Has the agency obtained and maintained general liability insurance for at $500,000? 5123:2-2-01 Effective 1/1/16 9.038 Are all in a direct services position enrolled in Rapback? Staff hired prior to October 1, 2016 must be enrolled in If an employee is not able to get a BCII via fingerprints they cannot be enrolled in Rapback. The provider agency must continue to complete the 5 year BCII/FBI.
Rapback at the point of their next five year BCII. Staff hired on or after October 1, 2016 must be enrolled into Rapback at the point of their initial BCII. 5123:2-2-01, 5123:2-3-01 9.039 Has the provider agency established an internal compliance program that ensures compliance with (1) provider certification, (2) background checks, (3) service delivery, service documentation and billing? 5123:2-2-01; 5123:2-3-01 Does the provider have an assigned internal compliance manager or committee? Does the provider have policies as required in rule and for certification requirements, background checks and service delivery, documentation and billing? Do the outcomes of this review indicate that the provider’s internal compliance program is working? 9.040 Licensed Facility Only Was evidence the Administrator completed the new Administrator Orientation? 5123:2-3-01 LICENSED FACILITY ONLY For administrators hired after 10/1/16 Training found on DODD website 9.041 Licensed Facility Only Did the Administrator have annual training in facility roles and responsibilities, including Person Centered Planning Community Participation and Integration Self-determination Self-advocacy Individual Rights MUI, including review of health and welfare alerts 5123:2-3-01 LICENSED FACILITY ONLY 9.042 Does the facility have an Administrator directly involved in the LICENSED FACILITY ONLY Verify through interview the frequency of administrator presence in the facility.
11.003 Licensed Facility Only When there is a swimming pool on the grounds, is the pool only used in the presence of staff with a; American Red Cross or equivalent lifeguarding certificate Shallow water lifeguarding certificate for pools less than 5 feet deepRequired for licensed facilities and CB; 5123:2-3-01 LICENSED FACILITY ONLY Check for rule waivers 11.004 Licensed Facility Only Are the interior, exterior and grounds of the building maintained in good repair and in a clean and sanitary manner? 5123:2-3-02 LICENSED FACILITY ONLY 11.005 Licensed Facility Only Are there appropriate and comfortable equipment, furniture and appliances in good condition except for normal wear and tear adequate to meet the needs and preferences of the individual? 5123:2-3-02 LICENSED FACILITY ONLY Furniture and equipment should be safe. Equipment also includes working smoke detectors and fire extinguishers on each floor and at least one carbon monoxide detector for homes with gas heat, dryers or stoves. The home should have equipment necessary based on the needs of the individuals served (i.e.: grab bars, ramps, visual fire alarms, etc.) 11.006 only Are the entrances, hallways, corridors and ramps clear and unobstructed? 5123:2-3-02 LICENSED FACILITY AND CB ONLY 11.007 only Does the program/facility have suitable first aid facilities, equipment and supplies and is there access to emergency services? 5123:2-3-02 LICENSED FACILITY AND CB ONLY 11.008 County only power equipment is used, does the equipment have appropriate safeguards? Safety Guards Kill Button COUNTY BOARD ONLY Required where power equipment is in use
SECTION – EARLY INTERVENTION Question # Question Guidance/Additional Information Compliant Yes/No Plan of Correction (If not compliant) 13.001 Does the CB provide evidence based EI services to EI system? 5123:2-1-02 EI services may include service coordination, special instruction, physical, and speech and occupational therapy services. Reference federal regulations (303.302) or HMG Rule 3701-8-01 (U) to see a list of other EI services. 13.002 Does the CB participate in the Evaluation/Assessment for children referred to the local EI system? 5123:2-1-04 If so, must be completed within the 45-day timeline from the date of program referral (DOR) to the HMG system to the signing of the initial IFSP. This includes a functional child assessment and the *family directed assessment. *Families may decline to participate in the Family Directed Assessment. 13.003 Does the CB use more than one method to conduct functional assessments? 5123:2-1-02 Assessed in all 5 developmental domains (Required) Multiple methods (i.e. could include: parent interview/report, observation, record review, criterion reference tools and working through multiple strategies. Multidisciplinary to attachment A, Child Assessment section to verify assessment methods/disciplines. 13.004 Does the CB use one of the DODD approved tools to evaluate children? 5123:2-1-02 Approved tools for evaluation: Bayley or Battelle
prior to October 1: 2 hours. After September 30 but prior to succeeding January 1: 1 hour. 18.015 Licensed facility only Is the facility operating over its licensed capacity without a rule waiver? 5123:2-3-01 LICENSED FACILITY ONLY 18.016 County board only Did the county board have a process for monitoring contracts? 5123:2-1-02 ORC 5126.05 COUNTY ONLY The county board must demonstrate a process for ensuring that contracted entities are in compliance with rules and statute.